Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

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ISSN: 2177-5281 (Online)

Vol. 16 nº 1 - Jan/Mar - 2019

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Páginas 103 a 112


Evaluation and treatment of puberphonia: literature review

Evaluación y tratamiento de la puberfonia: revisión de la literatura

Avaliação e tratamento da puberfonia: revisão da literatura

Autores: Loreto Nercelles Carvajal

Doctor in Disturbances of Human Communication by the University of the Argentinean Social Museum - Argentina. Teacher. Voice Area Coordinator - School of Speech Therapy - Universidad Andres Bello. Santiago, AC, Chile

Loreto Nercelles Carvajal
Dirección: Fernández Concha 700, Las Condes
Santiago. Chile. CEP: 7560356
loreto.nercelles@unab.cl

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Keywords: Voice Disorders; Speech, Language and Hearing Sciences; Dysphonia.
Palabra Clave: Disturbios de la Voz; Fonoaudiología; Disfonia.
Descritores: Distúrbios da Voz; Fonoaudiologia; Disfonia.

Abstract:
INTRODUCTION: Puberphonia is a voice disorder that begins in the adolescence and it is characterized by the use of a high fundamental frequency after the period of vocal alteration. It has multiple causes, going from alack of adaptation of the laryngeal muscle to environmental and psychosocial influences.
OBJECTIVE: The aim of present study was to collect and analyze the current scientific evidence on the evaluation and treatment of puberphonia.
DATA SOURCES: We carried out a search of published works from 2008 to 2018 in the PubMed and LILACS (Latin American Literature) databases. The search terms used were puberphonia, mutational falsetto, disorder of the vocal change and all possible combinations in Spanish, English and Portuguese. The exclusion criteria used were: articles published in other languages, bibliographic reviews, articles that in their summary didn´t include methodology, results or conclusions of the research.
DATA SYNTHESIS: The literature review revealed 16 articles that met the inclusion and exclusion criteria. The studies reviewed had a total sample between 1 to 45 subjects with puberphonia, all male. The majority of the sample designs were non-experimental and only two were experimental type (control case).
CONCLUSION: Puberphonia is a voice disorder characterized by the use of more acute tone, bitonality and vocal instability. The voice therapy is the most effective measure according to the revision of the literature. However, there is also type III thyroplasty as a surgical alternative, especially in cases where voice therapy does not present good results.

Resumen:
INTRODUCCIÓN: La puberfonia es un desorden de la voz que empieza en la adolescencia y se caracteriza por el uso de un tono más agudo luego del periodo de alteración vocal. Las causas son múltiples, yendo desde falta de adaptación del músculo laríngeo hasta influencias ambientales y psicosociales.
OBJETIVO: El objetivo de este estudio fue recoger y analizar las evidencias científicas actuales sobre la evaluación y tratamiento de la puberfonia.
FUENTE DE DATOS: Fue realizada una búsqueda de trabajos publicados de 2008 a 2018 en las bases de datos PubMed y LILACS (Literatura Latinoamericana). Los términos de pesquisa utilizados fueron puberfonia, falsete mutacional, desorden de la mudanza vocal y todas las combinaciones posibles en español, inglés y portugués. Los criterios de exclusión utilizados fueron: artículos publicados en otras lenguas, revisiones bibliográficas, artículos que en su resumen no incluyeron metodología, resultados o conclusiones de la pesquisa.
SÍNTESIS DE DATOS: La revisión de la literatura reveló 16 artículos que atendieron a los criterios de inclusión y exclusión. Los estudios revisados tuvieron una muestra total entre 1 a 45 sujetos con puberfonia, todos hombres. La mayoría de los diseños de la muestra fueron no experimentales y apenas dos tipos experimentales (caso de control).
CONCLUSIÓN: La puberfonia es um disturbio de voz caracterizado por el uso de tonos más agudos e inestabilidad vocal. El tratamiento fonoaudiológico es la medida más eficaz de acuerdo con la revisión de la literatura. Sin embargo, también existe la tiroplastia tipo III como alternativa quirúrgica, principalmente en los casos en que la terapia fonoaudiológica no presenta buenos resultados.

