Section 8

Question 1

Name the muscles of the velum including their function and what innervates them.

Answer 1

Levator Veli Palatini (CN X) → elevates velum
Tensor Veli Palatini (CN V) → assists levator veli palatini, tenses velum for support for
pharyngeal elevation during swallow, opens Eustachian tube for pressure equalization between tympanic cavity and outside air
Palatoglossus (CN X) → elevates posterior tongue, depresses velum (downward and forward)
Palatopharyngeus (CN X) → depresses velum
Uvulus (CN X) → shortens uvula, adds bulk and stiffness to velum

Question 2

What are the methods of proper VP closure?

Answer 2

1. Velar elevation
2. Inward movement of lateral pharyngeal walls
3. Combined velar elevation + inward movement of lateral pharyngeal walls
4. Velar elevation + inward movement of lateral pharyngeal walls + movement of posterior pharyngeal walls

Question 3

What are the passive forces of velopharyngeal movement?

Answer 3

Natural recoil of muscles, cartilages, and connective tissues
Surface tension between structures in apposition
Pull of gravity → have to contract muscles to raise velum but not to lower
Aeromechanical forces within the upper airway (throat, mouth, nose) → sneeze

Question 4

Describe normal VP function.

Answer 4

VP raises/closes for oral sounds, especially stops (high pressure)
VP open for nasal sounds
VP closure = swallowing (oral phase)

Question 5

What are some examples of abnormal velopharyngeal function?

Answer 5

Hypernasality → usually caused by VPI, palatal fistula, misarticulation if phoneme-specific (Speech therapy is phoneme specific)
Hyponasality → obstruction in nasopharynx or nasal cavity
Mixed Nasality → combo of VPI and significant nasal airway blockage
Cul-de-sac resonance → obstruction at the exit of a cavity of oral tract (oral, nasal, pharyngeal)

Question 6

Compare and contrast CP insufficiency, incompetency, and misleading.

Answer 6

Insufficiency: structural
- Etiologies include submucous/cleft palate, cranial base anomalies, post adenoidectomy, Palatopharyngeus disproportion, Ablative palatal lesions
Incompetency: neurogenic, neurophysiological, and be congenital or acquired and associated with motor control (dysarthria) or motor programming (apraxia)
Mislearning: Phoneme-specific nasal emission, persisting post-op nasal emission (with adequate closure ability), compensatory misarticulations, deafness/hearing impairment

Question 7

What is normal resonance?

Answer 7

The result of the transfer of sound produced by vocal folds through vocal
tract comprised of pharynx, oral cavity, and nasal cavity. Vocal tract filters this sound, selectively enhancing harmonics based on size and/or shape of vocal tract. Perceived resonance is the
result of this filtered tone
Achieved through an appropriate balance of oral and nasal sound energy, based on the intended speech sound

Question 8

What is hypernasality?

Answer 8

Occurs when there is sound energy in nasal cavity during production of (voiced) oral phonemes
Particularly perceptible on vowel sounds, and on oral consonants
Often accompanied by nasal air emission during consonant production
Lack of adequate intra-oral air pressure for consonant production commonly results in development of compensatory articulatory phonemes
Often caused by structural/neurophysiological disorders

Question 9

What is hyponasality?

Answer 9

Reduction of nasal resonance during speech due to blockage in nasopharynx or in entrance to nasal cavity
Denasality = complete occlusion of nasal cavity during speech
Particularly effects production of nasal consonants (/m/, /n/, /ng/) → can sound similar to their oral cognates (/b/, /d/, /g/)

Question 10

What is mixed resonance?

Answer 10

When speech has characteristics of both hypernasality + hyponasality
The hypernasality occurs on oral sounds and hyponasality occurs on nasal sounds

Question 11

What is cul-de-sac resonance?

Answer 11

Occurs when sound resonates in a cavity (oral, nasal, pharyngeal) but is “trapped” and cannot exit because of obstruction
Oral cul-de-sac resonance: sounds like mumbling or speaking without opening mouth
Pharyngeal cul-de-sac resonance: “potato-in-mouth” speech → most common one

Question 12

What are some causes of hypernasality?

