A Simple Technique for Determining

Velopharyngeal Status during Speech

Production
Kate Bunton, Ph.D., CCC-SLP,1 Jeannette D. Hoit, Ph.D., CCC-SLP,1
and Keegan Gallagher1

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ABSTRACT

Clinical evaluation of velopharyngeal function relies heavily on

auditory perceptual judgments that can be supported by instrumental
examination of the velopharyngeal valve. Many of the current instru-
mental techniques are difficult to interpret, expensive, and/or unavail-
able to clinicians. Proposed in this report is a minimally invasive and
inexpensive approach to evaluating velopharyngeal function that has
been used successfully in our laboratory for several potentially difficult-
to-test clients. The technique is an aeromechanical approach that
involves the sensing of nasal ram pressure (N-RamP), a local pressure
sensed at the anterior nares, using a two-pronged nasal cannula. By
monitoring the N-RamP signal, it is possible to determine the status of
the velopharyngeal port (open or closed) during speech production.
Four case examples are presented to support its clinical value.

KEYWORDS: Velopharynx, evaluation

Objectives: As a result of this activity, the reader will be able to (1) identify techniques used to assess
velopharyngeal function, and (2) discuss the advantages of the N-RamP technique as it applies to clinical
populations.

V elopharyngeal closure is critical for pro- uals with dysarthria, have impairments in
duction of vowels and oral consonants and thus velopharyngeal function that contribute to
has a profound impact on speech intelligibility. problems with speech production. Clinical eval-
Several clinical populations, for example, chil- uation of velopharyngeal function often relies
dren with a history of a cleft palate or individ- heavily on the clinician’s auditory perceptual

1
Department of Speech, Language, and Hearing Sciences, Hoit, Ph.D., CCC-SLP.
University of Arizona, Tucson, Arizona. Semin Speech Lang 2011;32:69–80. Copyright #
Address for correspondence and reprint requests: Kate 2011 by Thieme Medical Publishers, Inc., 333 Seventh
Bunton, Ph.D., 1131 E. 2nd Street, P.O. Box 210071, Avenue, New York, NY 10001, USA. Tel: +1(212) 584-
Tucson, AZ 85721-0071 (e-mail: [email protected]). 4662.
Bridges between Speech Science and the Clinic: A DOI: http://dx.doi.org/10.1055/s-0031-1271976.
Tribute to Thomas J. Hixon; Guest Editor, Jeannette D. ISSN 0734-0478.
69
70 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 32, NUMBER 1 2011

judgment. For example, a clinician might judge nasometry. Nasometry requires the use of two
a client’s speech to be hypernasal or hyponasal microphones, one positioned in front of the lips
and assign a severity rating to it (e.g., mildly and one positioned in front of the anterior
hypernasal). However, auditory perceptual nares. A cumbersome, horizontally oriented
judgments are known to be unreliable1 and are plate is positioned between the microphones
not necessarily well correlated to velopharyngeal to isolate the sound energy from the two
status.2–4 Therefore, auditory perceptual judg- sources. Nasometry allows for the calculation
ments of velopharyngeal function are often of nasalance, which is the quotient of nasal
supplemented with instrumental evaluation. In- sound pressure level to nasal þ oral sound pres-
strumental approaches to understanding velo- sure level. Although nasalance values have been
pharyngeal function have proven to have both found to be strongly associated with perceptual
clinical and research value. Unfortunately, some judgments of nasality (at least when specified
of these are intrusive, difficult to interpret, cutoff scores are used), they have been found to

