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Puberphonia Conservative Approach a Review

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Puberphonia Conservative Approach a Review ISSN: 2250-0359 Volume 5 Issue 1.5 2015 Puberphonia Conservative approach A review Balasubramanian Thiagarajan Stanley Medical College Abstract: Pathophysiology: Puberphonia is persistence of adolescent voice In infants the laryngotracheal complex lies at after puberty in the absence of organic cause. a higher level. It gradually descends. During This common condition is seen in males. These puberty in males this descent is rapid, the larynx patients have a high pitched voice. This article at- becoming larger and unstable and on top of it the tempts to review published literature on this topic brain is more accustomed to infant voice. The with specific focus on conservative management. boy may hence continue to use a high pitched This condition is also considered to be a psycho- voice or it may break into higher and lower pitch- genic voice disorder. Conservative management es 3. has met with excellent success. Conservative man- agement modalities for this condition ranges from Etiology: include voice therapy to laryngeal manipulation. 1. Emotional stress 2. Delayed development of secondary sexual Introduction: characters The persistence of adolescent voice even after pu- 3. Psychogenic berty in the absence of organic cause is known as 4. Hero worship of older boy or sibling Puberphonia1. This condition is commonly seen 5. Excessive maternal protection in males. This is uncommon in females because 6. Non fusion of thyroid laminae laryngeal growth spurt occurs commonly only in 7. Increased laryngeal muscle tension causing males. According to Banerjee the incidence of laryngeal elevation Puberphonia in India is about 1 in 900,000 pop- Complaints: ulation 2. In females this condition is known as “Juvenile Resonance Disorder” or a “Little Girl’s 1. Unusual high pitched voice persisting beyond Voice”. This condition is characterised by vocal puberty instability with extensive frequency swing. 2. Hoarseness of voice 3. Breathy voice 4. Inability to shout drtbalu’ s Otolaryngology online 5. Vocal fatigue 3. The patient must be convinced that the new low pitch should be used instead of the old high The typical fundamental frequency of adult pitch voice male voice ranges between 85-180 Hz and that of a typical adult female is about 165-255 Hz 4. In Puberphonia the boy continues to use a Treatment modalities available: higher pitch which stresses the laryngeal mus- culature. 1. Voice therapy Examination of these patients should include a 2. Larynx manipulation complete physical examination including a geni- tal examination also. Secondary sexual charac- 3. Surgery ters should be assessed, hypogonadism should be ruled out. A complete psychological profile Voice Handicap Index (VHI): of the patient in question should be built to rule out psychological causes. If psychological In order to clinically access the impact of the causes could be identified they treating it should voice disorder and effect of treatment Voice take precedence over other modalities. Handicap Index developed and validated by Jacobson and Johnson is commonly utilised 6. These patients speak in a double voice, both in The first version of Voice Handicap Index had high pitch and low pitch. 85 items, which was later pruned down to 30 The impact of this voice disorder varies from item list. This index has 3 subsections, each of person to person. This depends on the follow- which has a weightage of 40 points making the ing variables: total score of 120. 1. Occupation 5 The impact of VHI score is: 2. Environment 1. 0-30 – Minimal handicap / normal score 3. Family members 2. 31-60 – Moderate handicap associated 4. Personality with the voice disorder 3. 60-120 – Serious amount of handicap Goals of treatment of Puberphonia: associated with the voice disorder This scoring is useful in: 1. The patient should be taught to phonate at a 1. Assessing the degree of disability associ- low pitch ated with the voice disorder 2. Assessing and monitoring the treatment 2. The patient should be taught to fully utilise efficacy 7 the Phonatory and Respiratory musculature 3. Assessing the impact of voice disorder in patient’s daily living drtbalu’ s Otolaryngology online drtbalu’ s Otolaryngology online Voice characteristics of a patient with Puberpho- In addition to auditory feedback visual feedback Establishing diaphragmatic breathing: This causes increased muscular tension in the nia: should also be used. These include digital pitch Patients should lie on their back. laryngeal area. The vowel is uttered as the air is scales and electroglottography. A book is placed over the diaphragm. breathed out. This procedure enables a patient 1. Abnormally high pitched voice for the patient’s Vegetative tasks: Patient is asked to place one hand over the book with Puberphonia to settle down to their basic age and expected norms Performing the following vegetative tasks would and the other over the chest. fundamental frequency of voice. 