|Year : 2012 | Volume
| Issue : 1 | Page : 26-29
Voice therapy outcome in puberphonia
Vrushali Desai, Prasun Mishra
Department of Laryngology and Speech Therapy, Vasant Oswal Voice Disorder Clinic, Deenanath Mangeshkar Hospital and Research Centre, Pune, Maharashtra, India
|Date of Web Publication||9-Apr-2012|
Department of Laryngology and Speech Therapy, Deenanath Mangeshkar Hospital and Research Centre, 8+13/2, Erandwane, Pune - 411 004, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Puberphonia is inappropriate use of high-pitched voice beyond pubertal age in males. It is usually seen in the immediate post-pubescent period when the male vocal mechanism has undergone significant changes in size and function caused by hormonal changes. Voice therapy is one of the modality of management for puberphonia. Aim: To evaluate the efficacy of voice therapy provided to a group of 30 Puberphonia cases as the sole treatment approach to lower the pitch range. Setting: The study was carried out in a tertiary voice care and laryngology center. Materials and Methods: This is a prospective study of 30 cases diagnosed with Puberphonia managed with various techniques of voice therapy. The subjective assessment was done with GRBAS scale and objective assessment was done by acoustic analysis using Multi Dimensional Voice Profile. Results: All 30 patients achieved appropriate pitch range following Voice Therapy. Conclusion: This study encourages speech and language professionals to advice and use voice therapy as the foremost treatment modality for Puberphonia.
Keywords: Fundamental Frequency, normal pitch range, puberphonia, voice therapy
|How to cite this article:|
Desai V, Mishra P. Voice therapy outcome in puberphonia. J Laryngol Voice 2012;2:26-9
| Introduction|| |
Puberphonia is defined as the persistence of a high-pitched voice beyond the age at which voice change is expected to have occurred.  These individuals present with a complaint of a high-pitched voice which is deemed inappropriate for their age and sex. The incidence of puberphonia in general population is 1 in 900000 (Bannerjee et al., 1995). 
The most common symptoms include pitch breaks, hoarseness, breathiness, difficulty in vocal projection, and visible laryngeal muscle tension. Several reasons have been cited in literature  regarding the development of puberphonia, such as increased laryngeal muscle tension causing laryngeal elevation, embarrassment of the newly achieved vocal pitch, failure to accept the new voice, social immaturity, etc. Puberphonia patients very often seek treatment with a Speech Pathologist following formal laryngological assessment and diagnosis.
Voice therapy for puberphonia is a promising modality of treatment but not much reported in literature. The research outcome implicating effectiveness of Voice Therapy is sparse. Ours being a tertiary care laryngology and voice center do have a good number of patients of puberphonia. Many patients are managed with voice therapy. In the present study, we aim to study the efficacy of Voice Therapy in puberphonia patients. The objective of the study was to validate the use of a customized voice therapy program for puberphonia patients based on comprehensive voice assessment and behavioral therapy techniques.
| Materials and Methods|| |
A prospective study was conducted at this tertiary care laryngology and voice care center over a period of 2 years. The patients reporting to this center with history of high-pitched voice (perceptually) and found to have high FO (Fundamental Frequency) on Multi Dimensional Voice Program (Kay Pentax) were diagnosed as puberphonia and were included in the study. Males between the age group 14 to 18 years were included in the study. This was considered since literature suggests that a high-pitched voice in age group more than 18 years is considered as mutational falsetto. 
These patients underwent detailed ENT evaluation by an ENT surgeon and a stroboscopic evaluation was done using Kay Pentax 9105 System. Stroboscopy was used to obtain a visual assessment of the vocal cords. The stroboscopic evaluation provided measures of vibratory behavior of the vocal folds such as presence or absence of mucosal wave, vibratory symmetry, and amplitude; type of glottic closure; hyperfunction; arytenoids movement and symmetry; ventricular movement, etc. Stroboscopy also yielded a measure of the patient's fundamental frequency (Fo) during sustained phonation.
A perceptual assessment of patient's voice was done using the GRBAS scale. This scale consists of judgment of voice quality on the basis of Grade (G), Roughness (R), Breathiness (B), Asthenia (A), and Strain (S) in voice production. The severity was graded on a 4-point rating scale, on which 3 being worst and 0 being normal. 
Objective acoustic evaluation of voice was done with the Multi Dimensional Voice Profile (MDVP). MDVP is considered as the gold standard software tool for quantitative acoustic assessment of sustained phonation. It results in as many as 33 voice parameters.
The perceptual and acoustic analyses were performed once prior to onset of therapy and repeated prior to planning discharge from therapy.
All patients were explained the diagnosis and the possible etiopathology of the voice disorder. The voice therapy treatment protocol included therapy techniques commonly applied for achieving lowering of pitch. Some techniques which were commonly used were as follows:
The frequency of therapy was one session per week. The therapy techniques were practiced according to patient's comfort, ease of production, and improvement in pitch. Simultaneously, all the patients practiced relaxation exercises to reduce the compensatory laryngeal tension. During the course of therapy, the patients were allowed to note the difference in their habitual pitch and lowered pitch and were counseled regarding the appropriateness and use of this "new voice."
