Praxis 5331 Resonance & Cleft Palate Questions

Hypernasality is excessive nasal resonance on vowels and voiced oral consonants, and it points to incomplete velopharyngeal closure. Hyponasality is reduced nasal resonance on the nasal consonants /m n ŋ/, and it points to blockage in the nasal cavity from adenoids, congestion, or septal deviation. Cul-de-sac resonance is a muffled quality produced when sound enters a cavity but cannot exit, and mixed resonance combines patterns, often in patients with both velopharyngeal dysfunction and airway obstruction.

Nasal air emission is a separate finding from hypernasality: it is audible or visible airflow through the nose on pressure consonants, best detected with a mirror under the nares during /s/, /p/, and /t/ productions. Items often pair the two to check whether you can distinguish a resonance problem from an airflow problem.

Velopharyngeal insufficiency is a structural problem — insufficient tissue, as in unrepaired or short palate, or after adenoidectomy. Velopharyngeal incompetence is a neuromotor problem — the tissue exists but does not move adequately, as in dysarthria. Velopharyngeal mislearning is a learned articulation problem in which closure is physically possible but the speaker substitutes nasal or pharyngeal productions.

This distinction determines the correct management answer, which is why ETS tests it so often. Insufficiency requires surgical or prosthetic management such as a pharyngeal flap, sphincter pharyngoplasty, palatal lift, or obturator. Incompetence is managed medically and prosthetically, with speech therapy targeting compensations. Mislearning is the only category that speech therapy alone can resolve — and it is the category where therapy is the correct answer.

Children with a history of cleft palate often develop compensatory placements that move production behind the velopharyngeal valve where pressure can still build. The classic set includes the glottal stop replacing oral stops, the pharyngeal fricative replacing /s/ and /ʃ/, the pharyngeal stop replacing /k/ and /g/, the mid-dorsum palatal stop, and the posterior nasal fricative.

These are learned behaviors, so they persist after successful surgical repair and require direct therapy targeting anterior placement, oral airflow, and pressure consonants. Because they are learned rather than structural, a stem describing persistent glottal stops in a child with an adequately repaired palate calls for speech therapy, not repeat surgery.