Short Course 32: Part 3:Treatment of Resonance

Disorder

Lynn Marty Grames, MA, CCC-SLPSt. Louis Childrens Hospital

Cleft Palate and Craniofacial Institute

Video Examples of Resonance Disorder

Video Examples of Resonance Disorder

Video Examples of Resonance Disorder

Video Examples of Resonance Disorder

Video Examples of Resonance Disorder

Objectives

Identify the type of resonance disorderIdentify possible causes of resonance

disorderDescribe which types can be treated with

therapy, and which with medical/surgical/dental management

Identify articulations that enhance or mimic resonance disorder

What is resonance? Phonetics . a. amplification of the range of

audibility of any source of speech sounds, especially of phonation, by various couplings of the cavities of the mouth, nose, sinuses, larynx, pharynx, and upper thorax, and, to some extent, by the skeletal structure of the head and upper chest.

b. the distribution of amplitudes among interrelated cavities in the head, chest, and throat that are characteristic for a particular speech sound and relatively independent of variations in pitch.

The Resonance Subsystem

What is a resonance disorder?

Difference in the amplified phonation caused by structural anomaly or by inefficient or ineffective use of the structures of the

supraglottal airway

Resonance Disorder

Hyponasality Hypernasality Mixed hyper/hyponasality Cul-de-sac resonance Decreased oral resonance

Potato in the mouth?!?

Hyponasality

Insufficient sound amplification through the nasal cavities

Consonants affected will include [m,n,] May sound like [b,d,g] May not be affected to the same degree

Mouth breathing and nasal congestion may be present.

Hyponasal resonance

How to test for hyponasality?

Nasal consonant loads

Words: Mom Money Hammer Noon Nine Banana Hanger Hamper

Phrases: Mama made

lemonade No more money My mom made jam Jane came in The phone rang again Banana nut muffin The singer sang a

song

Also evaluate:

Nasal airway patencyLips closed: breathe in, breathe out

Look for mouth breathing at rest Intraoral Exam

Is the adenoid visible on phonation? Stimulability for nasal consonants

Nasal Airwayis not Patent: Can the child

clear it?

Yes.Retest.

No.Consider cause,

Refer.

Somewhat.Consider causes,

Refer.

Resonanceimproves: may

have cold or allergies

Resonance does not improve, test for stimulability

If the nasal airway is patent, the hyponasality may be functional

Teach nasal consonants!

Other questions to ask:

Is breathing noisy some or all of the time? Does the child snore at night? Do parents notice gasping, sweating,

restlessness during sleep? Is the child frequently sleepy or

hyperactive? Does the child have difficulty concentrating

at school?

Nasal Airway Obstruction

Causes: Enlarged adenoid Allergies Colds Nasal septal deformity Turbinate hypertrophy Cleft nasal deformity Choanal stenosis Obstructive velopharyngeal surgery

Associated issues: Snoring Obstructive sleep

apnea Lip closure for feeding

Nasal airway obstruction requires medical referral

Pediatrician, ENT,Allergist, or Cleft Palate Team

Always have parents sign a release allowing you to

communicate with the care provider

Contact provider with your findings and questions. Stay in

touch!

Hypernasality

Results from excessive or inappropriate airflow into the nose

during speech.

Manifestations of Excessive or Inappropriate nasal airflow

Hypernasal resonance (vowels) Weakened oral pressure consonants Reduced plosion and stridency Nasal emission Nasal turbulence Nasal grimacing

Hypernasality with nasal emission and grimacing

Manifestations of Nasal Fricative/Stop Production

Hypernasal resonance Weakened oral pressure consonants Reduced plosion and stridency Nasal emission Nasal turbulence Nasal grimacing

Hypernasality, nasal turbulence, nasal stops and fricatives

How do we tell the difference?

Careful evaluation!Resonance vs. Articulation Quick

CheckEmail lynnmg@bjc.org

Phrases with oral consonant loads

Pop a bubble Buy a puppy Purple paper Pack your backpack Daddy did it I did it too Its too tight Go get it Cookie and cake

Sissy saw it Zippers are easy Shoes and socks You should wash Check your watch Jump for joy Four or five Four fire fighters There they are

What if you find.

Improved plosion Improved resonance Cul-de-sac resonance Improved stridency Child sounds better! This child needs a

complete velopharyngeal evaluation.

What if you find.

Stops and plosives sound good

Some or all fricatives are stops, or a posterior click

Child seems like he is blowing his brains out on some fricatives

This child has an articulation disorder that you will need to treat.

Video Examples of Resonance Disorder

What if you find

Not much improves Plosives sound off (or

odd) Fricatives sound off

(or odd) Resonance doesnt

really change much with the nose plugged

This child may have VPD, but may need some articulation therapy first in order to prepare for a valid exam.

