Puberphonia

• Emotional stress[13]
• Delayed development of secondary sex characteristics[13]
• Resistance to pubertal changes[3]
• Self-consciousness resulting from an early breaking of the voice[11]
• Self-consciousness resulting from emerging adulthood[1]
• Excessive admiration of another male or sibling[14]
• Excessive maternal protection[14]

• Laryngeal muscle tension which then causes laryngeal elevation[12]
• Muscle incoordination[15]
• Congenital anomalies of the larynx[12]
• Vocal fold asymmetries[12]
• Unilateral vocal fold paralysis[12]
• Non-fusion of the thyroid laminae. When this is the case, it is important that hypogonadism is ruled out, as this may be the cause.[12]

Puberphonia is most often diagnosed in adolescent or adult male patients.[16] 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.[16] 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][14]

Puberphonia is a functional voice disorder. 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]

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

• Examining for tension in the neck and throat: The clinician will visually examine the area around the larynx to see if the voice box sits high in the throat, and palpate the area to determine whether there is excessive muscular tension.[4]
• Determining the relationship between tension and vocal pitch: The clinician will ask the patient to perform warm-up and relaxation exercises such as those listed in the Treatment section below to determine whether the patient has access to their modal voice register.[4]
• Establishing vocal range: The clinician will ask the patient to produce the lowest and highest pitch that they can, and perform different speaking or singing activities at various pitches.[16]
• Listening for abnormal traits: The clinician will listen for the presence of breathy voice, an indication of speech in the falsetto register, and other distortions of vocal quality.[16]
• Taking aerodynamic measurements: Many individuals with puberphonia may have limited breath support caused by the thoracic or shallow breathing patterns often used to support speech in the falsetto register.[4] These symptoms are assessed using vocal tasks such as maximum phonation time and direct measures of breath support such as glottal airflow and subglottal pressure.[4][6]

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][16]

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]

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]

• Vocal exercises: Any vocal exercises should always be done under the supervision of Speech Language Pathologists (SLPs) who are experts in treating voice disorders. Wrong methods of doing vocal exercises, or wrong specific vocal exercises, may damage the voice or vocal cords, sometimes permanently. Wrong vocal exercises are a kind of vocal abuse. Vocal abuse can result into vocal nodules, muscle tension dysphonia, vocal polyps, or a hoarse and breathy voice.
• Cough: The patient is asked to apply pressure on the Adam's apple and cough. This results in the shortening of the vocal folds which is the physiological mechanism that reduces pitch. The patient can thus practice voicing at a lower pitch.
• Speech range masking: This procedure is based on the theory that when speaking in noisy backgrounds, people speak louder and more clearly in order to be heard. The patient practices speaking while a masking noise is playing. Then, the patient listens to a recording of his/her voice during the masking session and tries to match it without the masking. By doing this, the patient practices their 'loud and clear' voice.
• Glottal attack before a vowel: A glottal attack is when the vocal folds are fully closed and then pushed open by the air pressure from breathing out or making a sound. In this technique, the patient breathes in and then makes a vowel as he/she breathes out.
• Effortful closure techniques: this procedure is based on pushing, pulling, or isometric exercises to forcefully close the glottis, while the patient phonates, which effectually lowers the pitch due to the lowering of the larynx. The targeted sounds or words can then be shaped from the phonation produced during the exercises. In pushing exercises, the patient pushes against a structure (e.g., a wall) or object; in pulling exercises the patient pulls an object (e.g., a chair they are sitting on); in isometric exercises the patient holds a position (e.g., pushing hands together). Additionally, effortful closure techniques can be achieved through holding one’s breath or grunting.
• Laryngeal musculature relaxation techniques: Laryngeal muscles surround the vocal folds and by relaxing them, there is reduced pressure on the vocal folds. This can be done by yawning and subsequently sighing, exaggerated chewing while speaking, and speaking or singing the 'm' sound.
• Lowering of larynx to appropriate position: The larynx is lowered by the patient by putting pressure on the Adam's apple. By lowering the larynx, the vocal folds relax, and thus pitch is lowered. The patient does this while speaking to practice speaking with a lower pitch.
• Humming while sliding down the scale: The patient starts humming at the highest pitch that they can reach and then keeps lowering the pitch while humming. This allows the patient to practice using a lower pitch and also to relax the laryngeal muscles.
• Half swallow boom technique: The patient says 'boom' just after swallowing. This is repeated with the patient turning his/her head to either side and also while lowering the chin. After practice, the patient adds more words. This technique helps to close the vocal folds completely.

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]

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.[15] Incorporating audiovisual feedback in speech and voice therapies has been successful in intervention by improving motivation and guidance.[15]

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]