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Table of Contents
Year : 2012  |  Volume : 2  |  Issue : 2  |  Page : 64-69

Treatment of laryngeal hyperfunction with flow phonation: A pilot study

1 Department of Communication Sciences and Disorders, University of Central Arkansas, Little Rock, AR, USA
2 Department of Audiology and Speech Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
3 Department of Communication Sciences and Disorders, University of Central Arkansas; Department of Audiology and Speech Pathology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
4 Speech Pathology Program, University of Arkansas for Medical Sciences Medical Center, Little Rock, AR, USA
5 Department of Otolaryngology Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, AR, USA

Date of Web Publication5-Feb-2013

Correspondence Address:
Gary H McCullough
University of Central Arkansas, Department of Communication Sciences & Disorders, 201 Donaghey Avenue, Conway, AR 72035
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2230-9748.106980

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Context: While clinical successes and descriptions have been reported in a few texts, no data exist to define the utility of flow phonation to improve voice quality in patients with laryngeal hyperfunction. Aims: To provide pilot data regarding the utility of three exercises (gargling, cup bubble blowing, and stretch-and-flow) to improve phonatory airflow during voicing in patients with laryngeal hyperfunction. Settings and Design: Outpatient Voice and Swallowing Center in a University Medical Center. Materials and Methods: Participants received five treatment sessions and were evaluated prior to treatment and after each session using a Phonatory Aerodynamic System to measure airflow during voicing tasks. Noise-to-harmonic ratio and perceptual voice measures were also obtained, as was self-perception of voice handicap. Statistical Analysis Used: Repeated All increased airflow and decreased laryngeal airway resistance over five sessions. Measures Analysis of Variance. Results: Six participants completed the protocol. All participants decreased self-perception of voice handicap and improved on noise-to-harmonic ratio and perceptual ratings of vocal quality. Conclusions: Data derived on a small sample of patients in an exploratory investigation suggest further research into the use of these three exercises to improve airflow with voicing and improve vocal quality in patients with laryngeal hyperfunction is warranted.

Keywords: Dysphonia, hyperfunction, treatment, voice

How to cite this article:
McCullough GH, Zraick RI, Balou S, Pickett HC, Rangarathnam B, Tulunay-Ugur OE. Treatment of laryngeal hyperfunction with flow phonation: A pilot study. J Laryngol Voice 2012;2:64-9

How to cite this URL:
McCullough GH, Zraick RI, Balou S, Pickett HC, Rangarathnam B, Tulunay-Ugur OE. Treatment of laryngeal hyperfunction with flow phonation: A pilot study. J Laryngol Voice [serial online] 2012 [cited 2022 May 17];2:64-9. Available from: https://www.laryngologyandvoice.org/text.asp?2012/2/2/64/106980

   Introduction Top

Laryngeal hyperfunction can manifest behaviorally in varying forms affecting the balance of laryngeal activity as air flows through the glottis. [1],[2] Hoarseness, vocal fatigue, and pain can result. [3] Stone and Casteel [4] proposed the therapeutic use of airflow exercises, described as flow phonation. Flow phonation is the idea of proper channeling of air stream achieved using a relaxed laryngeal position, which eventually facilitates clear vocal quality. The exercises are believed to facilitate relaxation and reduce strain and tension in the extra-laryngeal musculature. [5],[6]

Airflow is a critical component to normal voicing and has been targeted in related ways. For some patients, respiratory support is inadequate for voicing or vocal fold closure is inadequate, as is often the case in patients with Parkinson's disease or unilateral vocal fold paresis-or even in otherwise normal aging individuals. Sapienza's expiratory muscle strength training has emerged as a valuable tool for improving respiratory strength for voicing and swallowing when respiratory drive is inadequate. [7] Stemple's vocal function exercises have been successfully used to improve vocal fold function in hyper- or hypofunctional patients but have greatest support for improving vocal fold closure, decreasing glottal airflow, and increasing aerodynamic resistance when vocal fold closure is compromised. [8] The patients targeted in this study presented with laryngeal hyperfunction characterized by muscle tension pattern (MTP) 1, and sometimes 3, with resulting changes in airflow and laryngeal resistance. The objective was to determine the effects of flow phonation on phonatory airflow and laryngeal aerodynamic resistance in these patients.

