Puberphonia

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Puberphonia (also known as mutational falsetto,functional falsetto, incomplete mutation, adolescent falsetto, or pubescent falsetto) is a functional voice disorder that is characterized by the habitual use of a high-pitched voice after puberty, hence why many refer to the disorder as resulting in a 'falsetto' voice. [1] The voice may also be heard as breathy, rough, and lacking in power. [2] The onset of puberphonia usually occurs in adolescence, between the ages of 11 and 15 years, at the same time as changes related to puberty are occurring. [2] This disorder usually occurs in the absence of other communication disorders.

Contents

There is a higher male prevalence of puberphonia, as the voice disorder is characterized by a high pitch that would be inappropriate for the age and sex of the patient. [1] Typically, individuals with puberphonia do not present with underlying anatomical abnormalities. Instead, the disorder is usually psychogenic in nature, meaning resulting from psychological or emotional factors, [3] and stems from inappropriate use of the voice mechanism. The habitual use of a high pitch while speaking is associated with tense muscles surrounding the vocal folds. [4] Assessment and treatment of puberphonia is usually conducted by a speech-language pathologist (S-LP) or an otolaryngologist (ENT). [5] [6] Puberphonia is not a disorder that is likely to go away on its own. Without treatment, the changes in the patient's voice can become permanent. [2] Treatment can involve direct voice therapy, indirect voice therapy, or audiovisual feedback. [5]

Signs and symptoms

The laryngeal prominence, commonly known as the Adam's apple. Myneck.JPG
The laryngeal prominence, commonly known as the Adam's apple.

During puberty, changes in the larynx typically result in a decrease in pitch in both males and females. On average, the male voice deepens by one octave while the female voice lowers by a few semitones. [7] The fundamental frequency (pitch) of an adult female typically falls between 165 and 255 Hz and an adult male between 85 and 180 Hz. [8] Anatomical changes during puberty include enlargement of the larynx for both sexes. However, the larynx descends and grows significantly larger in males which often results in a visible laryngeal prominence on the neck (Adam's apple). [9] Additionally, male vocal folds become longer and thicker and resonant cavities become larger. [9] These changes contribute to a deepening of the voice characteristic of pubescent males.

Puberphonia is characterized by the failure to transition into the lower pitched voice of adulthood. In conjunction with an atypically high pitch, common symptoms include a weak, breathy, or hoarse voice, as well as a low vocal intensity, pitch breaks, and shallow breathing. [9] [10]

Causes

There are a number of proposed causes for the development of puberphonia. The aetiology of puberphonia can be both organic (biological) or psychogenic (psychological) in nature. In males, however, organic causes are rare and psychogenic causes are more common. [11]

Puberphonia is described as having three main variants, related to the level of anatomical change. [12] The most common presentation of the condition is characterized by a normal adult larynx and an increased pitch due to the vocal folds adopting the falsetto position. A second variant can occur when the laryngeal development is prolonged during puberty. Lastly, puberphonia can occur due to an incomplete transformation of the larynx into the adult form. [12]

Psychogenic causes

Organic causes

Assessment

To determine whether a patient presents with puberphonia, a complete voice assessment including medical and diagnostic evaluations is recommended. These assessments are performed by otorhinolaryngologists and speech-language pathologists. [6]

Patient profile

Puberphonia is most often diagnosed in adolescent or adult male patients. [15] These patients often seek referral to a voice professional because of the social consequences of speaking in the falsetto register. Because a high-pitched voice is not pathologized in women, women are less likely to be referred to clinicians to treat falsetto speech. [15] Some older adult women, however, may seek a referral for this disorder due to increasing weakness of their voice and vocal fatigue at the end of the day (these cases are often referred to as "juvenile voice" or "little girl's voice" rather than puberphonia). [4] [16]

Medical evaluation

Puberphonia is a functional voice disorder[ citation needed ]. To rule out problems in the structure of the larynx as the cause of their voice issues, patients are often referred to otorhinolaryngologists for a physical examination of the larynx and vocal folds. Once physical pathologies are ruled out, a behavioural evaluation can occur. [6]

Behavioural evaluation

A behavioural assessment for puberphonia will consist of several types of tasks, and may include:

