Puzzled by Learned Nasal Air Emission? You’re Not Alone - Ep. 93
Tired of feeling perplexed by nasal air emission and phoneme-specific nasal emission? We’ve got you covered in this enlightening episode! We’ll unravel these complex issues that often trip up even the most experienced SLPs, providing you with a wealth of knowledge and practical strategies. Expect to gain a clearer understanding as we dissect hypernasality, nasal air emission, and phoneme-specific nasal emission, shedding light on how to distinguish and treat these conditions effectively. Through engaging case histories, we share our journey to resolution.
Two cases are discussed, along with the considerable it took to correct them: a case where a preschooler produced a pharyngeal fricative for S and Z, and a case of phoneme specific nasal air emission. Tune in to get some tips on solving the puzzle of nasal air emission.
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Transcript
Welcome to the Speech Umbrella, the show that explores simple but powerful therapy techniques for optimal outcomes. I'm Denise Stratton, a pediatric speech-language pathologist of 30-plus years. I'm closer to the end of my career than the beginning and along the way I've worked long and hard to become a better therapist. Join me as we explore the many topics that fall under our umbrellas as SLPs. I want to make your journey smoother. I found the best therapy comes from employing simple techniques with a generous helping of mindfulness. Hello and welcome to the Speech Umbrella podcast. If you're a school SLP, you've probably said goodbye to your summer break and are getting to know your new referrals. If your private practice is anything like mine, your phone will soon start ringing off the hook because parents have been alerted to a speech-language problem and now they want your services. Regardless of where you work, fall is a busy time. It's a time when small but persistent articulation issues can feel like a thorn in your side. You might be thinking why can't I fix this artic issue and just graduate this child already? Today I'm going to talk about two issues that pop up in the speech therapy world Nasal air emission and phoneme-specific nasal emission. If you haven't heard of them, don't be too surprised. I had to research it to find out what it was called when I first encountered it, and it certainly can cause SLPs a headache or two. A good title for this podcast could be Another Thing I Didn't Learn in Grad School. Seriously, though, this podcast is actually called Case Studies in Treating Nasal Air Emission, and here's what we'll be covering what is nasal air emission and what is phoneme-specific nasal air emission, and I'll be talking about a case history of each type of emission and how they were successfully resolved.
Speechpathology.com has a great breakdown of the differences between hypernasality, nasal air emission and phoneme-specific nasal emission. I'm paraphrasing what they've written here, so let's talk about hypernasality. Hypernasality is most commonly associated with velofaryngeal dysfunction, impaired movement, coronation and timing of the velofaryngeal valve because of velofaryngeal insufficiency or incompetency. It indicates an abnormal coupling of the oral and nasal cavities during speech. Hypernasality occurs with phonated sounds, not voiceless consonants. Hypernasality is a resonance issue that occurs both throughout conversation and with individual words, and it's very evident on vowels. If that's hypernasality, then what is nasal air emission? Well, nasal air emission refers to the inappropriate release of air pressure through the nasal cavity during speech. It only occurs on consonants, especially pressure consonants. It affects articulation and not resonance.
Nasal air emission can occur because of velofaryngeal insufficiency or incompetence, or it could also be a result of faulty learning or from a fistula. The easy way to think of it is nasal emission is a type of speech error where air is forced through the nose while producing sounds that don't normally require nasal air flow. Finally, what is phoning Specific nasal emission? It is the release of air pressure that occurs on certain phonemes only. It is the result of faulty articulation due to mislearning, rather than velofaryngeal dysfunction. Therapy needs to change articulation placement.
Now, personally, I don't discern a lot of difference between nasal air emission and phoning specific nasal emission, except for the placement issue. Speechpathologycom says phoning specific nasal air emission requires a change in placement where nasal emission is using nasal air flow when it is not required. So of the two, it seems that phoning specific nasal emission would be the more severe problem to treat. If we are only talking about mislearning and indeed that's all we are talking about today we are not talking about VPI or fistulas or anything structural. Okay, that was some pretty heavy reading there with all of those words. You don't know how many times I had to say that over again for you guys to understand.
