Speech Therapy 
Hyponasality Resonance disorder
Hyponasality Resonance Disorder is a condition that most speech-language pathologists are likely to encounter with a client at some point in their career.
Resonance can be defined as the quality of the voice as determined by the balance of sound vibration within the nasal, oral, and pharyngeal cavities during speech production.
Resonance disorders, according to ASHA, result from too little or too much nasal and/or sound energy in the speech signal. Structural or functional factors can cause a resonance disorder. The three types of resonance disorders are: hypernasality, hyponasality, and cul-de-sac resonance.
Hyponasality occurs when not enough sound is resonating within the nasal cavity during speech production. This can make the voice sound as if the individual’s nose is stuffed up.
Hyponasal speech can profoundly impact an individual’s social interaction, academic performance, and overall well-being. SLPs can help individuals improve their resonance by having a thorough understanding of hyponasality and how to address the disorder in therapy.
Let’s explore hyponasality, including a thorough definition, assessment and treatment techniques, challenges, and more.
What is Hyponasality Resonance Disorder?
Resonance disorders such as hyponasality fall under a broader category of voice disorders. This includes difficulties with voice quality, resonance, loudness, and pitch.
Hyponasality resonance disorder occurs when there is reduced nasal energy upon production of certain speech sounds.
This resonance disorder typically occurs as a result of a blockage/obstruction in the nasopharynx or nasal cavity, or can be due to an associated neurological condition.
Characteristics of hyponasality include:
- Voice sounds “stopped up”
- May be due to a blockage or congestion in the nose/throat
- Reduced nasal resonance on production of vowels, sonorants, and nasal consonants
- Sonorants are nasal, liquid, and glide consonants ( /y ,w, l, r, m, n, ng/) that are marked by a continuing resonant sound and are produced with more acoustic energy than other consonants.
- Nasal consonants are /m/, /n/, and /ng/, which are made by lowering the velum to allow air to freely escape through the nose.
Assessment of Hyponasal Resonance Disorder
A comprehensive clinical evaluation of speech resonance is essential for identifying resonance disorders such as hyponasality.
The typical components of this assessment include:
Case history
Review the client’s medical history, including presence of a neurological condition, surgical history (ex: tonsillectomy or adenoidectomy).
Note the presence of any known or suspected genetic conditions. Review developmental history. Obtain details about the individual’s resonance problem, such as length of time experienced, and any fluctuations
Oral Mechanism Examination (OME)
Evaluate the structure and function of oral structures. Look for the presence of enlarged tonsils (which can cause hyponasality) Check for evidence of any past surgeries (such pharyngeal flap or scarring)
Perceptual Evaluation of speech
Assess the following: Resonance and airflow, classification of speech sound errors, and correlate perceptual speech data with findings from the OME.
An assessment of speech sound production should include examination of distortions due to nasal obstructions (for example, a denasalized production of the /m, n, ng/ sounds)
Resonance can be assessed through standard measures and perceptual rating methods (such as interval rating scales). The Universal Parameters for Reporting Speech Outcomes (known as the UPS) is cited as a measurement of resonance in several studies.
Use low-tech/no-tech procedures for assessing resonance. Feel the sides of the nose or place a mirror under the nose as the client produces nasal consonant sounds. A lack of vibration or air flow can indicate hyponasality.
SLPs can record errors and observations as the client produces select words and sentences. This includes utterances containing several nasal consonants, such as “Nina has a niece and nephew.”
Reviewing samples of abnormal resonance can help SLPs judge the severity of abnormal resonance such as hyponasality.
When diagnosing Hyponasality, SLPs should use the ICD-10 code R49.22. This is categorized under R49: Voice and resonance disorders.
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Differential diagnosis
It is crucial to differentiate hyponasal resonance from other resonance disorders, such as hypernasality, mixed resonance, and cul-de-sac resonance.
Hypernasality is the presence of excessive nasal airflow during speech production. This results in a nasal sounding voice.
Cul-de-sac resonance sounds muffled. Consonants do not sound distinct as a result of a blockage present at the exit of the oral, nasal, or pharyngeal cavity.
