Sunday, November 23, 2014

Voice Therapy Outcome in Puberphonia

Desai, Vrushali and Prasun Mishra. “Voice Therapy Outcome in Puberphonia”. Journal of Laryngology and Voice (2012), Vol. 2 (1), pp.26-29.

Puperphonia is defined as the persistence of high-pitched voice beyond the age at which voice change is expected to have occurred.[1] Those that suffer from this disorder are deemed to have an inappropriately high-pitched voice for their age and sex, and are in need of a lowering in fundamental frequency. In this research, the authors, Vrushali Desai and Prasun Mishra aimed to study the efficacy of Voice Therapy in puberphonia, hoping to validate the use of a “customized voice therapy program for patients based on comprehensive voice assessment and behavioral therapy techniques.”[2]

Their study was conducted over two years in the Department of Laryngology and Speech Therapy, at the Deenanath Mangeshkar Hospital and Research Centre in Pune, India. 30 male patients who had been diagnosed with puberphonia, aged between 14 and 18 years were included. Each patient had a detailed ENT evaluation and a stroboscopic evaluation, looking at the movement of the vocal folds, testing for symmetry, amplitude, glottis closure, hyperfunction, arytenoids movement, presence or absence of mucosal wave etc. Because the most common symptoms in puberphonia patients include pitch breaks, hoarseness, breathiness, lack of projection, and visible laryngeal muscle tension, the assessment included a grading according to the GRBAS (grade, roughness, breathiness, asthenia, and strain) scale. Apparently, 3 is the worst and 0 is normal.

Upon completion of their voice evaluation, the 30 patients underwent voice therapy, which included common techniques applied for lowering the pitch of the voice. Some of these were:
1. Humming while gliding down a scale
2. Phonation of vowel sounds with a glottal attack
3. Use of sounds like a cough or throat clearing in order to initiate voicing
4. Production of vocal fry
5. Manipulation of the thyroid cartilage during vowel production. Patients were taught to apply a gentle inward push on the anterior aspect of the thyroid cartilage while sustaining a vowel.
The number of sessions would depend on the patient and their implementation of techniques in their own home, but there was just the one therapy session per week, lasting between 1-4 weeks after the initial session.

The results revealed that after therapy, all 30 patients were able to eliminate symptoms; their voices lowered to a normal pitch range. Their GRBAS scale ratings were normal, showing “no perceptual evidence of breathiness and asthenia.”[3] Initially, the average fundamental frequency of a patient before therapy was 208 Hz, but following it, the frequency had dropped to an average of 105 Hz. Therefore, the research shows the effectiveness of voice therapy, and it would seem in return, achieves its goal of encouraging speech professionals to advise therapy as the primary modality for treating puberphonia.

Knowing that this affects approximately 1 in 900,000 people (Bannerjee et al. 1995), it is great to know that this is a disorder that can be treated through therapy and not by taking drugs, or undertaking surgery. However, I had my reservations about therapy as a 100% certifiable treatment, because as with many disorders, there are extreme cases where methods such as these might not work. I had to explore it further! What I discovered was that there are cases where conservative methods don’t work, and so it IS in fact advisable to resort to surgery. Interestingly enough, the first case of surgically corrected puberphonia occurred in 2000 at the department of Otolaryngology, Leicester Royal Infirmary, in Leicester, England. Further information about the surgery can be found in the Otolaryngology Online Journal, Volume 4, Issue 1 2014, in the article titled “Mutational Falsetto: A Panoramic Consideration.” Please be aware that some of the images are descriptive.

Puberphonia is a real issue for many boys (and some females), for not only does this disorder affect the quality of the voice, but also the quality of their life. First of all, there are several reasons for the development of puberphonia. These include:
·       Increased laryngeal muscle tension
·       Embarrassment of and a reluctance to accept the newly developed voice
·       Social immaturity
·       Emotional stress
·       Delayed development of secondary sexual characteristics
·       Psychogenic
·       Skipped fusion of thyroid laminae
Sadly, patients whose voices haven’t yet descended often feel bullied for their voices, harassed by their peers. These teenage boys end up being “the butt of many jokes…this ultimately results in his self-esteem and confidence taking a beating.”[4] As a result, it affects their ability to interact in social situations.