I don't pretend to be an expert in voice issues, but my experiences with clients who recruit too many muscles to the task at hand has given me a helpful perspective on treating faulty nasal emission. So let me explain what I mean by recruiting too many muscles. When a child mis-articulates a sound, they can either call too many muscles to the task. So anytime we want to do something, our brain says, hey, you need to do this. Well, let's get these muscles in action to do this motor action, and they just recruit too many muscles, or they can recruit too few muscles and mis-articulate the sound and it can get kind of tricky to figure out what's going on. A child who doesn't make bilabial contact for M could be recruiting too few muscles. However, that would only be true if their jaw was hanging open and they appeared all slack. See, they're not using the muscles to bring their jaw up. But if they're not making bilabial contact because their lips and cheeks are pulled back in extreme retraction like a huge smile, that error is due to recruiting too many muscles in one direction. They don't have balance between retraction and rounding of their muscles and they probably lack a neutral resting posture too. Looking at muscle recruitment is more valuable for me than looking at placement, because so often the muscle recruitment proceeds or is the cause of the placement issue.
I've learned the supplies to learn nasal emission in almost every case. I can illustrate this best with two case histories. The first case I'm going to talk about I would classify as phoning specific nasal emission, and that's because this preschool client was producing a pharyngeal fricative for SMZ. I can't even reproduce that pharyngeal fricative. It was like something happening in the back of your throat that sounds super weird.
So placement was an issue in addition to his nasal emission. It was a very strange sounding substitution. He had already been checked out by an ENT and there were no structural problems. So I knew that therapy alone could correct it. But it was not an easy fix. The first thing I noticed was he had extreme tension and over-retraction of his lips and his cheeks. I'm a prompt trained therapist so I'm used to looking at how the muscles are working to control the jaw and the lips and the cheeks and the tongue. And this prompt training stood me in really good stead because I understood that he needed to get more balanced muscle movement through rounding. So you see he was retracting, he was pulling back his lips and cheeks and so we need to counter that movement with rounded sounds which are O and O.
And we did lots of activities combining the vowels O and U with M, p, b, n, d and T. I avoided S and Z completely for a long time and this was because he couldn't produce them with a vowel at all, he just made the pharyngeal fricative. He could say S or Z in isolation, but the minute you tried to move him to a word, that pharyngeal fricative would come back. So he couldn't combine S and Z with a vowel. And the reason I targeted N, d and T with O and U is that the alveolar placement is really close to S and Z. The reason I targeted M, p and B is I wanted to get nice, relaxed, bilabial placement with rounding. Remember he overused his muscles to pull his lips and cheeks back and that interferes with a really nice neutral lip contact. And we also used H as it's a great early consonant.
And who and ho, as in Santa says ho, ho are really nice words to use, are fun target words. It was also necessary for me to help him get the correct jaw grading for the vowels A and A because he was really tight and really tense with those vowels, but rounding was always part of every session. We spent a long time on this and near the end of his therapy journey, when he was able to combine S and Z with a vowel, his progress just took off. It just accelerated so quickly. And then he needed just a little bit of work on generalization and he was done. So if you were to look at the number of sessions we actually worked on S and Z, which were the problem sounds compared to the other phonemes, you might have a hard time believing that these fricatives were the sounds he needed to learn.
And in case you're wondering what kinds of words and activities we used, here are a couple of my favorites for what I call rounding work. We use play-doh and cookie-cutters because you've got dough, you've got who. I have an owl home for a house of barn, but I have ho ho. I have a Santa cookie cutter. Moo for the cow boo for a ghost woof, for a dog bone for the dog. Two you want to make two. We want to cut out. Two. We want to give it two eyes. We want to do it. By the way, I have lots of ideas for activities and games with the younger crowd. On episode 91, when I talk more about this play-doh stuff and if you're looking for an activity for very early rounding work, like just the O sound, check out my Instagram reel, one about using Cheerios on a stick, and I also have an Instagram reel on painting a rainbow. I talk about how just to use the word bow, which is great for early rounding work. So that's how that situation was resolved by working on rounding, rounding, rounding and decreasing his tension, which was caused by over recruitment of muscles.
