Voice and Resonance Disorders 71Hard glottal attack resembles harshness; however, the forced closure occurs only on the initial
sounds or syllables of words. The strangled voice quality is similar to harshness and sounds as
though speech is being produced with extremely tense neck muscles. (Some patients have mucous
buildup in the speech tract, giving the strained, strangled voice a “wet” quality.) The vocal fry voice
quality is also known as glottal fry. The voice is low pitched and pulsating, sometimes described
as creaking.
Humans are marvelous sensing creatures, and the quality of a person’s voice signals many
personality traits and emotional states. According to Gobl and Ní Chasaide (2002), there is no
one- to- one mapping between voice quality and affect; instead, a given voice quality tends to be
associated with a cluster of affective attributes. The nonverbal cues of a person’s voice can carry
as much communication information as the actual words— and sometimes more. In addition, if
there is a conf lict between the verbal and nonverbal information, the listener will usually believe
the latter: How something is spoken often speaks louder than what is said.
Cleft Lip and Palate
During the early weeks of pregnancy, the fetus’s palatal shelves and nasal structures fuse. In
about 1 in 700 live births, this pro cess is incomplete, resulting in cleft lip and palate (Williams,
Sandy, Thomas, Sell, & Sterne, 1999). There is no consensus on the cause of this birth defect, but
genes and prenatal factors are thought to play a role in disrupting the fusion. (The role of folic acid
in birth defects is a promising area of current research.) The majority of the fusion pro cess can be
disrupted, resulting in bilateral complete clefts of the lip and palate; in other cases, the cleft can be
incomplete and limited to one side of the oral- maxillary region. Rarely is the cleft limited to the
lip. A submucous cleft occurs when there is an absence of bone in the palate but the tissue remains
intact. In addition, children with cleft lip and palate have a high incidence of middle ear dysfunc-
tion and tend to be delayed in language acquisition.
The effect of cleft lip and palate on speech depends on the severity of the defect, the success
of surgery in repairing the orofacial anomalies, and the results of speech therapy. Three factors
ultimately affect speech production in persons with cleft lip and palate. First, cleft lip and related
defects of the face can cause articulation disorders, especially of labial phonemes. Usually they
interfere only minimally with the child’s ability to produce speech because successful surgeries
reconstruct the lip and related structures to serve as articulators, and therapies teach compensa-
tion for residual deficiencies. Second, nasal emission, an audible hissing through the nose, can
interfere with normal speech production. It is usually a result of velopharyngeal incompetence, in
which the soft palate does not completely approximate the posterior pharyngeal wall. Not only is
the nasal emission obtrusive, it also reduces the amount of air pressure that can be used to produce
plosives and other pressure consonants. Third, children with cleft lip and palate can have hyper-
nasality, that is, too much nasal resonance on non-nasal sounds. Hypernasality can result from a
slow, sluggish velum or an unrepaired cleft. The speech- language pathologist is a key member of
the cleft palate team and addresses the communication disorders associated with this birth defect.
Vocal Cord Paralysis
The vocal cords can be para lyzed by strokes, tumors, degenerative neurological and muscular
diseases, and trauma. The paralysis or paresis (weakness) may involve abduction or adduction
of one or both sides of the vocal folds. Spastic paralysis of the larynx results from bilateral upper
motor neuron damage. Duffy (1995, 2012) has identified unilateral upper motor neuron dysarthria
that can affect phonation. It results in weakness on the opposite side of the body and resulting
dysphonia (impaired voice; aphonia: loss of voice). Spastic vocal cord paralysis is common in
strokes, reducing the range of motion of the vocal cords. Spastic laryngeal paralysis often causes a
harsh or hoarse voice quality. When the cerebellum and the tracts leading to and from the larynx