Other evaluations

Clinicians can also request a self-assessment, in which the patient describes their symptoms and their effects on activities of daily living. [6] The clinician may direct this self-assessment to include the identification of personality traits that may maintain the disorder, the social and emotional consequences of the symptoms experienced, and whether the patient has any access to their modal voice register. [4] [15]

A complete assessment for puberphonia or any other voice disorder may require a referral to another healthcare professional, such as a psychologist or a surgeon, to determine candidacy for various treatment options. [17]

Treatment

Direct voice therapy

This condition is most often treated using voice therapy (vocal exercises) by speech-language pathologists (SLPs) or Speech Pathologist who have experience in treating voice disorders. The duration of treatment is commonly one to two weeks. [18]

Techniques used include: [19] [20] [1]

Indirect voice therapy

Indirect treatment options for puberphonia focus on creating an environment where direct treatment options will be more effective. [17] Counselling, performed by the S-LP, a psychologist, or counsellor, can help patients identify the psychological factors that contribute to their disorder and give them tools to address those factors directly. [17] [4] Patients may also be educated about good vocal hygiene and how their behaviour could have long term effects on their voice. [17]

Audiovisual feedback

In puberphonia, the use of audiovisual feedback allows the patient to observe graphic and numerical representations of their voice and pitch. This allows the patient to determine an ideal pitch range based on normative data on age and gender, and incrementally work through speech tasks while working in that desired pitch range. As the patient improves, speech tasks progress to become more natural, involving tasks such as reciting automatic information, to reading, to spontaneous speech and conversation. [14] Incorporating audiovisual feedback in speech and voice therapies has been successful in intervention by improving motivation and guidance. [14]

Surgery

In some cases when traditional voice therapy is ineffective, surgical interventions are considered. This can occur in situations where intervention is delayed or the patient is in denial, causing the condition to become resistant to voice therapy. [21]

There are different types of surgical interventions which have been successful in lowering the vocal pitch in men with puberphonia who had previously received ineffective voice and psychotherapy. The first surgical intervention developed, called relaxation thyroplasty or tetrusion thyroplasty, involves a bilateral excision of 2 to 3 mm vertical strips of thyroid cartilage which lowers the vocal pitch through anteroposterior relaxation and shortening of the vocal folds. It can be performed under local or general anaesthesia. [21]

Relaxation thyroplasty by a medial approach is a modified approach of traditional relaxation thyroplasty. This version involves lowering the vocal pitch by creating an incision bilaterally in the thyroid lamina and then depressing the anterior segment of the thyroid cartilage. [21]

A more recent, less invasive intervention is the window relaxation thyroplasty. This approach involves creating a window at the anterior commissure, which is then displaced posteriorly. [21]

Epidemiology

The incidence of puberphonia is estimated to be about 1 in 900,000 population. [22]

Related Research Articles

The term phonation has slightly different meanings depending on the subfield of phonetics. Among some phoneticians, phonation is the process by which the vocal folds produce certain sounds through quasi-periodic vibration. This is the definition used among those who study laryngeal anatomy and physiology and speech production in general. Phoneticians in other subfields, such as linguistic phonetics, call this process voicing, and use the term phonation to refer to any oscillatory state of any part of the larynx that modifies the airstream, of which voicing is just one example. Voiceless and supra-glottal phonations are included under this definition.

<span class="mw-page-title-main">Vocal cords</span> Folds of throat tissues that help to create sounds through vocalization

In humans, the vocal cords, also known as vocal folds, are folds of throat tissues that are key in creating sounds through vocalization. The size of vocal cords affects the pitch of voice. Open when breathing and vibrating for speech or singing, the folds are controlled via the recurrent laryngeal branch of the vagus nerve. They are composed of twin infoldings of mucous membrane stretched horizontally, from back to front, across the larynx. They vibrate, modulating the flow of air being expelled from the lungs during phonation.

<span class="mw-page-title-main">Human voice</span> Sound made by a human being using the vocal tract

The human voice consists of sound made by a human being using the vocal tract, including talking, singing, laughing, crying, screaming, shouting, humming or yelling. The human voice frequency is specifically a part of human sound production in which the vocal folds are the primary sound source.

