Nasality disorders are hyper- or hyponasality and manifest themselves accordingly in open or closed nasal passages. In addition to organic causes such as inflammation, clefts, or tumors in the oropharynx, functional causes may be responsible for nasality disorder. Therapy consists of causative treatment and exercise therapy steps to direct the articulation airflow.
What is a nasality disorder?
So-called nasals are sounds with a special type of articulation. In oral sounds, the posterior and soft palate moves more or less closely to the back wall of the pharynx, where it closes the nasal cavity. In nasal sounds, the opposite is true. Articulation of nasals requires oral closure, where the velum descends. Thus, much of the air flows out of the nose. The resonant space for articulation is the nasal cavity and the oral cavity up to the point of oral closure. In German, only a few nasals exist, such as the M and N. An acoustically audible deviation from physiological nasality in the articulation of a nasal is called a nasality disorder. The terms rhinolalia, rhinophonolalia, rhinophonia, palatophonolalia, and dysglossia palatalis are synonymous terms that imply the disorder causes, effects, or disorder locations. Nasality disorders include open nasality in the sense of hypernasality and closed nasality in the sense of hyponasality. Mixed nasality is relatively rare.
Causes
In hypernasality, the nasal resonant cavities experience increased involvement, so typically because of organic causes such as cleft palate. In hyponasality, the same resonant spaces experience decreased involvement, as is organically characteristic of rhinitis. In mixed nasality, there is a combination of insufficiencies of the soft palate and obstruction of the nasal cavity. In all speech disorders, a distinction is made between organic causes and functional causes with regard to the causes. Organic causes are related to a physically manifest impairment of the soft palate and are usually due to malformations such as cleft palate. On the other hand, paralysis of the muscles involved, injuries or tumors and other types of changes in the area of the nasal cavity can also correspond to the primary causes of nasal disorders. Functional causes of nasality disorders include mainly psychological causes such as unconscious or conscious protective posture after operations in the area of the involved structures. The organic functions and anatomy of the area relevant to articulation are intact in functional causes.
Symptoms, complaints, and signs
Patients with nasality disorder suffer from perceptually abnormal phonation during articulation of nasal sounds. The natural physiology of their nasality is disturbed. In hyponasality, the nasal sounds appear too little nasalized. In hypernasality, there is too much nasalization. Especially the articulation of nasals and subsequent plosives makes the disorder appear. In general, however, the disorder can also refer to the combination of nasals and certain vowels or consonants. In some cases, all sound combinations with a nasal are affected by the altered pronunciation. Depending on the primary cause of the disorder, different accompanying symptoms may be present. For example, pain is not excluded in primary organic nasality disorders. In primary functional nasality disorders, concomitant symptomatic pain is usually not present.
Diagnosis and course of the disease
In the diagnosis of nasality disorder, the subjective auditory nasal impression is applied as a basic component. The physician or speech therapist obtains an initial impression of the disorder by listening to the patient’s spontaneous speech, primarily checking for combinations of nasal sounds and plosives. For the Anglo-American language area, standardized test sets exist for confirming the diagnosis, for example the Gutzmann test. This test variant is based on the different velum closure for the vowels /a/ and /i/. Physiologically, the former vowel has a large opening and the latter a closure. The recording of nasal breath sounds during articulation is performed using a Czermak plate.In regions of Germany, standard values for nasalance exist, with which the measured nasalance is compared. In order to determine the primary cause of the nasality disorder, organic diagnostics are performed. This diagnosis involves an examination of the oropharynx, during which palatal segeal activity, the nasopharynx, and the nose are assessed. Closure activity of the velum can be determined fiberoptically by transnasal endoscopy.
Complications
As a result of nasal dysfunction, affected individuals primarily suffer from a speech disorder. The nasal sounds are pronounced and emphasized incorrectly, so the patient may experience speech difficulties or other communication difficulties. Furthermore, the nasality disorder can also lead to teasing or bullying, if this complaint already occurs in school or in the adolescent age of the affected person. Pain usually does not occur. The disease itself is treated causally, so that further complications and also the further course of the disease depend strongly on the underlying disease. However, the symptoms can be limited in most cases. Not infrequently, the nasality disorder can also lead to depression or other psychological complaints, so that the patients are dependent on psychological treatment in this case. Through various therapies, the correct pronunciation can be learned so that further complications can be avoided. Taking medication is not necessary for this disease. However, in some cases, surgical procedures are necessary to correct the symptoms of nasality disorder. Similarly, the life expectancy of affected individuals is not affected or reduced in this disease.
When should you see a doctor?