Answer 12

Usually caused by structural or neurophysiological disorder
Velopharyngeal dysfunction
Genetics → 22q11.2 deletion syndrome (CLP), Treacher Collins syndrome
Large oronasal fistula following cleft palate repair

Question 13

What are some causes of hyponasality?

Answer 13

Caused by obstruction in nasopharynx/nasal cavity
- Adenoid hypertrophy
- Swelling of nasal passages 2º to allergic rhinitis
- Common cold
- Deviated septum
- Choanal atresia (= congenital blockage of opening into nasopharynx from nasal fossa)
- Stenotic naris
- Midface deficiency
Can also be caused by apraxia → inconsistent, abnormal VP closure on nasal phonemes

Question 14

What are some causes of mixed resonance?

Answer 14

Combo of VPI and any form of nasopharyngeal obstruction
Can also be caused by apraxia → motor sequencing problems can affect timing of upward/downward movement of velum, resulting in inappropriate closure/opening of velum

Question 15

What are some causes of cul-de-sac resonance?

Answer 15

Oral: microstomia
Nasal: combo of VPI + blockage at anterior of nose
- Most commonly found in individuals with history of cleft palate with VPI, and stenotic nares or deviated septum
Pharyngeal: caused by large tonsils that block sound from entering oral cavity during speech

Question 16

What are compensatory articulation errors?

Answer 16

Incorrect articulation placement in response to abnormal structure
Glottal stops, pharyngeal plosives, pharyngeal fricatives, pharyngeal affricates, posterior nasal fricatives as substitutions for oral pressure sounds
These compensatory productions can often be coarticulated with correct oral sounds

Question 17

What are obligatory articulation errors?

Answer 17

Characterized by abnormal acoustic production due to structural abnormality, despite normal articulatory placement
Some oral phonemes will sound like their nasal cognates (b → m, d → n, g → ng)
Hypernasality +nasal air emission with normal articulation
Because obligatory articulation is caused by abnormal structure and not abnormal function, they cannot be correct with speech therapy

Question 18

Whare are some factors associated with abnormal resonance?

Answer 18

Articulation issues
Voice - Dysphonia: common in CLP and results in breathiness, hoarseness, low voice intensity
- Laryngeal hyper function retesting in MTD
Language: Delayed expressive and receptive language/ decreased MLU
Phonology - slower sound acquisition and restricted sound inventory

Question 19

What are some psychosocial impacts of CLP?

Answer 19

Psychosocial issues stemming from realization of one’s facial differences and the reactions/ judgements of others. These issues include:
- Poorer self-concept
- Lower self-confidence
- Feelings of depression and anxiety
- Difficulties in initiating and maintaining friendships
False stereotypes and misconceptions may lead to lower expectations in the classroom → for example, teachers may assume that child has lower IQ and consequently may lower student’s learning standards
Vulnerability to teasing/ bullying and discimination on basis of appearance

Question 20

What are the speech symptoms of a cleft palate?

Answer 20

Hypernasality
Audible or turbulent nasal air emission on high pressure sounds
Weak pressure on sounds, nasal substitutions, and compensatory articulation errors
Voice: Dysphonia, VF nodules, laryngeal hyperfunction leading to MTD

Question 21

What speech issues might you see in a baby with a cleft palate?

Answer 21

Vocalize as frequently as typical babies but may have delayed onset of canonical babbling and less variety
More restricted consonant inventory when babbling
Demonstrate fewer total consonant prod’ns (eg., fewer oral stops and more glottal stops)
Preference for nasal glides + glottal fricative /h/
Delayed onset of 1st word and acquire words more slowly
Demonstrate preference for words beginning with sonorants (nasals, liquids, glides, vowels)

Question 22

What speech issues might you see in older children with CLP?

Answer 22

Articulation may be characterized by restricted consonant inventory, sound substitutions/omissions, and compensatory articulation errors
Expressive language development can be delayed but often catches up with age
Child with syndromes may experience more severe language disorders than children without syndrome due to developmental delays associated with syndrome

Question 23

What are some impacts resonance disorders can have on education?