   Materials and Methods Top

Selection and description of participants

Study participants were recruited from the University of Arkansas for Medical Sciences (UAMS) Voice and Swallowing Center. In order to take part in this study, patients met the following inclusion criteria: (1) at least 18 years of age, (2) evident laryngeal hyperfunction (3) English preference skills at a level which allowed participation, and (4) informed consent to participate. Patient exclusion criteria included: (1) presence of a concomitant speech and/or cognitive-language disorder, (2) unilateral or bilateral vocal cord paresis, (3) history of stroke or neurodegenerative disease, and (4) structural abnormality that could affect respiration, phonation, resonance, or swallowing. All six participants exhibited MTP 1 and sometimes 3 type of hyperfunction. Five had evidence of laryngopharyngeal reflux (LPR). None had vocal fold lesions. Some patients had various other medical conditions requiring medications, none with the potential to directly impact the voice. The UAMS Institutional Review Board approved this study.


Patients underwent a medical evaluation performed by an otolaryngologist fellowship trained in care of the professional voice (co-author OT). This evaluation included rigid laryngostroboscopy recorded on a KayPentax computer-based system (KayPentax Corp., Lincoln Park, NJ, USA). During this examination, the patient sustained "ah" for at least 3 seconds at the most comfortable speaking pitch and loudness, as well as at the lowest pitch and highest pitch increasing and decreasing loudness. Vocal fold function was examined in regular halogen mode and with stroboscopy. In addition, prior to the passage of the scope but with audio recording, each participant: (a) sustained the vowel /a/ for 3 seconds, (b) read aloud select sentences, (c) read aloud the first paragraph of the Rainbow Passage, [9] and (d) produced a short conversational speech sample. The otolaryngologist and two other authors with extensive experience evaluating and treating voice disorders reviewed videostroboscopic examinations to ensure proper fit for the study.

Patients' perception of voice handicap

The Voice Handicap Index (VHI), [10],[11] a validated patient-reported outcomes questionnaire, was used to determine each participant's self-perceived degree of voice handicap. Each participant completed the VHI at the beginning and at the end of treatment.

Perceptual voice analysis

Perceptual analysis involved auditory-perceptual judgments of overall severity, roughness, breathiness, strain, pitch, loudness, asthenia (vocal weakness), and hoarseness using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). [12],[13] All voice samples were rated at the beginning and at the end of treatment by one of the study clinicians and then re-rated blindly by authors with at least 10 years experience with voice evaluation and treatment. Samples were randomly ordered and coded. The severity of each judgment was quantified by an "X" mark through a 100-mm horizontal line, where the far left end of the line represented normal (and thus assigned a rating of 0) and the far right end of the line represented most abnormal (and thus assigned a rating of 100).

Acoustic analysis

Noise-to-harmonic ratio (NHR) was obtained in a treatment room, which exhibited nominal ambient room noise. NHR has been reported to be the most correlated acoustic measure with perceptual judgments of roughness, breathiness, and hoarseness. [14] The KayPentax Computerized Speech Lab (CSL) Model 4500 (KayPentax Corp., Lincoln Park, NJ) was used to record the /ah/ vowel sustained for 5 seconds, which was then analyzed for NHR. The default calibration settings of the CSL Model 4500 were used, and the microphone was kept at a consistent distance of approximately 6 inches from the speaker's mouth.

Aerodynamic analysis

Measures of laryngeal airflow and voicing were obtained at the beginning of treatment session 1 and after each of 4 subsequent treatment sessions. The KayPentax Phonatory Aerodynamic System (PAS) Model 6600 (KayPentax Corp., Lincoln Park, NJ) was used to collect the acoustic and aerodynamic data from each participant. There is now adult normative data for the PAS Model 6600 allowing for comparison to our results. [15]

At the beginning of each session, airflow and pressure calibration of the PAS were carried out according to the manufacturer's recommendations. Data were then collected using six protocols: (1) Air Pressure Screening, (2) Vital Capacity, (3) Maximum Sustained Phonation, (4) Comfortable Sustained Phonation (CSPH), (5) Variation in Sound Pressure level, and (6) Voicing Efficiency. For this data analysis airflow with voicing was the chief focus; therefore, the CSPH and Voicing Efficiency (VOEFF) protocols were chosen, and implemented as follows:

Comfortable sustained phonation

The participant was instructed to take a deep breath, then to produce a sustained open vowel ("aaah") at a comfortable pitch and loudness for at least 5 seconds once data capture was initiated. The middle 5 seconds of each utterance was analyzed.