Vocal cord nodules are bilaterally symmetrical benign white masses that form at the midpoint of the vocal folds. Although diagnosis involves a physical examination of the head and neck, as well as perceptual voice measures, visualization of the vocal nodules via laryngeal endoscopy remains the primary diagnostic method. Vocal fold nodules interfere with the vibratory characteristics of the vocal folds by increasing the mass of the vocal folds and changing the configuration of the vocal fold closure pattern. Due to these changes, the quality of the voice may be affected. As such, the major perceptual signs of vocal fold nodules include vocal hoarseness and breathiness. Other common symptoms include vocal fatigue, soreness or pain lateral to the larynx, and reduced frequency and intensity range. Airflow levels during speech may also be increased. Vocal fold nodules are thought to be the result of vocal fold tissue trauma caused by excessive mechanical stress, including repeated or chronic vocal overuse, abuse, or misuse. Predisposing factors include profession, gender, dehydration, respiratory infection, and other inflammatory factors.

Falsetto is the vocal register occupying the frequency range just above the modal voice register and overlapping with it by approximately one octave.

Vocal fold cysts are benign masses of the membranous vocal folds. These cysts are enclosed, sac-like structures that are typically of a yellow or white colour. They occur unilaterally on the midpoint of the medial edge of the vocal folds. They can also form on the upper/superior, surface of the vocal folds. There are two types of vocal fold cysts:

  1. Sub-epithelial vocal fold cysts- located in the superficial lamina propria of the vocal folds.
  2. Ligament vocal fold cysts- located within the deeper layers of the lamina propria or on the vocal ligament.

Dysarthria is a speech sound disorder resulting from neurological injury of the motor component of the motor–speech system and is characterized by poor articulation of phonemes. In other words, it is a condition in which problems effectively occur with the muscles that help produce speech, often making it very difficult to pronounce words. It is unrelated to problems with understanding language, although a person can have both. Any of the speech subsystems can be affected, leading to impairments in intelligibility, audibility, naturalness, and efficiency of vocal communication. Dysarthria that has progressed to a total loss of speech is referred to as anarthria. The term dysarthria is from Neo-Latin, dys- "dysfunctional, impaired" and arthr- "joint, vocal articulation".

<span class="mw-page-title-main">Bogart–Bacall syndrome</span> Voice disorder caused by abuse or overuse of the vocal cords

Bogart–Bacall syndrome (BBS) is a voice disorder that is caused by abuse or overuse of the vocal cords.

A hoarse voice, also known as dysphonia or hoarseness, is when the voice involuntarily sounds breathy, raspy, or strained, or is softer in volume or lower in pitch. A hoarse voice can be associated with a feeling of unease or scratchiness in the throat. Hoarseness is often a symptom of problems in the vocal folds of the larynx. It may be caused by laryngitis, which in turn may be caused by an upper respiratory infection, a cold, or allergies. Cheering at sporting events, speaking loudly in noisy situations, talking for too long without resting one's voice, singing loudly, or speaking with a voice that's too high or too low can also cause temporary hoarseness. A number of other causes for losing one's voice exist, and treatment is generally by resting the voice and treating the underlying cause. If the cause is misuse or overuse of the voice, drinking plenty of water may alleviate the problems.

"Voice therapy" or "voice training" refers to any non-surgical technique used to improve or modify the human voice. Because voice is a social cue to a person's sex and gender, transgender people may frequently undertake voice training or therapy as a part of gender transitioning in order to make their voices sound more typical of their gender, and therefore increase their likelihood of being perceived as that gender. Having voice and speech characteristics align with one's gender identity is often important to transgender individuals, whether their goal be feminization, neutralization or masculinization. Voice therapy can be seen as an act of gender- and identity-affirming care, in order to reduce gender dysphoria and gender incongruence, improve the self-reported wellbeing and health of transgender people, and alleviate concerns over an individual being recognized as transgender.

<span class="mw-page-title-main">Contact granuloma</span> Medical condition

Contact granuloma is a condition that develops due to persistent tissue irritation in the posterior larynx. Benign granulomas, not to be confused with other types of granulomas, occur on the vocal process of the vocal folds, where the vocal ligament attaches. Signs and symptoms may include hoarseness of the voice, or a sensation of having a lump in the throat, but contact granulomas may also be without symptoms. There are two common causes associated with contact granulomas; the first common cause is sustained periods of increased pressure on the vocal folds, and is commonly seen in people who use their voice excessively, such as singers. Treatment typically includes voice therapy and changes to lifestyle factors. The second common cause of granulomas is gastroesophageal reflux and is controlled primarily through the use of anti-reflux medication. Other associated causes are discussed below.