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expensive, and/or unavailable to clinicians. Pro- be weakly correlated with estimated velophar-
posed in this report is a simple, minimally yngeal orifice area.5 The weak correlation be-
invasive, and inexpensive approach to evaluating tween nasalance values and velopharyngeal
velopharyngeal function that has been success- orifice size is likely due, at least in part, to the
fully used for several potentially difficult-to-test effects of variables such as turbulent nasal air
clients. flow and degree of mouth opening on nasal-
ance.5,6
Visual imaging is another common ap-
INSTRUMENTAL APPROACHES TO proach to evaluating velopharyngeal function
EVALUATING VELOPHARYNGEAL in clinical practice. One type of imaging is
FUNCTION DURING SPEECH videonasendoscopy, which involves passing a
PRODUCTION flexible endoscope posteriorly through the nasal
There are many instrumental approaches to pathways and viewing the velopharynx from
evaluating velopharyngeal function during above. Another type is videofluoroscopy, which
speech production. The focus here is on those involves the use of X-ray to view oral, nasal,
that are commonly used in clinical settings by pharyngeal, and laryngeal structures from both
speech-language pathologists and other clinical sagittal and coronal perspectives (though not
professionals and include selected acoustical, simultaneously). These two imaging techni-
visual imaging, and aeromechanical ap- ques permit direct observation of the velum
proaches. and pharyngeal walls as they move in relation to
An acoustical approach to velopharyngeal one another during speaking and swallowing.
evaluation is attractive because the data are A major motivation for using a visual imaging
generally easy to record, requiring only a micro- approach is to examine contributions of the
phone and a recording device. Analysis of the velum and lateral and posterior pharyngeal
speech signal often involves spectrographic walls to velopharyngeal closure, information
analysis with an emphasis on selected acoustic that is often critical in planning medical man-
features: for example, formant bandwidth (cou- agement, including surgical and prosthetic in-
pling of the velopharyngeal-nasal pathway to terventions. Visual imaging can be expensive
the oral pathway is associated with wider and invasive and poses safety risks and is,
bandwidths) and formant frequencies (coupling therefore, applied selectively.
of the velopharyngeal-nasal pathway to the oral Aeromechanical approaches are also used
pathway usually introduces a low-frequency frequently to evaluate velopharyngeal function
‘‘nasal formant’’ into the spectrum). Neverthe- during speech production. Perhaps the most
less, this type of analysis can be difficult to carry powerful aeromechanical method involves ob-
out and interpret without substantial experi- taining simultaneous measures of nasal airflow,
ence and expertise. oral air pressure, and nasal air pressure. By
Another more widely used acoustical tech- entering these measures into an equation de-
nique for evaluating velopharyngeal function is veloped by Warren and DuBois,7 it is possible
 VELOPHARYNGEAL STATUS DURING SPEECH PRODUCTION/BUNTON ET AL 71

to estimate the size of the velopharyngeal port ment during sound production in infants. By
during running speech production. Knowing the 1990s, Thomas Hixon and Jeannette Hoit,
the size of the velopharyngeal port allows the along with their coworkers, had conducted in-
clinician to determine if medical management vestigations of velopharyngeal function in
is necessary or if behavioral management alone healthy children as young as 3 years of age9
may be appropriate. and in healthy adults as old as 97 years.6 For
Perhaps the simplest aeromechanical tech- these earlier investigations, they had used the
nique currently in use involves the sensing of nasal airflow technique (described above) to
nasal airflow. A small mask is attached to a determine if the velopharynx was open or closed
pneumotachometer and placed over the outer during speech production. However, when they
nose. The pneumotachometer is connected to a attempted to place a mask over an infant’s nose,
sensitive differential pressure transducer, and the infant moved his head and arms, tried to
the signal is calibrated so that mass airflow push the mask away, and cried most of the time.

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exiting the nose can be measured. Nasal airflow Hixon and Hoit explored other means of de-
is relatively well correlated to velopharyngeal tecting nasal airflow in infants, including ther-
port size, but only at small sizes8; the correla- mal imaging and nasal thermistors, but these
tion decreases as velopharyngeal size increases. presented their own challenges. Finally, they
Nevertheless, nasal airflow provides an excel- tested a technique involving the use of nasal ram
lent means of determining if the velopharynx is pressure (N-RamP) and found it to be success-
open or closed during speech production. For ful with infants.
example, if nasal airflow is detected during oral The N-RamP technique requires the use
sound production, it can be inferred that the of a two-pronged nasal cannula, such as that
speaker has a velopharyngeal leak. shown in Fig. 1. This is the same type of nasal
cannula that is used to deliver oxygen to sick
infants. The two probes that insert into the
THE NASAL RAM PRESSURE anterior nares are sometimes cut short so that
TECHNIQUE the distal ends do not touch the nasal mem-
The motivation for creating a less cumbersome branes. To detect pressure change, the other end
aeromechanical technique came from an inter- of the nasal cannula is connected to a sensitive
est in documenting velopharyngeal develop- differential pressure transducer (with a
2 cm

Figure 1 A nasal cannula.