- Humming while gliding down the pitch scale, i.e., humming while gliding from a higher note to a lower note
- Phonation of vowel sounds with a glottal attack, i.e., forceful initiation of voice during production of vowels
- Use of vegetative sounds like cough or throat clear to initiate voicing
- Production of glottal fry (i.e., lowest possible pitch which the patient can produce)
- Digital manipulation of thyroid cartilage during vowel production-patient is taught to apply a gentle inward push on the anterior aspect of the thyroid cartilage while sustaining a vowel.
The lowered pitch was stabilized using the standard therapy hierarchy (starting from vowel sounds and habituating to conversational level). All the patients underwent therapy once a week (half hour sessions). The patients were evaluated at the end of the therapy regime, once the newly acquired pitch had stabilized. The perceptual and acoustic analysis was done as was done prior to therapy by GRBAS scoring and MDVP software.
| Results|| |
A total of 30 patients formed the sample size during the study period of 2 years. They were in the age group range of 14 to 18 years, diagnosed with puberphonia by ENT Surgeon and Speech Pathologist on videostroboscopy findings (rigid/flexible), perceptual and acoustic analyses.
The bar diagram in [Figure 1] shows the various techniques used for voice therapy and number of subjects. In some subjects, more than one therapy technique was used.
Clinical improvement in patients
The number of sessions required to achieve desired results varied depending upon the pre-therapy F0 (fundamental frequency), patient compliance and motivation during therapy, and implementation of techniques outside the therapy situation. The duration of follow-up varied among the patients from one session (1 week) to a maximum of four sessions (4 weeks). Majority of patients needed four sessions to achieve the expected results.
[Figure 2] shows the number of sessions required among the patients for clinical improvement.
Stroboscopic Findings: Of the 30 patients, 23 had normal stroboscopic evaluation. Seven of the 30 patients had minimal phonatory Gap as the only clinical finding. The remaining stroboscopic parameters were normal. Since the pre-therapy findings were not clinically significant, the stroboscopy was not repeated during the follow-up.
Perceptual Ratings: The pre-therapy perceptual ratings revealed mild deviance in overall grade, asthenia, and breathiness . The post-therapy ratings showed improvement to a "normal" overall rating with no perceptual evidence of breathiness and asthenia. All 30 patients had G0R0B0A0S0. The pre-therapy high-pitched voice had lowered to a normal pitch range at the end of therapy.
Acoustic Analysis: Fundamental Frequency (F0) was assessed pre- and post-therapy for all the patients. The average value of F0 before therapy was 208 Hz, and following therapy, it lowered to an average of 125 Hz, which was a significant improvement.
[Figure 3] shows the change in F0 values in each of the 30 patients.
| Discussion|| |
This study was carried out to evaluate the effect of voice therapy to treat puberphonia. All of the 30 patients who were in the age range of 14 to 18 years showed improvement. The pitch level lowered appropriately and the voice therapy could be stopped after three to four sessions after patient developed habituation of the newly achieved pitch level.
The therapy techniques used with the patients were humming-loud and glide, effortful phonation using hard glottal attack, use of vegetative techniques, glottal fry, and digital manipulation. The therapy program comprising of the selected technique was customized for each patient.
Not many studies are found on this subject in literature search. The results of this study are comparable with a similar study carried by Kizilay and Firat, where in a series of 16 patients, the mean F0 level improved from 246 to 134 Hz after treatment. In present study, the mean F0 improved from 208 to 125 Hz. 
Five of the 30 patients could achieve a normal pitch level in a single therapy session which included mainly counseling and habituating the lowered pitch to conversational level.
The lowering of pitch was quantified on the GRBAS scale and MDVP acoustic analysis. One patient went for Thyroplasty type III. Though his lowered F0 was in the normal range, the patient desired for further lowering of pitch.
| Conclusion|| |
The results of the above study indicate the effectiveness of voice therapy to treat puberphonia. Implementation of various therapy types through a step-by-step approach forms an effective method of management. This study encourages speech and language professionals to advice and use voice therapy as the foremost treatment modality for puberphonia.
| References|| |
|1.||Colton RH, Casper JK. Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment. 2 nd ed. Williams & Wilkins,USA ;1990. p. 82-4. |
|2.||Banerjee AB, Eajlen D, Meohurst R, Murty GE. Puberphonia -A Treatable Entity 1st World Voice Congress Oporto: Portugal; 1995. |
|3.||Stemple JC. Voice Therapy: Clinical Studies. Mosby Year Book; 1993. p. 110-6. |
|4.||Dagli M, Sati I, Acar A, Stone RE Jr, Dursun G, Eryilmaz A. Mutational Falsetto: Intervention outcomes in 45 patients. J Laryngol Otol 2008;122:277-81. |
|5.||Voice: Assessment and Management. Proceedings of the National Workshop on Voice: Assessment and Management held on 14-15 February 2008. p. 72. |
|6.||Kizilay A, Firat Y. [Treatment algorithm for patients with puberphonia]. Kulak Burun Bogaz Ihtis Derg 2008;18:335-42. |
[Figure 1], [Figure 2], [Figure 3]
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