Balasubramanian M.S. D.L.O.
falsetto, Voice break.
Definition: The persistence of adolescent
voice even after puberty in the absence of organic cause is known as
Puberphonia. This condition is commonly seen in males.
This is uncommon in females because laryngeal growth spurt occurs
commonly only in males. According to Banerjee the incidence of
Puberphonia in India is about 1 in 900,000
Pathophysiology: In infants the
laryngotracheal complex lies at a higher level. It
gradually descends. During puberty in males this descent is
rapid, the larynx becoming larger and unstable and on top of it
the brain is more accustomed to infant voice. The boy may
hence continue to use a high pitched voice or it may break into
higher and lower pitches.
2. Delayed development of secondary
4. Hero worship of older boy
5. Excessive maternal protection
6. Non fusion of
1. Unusual high pitched
voice persisting beyond puberty
2. Hoarseness of voice
4. Inability to shout
Examination of these patients should include a
complete physical examination including a genital examination
also. Secondary sexual characters should be assessed,
hypogonadism should be ruled out. A complete
psychological profile of the patient in question should be
built to rule out psychological causes. If psychological
causes could be identified they treating it should take precedence
over other modalities.
These patients speak in a
double voice, both in high pitch and low pitch.
Goals of treatment of
1. The patient should be taught to phonate
at a low pitch
2. The patient should be taught to fully
utilise the Phonatory and Respiratory musculature
patient must be convinced that the new low pitch should be used
instead of the old high pitch voice
1. Voice therapy
2. Speech range masking
attack before a vowel
4. Relaxation techniques to relax the
5. Visi pitch
6. Lowering of larynx to
7. Humming while sliding down the
8. Half swallow Boom
Cough: Patient is taught to cough
with pressure over the adams apple. This manuver shortens the
length of the vocal cord there by reducing its vibrating
pitch. The patient is advised to perform this exercise at
home. This will enable the patient to get used to a lower
basic speech frequency.
masking: This procedure is known to improve the quality of
voice. It has been established that speaking in a noisy
background has profound effects on how an individual speaks.
It can alter the quality of speech of an individual. This
procedure also makes the voice clearer and louder.
For this purpose an instrument known as the facilitator is
used. The masking bandwith is between 100 - 8000 Hz. The
advantage of using this frequency is that it covers the speech
range and masking is possible at much lower sound levels when
compared to a white or pink noise which are commonly used for
purposes of masking. A tape recording of the voice
of the patient during and after masking is provided to the
patient and the patient should try to match the voice generated
during masking on a consistent basis.
Glottal attack before a
vowel: Vowel is a very important sound
in speech. It is also easily amenable to therapy /
change. Glottal attack involves bringing both vocal cords
into close approximation. The patient is asked to breathe
in, build air pressue in the subglottic area. This causes
increased muscular tension in the laryngeal area. The vowel is
uttered as the air is breathed out. This procedure enables a
patient with puberphonia to settle down to their basic
fundamental frequency of voice.
to relax laryngeal musculature:
Laryngeal muscles can be
relaxed using the following relaxing procedures:
technique: The patient is advised to practise yawning,
followed by generation of a sighing sound. This procedure
reduces the tension on the vocal folds.
Chewing technique: First the
act of chewing in an exaggerated manner is practised. Then
gradually random sounds, words and sentences are added to this
task. This act reduces the tension of the laryngeal
/M/ warm up: To warm up the vocal cords
the consonent M is spoken or sung before the words. This helps
to produce a gentle air flow through the larynx as phonation
Visipitch: This instrument is commonly used by
speech pathologists to treat various speech disorders. This
machine helps in extraction of Critical
speech and voice parameters and displays them in true
real-time to help clients achieve therapy goals with visual
feedback. This machine helps in training the patient in
nuances of normal speech production.
Boone's technique of
larynx lowering: This method is also known as "Yawn - sigh"
method. The patient is asked to simulate a yawn and while
yawning is in progress asked to sigh. This manuver
not only lowers the larynx it also relaxes it.
Humming while sliding down the scale: In this exercise
the patient is taught to hum in the highest pitch possible and the
humming is continued by lowering the pitch. This exercise
helps not only in tuning the vocal cords it also relaxes the
swallow Boom technique: In this technique the
patient is asked to swallow. While swallowing is in progress
the patient is asked to say "Boom". Then the patient is asked
to turn to one side and say "BOOM". The
same exercise is repeated by turning the head to the
The patient is
then asked to lower the chin, and say Boom. The patient is
taught to add words to the BOOM.
The swallow procedure is
known to maximise the closure of larynx. The sound Boom is
produced by posterior pressure to the larynx. The patient
gradually learns to lower the pitch of his voice.
Antero posterior compression of thyroid cartilage:
Compression is applied to the Adam's apple area in the neck using
the thumb and the patient is asked to speak. This procedure
relaxes the vocal cord and lowers its basic pitch. The patient
is instructed to repeat this exercise frequently while attempting to
speak. This helps in reducing the basic pitch of the patient's
manipulation: This is a quite recent method in the treatment
of puberphonia. This was first reported by Sudhakar vaidya in
Laryngoscope journal in 1995. Patient was
asked to come nil by mouth for six hours before the procedure
in the ENT outdoor. Patient was examined under xylocaine spray
anesthesia by anesthesiologistís intubation laryngoscope
(Macintosh).Long blade of laryngoscope was put in valleculae
and patient was asked to speak a long eeeee. Pressure over the
valleculaestretched the vocal cords. Sometimes-additional pressure
was applied by a laryngeal biopsy forceps over the anterior
commisure. The external digital pressure over the thyroid cartilage
also helped in improvement of the voice quality.The procedure was
repeated 3-4 times in a single sitting.
Surgical therapy: It was first
reported by Pau and Moorthy who mobilized the hyoid bone by
dissecting the supra hyoid musculature. This procedure reduces
the distance between the thyroid and cricoid cartilage.
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