72 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 32, NUMBER 1 2011

H2O diaphragm, such as is often used to detect was open or closed. Specifically, the signal
airflow during speech production). As shown in could be interpreted as follows: (1) negative
Fig. 2, the probes of the cannula are inserted into pressure ¼ inspiration through the nasal air-
the anterior nares and the tubing is taped to the way, (2) positive pressure ¼ expiration through
cheeks. In addition, a small microphone is taped the nasal airway, and (3) pressure at zero
to the forehead. The resultant air pressure signal (atmospheric) ¼ no airflow (breath holding)
and acoustic signal are each amplified, displayed or a closed velopharynx during inspiration or
on an oscilloscope for online monitoring, and expiration. Thus, during vocalization (which
recorded on a multichannel digital recorder for almost always occurs during expiration), pos-
later analysis. The infant is also videotaped at itive pressure indicates an open velopharynx
close range (with the audio signal from the and pressure at zero indicates a closed velo-
microphone routed into the video camera). pharynx. It is also important to determine if the
The purpose of the video is to have a record of mouth is open or closed. If the mouth is closed,

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mouth status and body movements (discussed nasal pressure is necessarily positive during
later), as well as documentation of the commu- vocalization (except in the case of instantane-
nication situation. ous mouth closure for /p/ and /b/). Thus, the
In this context, the nasal air pressure signal vocalizations that are of greatest interest are
reflects a ram pressure; that is, the local average those produced with the mouth open.
pressure in the probe tube. This is akin to the One of the major advantages of the N-
ram pressure that is used to measure aircraft RamP technique over nasal airflow is that most
speed. This local pressure is directly related to head or body movements do not affect the N-
the local airflow within the tube, but it is not RamP signal. This is because the sensing probes
necessarily related to the mass airflow from the are free to move within the nasal vestibules and
nose (because air escapes around the probe are not sealed airtight into the anterior nares.
tubes). For this reason, Hixon and Hoit de- Thus, they are part of an open system and are
cided that it was not useful to attempt to not sensitive to the types of artifacts that often
calibrate the pressure signal, as it would not prevail in closed aeromechanical systems (such
provide meaningful information. What it did as a nasal mask coupled to the face). The only
provide, however, was critical information that major exception that we have encountered is
could be used to determine if the velopharynx when a child bounces vertically in his chair or
when a baby is bounced on a parent’s knee.
Despite its relative immunity to movement
artifacts, the N-RamP signal is very sensitive
to local pressure changes that are associated
with velopharyngeal opening and closing.a
The N-RamP technique was first applied
to the study of velopharyngeal function during
vocalization in a longitudinal study of six infants
(from age 2 to 6 months) conducted by Thom
and colleagues.10 All six infants tolerated the
nasal cannula and the vast majority of vocal-
izations recorded from them were nondistress
(i.e., ‘‘happy’’) vocalizations. The results of this
study indicated that the frequency of velophar-
yngeal closure generally increases with age, but
that consistent closure for oral sound produc-
tion is not yet achieved by 6 months. These

