Voice Therapy Outcome in Puberphonia

Source:

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

Summary:

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.

Comment/Reflections:

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 https://www.youtube.com/watch?v=bQnEdgZX9es 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.” 2^nd 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.” 2^nd 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.