Voicing efficiency

The participant was instructed to repeat the voiced vowel /a/ and the voiceless stop plosive /p/ nine times in vowel/consonant format (i.e., /apapapapapapapa/), placing equal stress on each syllable. To ensure equal rhythm, participants were trained in each speaking task until they produced the syllable trains at the appropriate pace and were speaking at their comfortable loudness level.

Measures of peak (intra-oral) air pressure during the production of the consonant /p/ were used to provide an estimate of subglottal pressure. Mean airflow during voicing was derived from the oral airflow measures recorded during the vowel segment of the /apapapapapapapa/ production. Mean phonatory sound pressure level (SPL) was also measured during this vocal efficiency task. Three measures (peak air pressure, mean airflow during voicing, and mean SPL during voicing) were subsequently used by the PAS software to calculate phonatory resistance (laryngeal airway resistance), aerodynamic power, and aerodynamic efficiency values. The airflow signal was examined to be certain it went down to baseline (zero) for each pressure peak, so as to not underestimate subglottic pressure. The peak oral pressures of the second through eighth productions of each utterance were averaged and comprised one trial per utterance.


Each treatment session took place in the same clinical room as the assessment and utilized three exercises: gargling, cup bubble blowing, and stretch and flow. Each exercise used a built in form of biofeedback (water or tissue) and the same basic progression of activities (with minor alterations): (1) airflow task without voicing to establish positive airflow, (2) adding voicing to the task, (3) moving up and down the pitch range during the voicing task, (4) moving to a speaking/voicing task, and (5) removing biofeedback. During each vocalization attempt, the clinician listened for a clear and effortless vocal quality and training the participant to listen.

The gargling exercise required the participant to place a small amount of water in the mouth, recline the head, and gargle without voice 10 times for 5-6 seconds with breaks in between. Participants were instructed to relax the throat and gargle with enough airflow to make the bubbles pop up out of the mouth. After this was accomplished, the next step was to gargle the same way but with voice-again ensuring bubbles popped up out of the mouth. The third step was to gargle with the voice moving up and down pitch scales freely and relaxed. This was done 10 times, as well. The fourth step began with participants gargling with the voice and then required them to roll their head forward while gargling, closing the mouth as their head rolled forward allowing the sound to come out the nares into a hum. Participants then swallowed the water, took an easy breath, and repeated "mmmma ma ma ma," "mmmmay, may, may, may," and continued with other vowels. When voicing sounded sufficiently relaxed and nasal without laryngeal tension, it was carried over into words, such as mamma, mary, many, maybe, marble. It is important to note this exercise may be contraindicated in patients with dysphagia. For those patients, the cup bubble exercise should be used instead.

The cup bubble blowing exercise required participants to take a clear, plastic cup of water filled about 2/3 of the way up, place their mouths over the cup and tip it up until the top lip was in the water. The participants drew in a breath and blew bubbles without using voice, again to establish positive airflow. Bubbles were supposed to be actively popping up from the cup. This was done 10 times and then voicing was added for 10 trials to make a "motor boat" sound. When voicing was added, bubbles remained just as active as they were without the voice. In the third step, participants blew bubbles with voice moving freely and relaxed up and down in pitch. In the fourth step, participants began by blowing bubbles with the voice then slowly pulled the cup away from the mouth. As the cup pulled away pursed lips were maintained and the sound continued into a relaxed, breathy "oooh." After a breath, "ooh" was repeated. This step was repeated 10 times.

The final exercise was "stretch and flow." For this exercise participants took a piece of tissue paper, separated the layers, and folded one layer in half. The tissue was held between the index and middle fingers near the top of the tissue, and the tissue was held in front of the face hanging down where the mouth was centered around the junction of the bottom and middle third. In the first part, participants blew air into the tissue such that the tissue moved back parallel to the floor for 4-5 seconds. This was done 10 times with breaks in between. The airflow was to feel easy and effortless. Then, participants began as in step 1, blowing air into the tissue. When the tissue was parallel to the floor, participants added in voice. The tissue was to remain parallel to the floor, so the voice would be very breathy. This was done 10 times with sufficient breaks. In step 3, participants began blowing air into the tissue and voicing simultaneously, ensuring it was parallel to the floor, and then said "one" with the same easy, breathy voice. The tissue would come down. This was repeated for numbers two, three, etc, up to ten. The fourth step was done the same way but with "H" and "WH" initiated phrases rather than words (i.e., "How are you?" "What time is it?").