Figure 2 An infant seated in a high chair with a a

The rainbow passage has been shown to contain a mixture of
microphone taped to her forehead and a nasal oral and nasal consonants equivalent to that found in conversa-
cannula in place. tional speech, and normative data are available.21
 VELOPHARYNGEAL STATUS DURING SPEECH PRODUCTION/BUNTON ET AL 73

findings challenged previously published acous- primarily vowel-like productions. He proceeded

tic and perceptual data that suggested that through the expected phases of babble, proto-
velopharyngeal closure occurs by 4 months words, and real words. At 20 months of age he
of age.11,12 had an expressive vocabulary of roughly 100
words, was producing two- to three-word utter-
ances spontaneously, and could imitate utter-
CASE EXAMPLES ances cued by the investigator. His utterances
We have had the opportunity to use the N- were analyzed by breath group (between inspi-
RamP technique to evaluate velopharyngeal rations) and were classified as being open
function in a variety of individuals. Here, we throughout the breath group, closed throughout
offer descriptions of four case examples that the breath group, or closed during part of the
illustrate the ease and value of the N-RamP breath group.
technique: a healthy infant, a school-aged child Fig. 3 shows the percentage of nondistress

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with a speech sound disorder, a teenager with mouth-open utterances that Z produced at
an orofacial syndrome, and an adult with each monthly visit wherein his velopharynx
amyotrophic lateral sclerosis. was either closed throughout (N-RamP ¼ 0)
or closed during part of the breath group (N-
RamP ¼ 0 for part and N-RamP ¼ positive for
Healthy Infant part). His nondistress utterances included rasp-
Z was a healthy male infant who was seen in our berries, syllable utterances (e.g., vowel produc-
laboratory once a month beginning at age tions of long or short duration, consonant-
6.5 months and continuing until age 19 months. vowel combinations produced in isolation or
Z was a typically developing infant, as deter- in multiples, and reduplicated and variegated
mined by data collected at each visit using the babbling), protowords, and words.
Brigance Diagnostic Inventory of Early Devel- Results show that Z obtained velophar-
opment (gross and fine motor subtests),13 the yngeal closure for nearly all vowel-like and
MacArthur Communicative Development In- babble utterances containing oral consonants
ventory,14 and the Vocal Development Check- at 8 months of age (91% were closed through-
list.15 During his first visit, Z was producing out or closed during part). This percentage

Figure 3 Longitudinal data for Z shown as percentage of breath groups containing nondistress
utterances produced with the velopharynx either closed throughout (closed) or closed during part (mixed).
74 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 32, NUMBER 1 2011

decreased at 9, 10, and 11 months of age (range possible to make certain qualitative observa-
50 to 75%) but was consistently over 85% for all tions. For example, we found that when B
subsequent months. During the period from 9 attempted to produce a high-pressure conso-
to 11 months, Z’s consonant inventory in- nant in the context of an upcoming nasal
creased from two to eight consonants being consonant, he often generated a large nasal
produced at least twice during a recording pressure pulse during the pressure consonant.
session. It is unclear if this increase relates to This is illustrated in Fig. 4 during the produc-
the lower percentage of utterances being pro- tion of /k/ (which he substituted for /g/) in
duced with the velopharynx closed. It is clear, ‘‘again.’’ The large positive pressure spike asso-
however, that the N-RamP technique can be ciated with the /k/ indicated that his velophar-
successfully applied to the study of velophar- ynx was open momentarily. Fig. 5 also shows a
yngeal development in very young children. large positive pressure spike during the produc-
tion of a fricative consonant that preceded a