Answer 23

Some studies suggest that individuals born with CLP are less likely to attain the same educational achievements
Others found few differences in educational achievement
In a study with 52 participants, most participants believed that having a cleft did not make a difference in their educational experience, that it did not hold them back
Some reported that they had to work harder in school but were able to work through with support from tutor

Question 24

What are some impacts resonance disorders can have on employment?

Answer 24

Presence of CLP did not influence the selection of employment/influence ability to find a job
Having CLP did not negatively affect their vocational achievement
Consider client on an individual basis

Question 25

What impact does a resonance disorder have on respiration?

Answer 25

Children with CLP are at risk for upper airway obstruction
Children born with Pierre Robin sequence, including micrognathia and glossoptosis tend to have very small oropharynx, which primarily affects respiration but also resonance
Unilateral CLP often have deviated septum (= reduction in airflow)
For older children + adults, size of nasal cavity and depth of pharynx may be affected by maxillary retrusion

Question 26

What impact does a resonance disorder have on laryngeal function?

Answer 26

Breathiness or hoarseness may indicate the presence of vocal nodules that are commonly found in patients with mild VPI
In an attempt to compensate for effects of VPI, these children may demonstrate laryngeal hyperfusion
In addition, compensatory valving activities and use of glottal stops may also contribute to development of nodules

Question 27

What are some aerodynamic measures that can be done to look for resonance issues?

Answer 27

To measure airflow, air pressure, and air volume.
Prolongation of single vowels
Repetition of syllables with pressure-sensitive phonemes, and high and low vowels (papapapa; pipipipi; sasasasa; sisisisi;
etc.)
Prolongation of /s/
Sentences that are loaded with pressure-sensitive phonemes (Sissy sees the sun in the sky. She went shopping. I eat
cherries and cheese.)
Counting from 60–70
Repetition of nasal consonants (mamamama; nananana)
Prolongation of /m/

Question 28

What are some acoustic measures used to assess resonance?

Answer 28

Resonance Rating Scale
● Use of 5 subjective qualifiers to measure hyper/hyponasality of
different speech tasks
● “Absent”, “slight”, “mild”, “moderate”, “severe”
Nasal Air Emissions Rating Scale
● Assesses type of NAE and consistency using 3 qualifiers of different speech tasks
● “Normal”, “turbulent”, “audible

Question 29

Name some instrumental measures of velopharyngeal adequacy.

Answer 29

Multiview videofluoroscopy
Nasometry
Nasoendoscopy

Question 30

Name some possible referrals for velopharyngeal concerns.

Answer 30

Geneticist: rule in/out genetic syndromes, support potential cause and prognosis
ENT
Audiologist: contribute to velopharyngeal mislearning
Orthodontist
Prosthodontist
Surgical consultation
Pediatrician

Question 31

What consonants are most affected by hypernasality?

Answer 31

Perceived when there is excessive nasal resonance, typically on vowels, glides, liquids, and, in severe cases, voiced oral consonants (e.g., /b/, /d/, and /ɡ/).
High vowels (/u, i/) are most susceptible to effects of hypernasality and are often the first vowels in which the listener notices its presence.
Voiced pressure consonants may be perceived as their nasal cognates (e.g., /n/ for /d/ or /m/ for /b/).

Question 32

What consonants are most affected by hypo nasality?

Answer 32

Perceived when there is reduced nasal resonance on vowels, sonorants, and
nasal consonants.
In more severe cases, hyponasality co-occurs with denasalization of nasal
consonants (/m/, /n/, and /ŋ/), making them sound more oral in quality (e.g., /b/ for /m/, /d/ for /n/, and /ɡ/ for /ŋ/)

Question 33

What are some speech signs of mixed resonance?

