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.

1 comment:

Doug Brenton said...

Puberphonia is rarely talked about and I thank you for posting such an interesting topic! I am not a fan of laryngeal surgery in this case because either way, the patient will have to undergo some type of rehabilitative therapy; especially after laryngeal surgery.
I agree with most of your reflections. I love how the human voice conveys a wide range of emotions, feelings, attitudes, and affections. It is a dynamic, complex mechanism that is central to verbal communication and is so individualized that for all practical purposes, no two voices are alike. This research proves that a person's voice may be aesthetically displeasing or may convey a particular personality or emotional state. It is possible to hear a tremulous voice when a person faces fear or danger, an aphonic or dysphonic voice when someone endures extreme emotional stress, or an abnormal vocal pitch in which a man may sound like a woman or a woman like a child. Thus, the human voice has an extremely wide range of pitch, loudness, flexibility, and qualities, but the boundaries between normal and abnormal are not clearly defined. Some interesting research in 1990, Arnold Aronson defined a voice disorder as one that differs in terms of pitch, loudness, quality, or flexibility from the voices of other individuals of similar age, gender, and/or cultural group. However, there is no universal agreement of when either a normal or an abnormal voice exists.
I often wonder if Puberphonia falls within the umbrella of Psychodynamic voice disorders?
I think this is really interesting research because what is found in this type of disorders can maybe enhance other types of therapy methods. For example, sex reassignment therapy, i.e. the process of transition in transgender clients, as a rule that includes voice therapy by a speech language pathologist. From my knowledge, voice therapy in transgender clients is special, however, and is significantly different from what is usually understood by voice therapy in speech language pathology. As transsexualism is becoming more and more accepted in society, I believe more speech language pathologists have a chance of being called upon for helping transsexual clients. Puberphonia can help do the opposite of its research and provide data that will potentially enhance voice therapy in transgender clients. Just a thought! Great posting and addition to the blog! Thank you!