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nasal consonant when producing the name
School-Aged Child with Speech Sound ‘‘Sean.’’ Apparently, B opened the velopharynx
Disorder inappropriately early in anticipation of the
B, a 6-year-old boy, was referred for an evalua- upcoming nasal consonant. It is important to
tion of his velopharyngeal function. According note that this pattern was not consistent; there
to his school speech-language pathologist, B were many instances in which B produced
was ‘‘struggling to produce certain high-pres- similar utterances with appropriate velophar-
sure consonants,’’ which generated a concern yngeal closure.
that he might have a velopharyngeal leak. He We concluded that B did exhibit a velo-
was diagnosed with a moderate-severe speech pharyngeal leak during what should have been
sound disorder, mild motor programming def- oral sound productions, but that the velophar-
icit, and severe tongue thrust. Upon oral ex- yngeal leak was inconsistent and not attribut-
amination, a slightly asymmetric elevation of able to a structural or peripheral neural
the uvula was noted. An audiometric screening impairment. The inappropriate velopharyngeal
indicated that his hearing sensitivity was within opening was concerning, although it appeared
normal limits (20 dB HL16), and a language to be inconsistent and had less impact on his
screening indicated that his receptive and ex- speech output than the pervasive tongue thrust.
pressive language were within normal limits A report of the findings was sent to his school
(Clinical Evaluation of Language Fundamen- speech-language pathologist so that treatment
tals 4th ed. [CELF-4] screening17). could be tailored to include strategies such as
Velopharyngeal function during speech biofeedback to address the unusual velophar-
production was evaluated using the N-RamP yngeal pattern.
technique. The speech tasks included imitation
of nonsense words imbedded in a carrier phrase
(e.g., ‘‘Say /isi/ again’’), imitation of high- Young Adult with Goldenhar Syndrome
pressure consonant-loaded sentences (e.g., S, a 21-year-old male with hemifacial micro-
‘‘The puppy was playing with a rope’’), picture somia (Goldenhar syndrome), referred him-
naming using the Iowa Pressure Articulation self to the University of Arizona Clinic for
Test (IPAT18), and conversational speech. Adult Communication Disorders for an eval-
The protocol was designed to determine uation 12 months after he had undergone a Le
the percentage of high-pressure consonants Fort I osteotomy. This is a surgical procedure
produced with a closed velopharynx. However, wherein the maxillary bone and hard palate are
due to his tongue thrust and speech sound separated from the skull and repositioned; the
disorder, many of the targeted high-pressure procedure is designed to move the maxillary
consonants were substituted with a /u/ or bone forward for better alignment with the
another off-target consonant. Because of this, mandible. S stated his primary complaint
it was not possible to calculate quantitative data as follows: ‘‘I have had VPI since the surgery.
as originally intended. Nevertheless, it was It was worse right after the surgery but it
 VELOPHARYNGEAL STATUS DURING SPEECH PRODUCTION/BUNTON ET AL 75

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Figure 4 Glottal waveform and nasal pressure (Pnas) signal for the target utterance ‘‘again’’ produced by
S. Note that the transcription in the figure is based on S’s actual production and that it does not match the
target ‘‘again.’’ A positive Pnas peak can be seen near the release for the stop consonant /k/.

improved after about 2 to 3 months. People A full clinical evaluation was completed
would ask me to repeat what I said. It has that included an oral mechanism examination,
continued to get better but I still don’t sound intelligibility testing, nasometry (Nasometer;
like I did before the surgery.’’ His parents gave Kay Elemetrics, Lincoln Park, NJ), an aero-
a similar account. mechanical assessment (PERCI-SARS;

Figure 5 Glottal waveform and nasal pressure (Pnas) signal for the target utterance ‘‘Sean’’ produced by
S. Note that the transcription in the figure is based on the S’ actual production and that it does not match
the target utterance. A positive Pnas peak can be seen during production of the fricative.
76 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 32, NUMBER 1 2011

Chapel Hill, NC), as well as data collection to closure on the majority (67 to 90%) of syllable
assess velopharyngeal status using the N-RamP utterances (consonant-vowel [CV], vowel-con-
technique described in this article. The speech sonant-vowel [VCV], and vowel-consonant
protocol consisted of three productions each of [VC]) in which the consonant was a stop. By
plosive consonants (p, b, t, d, k, g) and fricative contrast, he achieved closure on only a minority
consonants (s, z, ∫ , ) in syllable initial, final, of the syllable utterances (25 to 37% were closed
and medial positions combined with the vowels throughout, and 15 to 34% were closed during
/i/ and / /. In addition, sentence reading part) in which the consonant was a fricative.
(GOS.SP.ASS sentences19), passage reading To compare data from different instrumen-
(Rainbow Passage20), and conversational tal techniques used during the same session for
speech samples were recorded. S, a correlation was computed to determine
Table 1 shows the percentage of breath level of agreement for the N-RamP data (closed
groups produced with the velopharynx closed throughout only) and the nasometer data.

