PSN Issue | Parenting Special Needs Magazine

P.i.N.C.H. Therapy

By: Hélène Rosman Fisher, SLP.D., CCC Nova Southeastern University

An Experimental Technique to Reduce Hypernasality by Reducing Velopharyngeal Surrender

Speech is an important part of communication. To be effective, speech needs to be intelligible. One of the factors that can impair intelligibility is faulty resonance.

Resonance in speech refers largely to the vibration and amplification of speech sounds in either the nose (nasal cavities) or the mouth (oral cavity). Most sounds (all vowels and most consonants) in English should resonate in the mouth. These are oral sounds. Only "m", "n" and "ng" should resonate in the nose. These are nasal sounds.

A valve-like mechanism toward the back of the nose and mouth involving the soft palate (velum) and throat (pharynx) walls, directs sound either into the nose or into the mouth. This mechanism is called the velopharyngeal (VP) port. When the port is open, sounds enter and resonate in the cavities of the nose. When the port is closed, sounds are directed into the mouth and resonate in the oral cavity.

When the port is functioning correctly, the port will open to direct only nasal sounds to the nasal cavities, and close to direct only oral sounds into the oral cavities. If the port is malfunctioning where the port does not close adequately and there is a gap between the soft palate and throat walls, then oral sounds may escape into, and resonate in, the nasal cavities. This resonance in the nasal cavities causes speech to sound like the individual is "talking through their nose." The clinical term for this is "hypernasality." Common physical/ structural causes of VP inadequacy and a VP gap include a short soft palate or weak muscles of the palate and throat. Surgery is a common form of intervention for a VP gap associated with a physical/ structural deficit.

Having a VP port that does not close adequately makes it difficult to build up air pressure in the mouth during speech. Studies have led to the speculation that the brain responds to the presence of high air pressure in the mouth during speech by directing the VP port to close. If there is a lack of high air pressure in the mouth during speech, then, it is speculated, the brain does not direct the VP port to close. The VP port remains open and inactive. This physiological inactivity of the VP port is called Velopharyngeal Surrender, a term coined by Sally-Peterson Falzone, Ph.D.

Velopharyngeal surrender, therefore, can also cause a VP gap. Unlike a VP gap caused by a physical, structural deficit, VP surrender creates a VP gap as a typical, physiological reaction to a lack of high pressure in the mouth during speech.

A VP gap, in this author's opinion, therefore, may be a result of a combination of factors, physical/structural, and a physiological, reactive VP surrender. Thus, any VP gap that exists because of a structural, physical deficit also has an accompanying VP surrender that exacerbates the gap. It is this author's opinion, that speech pathologists should play a significant role in minimizing the VP surrender and that such speech therapy intervention should routinely precede any surgical intervention for a physical/structural VP deficit. By first eliminating/minimizing the VP surrender, a smaller VP gap may be revealed and surgery to repair the smaller gap may potentially be less extensive.

This author developed a speech therapy technique called Prolonged Nasal Cul-De-Sac with High Pressure Speech Acts (P.i.N.C.H.) to reduce/minimize velopharyngeal surrender. This technique is experimental and has only been studied in individual cases. Individuals undergoing P.i.N.C.H. therapy wear nose-clips to occlude the nose and prevent air leaking from the mouth into the atmosphere. The individual, with nose occluded, then drills word- and phrase lists containing only oral sounds that the individual is able to articulate correctly. The stimulus words and phrases are loaded with high pressure speech sounds such as "p", "b", "t", "d", "k", "g", "s", "z", "sh", "ch", "j", "f", "v" and "th". The occluded nose and the repeated production of high-pressure speech sounds allow for the build-up of air pressure in the mouth during speech. The drills are conducted for 10-40 minute periods, without interruption, depending upon the individual's endurance and age. The P.i.N.C.H. drills are speculated by this author as a form of potentially prolonged sensory stimulation to the brain via the introduction of high pressure speech to the oral cavity. The author speculates that the brain responds to this sensory stimulation by directing the VP port to actively close.

If your child seems to be talking through his/her nose (hypernasality), it is highly recommended that a craniofacial team evaluate your child. To find a team in your state/area, contact the American Cleft and Craniofacial Association (ACPA). The craniofacial team is made up of several medical specialists that may include a geneticist, pediatrician, plastic surgeon, oro-maxillary (mouth-upper jaw) surgeon, otolaryngologist, speech-language pathologist, dentist, orthodontist, audiologist, social worker, psychologist, and case manager. The team will evaluate your child, make recommendations for further testing, if indicated, recommend intervention, if indicated, and coordinate all services for you.

Other articles on/related to P.i.N.C.H.

H.R. Fisher (2004). Preliminary Studies on the Efficacy of prolonged Nasal Cul-De-Sac with high Pressure Speech Acts (PiNCH) on Hypernasality. ijasp.nova.edu, 2.

H.R. Fisher (2004). Oral Pressure and Velopharyngeal Function: A Bi-directional Relationship. Florida Journal of Communication Disorders, 21, 24-27.

H.R. Fisher (2009). PiNCH Therapy to reduce Velopharyngeal Surrender. FLASHA FORUM, Spring, 6-7.

L. M. Grames (2009). Speech Therapy for the Child with Cleft Palate. In J. E. Losee & R. E. Kirschner (Eds.) Comprehensive Cleft Care (pp. 619-626). New York: McGraw Hill. Page 621.