Pharyngeal stops

Voiced [ ]Voiceless [ ]

Pharyngeal Fricatives

Voiced [ ]Voiceless [ ]

Pay careful attention to what you learn about articulation

from the exam.

Remember that velopharyngeal dysfunction

affects resonance..

If an articulation does not change with the nose plugged, changing VP function will not change the

articulation.

Whether or not true hypernasality is present.

If stop/plosive consonants are not articulated correctly, teach the correct articulation.

If fricatives or affricates are not articulated correctly, teach the appropriate articulation.

Specific Tx Techniques are needed

Use a motor learning approach

Do not use oral motor exercises

Do not worry about sensory stim

Use speech to teach speech

You may need to plug the nose!

Peterson-Falzone, Trost-Cardamone, Karnell and Hardin-Jones:

A Clinicians Guide to Treating Cleft Palate Speech

If the velopharynx is truly dysfunctional, can I still treat

any articulation errors I discover?

Yes! And you should!

Video Examples of Resonance Disorder

What do I do if the velopharynx is dysfunctional?

Refer to a cleft palate center that performs velopharyngeal diagnostic exams

In most cases a referral to a community ENT physician is not helpful.

Most importantly

Have parents sign a release for you to communicate with the treating medical team.

Send a report with your concerns and test results.

Stay in touch! Dont be afraid to ask questions!

What will be done?

Full diagnostic exam Perceptual speech exam Medical history

Various imaging or instrumental assessments: Velopharyngeal endoscopy Speech Videofluoroscopy Nasometry Pressure-flow studies

Physical management

Furlow Double-opposing z-plasty

Physical management

Sphincter pharyngoplasty

Physical Management

Pharyngeal Flap

Intermittent or neurologically based hypernasality

Video Examples of Resonance Disorder

Intermittent or neurologically based hypernasality

Evaluate influence of rate and respiratory drive on speech resonance

If concerns are identified, try to treat those concerns

Evaluate results, and consider referral for diagnostic studies if needed.

ALWAYS refer if the symptoms are new!

Treatment options?

Some centers may choose a trial with a prosthesis. Reversible Costly (time and $) Insurance may not

cover Motor relearning

phase may be problematic

Is this necessary?

The child who becomes hypernasal after adenotonsil

surgery

Be patientmany centers wait 6 weeks to 6 months to evaluate

Should I buy some special equipment?

See-scape?Nasometer?

Flexible tubing?

Cultivate a relationship with a cleft palate team SLP

Dont be afraid to ask questions.Collaboration can be the best

technique with hard-to-treat kids.

Questions?

Thank you for attending our short course. Please be sure to

complete your online evaluation forms for your CEUs.

Short Course 32: Part 3:Treatment of Resonance DisorderVideo Examples of Resonance DisorderVideo Examples of Resonance DisorderVideo Examples of Resonance DisorderVideo Examples of Resonance DisorderVideo Examples of Resonance DisorderObjectivesWhat is resonance?The Resonance SubsystemWhat is a resonance disorder?Resonance Disorder HyponasalityHyponasal resonanceHow to test for hyponasality? Nasal consonant loadsAlso evaluate:Slide Number 17If the nasal airway is patent, the hyponasality may be functionalOther questions to ask:Nasal Airway ObstructionNasal airway obstruction requires medical referralAlways have parents sign a release allowing you to communicate with the care providerHypernasalityManifestations of Excessive or Inappropriate nasal airflowHypernasality with nasal emission and grimacingPosterior Nasal Fricative [ ]Manifestations of Nasal Fricative/Stop ProductionHypernasality, nasal turbulence, nasal stops and fricativesHow do we tell the difference? Phrases with oral consonant loadsWhat if you find.What if you find.Video Examples of Resonance DisorderWhat if you findThe Glottal Stop [ ]Pharyngeal stops and fricativesPharyngeal Stops and FricativesPay careful attention to what you learn about articulation from the exam.Remember that velopharyngeal dysfunction affects resonance..Whether or not true hypernasality is present.Specific Tx Techniques are neededIf the velopharynx is truly dysfunctional, can I still treat any articulation errors I discover? Video Examples of Resonance DisorderWhat do I do if the velopharynx is dysfunctional?Most importantlyWhat will be done? Physical managementPhysical managementPhysical ManagementIntermittent or neurologically based hypernasalityVideo Examples of Resonance DisorderIntermittent or neurologically based hypernasalityTreatment options?Is this necessary?The child who becomes hypernasal after adenotonsil surgeryShould I buy some special equipment? Cultivate a relationship with a cleft palate team SLPQuestions?