Resumo:
INTRODUÇÃO: A puberfonia é uma desordem da voz que começa na adolescência e caracteriza-se pelo uso de um tom mais agudo após o período de alteração vocal. As causas são múltiplas, indo desde falta de adaptação do músculo laríngeo até influências ambientais e psicossociais.
OBJETIVO: O objetivo deste estudo foi recolher e analisar as evidências científicas atuais sobre a avaliação e tratamento da puberfonia.
FONTE DE DADOS: Foi realizada uma busca de trabalhos publicados de 2008 a 2018 nas bases de dados PubMed e LILACS (Literatura Latino-Americana). Os termos de pesquisa utilizados foram puberfonia, falsete mutacional, desordem da mudança vocal e todas as combinações possíveis em espanhol, inglês e português. Os critérios de exclusão utilizados foram: artigos publicados em outras línguas, revisões bibliográficas, artigos que no seu resumo não incluíram metodologia, resultados ou conclusões da pesquisa.
SÍNTESE DE DADOS: A revisão da literatura revelou 16 artigos que atenderam aos critérios de inclusão e exclusão. Os estudos revisados tiveram uma amostra total entre 1 a 45 sujeitos com puberfonia, todos homens. A maioria dos desenhos amostrais foram não experimentais e apenas dois tipos experimentais (caso de controle).
CONCLUSÃO: A puberfonia é um distúrbio de voz caracterizado pelo uso de tons mais agudos e instabilidade vocal. O tratamento fonoaudiológico é a medida mais eficaz de acordo com a revisão da literatura. No entanto, também existe a tireoplastia tipo III como alternativa cirúrgica, principalmente nos casos em que a terapia fonoaudiológica não apresenta bons resultados.

INTRODUCTION

During the course of life, the voice undergoes different changes that obey developmental factors, where the nervous system and the hormonal system intervene in a preponderant way1. However, during puberty a change happens called period of the vocal change. At this stage, especially in males, there are a number of important transformations where the teenager abandons the characteristic high pitch into a mature voice with severe tonality. This change is usually a consequence of a morphological adaptation of the larynx to the development of the organism2.

The period of vocal change represents a stage of imbalances, characterized by anatomical changes such as: increased neck length, laryngeal descending, enlargement of the thorax, growth of the resonance, tracheal and lung cavities3-5. Voice change occurs in men around the age of 13 to 15 years, while in women it occurs around 12 to 14 years2,6.

The structural changes are generating changes in the level of vocal parameters, especially in the acute tone of the voice. The voice becomes unstable, with many fluctuations and bitonality. Most researchers agree that this adaptation can last from three to six months7, 8. This process of vocal change isn´t always performed normally. There are times when the voice change is delayed or not complete a child's voice persists9. These disorders are known as vocal change disorders or puberphonia, whose main symptomatology is the most acute voice frequency. In addition, there may be bitonality, breathing and phono-respiratory coordination with possible alterations, increased tension in the peri-laryngeal zone generated by the effort to keep the larynx in a high position3,7,10-14.

The causes of this condition are multiple, but are usually associated with muscular, environmental or psychosocial adaptation problems11. When the cause is the lack of muscular accommodation, the individual performs a modification of the entire vocal apparatus to maintain a child's voice, usually maintaining the elevated position of the larynx15. Regarding environmental or psychosocial causes, some researchers have related puberphonia to dominant mothers, very demanding or overprotective parents who do not allow their children to cope with adult responsibilities2. Others have associated a weak father figure16. Finally, we also describe cases in which the individual wants to retain his acute voice due to identification with some childlike character that has a keen tone and likes to imitate17.


OBJECTIVE

To collect and analyze the scientific production on evaluation and treatment of puberphonia.


METHODOLOGY

To reach the objective of this study, an integrative search of the literature was carried out through an analysis of articles published between 2008 and 2018 in databases (PubMed and LILACS). They were used as descriptors of the subject in the advanced research: puberphonia, mutational falsetto and disorder of vocal change in Spanish, English and Portuguese in all possible combinations.

Subsequently a definition was elaborated applying exclusion criteria. We eliminated the studies classified as a review article in the literature and those that didn´t present in their summary the methodology and conclusions or results of the investigation. The final number of articles selected was 16 searches.


RESULTS

The reviewed studies have a total sample comprising between 1 and 45 individuals, all males. Table 2 shows the research drawings, which in the majority had non-experimental sample designs and only two of the experimental type (control case).






Table 3 shows the different treatment techniques presented in the research. Most of the researches that have deepened the evaluation and therapy of the subjects with puberphonia use speech therapy as a treatment exclusive resource (62.5%), and only five (31.2%) studies presented the surgical technique as treatment of this vocal disorder.