<span class="mw-page-title-main">Speech–language pathology</span> Disability therapy profession

Speech–language pathology is a field of healthcare expertise practiced globally. Speech–language pathology (SLP) specializes in the evaluation, diagnosis, treatment, and prevention of communication disorders, cognitive-communication disorders, voice disorders, pragmatic disorders, social communication difficulties and swallowing disorder across the lifespan. It is an independent profession considered an "allied health profession" or allied health profession by professional bodies like the American Speech-Language-Hearing Association (ASHA) and Speech Pathology Australia. Allied health professions include audiology, optometry, occupational therapy, rehabilitation psychology, physical therapy and others.

Vocal cord paresis, also known as recurrent laryngeal nerve paralysis or vocal fold paralysis, is an injury to one or both recurrent laryngeal nerves (RLNs), which control all intrinsic muscles of the larynx except for the cricothyroid muscle. The RLN is important for speaking, breathing and swallowing.

Spasmodic dysphonia, also known as laryngeal dystonia, is a disorder in which the muscles that generate a person's voice go into periods of spasm. This results in breaks or interruptions in the voice, often every few sentences, which can make a person difficult to understand. The person's voice may also sound strained or they may be nearly unable to speak. Onset is often gradual and the condition is lifelong.

Vocal cord dysfunction (VCD) is a pathology affecting the vocal folds characterized by full or partial vocal fold closure causing difficulty and distress during respiration, especially during inhalation.

<span class="mw-page-title-main">Voice therapy</span> Used to aid voice disorders or altering quality of voice

Voice therapy consists of techniques and procedures that target vocal parameters, such as vocal fold closure, pitch, volume, and quality. This therapy is provided by speech-language pathologists and is primarily used to aid in the management of voice disorders, or for altering the overall quality of voice, as in the case of transgender voice therapy. Vocal pedagogy is a related field to alter voice for the purpose of singing. Voice therapy may also serve to teach preventive measures such as vocal hygiene and other safe speaking or singing practices.

Speech and language impairment are basic categories that might be drawn in issues of communication involve hearing, speech, language, and fluency.

Flaccid dysarthria is a motor speech disorder resulting from damage to peripheral nervous system or lower motor neuron system. Depending on which nerves are damaged, flaccid dysarthria affects respiration, phonation, resonance, and articulation. It also causes weakness, hypotonia, and diminished reflexes. Perceptual effects of flaccid dysarthria can include hypernasality, imprecise consonant productions, breathiness of voice, and affected nasal emission.

Thyroplasty is a phonosurgical technique designed to improve the voice by altering the thyroid cartilage of the larynx, which houses the vocal cords in order to change the position or the length of the vocal cords.

Muscle tension dysphonia (MTD) was originally coined in 1983 by Morrison and describes a dysphonia caused by increased muscle tension of the muscles surrounding the voice box: the laryngeal and paralaryngeal muscles. MTD is a unifying diagnosis for a previously poorly categorized disease process. It allows for the diagnosis of dysphonia caused by many different etiologies and can be confirmed by history, physical exam, laryngoscopy and videostroboscopy, a technique that allows for the direct visualization of the larynx, vocal cords, and vocal cord motion.