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throughout and closed during part. Note that Three correlations were computed. These in-
the reading passageb and conversational speech cluded the pooled syllable data (CV, VCV, VC)
samples contained a mixture of oral and nasal data (r =  .78), passage reading (r =  .84), and
consonants; therefore, the number of breath conversational speech sample (r =  .89). In all
groups that were closed during part were ex- cases, the correlation was negative because a
pected to be higher than if only breath groups high mean nasalance score (reflecting the fact
containing oral consonants were analyzed. This that there is considerable acoustic energy ema-
analysis approach was selected because it was nating from the nose) corresponded to a small
judged to be more directly comparable to the percentage of utterances produced with the
analysis approach typically used for nasometry velopharynx closed, and a low mean nasalance
data (for which mean nasalance values are corresponded to a high percentage of utterances
calculated across speech samples containing produced with the velopharynx closed.
both oral and nasal sounds). The N-RamP Although we do not expect a perfect correlation
data indicated that S achieved velopharyngeal because nasometry has been shown to be sus-
ceptible to variations in oral acoustic impe-
Table 1 Speech Tasks Produced by S and dance,21 our correlations suggest that there is
Percentage of Utterances Identified as Being a reasonable level of agreement between the two
Produced with the Velopharynx Closed
Throughout and Closed during Part of the
techniques. Direct comparison of the data from
Breath Group the PERCI-SARS was not completed because
Closed Closed
S had a severely deviated nasal septum and
Speech Throughout During results differed when the placement of the nasal
Task (%) Part (%) flow and nasal pressure transducers were
switched. In general, larger velopharyngeal
/b/ 84 0
port openings were found for utterances con-
/p/ 82 0
taining fricative consonants compared with
/d/ 88 0
those with stop consonants. This is consistent
/t/ 90 0
with both the nasometry and N-RamP findings.
/g/ 67 0
We concluded that S might benefit from a
/k/ 72 0
period of trial behavioral therapy, with an em-
/s/ 25 32
phasis on achieving velopharyngeal closure in
/z/ 31 15
fricative consonant contexts. We recommended
/∫ / 37 24
that the N-RamP signal be used for visual
Reading 76 14
biofeedback so that S could monitor his velo-
(Rainbow
pharyngeal closure on line.
Passage)
Conversational 72 17
b
speech (across The Rainbow passage has been shown to contain a mixture of
all consonants) oral and nasal consonants equivalent to that found in conversa-
tional speech and normative data are available.21
 VELOPHARYNGEAL STATUS DURING SPEECH PRODUCTION/BUNTON ET AL 77

Adult with Amyotrophic Lateral Table 2 Target Sounds Produced by C and

Sclerosis Percentage of Utterances Identified as Being
C, a 57-year-old male diagnosed with amyo- Produced with the Velopharynx Closed
Throughout and Closed during Part of the
trophic lateral sclerosis (ALS), came to the Breath Group
clinic for a speech evaluation to determine if
Closed Closed
he would be a candidate for augmentative and Target Throughout during
alternative communication. His speech was Sound (%) Part (%)
slow, effortful, and of abnormally low loudness.
/p/ 40 10
Velopharyngeal function was assessed using the
/b/ 0 0
N-RamP technique while he produced the
/t/ 20 0
nonword and sentence repetition tasks de-
/d/ 0 0
scribed in the previous two cases.
/k/ 16 33
Results indicated that he closed his velo-