This doesn’t affect only males though. While it doesn’t reveal itself in such an obvious fashion, it also affects women. This is known as “little Girl’s Voice.” I have actually heard this voice on the subway in Toronto, and have since found it to be a developing ‘epidemic’ in todays society. I have observed a couple of current vocal trends. One is where young men and women speak on ‘glottal fry’. This is because it is deemed cool. The other is to keep this ‘cute’ sounding voice, so their voice never descends into normal range. When you hear this voice this voice for the first time, it really is shocking to hear! For this reason, I would advise anybody to go to youtube to see an example of the condition.

It is fantastic that literature is being written on the subject, that we are aware of the condition, and that there are such positive outcomes. It is important that there be solutions to destabilizing disorders such as puberphonia, and the authors have done a fantastic job in showing how voice therapy, if begun with a speech therapist early enough, can change the lives of these young boys.

Works cited:
Colton RH, Casper JK. “Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment.” 2nd edition Williams & Wilkins, USA; 1990.

Kothandaraman, Srikamakshi and Balasubramanian Thiagarajan. “Mutational Falsetto: A Panoramic Consideration.” Otolaryngology Online Journal 2014, Volume 4, Issue 1.

[1] Colton RH, Casper JK. “Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment.” 2nd edition Williams & Wilkins, USA; 1990. p.82
[2] Desai, Vrushali and Prasun Mishra. “Voice Therapy Outcome in Puberphonia”. Journal of Laryngology and Voice (2012), Vol. 2 (1), p.26
[3] Ibid. p.28
[4] Kothandaraman, Srikamakshi and Balasubramanian Thiagarajan. “Mutational Falsetto: A Panoramic Consideration.” Otolaryngology Online Journal 2014, Volume 4, Issue 1.

Saturday, November 15, 2014

(Musical) Silence

Galloway, L. (2012, October 23). The quietest place on Earth. BBC Travel. Retrieved from

Summary & Commentary
          According to the Guinness Book of World Records, the “quietest place on earth” is an anechoic (echoless) chamber at Orfield Laboratories in Minneapolis, USA.  Its lack of echoes is credited to its construction.  After walking through two vault doors, one-metre long foam wedges line the room’s walls, ceiling, and even bottom; one must walk on a “floor” made of a trampoline-like mesh.  Virtually no sound is reflected off of the walls, which absorb 99.99% of all noise.  High-frequency sounds are directly absorbed by the fibreglass wedges, and low-frequency sounds bounce in between the wedges until they fizzle out.  As a result, its sound level is -9.4 dB (decibels)—humans can only detect sounds above 0 dB.  The decibel level of a room that an average person would consider to be “quiet”, for example, is 30 dB.
In the chamber, not only can you hear a pin drop, but you also start noticing the frenzy of activity that is going on inside your own body.  People have reported hearing their lungs breathing, their own heartbeat, their stomach digesting food, and even hearing the blood rush to their head and back through to their body.  Even ears themselves make sounds in the echoless room.  Steven Orfield, founder and owner of Orfield Laboratories, explains: “The ear is like a microphone and a loudspeaker. And when it is deprived of sound, it produces its own sounds.” (Weber 2012).  Orfield is talking about otoacoustic emissions (OAE) which are sounds generated by various cellular and mechanical processes in the inner ear, and usually go completely unheard by the unknowing public.
Even after about five minutes in the room, people become disoriented, dizzy, nauseous, and feel like there’s tremendous “pressure” on their head.  “What seems to be happening is you are feeling some pressure in your ears,” explains Orfield, “but what you’re really feeling is pressure being taken off of your ears. Sound is technically called sound pressure level. And in this room we’re actually taking huge amounts of pressure off of your ear, so it’s highly sensitized by not being loaded with normal amounts of noise.” (Weber 2012).  People who visit the anechoic chamber usually sit in a chair.  Standing up and moving around becomes increasingly difficult because we rely so heavily on sound to keep our balance.  Walking feels strange because we have no aural reference (or if one is inside the room in the dark, no visual cues either) for mobility.  Without any feedback from the outside world—like the sound of your own feet moving, for example—uninterrupted action is almost impossible.  The chamber also causes many to feel claustrophobic.  Usually reverb or echo tells our auditory system that there is an ample amount of space, thus the complete absence of echo can instinctively send us into a panic.
          Furthermore, once you lose certain sensations, other perceptions become heightened.  A complete absence of noise can lead to a heightened sense of smell or touch, but can also cause your hearing to become much more sensitive.  As we already know, the auditory cortex sorts, organizes, and simplifies sounds.  And many of the bodily noise people report hearing in the echoless chamber would normally be victim to habituation.  We don’t need to hear these things when we’re out in the world and have to be aware of cars, animals, weather, other people, etc.  But when all of those stimuli disappear, undetectably quiet sounds seem louder, as if our brains have recalibrated to the new noise levels.  People have even reported hearing aural hallucinations, although none of my sources have described the nature of them in detail.
          How quiet is too quiet?  For people with sensitive hearing, the chamber might indeed be too quiet and they would have to get out of the room immediately.  The longest amount of time anyone has been able to spend in Orfield Lab’s anechoic chamber without panicking and needing to leave is 45 minutes.