My second case history concerns a client with what I would classify as nasal air emission, although it was only on one phoning. He had no placement issues, it was just a quirky way to say volcalic R. This client was nine when he came to me and he came just to learn to say the R sound and on his very first day I was able to elicit a bunched ur and I thought this is awesome. He's gonna be done so fast. But the best laid plans of mice and men go off astray, as they say, and this was the case with him. He had a boatload of phonemic awareness work to do so that he can even recognize when he was saying R correctly at the conversation or sentence level. And add to that he was an on edge kiddo kind of nervous and he was pretty devastated if he didn't get something right on his first try.
So it was a case of slowly and carefully moving him forward with pre-volcalic R, r-blends, phonemic awareness and then volcalic R. And you might think because he was able to say R right off the bat on his first day that the volcalic R was pretty easy to glide right into. But it wasn't. He was really off again, on again and he varied between omitting the volcalic R or saying it with a nasal emission, so it was slightly distorted. And one day he would nail it a nice pure ur with no distortion, and the next session it would be gone. And I couldn't find a consistent key to get rid of that nasality. He even got really good at hearing it. I would record him, he would listen back. He was like, oh, that came through my nose, but he didn't know how he's doing it. He didn't know what to do to stop the nasal distortion from coming through.
I have to say here I've often had our clients who have had the same issue with volcalic R, but I've always been able to guide them through it, just teaching them to relax and doing what I call relax practice. And if you want to know more about relax practice, I have an entire podcast on that called Peaceful Speech. That's episode 19. That's one of my most listened to episodes. By the way, relax Practice is a foundational piece of my impossible or may possible course, so check it out at thespeechumbrella.com slash R-course. Okay, let's get back to this client.
No amount of relax practice resulted in consistent change. One night I was strolling through my garden because that's how I relax pondering on this, and I thought what if I ask him to whisper volcalic R? I don't think he can be too nasal if he whispers R. He already knew the placement for volcalic R. He just needed to eliminate this small distortion. Well, I'm happy to report that that whisper technique worked like a charm. He had zero distortion when whispering, and so then I just gradually coached him to incrementally increase his volume, and anytime that nasal distortion came back, we dropped back down to the whisper and we just kept going up and we were on our way once more. And now he still needs to learn to be consistent with the vocalic R, because then he was omitting it sometimes. But that was manageable. I could do that and so could he. And don't you love it when you solve a problem? I do. That's why I love our profession and this whisper technique is going into my toolbox.
This particular kiddo was also recruiting too many muscles, although in a really subtle way. He did wring his hands a lot, to the point where I sometimes even gave him theropathy, hoping to make the hand wringing less of a distraction for him. And, as I mentioned before, he kind of operated on the edge as far as nervousness went. But when I saw the complete stillness he experienced when he whispered volcalicar, it made it really obvious to me oh yeah, tension was the problem here, and tension goes hand in hand with recruiting too many muscles to the task. To wrap things up, remember to take a look at over recruitment of muscles. When you have a client with nasal error mission that has you scratching your head, remember that it can look like nervousness and tension. It might just be the source of the problem. And when you master the simple source of the problem, then the complex takes care of itself and you can graduate that kiddo.
If you're in need of a reliable way to become an R Zen master, especially as a school year starts and the R referrals start piling up, take a look at my Impossible R Made Possible video course. It's two hours of instruction, including client videos showing how to elicit R and 60 plus pages of worksheets to save you time and energy. You'll find that at the speech umbrella dot com slash R dash course and on TPT. Thanks for joining me today on the speech umbrella podcast. Transcripts and links for this episode are located at the speech umbrella dot com slash blog. While there be sure to sign up for the free resource library where you have access to over 25 therapy and clinic resources for free, those are at the speech umbrella dot com slash free. I'm on social media now. I look forward to discussing speech therapy with you. Find me on Instragram at dstrattonslp, and Facebook and YouTube at the Speech Umbrella. Please tell a colleague about what you learned today on this podcast and invite them to join us under the Speech Umbrella. Bye for now.
Thanks for listening to the Speech Umbrella. We invite you to sign up for the free resource library at thespeechumbrellacom. You'll get access to some of Denise's best tracking tools, mindfulness activities and other great resources to take your therapy to the next level. All this is for free at thespeechumbrellacom. If you've enjoyed this podcast, subscribe and please leave us a review on Apple Podcasts and other podcast directories.