Participants started with gargling and/or cup bubble blowing. As they mastered one or both of these they were moved into stretch and flow. There is room for some variability from participant to participant depending on success with the exercises, but generally patients seem to benefit from gargling and/or cup bubble blowing prior to stretch and flow due to difficulty.

For exercise at home, each participant practiced as instructed four times per day for about 10 minutes per session. This regimen was employed to help prevent overuse and exacerbation of the hyperfunction and to promote carryover into speaking throughout the day. Participants maintained a log which required them to mark a check for each successful exercise attempt and an X for each attempt they believed was unsuccessful. All participants' logs were completed and returned demonstrating compliance.

Statistical analysis

Mean expiratory airflow during comfortable phonation and mean airflow and aerodynamic resistance during a voicing efficiency task (pa-pa-pa) were analyzed across all five treatment sessions-beginning of session 1 and end of sessions 2 through 5-using a repeated measures analysis of variance (RMANOVA). NHR, VHI Ratings, and overall severity based on the CAPE-V were analyzed with paired sample t-tests. Interjudge agreement for perceptual ratings on the CAPE-V was established by having one of two authors with many years experience working with voice patients blindly rate participants' samples. Agreement was within category range (mild, moderate, severe) 100 percent of the time. An intraclass correlation coefficient was also run (single measures = 0.558; average measures = 0.717; both significant at 0.001).

   Results Top

Six medically stable patients with dysphonia participated in this study. Ages ranged from 28 to 58 years with a mean of 44.5 years. Consensus review by the otolaryngologist and speech pathology authors confirmed each participant had laryngeal hyperfunction with a constricted laryngeal vestibule type MTP 1 and sometimes 3.

Mean changes from initial assessment to posttreatment in expiratory airflow during comfortable phonation (liters/second), mean airflow during voicing efficiency task (liters/second), and mean aerodynamic resistance during voicing efficiency task (cm/water) are provided in [Table 1]. Changes in each of these measures across five sessions are presented in [Figure 1] and [Figure 2]. Using RMANOVA, multivariate testing of the within subjects effect of treatment was significant (Wilks' Lambda value 0.024, F=16.762, P = 0.003, PES 0.976). Due to the small sample, univariate testing provided insufficient power.
Figure 1: Mean change across five sessions for expiratory airflow on comfortable phonation and airflow during voicing on a voice efficiency task (pa-pa-pa). Mean Ex Air = Mean expiratory airflow during comfortable phonation. Mean Air Dur Voice = Mean airflow during voice efficiency task

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Figure 2: Mean change across five sessions for aerodynamic resistance during a voice efficiency task (pa-pa-pa). Aero Res = Aerodynamic resistance during voice efficiency task.

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Table 1: Changes in measures of laryngeal airflow during comfortable phonation and voice efficiency tasks

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All participants were judged to have at least a mild-to-moderate degree of roughness on CAPE-V ratings consistent with laryngeal hyperfunction. Mean pre- and posttreatment values for overall severity based on the CAPE-V decreased from 43.00 to 10.33. NHR decreased from an initial mean of 0.290 to 0.178 after five sessions. Self-perception of voice impairment or VHI ratings decreased/improved from a mean of 80.5 to 40.83. Paired samples t-tests are as follows: CAPE-V Severity, t = 3.367, P = 0.02; NHR, t = 4.163, P = 0.053; VHI, t = 4.787, P = 0.005.

   Discussion Top

Laryngeal hyperfunction disrupts the balance of extrinsic and intrinsic laryngeal musculature affecting phonatory airflow and laryngeal resistance. The result is a stream of air that is difficult to control. In terms of perception, the result is a rough or sometimes harsh vocal quality. While reports of successful outcomes from treatment of laryngeal hyperfunction do exist in the research literature, [16],[17],[18] no current treatments are successful with all cases. The causes and symptoms associated with hyperfunction of the larynx are variable and more treatment options are needed, as are more data-based reports for treatments. Variants of flow phonation have been successfully used by various clinicians and clinical researchers for years and have been discussed in several texts. [5],[6],[19],[20],[21] No data, to our knowledge, have been provided in the research literature to validate clinical successes. The objective of this study was to report pilot data on six patients with laryngeal hyperfunction to determine whether any improvement in airflow during voicing occurs as a result of these exercises. Any consistent values in this phase 1 research would provide the impetus for additional study to refine the protocol, establish dose response and additional outcome measures, and include controls.