An individual may also have mixed resonance, which is when hypernasality, hyponasality, and/or cul-de-sac resonance are present in connected speech.
It’s important to note that hyponasal resonance can be caused by non-organic factors in some cases. This includes nasal obstructions due to allergies, or the presence of a deviated septum. Considering this can help SLPs complete an accurate assessment.
Treatment approaches for Hyponasal Resonance Disorder
Speech therapy plays an important role in treating hyponasal resonance. A behavioral modification approach of allowing the client to see, hear, and feel nasal versus oral airflow can be used.
Resonance-focused therapy to modify nasal airflow: Techniques such as using a dental mirror under the nose to provide visual feedback during production of target phonemes, or by using a See-Scape can help individuals differentiate oral versus nasal airflow.
Surgical intervention: In some cases, surgical management may be needed to correct an anatomical source of obstruction. This can include tonsillectomy/adenoidectomy, surgery to correct a deviated septum, removal of nasal polyps, and other procedures.
Individualized treatment plans for Hyponasal Resonance Disorder
Each individual with hyponasal resonance requires a tailored treatment plan. This should be based on the client’s specific needs, causes of the hyponasality, and goals. SLPs should work closely with the client and their family to develop this individualized treatment plan to improve the client’s resonance.
Progress monitoring and documentation
Progress monitoring can be completed through certain objective measures of nasality. Nasometry testing can be obtained to measure nasalance initially and at regular intervals. Comparing and documenting the results can help SLPs view the child’s progress and the effectiveness of Speech Therapy techniques.
Challenges in treating Hyponasal Resonance Disorder
Treating hyponasal resonance in speech therapy can pose several challenges that therapists should keep in mind.
First, accurately diagnosing the underlying cause of the resonance disorder can be difficult. Multiple factors can cause hyponasality, including structural abnormalities, neurological disorders, or functional difficulties.
Objectively measuring nasality can pose a challenge, as well as tailoring an effective treatment plan. SLPs should be sure to have a comprehensive understanding of the client’s individual medical history, speech characteristics, and goals.
Hyponasality is a resonance disorder that occurs when not enough sound is resonating within the nasal cavity during speech production. It can make the voice sound as if the individual’s nose is stuffed up, and can have implications on his or her social interaction and overall quality of life.
Speech therapists play a critical role in addressing hyponasal resonance. By employing a comprehensive and individualized approach in the assessment and treatment of hyponasal speech, SLPs can effectively help individuals improve their resonance.
Resources
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References
American Speech Language Association in Comprehensive Assessment for Resonance Disorders: Typical Components https://www.asha.org/Practice-Portal/Clinical-Topics/Resonance-Disorders/Comprehensive-Assessment-for-Resonance-Disorders
Brewer, Chung Hwa and Aparo, Miwa in Resonance Disorders: Adult Speech Therapy for Hypernasality and more, April 25, 2022. https://theadultspeechtherapyworkbook.com/speech-therapy-for-hypernasality
Kuehn DP, Imrey PB, Tomes L, Jones DL, O’Gara MM, Seaver EJ, Smith BE, Van Demark DR, Wachtel JM. Efficacy of continuous positive airway pressure for treatment of hypernasality. Cleft Palate Craniofac J 2002;39:267-276. https://acpacares.org/speech-samples
Kummer, Amy in AHSA wire Resonance Disorders and Nasal Emissions: Evaluation and Treatment using “Low Tech” and “No Tech” Procedures https://leader.pubs.asha.org/doi/10.1044/leader.FTR1.11022006.4
Rangwani, S., Baylis, A., Khansa, Pearson, G. Outcomes in Velopharyngeal Dysfunction Treatment: Comparing Two Approaches for Pharyngeal Flaps. Journal of Craniofacial Surgery 31(8):p 2167-2170, November/December 2020. DOI: https://journals.lww.com/jcraniofacialsurgery/Fulltext/2020/12000/Outcomes_in_Velopharyngeal_Dysfunction_Treatment_.15.aspx