2. Pitch breaks alleviate the symptom in a significant number of Patient should be instructed to raise the book up Relaxation techniques to relax laryngeal muscu- 3. Vocal instability patients. while breathing without raising the chest. lature: 4. Poor voice control After diaphragmatic breathing is established, 5. Complaints of lack of power in voice Cough: patient is asked to vocalise a deep sigh on their Laryngeal muscles can be relaxed using the fol- 6. Phonation is effortful Patient is taught to cough and clear the throat expiratory stream. lowing relaxing procedures: 7. Supralaryngeal pain because larynx is held ab- before initiating voice. Patient’s deep voice normally high is heard spontaneously during coughing and Speech range masking: Yawn technique: The patient is advised to prac- 8. Patient may be distressed by the voice generated laughing. In the next phase patient should This procedure is known to improve the quality tise yawning, followed by generation of a sighing initiate cough while applying pressure over of voice. The use of auditory masking to produce sound. This procedure reduces the tension on Voice therapy includes: the Adam’s apple. Pressure over Adam’s apple reflexive vocal response was first introduced in the vocal folds. reduces the length of the vocal fold and causes 1911 by Lombard 8. This effect also known as 1. Cough a reduction in the pitch of the voice generated. Lombard effect has been used to identify auditory Chewing technique: First the act of chewing in 2. Speech range masking This helps the patient to get used to lower basic malingerers. It has been established that speak- an exaggerated manner is practised. Then grad- 3. Glottal attack before a vowel frequency. ing in a noisy background has profound effects on ually random sounds, words and sentences are 4. Relaxation techniques to relax the laryngeal how an individual speaks. It can alter the quality of added to this task. This act reduces the tension musculature Vocalizing a deep sigh: speech of an individual. This procedure also makes of the laryngeal muscles. 5. Visi pitch Patient is asked to take a deep breath and sigh the voice clearer and louder. For this purpose an 6. Lowering of larynx to appropriate position out loud. instrument known as the facilitator is used. The /M/ warm up: To warm up the vocal cords the 7. Humming while sliding down the scale Tongue depressor manoeuvre: masking bandwidth is between 100 - 8000 Hz. The consonant M is spoken or sung before the words. 8. Half swallow Boom technique A tongue depressor is used to depress the pos- advantage of using this frequency is that it covers This helps to produce a gentle air flow through terior portion of the tongue, while asking the the speech range and masking is possible at much the larynx as phonation begins. Before subjecting the patient to voice therapy patient to groan. This manoeuvre lowers the lower sound levels when compared to a white or patient should be properly counselled on the basics hyoid bone and larynx causing relaxation of the pink noise which are commonly used for purposes Visipitch: of voice anatomy, human growth and voice gener- vocal folds. of masking. A tape recording of the voice of the This instrument is commonly used by speech pa- ation. This will help in alleviating patient’s anxiety patient during and after masking is provided to thologists to treat various speech disorders. This before the actual therapy. Patient positioning: the patient and the patient should try to match the machine helps in extraction of Critical speech Biofeedback: Patient is made to sit with the head tipping voice generated during masking on a consistent and voice parameters and displays them in true This is aimed at gauging patient’s response to voice slightly forwards and shoulders relaxed. Patient basis. real-time to help clients achieve therapy goals changes. This should be undertaken during the is instructed to vocalise “MM” while placing Glottal attack before a vowel: with visual feedback. This machine helps in initial stages of voice therapy. thumb and forefinger on the thyroid laminae so Vowel is a very important sound in speech. It is training the patient in nuances of normal speech a. Audio recording of male voice should be played that the tendency to elevate the larynx is moni- also easily amenable to therapy / change. Glottal production. and the patient’s response is judged tored. attack involves bringing both vocal cords into close b. The patient should hear the difference between Patient is asked to hold arms horizontally and approximation. The patient is asked to breathe in, a mature male voice and the voice generated in drop them heavily to the side while saying “ah”. build air pressure in the subglottic area. mutational falsetto The arms should be brought down with the force c. Headphones are ideally used of gravity. drtbalu’ s Otolaryngology online drtbalu’ s Otolaryngology online Boone’s technique of larynx lowering: Patient was asked to come nil by mouth for six References: This method is also known as “Yawn - sigh” meth- hours before the procedure in the ENT outdoor.
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