          This article made me think about the relationship between silence and music in two different ways: (1) musical auditory hallucinations as a result of silence, and (2) the idea of “musical” silence, or, periods of silence in between notes, phrases, or pieces, inserted for artistic purposes.
As previously mentioned, it is a shame that the alleged “auditory hallucinations” people have had in the Minneapolis anechoic chamber aren’t better documented. What do people come to “hear” without any outside stimulation when left in complete silence?  Do people ever perceive music that isn’t really there? Is it easier to remember or vividly visualize music in silence? Maybe because we’re so used to hearing everyday sounds, that when all of it is taken away we try to make up for what we’re accustomed to by creating the sounds ourselves?  After all, the healthy population is fully capable of recreating sounds—whether it be voices, street noises, or music—in the mind’s ear with minimal effort, so it’s not a far leap to say it can sometimes occur involuntarily due to sensory deprivation. 
          An echoless room is essentially a variation on John C. Lilly’s sensory deprivation tank, which he invented in 1954.  A physician and neuroscientist, Lilly aimed to isolate the brain from any external stimulation.  The small tank, which closes shut to stop any light from getting in, is filled with warm salt water allowing for a subject to float for extended periods of time.  The sensory deprivation tank operates on the principle that in total absence of external stimuli, the human brain creates its own perceptions.  The idea of perceptual isolation is known today as the Restricted Environmental Stimulation Technique (REST) which can occur in a room or in water.  Even with the psychological and neurological research done with REST, there are very few findings about auditory hallucination—or hallucination as a result of sensory deprivation—that doesn’t cross over into issues of psychosis (see Nayani & David 1996; Na & Yang 2009, for example).
Now, knowing everything we’ve just learned about our brain’s reaction to silence, what are the potential applications of silence in music?  And how can silence be used in music for artistic or dramatic purposes?  In “Moved by Nothing,” Margulis explored five functions of silence in active, participatory music listening: (1) silence as boundary, (2) silence as interruption, (3) silence as a revealer of the inner ear, (4) silence as a promoter of meta-listening, and (5) silence as a communicator.  She says that “since literally nothing happens for the extent of the duration of the silence, all of our various percepts, reactions, surmises, and senses reveal things we have brought to the silence.” (Margulis 2007, p.246).
In a setting where one has consciously sat down to listen to music, silence can be extremely powerful.  Like the commanding silence before the beginning of a piece, for example, where every attentive ear is hypersensitive to the slightest sound, getting mentally ready to hear what is to unfold before them.  In line with the anechoic chamber discussion, sounds emerging from silence are actually better processed by our brains, as the search for an auditory stimulus activates the auditory cortex (Voisin et al. 2006).  Moreover, EEG (electroencephalography) and MEG (magnetoelectroencephalography) tests show the brain’s detection of musical phrase boundaries shortly after the phrase’s offset, suggesting that listeners spend these silences synthesizing the preceding musical phrase and refocusing their attention on hearing the subsequent one (Margulis 2007, p.253).
Just like in a sensory deprivation tank, when auditory stimuli are removed in the context of music-listening our own personal auditory imagery, visualizations, imaginings, assumptions, and expectations come to the fore.  Musical silence can definitely serve to encourage this process, additionally acting as a sonic boundary that guides our auditory attention.

