Hypernasality is a speech disorder characterized by excessive nasal resonance due to abnormal airflow through the nasal cavity during phonation. It often accompanies dysarthria, velopharyngeal insufficiency, or structural abnormalities of the palate and nasopharynx. Hypernasality may also signal neuromuscular disorders affecting the soft palate.

Pathophysiology

• Velopharyngeal dysfunction:

  • Inadequate closure of the soft palate against the posterior pharyngeal wall allows air to escape through the nose during speech.

• Structural abnormalities:

  • Cleft palate, short or malformed soft palate, or post-surgical defects impair proper airflow modulation.

• Neuromuscular causes:

  • Weakness or paralysis of palatal muscles (e.g., due to stroke, myasthenia gravis, or cranial nerve lesions) leads to intermittent or sustained hypernasality.

Examination Technique

1. Patient positioning: Seated comfortably in a quiet environment.

2. Instruction: Explain that you will listen to speech with the nose open and then gently occluded.

3. Vowel testing: Ask the patient to produce sustained vowel sounds (e.g., /a/, /i/, /u/).

4. Nostril occlusion test: Pinch the nostrils and have the patient repeat the vowels.

5. Observation: Compare tone, resonance, and clarity between open and closed nostrils.

6. Documentation: Record the presence, severity, and consistency of hypernasality.

Clinical Features

Differential Diagnosis

Pediatric considerations

• Common in children with cleft palate or craniofacial anomalies.

• Early speech therapy is essential to prevent compensatory articulation errors.

Geriatric considerations

• May indicate neuromuscular weakness or post-stroke complications.

• Assess for swallowing difficulties and risk of aspiration.

Limitations

• Patient cooperation and clear phonation are required.

• Subtle hypernasality may need instrumental evaluation (nasometry or nasopharyngoscopy).

Patient counseling

• Explain that hypernasality reflects altered airflow, not a permanent “voice defect.”

• Discuss potential interventions: speech therapy, surgical correction, or management of underlying neuromuscular disease.

• Advise monitoring for associated swallowing or speech difficulties.

Conclusion

Hypernasality is a nasalized voice quality due to structural or neuromuscular dysfunction of the velopharyngeal mechanism. Proper assessment helps identify the underlying cause, guide therapy, and prevent complications in speech and swallowing.

References

1. Kummer AW. Cleft Palate and Craniofacial Anomalies: Effects on Speech and Resonance. 3rd ed. Clifton Park, NY: Delmar Cengage Learning; 2014.

2. Duffy JR. Motor Speech Disorders: Substrates, Differential Diagnosis, and Management. 4th ed. St. Louis, MO: Elsevier; 2013.

3. Sell D, et al. Hypernasality and velopharyngeal dysfunction. Curr Opin Otolaryngol Head Neck Surg. 2009;17(6):497–502.

4. National Institute on Deafness and Other Communication Disorders (NIDCD). Voice, Speech, and Language Disorders. 2021.