Answer 33

Co-occurrence of hypernasality and/or hyponasality in the same speech signal.
Hypernasality and hyponasality can occur at different times during connected speech (e.g., with apraxia).
Hypernasality and hyponasality may co-occur when VPD and any form of
nasopharyngeal obstruction are present

Question 34

What are some signs and symptoms of nasal air emission?

Answer 34

Occurs on pressure-sensitive consonants:
○ Plosives (p, t, k, b, d, g)
○ Fricatives (f, v, s, z, sh, zh)
○ Affricates (ch, j)
May present as inaudible, audible, turbulent, and with nasal snort/rustle, facial/ nasal grimacing

Question 35

What are some options to treat resonance issues?

Answer 35

Surgery
Prosthesis
Speech therapy

Question 36

When can speech therapy be used for resonance issues?

Answer 36

To correct compensatory
articulation productions ONLY
if:
- they are mild
- inconsistent
- child is stimulable for
reduction/elimination
- characteristic due to faulty articulation
- associated with oral motor dysfunction or dysarthria
- occurs when child is tired
- velopharyngeal opening is
slight/inconsistent as
demonstrated by instrumental
assessment
- pharyngeal flap, sphincteroplasty, or pharyngeal augmentation has been done and and client needs therapy to improve structures

Question 37

Discuss the different possible service delivery models for resonance disorders.

Answer 37

Regular review assessments: monitor over time
Home program: for young children, parents are trained on specific strategies, good for long-waits and to support carryover
Individual therapy
Group therapy
Referral

Question 38

What are some therapy suggestions for hypernasality?

Answer 38

Discrimination training
Nasal oral contrasts: child raise and lower velum during production of [a]
Simulate denasality: pretend to have a cold then gradually decrease
Increase oral activity and volume: tends to open oral cavity and promote oral resonance
Tactile feedback: touch side of nose to feel vibrations during nasals
Tougue blade manipulation: raise velum mechanically
Yawn technique: forcibly lowers back of the tongue and raise velum, use in vowel sounds and anterior consonents

Question 39

What are some therapy suggestions for nasal air emissions?

Answer 39

Auditory feedback
Tactile feedback: repetitive production of pressure sensitive phonemes (no nasals)
Visual feedback: see-scape or piece of paper
Cul-de-sac technique: pinch nostrils during production of pressure sounds to eliminate nasal emission
Light, quick contacts: during pressure sensitive phonemes to help eliminate backup of air pressure in nasopharynx and reduce occurrence of nasal emission.

Question 40

What are some therapy suggestions for weak consonants?

Answer 40

Visual feedback during pressure sensitive phonemes: produce with enough pressure to move the paper
Tactile feedback: hand in front of mouth during plosives
Increase volume and oral activity

Question 41

What are some therapy techniques for targeting the use of glottal stops as a substitution for plosives?

Answer 41

Produce voiced and voiceless plosives slowly with as aspirate /h/ or whisper to eliminate glottal stops, modify voice onset time by delaying the voicing on the plosive or vowel falling a plosive.

Question 42

What are some therapy techniques for targeting the use of pharyngeal plosives as a substitution for plosives?

Answer 42

Work on placement of bilabial and lingual alveolar plosives first then on velar plosives beginning with a /ng/.

Question 43

What are some therapy techniques for targeting the use of pharyngeal fricatives as a substitution for sibilant sounds?

Answer 43

Have child produce sibilant sounds with the nares occluded then open to get the feel for oral rather than pharyngeal air flow.
Work on /s/ by having child produce a hard /t/ with the teeth closed, increase the duration until it becomes /ts/, then eliminate the /t/.
Work on /sh/ by having child do a big sigh with the teeth closed. Try to increase the force of the oral air pressure then shape the lip position
Work on the /ch/ sound by going from a /t/ with the teeth closed to trying a loud sneeze sound with the teeth closed. Once mastered, add the voiced component for the /j/ sound.

Question 44

What are some therapy techniques for targeting the use of a nasal /l/ or ng/l substitution?

Answer 44

Ask the child to produce a yawn to get the base of the tongue down and the velum up. Have the tongue tip go up to produce the /l/ and gradually extinguish the yawn.