Margulis, E. H. (2007). Moved by nothing: Listening to musical silence. Journal of Music Theory, 51(2), 245-276.
Na, H.J., & Yang S. (2009). Effects of listening to music on auditory hallucination and psychiatric symptoms in people with schizophrenia. Journal of Korean Academy of Nursing, 39(1), 62-71.
Nayani, T. H., & David, A. S. (1996). The auditory hallucination: A phenomenological survey. Psychological Medicine, 26(01), 177-189. doi:10.1017/S003329170003381X
Veritasium. (2014). Can Silence Actually Drive You Crazy? YouTube. Retrieved from
Voisin, J., Bidet-Caulet, A., Bertrand, O., & Fonlupt, P. (2006). Listening in silence activates auditory areas: A functional magnetic resonance imaging study. The Journal of Neuroscience, 26(1), 273-278.
Weber, T. (2012, June 21). In Minneapolis, the world's quietest room. MPR News. Retrieved from

Tuesday, November 11, 2014

Autism and Pitch Processing: A Precursor for Savant Musical Ability?

Heaton, P., Hermelin, B., & Pring, L. (1998). Autism and pitch processing: A precursor for savant musical ability?. Music perception, 291-305.

Autism is a developmental disorder characterized by impairments in socialization, communication and cognition. (292) It has been used as an umbrella label to categorize children in the classroom that do not fit the defined "norm".  Early identification begins with the student that cannot sit still, that speaks out of turn, that cannot focus or contribute in group settings and whose progress is consistently slower than other students in the classroom. But sometimes students who are labeled "autistic" do something quite marvelous that the "norm" cannot master. Defined as idiot savants at the turn of the 19th century, these were individuals with low cognitive ability who were able to master a skill in an isolated area (291). The fascination with musical savants is evidenced in this blog. While many struggle with hours of practice and performance anxiety savants appear to be musical geniuses with the innate ability to perform music. Earlier research concludes that savants are present in 1 in 2000 of the learning disabled population.

Heaton, Hermelin and Pring theorise that savantism may actually be present in higher numbers and set out to research the "precursor" to savant like ability in autistic children. According to the study there is a high frequency of savant ability in the "general mentally handicapped population". They cite studies that have shown that autistic adolescents have been found to isolate information, what they describe as "local processing" as opposed to making sense of information as a whole, described as "global processing."

Their methodology tests ten identified autistic boys, between the ages of seven and thirteen with no prior musical training. The control group consisting of ten boys with average academic ability but younger in age. The children were matched by chronological age to the cognitive age of the autistic group. 

The children were given four pitches and four speech sounds linked to a picture of an animal. The note C was represented by a fish, a pig for the word "da" etc. After the pitch or sound was tested, the children took part in conversation for two and half minutes and then were re-tested again with the notes or sounds in random order. Pitch memory was tested after a period of one week.

The results were extraordinary. The study showed that the autistic group of children were far superior at retaining pitch memory and identifying pitch. However in the speech sound test, the control group tested higher. The results suggest that there may be something unique about musical ability in autistic children.
And has implications for music education in the special needs classroom. What is the untapped musical potential of autistic students?

In my own experience working with identified autistic children, pitch memory has not been the primary challenge. In fact, students work towards their first five notes quite rapidly. Music literacy has been the biggest challenge. The ability to put the note on the page and identify rhythm and pitch on the staff. In terms of music education, this study suggests that there may be value in teaching pitch first, through a listening mode, away from the staff, away from a method book. Have a student hear the pitch and have them recreate it. I am developing curriculum for differentiated learners that renames the pitch as 1, 2,3,4,5. This has enabled me to work on a unified line that everyone can read at the same time.  But my work is focused on eventual score reading. Although the staff is eliminated, it is still music that must be read. How can pitch be taught organically, further simplified? Just pitch and instrument? Notes are discovered. Once discovered, then repeated and then labeled. Internalized, identified and played. It also intrigues me that pitches were represented as animals. In what way can notes on a staff become a familiar image to a child, autistic and non-autistic? Is that even possible?

This study suggests that autistic children may process information selectively, laser-like in the vast world of information.  Music, which can be highly selective and specialized, may spark or activate savant characteristics in the autistic brain.  The opportunity to discover the precursor to musical or savant like ability in autistic children holds real potential and the findings are extraordinary. It also has the potential to change perspectives. Autistic students challenged with a learning disability can be perceived as children that have a unique untapped musical potential.