Consultation with a doctor is necessary as soon as abnormalities and peculiarities of speech become apparent. If there is a change in pronunciation, voice color, or clarity of speech, there is cause for concern. If there is a sudden slurring of speech, a doctor should be consulted. Since the cause of the symptoms in some patients may be a serious medical condition, a physician should be informed of the observations at the first sign of irregularity. If there are changes in salivation as well as disturbances in the swallowing cycle, consultation with a physician is necessary. Restriction of breathing or changes in breathing technique due to existing problems must be investigated and treated. If the complaints occur within the natural growth and development process of a child or adolescent, malpositions may be the cause. A doctor should be consulted to clarify the background. If speech delays are noticed or if speech is completely avoided, these are signs of a health impairment. Behavioral abnormalities or changes in personality may also indicate an inconsistency. Therefore, in case of withdrawal from social life, aggressive or depressive tendencies, a doctor should be asked for help. Often, those affected change their communication methods so that the complaints go as unnoticed as possible by the social environment.
Treatment and therapy
In the case of nasal disorders with an organic cause, the focus of treatment is on causal therapy. As far as the cause can be removed, the nasality disorder is also curable. The removal of the cause can, for example, correspond to the excision of tumors or be equivalent to the correction of a malformation. The elimination of the organic damage is done, where necessary, with surgery. For this purpose, for example, closure operations of clefts are available. Septoplasties and conchal acoustics may also be considered. In some cases, a surgical reduction of the distance between the velum and the posterior pharyngeal wall is a promising surgical option. The corresponding operation is also known as velopharyngoplasty. Exercise therapy procedures are used for functional nasal disorders and as an adjunct to organic therapies for organic nasal disorders. Patients learn to normalize pathologic airflow direction and approach physiologically intended nasality in these exertive procedures.
Outlook and prognosis
Nasality disorder can be treated surgically and therapeutically. As part of therapy, speech is improved through specific training. If this is done early, the prognosis is good.Activation of the soft palate muscles and targeted training of speech breathing are usually sufficient to improve speech sufficiently. The child can then speak and be understood again without any problems. An accompanying operation is also positive in most cases. The cause of the nasality disorder is decisive for the course of the disease. If it occurs in the context of a cleft lip and palate or similar malformations, these must first be treated. In principle, there is no danger to the life of the affected children. Life expectancy is also not reduced. The quality of life may be reduced due to poor speech. However, mentioned therapy measures are effective and always bring an improvement of the condition. The exact prognosis is made by the responsible speech therapist or pediatrician. Other specialists can treat the causative disease and make a prognosis for this. In principle, the prognosis for a nasality disorder is therefore positive, provided that the condition is recognized and treated at an early stage. In the absence of treatment, the disorder persists and manifests during childhood.
Prevention
Nasality disorders of a habitually functional nature can be prevented, for example, by not adopting a gentle posture after surgery or trauma. Nasality disorders of an organic nature can be prevented only to the extent that preventive measures are available for tumors, inflammation, and malformations of the oropharynx.
Follow-up
In most cases of nasal dysfunction, the affected person has very few and usually very limited measures and options for aftercare. For this reason, the affected person should see a doctor as early as possible to prevent the occurrence of other complications or complaints. The earlier a doctor is consulted, the better the further course of the disease usually is, so that a doctor should be contacted at the first symptoms and signs. As a rule, nasal dysfunction requires surgical intervention, which can permanently and completely limit the symptoms. Affected persons should in any case take it easy and rest after such an operation. Bed rest should also be observed. Furthermore, many of the patients are dependent on the help and care of their own family due to the nasality disorder. This can also prevent depression and other psychological upsets. Also the contact to other affected persons of the nasality disorder can be useful and lead to an exchange of information, which can facilitate the everyday life of the affected person. The disease itself does not reduce the life expectancy of the patient.
What you can do yourself
In the case of a nasality disorder, in addition to medical treatment, the affected person can train and improve his or her phonation through specific speech exercises. Together with a speech therapist, exercise units can be worked out and discussed, which are performed independently and on one’s own responsibility by the patient at regular intervals. This promotes self-awareness, supports correct breathing during phonation and leads to optimized interaction with other people. Supporting technical aids can be used for better communication in everyday life. Speech computers, apps, various writing techniques or sign language can be used in contact with fellow human beings. They often make it easier to deal with each other. It is particularly important to build up one’s own self-confidence. Despite the adversity caused by nasal dysfunction, the person affected should in no way allow themselves to be negatively influenced by other people’s comments. It is important to provide comprehensive information about the present disease and to inform people from the social environment. In this way, misunderstandings can be avoided and possible disagreements can be prevented. An exchange with people who cannot speak or can only speak partially leads to new insights and an easier handling of the disorder for many affected people. A dialogue about experiences in everyday life is perceived as helpful and supportive in joint contact. Tips from fellow people for changes in one’s own behavior can also be useful.