References

  1. 1 2 3 4 Colton, Raymond H.; Casper, Janina K.; Leonard, Rebecca (2011). Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment. Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN   978-1-60913-874-5. OCLC   660546194.[ page needed ]
  2. 1 2 3 Dagli, M; Sati, I; Acar, A; Stone, RE; Dursun, G; Eryilmaz, A (2008). "Mutational falsetto: intervention outcomes in 45 patients". The Journal of Laryngology & Otology. 122 (3): 277–281. doi:10.1017/S0022215107008791. PMID   17524172. S2CID   9959504.
  3. 1 2 Martin, Stephanie; Lockhart, Myra (2013). Working with Voice Disorders. New York: Speechmark Publishing Ltd. p. 37. ISBN   9780863889462.
  4. 1 2 3 4 5 6 7 8 C., Stemple, Joseph (2014-01-28). Clinical voice pathology : theory and management. Roy, Nelson,, Klaben, Bernice (Fifth ed.). San Diego, CA. ISBN   9781597569330. OCLC   985461970.{{cite book}}: CS1 maint: location missing publisher (link) CS1 maint: multiple names: authors list (link)
  5. 1 2 Jani, Ruotsalainen; Jaana, Sellman; Laura, Lehto; Jos, Verbeek (2008-05-01). "Systematic review of the treatment of functional dysphonia and prevention of voice disorders". Otolaryngology–Head and Neck Surgery. 138 (5): 557–565. doi:10.1016/j.otohns.2008.01.014. PMID   18439458.
  6. 1 2 3 4 5 "Voice Disorders: Assessment". American Speech-Language-Hearing Association. Retrieved 2017-11-11.
  7. ↑ C., Stemple, Joseph (2014). Clinical voice pathology : theory and management. Roy, Nelson,, Klaben, Bernice (Fifth ed.). San Diego, CA. ISBN   9781597565561. OCLC   985461970.{{cite book}}: CS1 maint: location missing publisher (link) CS1 maint: multiple names: authors list (link)
  8. ↑ Titze, I.R. (1994). Principles of Voice Production, Prentice Hall (currently published by NCVS.org) (pp. 188), ISBN   978-0-13-717893-3.
  9. 1 2 3 Aronson, Arnold Elvin; Bless, Diane M. (2009). Clinical Voice Disorders.
  10. ↑ The management of voice disorders. Morrison, M. D. (Murray D.) (1st ed.). London: Chapman & Hall Medical. 1994. ISBN   9781489929037. OCLC   623663763.{{cite book}}: CS1 maint: others (link)
  11. 1 2 Sinha, Vikas (2012). "Efficacy of Voice therapy for treatment of Puberphonia: Review of 20 cases". World Articles in Ear, Nose and Throat. 5.
  12. 1 2 3 4 5 6 7 Diagnosis and treatment of voice disorders. Rubin, John S. (John Stephen). New York: Igaku-Shoin. 1995. ISBN   978-0896402768. OCLC   31903364.{{cite book}}: CS1 maint: others (link)
  13. 1 2 Vaidya, Sudhakar; Vyas, G. (2006-01-01). "Puberphonia: A novel approach to treatment". Indian Journal of Otolaryngology and Head and Neck Surgery. 58 (1): 20–21. doi:10.1007/BF02907732. ISSN   0019-5421. PMC   3450609 . PMID   23120229.
  14. 1 2 3 Franca, Maria; Bass-Ringdahl, Sandie (June 2015). "A clinical demonstration of the application of audiovisual biofeedback in the treatment of puberphonia". International Journal of Pediatric Otorhinolaryngology. 79 (6): 912–920. doi:10.1016/j.ijporl.2015.04.013. PMID   25912681.
  15. 1 2 3 4 5 Voice disorders and their management. Freeman, Margaret., Fawcus, Margaret. (3rd ed.). London: Whurr. 2000. ISBN   9781861561862. OCLC   53964036.{{cite book}}: CS1 maint: others (link)
  16. ↑ Thiagarajan, Balasubramanian (2015-03-08). Puberphonia Conservative approach A review. Otolaryngology online. OCLC   910339432.
  17. 1 2 3 4 "Voice Disorders: Treatment". American Speech-Language-Hearing Association. Retrieved 2017-11-11.
  18. ↑ Boone, Daniel R.; MacFarlane, Stephen C.; Von Berg, Shelley L.; Zraick, Richard I. (2010). The voice and voice therapy. Allyn & Bacon.
  19. ↑ Morisson, Rammage, Murray, Linda. Management of Voice Disorders. Springer-Science+Business Media, B.V. ISBN   978-1-4899-2903-7.
  20. ↑ Fawcus, Margaret. Voice Disorders and their Management. Springer, Boston, MA. pp. 337–355. ISBN   978-1-4899-2861-0.
  21. 1 2 3 4 Remacle, Marc; Matar, Nayla (2010). "Relaxation Thyroplasty for Mutational Falsetto Treatment". Annals of Otology, Rhinology & Laryngology. 119 (2): 105–109. doi:10.1177/000348941011900207. PMID   20336921. S2CID   28757870.
  22. ↑ Banerjee AB, Eajlen D, Meohurst R, Murty GE (1995). Puberphonia—A Treatable Entity (abstract). 1 World Voice Congress. Oporto, Portugal.[ verification needed ]
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