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/g/ 0 0
pharynx during only 26% of his high-pressure
/v/ 0 0
consonant productions (11.1% were closed
/f/ 33 50
throughout the production; 14.8% were closed
/s/ 50 16
during part of the production). Table 2 con-
/z/ 0 20
tains the results for each of the target sounds
/ u/ 0 50
tested.
/ ð/ 0 0
Although our focus was on the status of
/ ∫/ 0 40
the velopharynx during high-pressure conso-
/ / 0 0
nant productions, the N-RamP waveforms
/ t ∫/ 0 25
provided us with other valuable information
/j/ 0 0
about velopharyngeal behavior. For example,
a
we noted several instances wherein N-RamP A signal-to-noise ratio (SNR) of the N-RamP signal was
determined by measuring the peak pressure (in arbitrary
was positive (indicating an open velopharynx) digital units) of three consecutive inspirations produced
during productions of vowels that surrounded by an adult and computing their mean value. Then, using
the same data acquisition settings, a sample was
the high-pressure consonants, one of which is recorded while the pressure tube was held in free space.
illustrated in Fig. 6. This figure contains two The mean of this recorded pressure (again in arbitrary
digital units) served as the noise floor signal. The SNR
consecutive productions of ‘‘Say /isi/ again’’ in was calculated as the mean peak pressure divided by the
which the velopharynx was closed during the mean noise pressure and then converted to a decibel
scale. The SNR for the system was found to be 71.4 dB.
/s/ segment in both; however, the second
production (on the right) shows that the velo-
pharynx was open during the /i/ that preceded The two graduate students identified the velo-
the /s/ and the /i/ that followed the /s/. This pharynx as closed when it was open on 54% and
velopharyngeal opening was not perceptible to 55.8% of the productions. The two speech-
the ear. language pathologists identified the velophar-
Although C produced the majority of the ynx as closed when it was open on 16% and
high-pressure consonants with his velophar- 28.4% of the productions. These findings sug-
ynx open, we noticed that several of these gest that the ear is not always a good judge of
productions sounded as if they had been pro- velopharyngeal status and that velopharyngeal
duced with the velopharynx closed. To inves- function may be impaired before it is detected
tigate this further, we conducted an informal in clients with ALS.
perceptual study with two speech-language
pathology graduate students and two certified
speech-language pathologists serving as lis- CONCLUSIONS
teners. The N-RamP technique has been used suc-
The listeners were presented with the cessfully in our laboratory to evaluate clients
speech samples (auditory only) and were asked with a variety of etiologies, as well as to track
to indicate ‘‘whether the velopharynx is open or velopharyngeal development in healthy in-
closed’’ during the target sound productions. fants and young children. We see N-RamP
78 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 32, NUMBER 1 2011

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Figure 6 Glottal waveform and nasal pressure (Pnas) signal for two repetitions of the target utterance
‘‘Say /isi/ again’’ produced by C. The first production (left) of the utterance indicates a closed velopharynx
during the ‘‘/isi/’’ (Pnas ¼ 0). During the second production of ‘‘/isi/’’ (right), Pnas is positive during the vowels
that precede and follow the consonant, indicating an open velopharynx.

as a powerful clinical tool for several reasons: 2. Mayo R, Dalston RM, Warren DW. Perceptual
(1) it is minimally invasive and comfortable assessment of resonance distortion in unoperated
and does not interfere with speech production; clefts of the secondary palate. Cleft Palate
Craniofac J 1993;30(4):397–400
(2) it is inexpensive and accessible and does
3. Warren DW, Dalston RM, Mayo R. Hyper-
not require much training or experience to use; nasality and velopharyngeal impairment. Cleft
(3) its data collection and interpretation/ Palate Craniofac J 1994;31(4):257–262
measurement procedures are relatively quick; 4. Watterson T, Emanuel F. Observed effects of
(4) it can be used with clients of any age with velopharyngeal orifice size on vowel identification
neural, structural, or functional disorders; (5) and vowel nasality. Cleft Palate J 1981;18(4):271–
it reveals information about velopharyngeal 278
5. Dalston RM, Warren DW, Dalston ET. Use of
function that is not easily detected in the
nasometry as a diagnostic tool for identifying
acoustic signal; and (6) it has potential as a patients with velopharyngeal impairment. Cleft
biofeedback tool for behavioral management Palate Craniofac J 1991;28(2):184–188; discussion
of velopharyngeal dysfunction. 188–189
6. Hoit JD, Watson PJ, Hixon KE, McMahon P,
Johnson CL. Age and velopharyngeal function
ACKNOWLEDGMENT during speech production. J Speech Hear Res
1994;37(2):295–302
This work was supported by NIH/NIDCD
7. Warren DW, Dubois AB. A pressure-flow
R01 DC010140. technique for measuring velopharyngeal orifice
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