The three exercises utilized in this study-gargling, cup bubble blowing, and stretch and flow-were used in concert to retrain laryngeal muscles to allow the air to flow through the larynx without voice, with voice, and then with voice and different pitches and different types of vocalizations. We utilized a guided progression of these exercises over the course of 5weeks and monitored changes in airflow with voicing using the KayPentax PAS Model 6600. Results are very preliminary but are, nonetheless, positive. All six participants normalized in the three major areas of airflow assessed: mean expiratory airflow during comfortable phonation, mean airflow during a vocal efficiency task ("pa-pa-pa"), and aerodynamic resistance during the vocal efficiency task. [22] Comparing results from these participants to normal volunteers [15] our participants moved from outside the range of normal to within the range of normal for most measures. Some overshot normal at times. As these are participants striving specifically to rebalance expiratory airflow and laryngeal resistance in treatment, and these measures were taken at the conclusion of the fifth treatment session, this is likely a very positive result. Different laryngeal imbalances, however, could potentially result if the treatment is overdone and not monitored. This should be considered in future studies with longer follow-up. Initial evidence, while based on a small sample, demonstrates that changes in airflow and resistance with these patients translates into improvements in NHR-a measure sensitive to vocal roughness-as well as perceptual ratings of voice (CAPE-V) and self-perceived voice handicap (VHI).

Reasons for the success of the airflow exercises have been proposed. Many patients with hyperfunction also exhibit an elevated position of the hyoid bone and the larynx. [23] Tilting the head back for the gargling exercise is believed to inhibit further laryngeal elevation and stretch extralaryngeal muscles. [6] Releasing air smoothly and consistently during the exercise complements relaxation of the extralaryngeal muscles, which in turn enables clarity in vocal quality. As the patients progress in the exercise, they are instructed to gradually move the head forward so that generalization of the clear voice is achieved even without the head being tilted. Another principle this exercise adopts is the traditionally accepted [20],[21] forward focus of voicing instead of a laryngeal focus. Reducing laryngeal activity and shifting the voicing focus higher up in the oral-nasal cavities improves voice quality. Moreover, it has been demonstrated that patients using forward focus to achieve a resonant voice adjust to a slightly adducted/slightly abducted configuration for improved voicing. [22],[24] It is possible a similar configuration may result from these exercises leading to the stabilization of flow v. resistance we observed and should be investigated further.

The cup bubble blowing exercise and stretch and flow also utilize the idea of relaxed airflow and forward focus. [6] Bubbles during the cup bubble exercise are stronger and consistent with relaxed flow of air and erratic with airflow through a tensed laryngeal system. The use of the stretch and flow exercise gives more visual feedback than the other two exercises but is, arguably, more difficult. The tissue is optimally lifted up only with a steady and consistent flow of air. [6] The airflow is consistent and smooth only when the larynx is relaxed and open, a point which is emphasized in therapy.

Based on our pilot study enrolment of six participants with laryngeal hyperfunction, use of these exercises appears to rebalance laryngeal airflow with resistance in voicing. Moreover, these improvements have the potential to translate into positive changes in self-perception of vocal impairment and acoustic and perceptual voice quality. We believe results justify additional research with larger numbers of patients in more rigorously designed methodologies. Additional research is underway to examine reasons for these improvements with a larger sample of participants, increase the acoustic and perceptual measures utilized, and define the most appropriate treatment regimen and dose-response.

   Acknowledgements Top

The authors would like to thank the UAMS Medical Center, Departments of Speech Pathology and Otolarynology for their support, including Glenn Ballard, Amy E. Chandler, and Rosemary J. Lumley for their willingness to provide time and space and help with subject recruitment and patient care. The authors also thank the patients who volunteered to participate in the study.

   References Top

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  [Figure 1], [Figure 2]

  [Table 1]

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