Table 4 summarizes the main aspects of articles found separated by author, year, article, objective, sample, methodology and results.




The results were then grouped according to the evaluation, speech therapy, surgical therapy and treatment time.

1) Evaluation of Puberphonia

Regarding the evaluation and reevaluation of puberphonia, the literature review indicates that it is important to complement the perceptual or auditory measurement performed by the speech-language pathologist with objective voice analysis using software such as MDVP18, Speech Range Profile (SRP) 19, electroglotography20, 21 and to measure aerodynamic performance22.

The evaluation guidelines that analyze the information of the physical, emotional and social deficient should also be applied at the beginning and at the end of the therapy. The most commonly used evaluation was the Vocal Inability Index in its reduced version (VHI-10) 21-23.

With regard to otorhinolaryngological evaluation, the literature advises to discard organic lesions of vocal folds, auditory pathologies and endocrine dysfunctions21. The recommended instrumental exam was videoostroboscopy21,24.

It is also indicated the need for a psychological evaluation or intervention for more information about the emotional state of the adolescent and to explore if there is any component that interferes in the normal vocal change25,26.

2) Speech Therapy

The studied evidence establishes that speech-language therapy is successful and can reduce the tone of the voice from acute to severe and the fundamental frequency after therapy stabilizes27,28. Other studies add gains in intensity stability29.

Speech and language therapy describes a variety of methods and techniques to address vocal change disorder. It should be noted that the techniques employed during therapy will depend on the type of patient and their needs or vocal requirements. In addition, these will be chosen according to the comfort and discretion of each therapist. Laryngeal manual repositioning therapy has been shown to be an effective and efficient method for lowering voice tone30. In addition, research describes that visual feedback should be added so that the patient better understands the variations of the tone that must be performed31. Likewise, the therapy with DoctorVox is highly effective for the treatment of puberphony21.

3) Surgical therapy

Surgical therapy, specifically type III thyroplasty was the most indicated when speech therapy cannot achieve significant progress. In this surgery a shortening of the vocal cords is performed by means of the incision of the anterior segment of the cartilage. During this procedure two portions of the thyroid cartilage are removed, retracting the anterior commissure towards the posterior region of the glottis. As a consequence, there will be a decrease in vocal cord tension, which will produce a more serious voice23,24,28,29,32,33. Another study refers to a case of surgery applying bilateral laryngoplasty by means of the injection of hyaluronic acid, which allowed lowering the frequency of the voice, bilaterally and immediately28.

4) The optimal therapy time and the duration of progress

It is estimated that within four weeks of therapy voice changes could be achieved. This time is shorter for subjects who present vocal hyperfunction. Of the same, the subjects without hyperfunction could require more time of therapy22. Regarding the duration of therapeutic progress, there are studies that make between 6 and 24 months of follow-up after speech therapy, maintaining frequency values18,21,28.


DISCUSSION

Regarding the choice of approach for puberphonia, most of the reviewed studies agree that the best therapeutic option is to start with speech therapy and if this type of therapy does not provide positive results it is possible to seek a surgical option. The recommended surgery is type III thyroplasty. On the other hand, the investigations reveal that the therapy is very efficient in relation to the number of sessions, since in the same month it would be possible to obtain consistent changes in the voice.

Within the limitations found, it highlights the lack of information about puberphonia in women. Although most of the changes occur in men according to the literature, it would be interesting to ask what happens in the assessment and therapy of the female voice hyperacusis. In addition, it would be important to have more studies with more numerous samples and more publications with experimental designs and the case control or cohort type to provide greater reliability to the results.


CONCLUSION

Puberphonia is a disorder of the voice characterized by the use of the most acute tone, bitonality and vocal instabilities. The reviewed bibliography highlights speech therapy as an excellent therapeutic measure. In addition, other studies present type III thyroplasty as the most widely used surgical alternative, especially in cases where speech therapy does not give good results.


REFERENCES

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2. Behlau M. Avaliação e tratamento das disfonias: Editora Lovise; 1995.

3. Anelli W, Costa H, Duprat A, Eckley C. Entendendo a muda vocal. Laringologia pediátrica. Sao Paulo: Roca; 1999. p. 39-44.

4. Behlau M. Voz: o livro do especialista. Rio Janeiro: Revinter; 2005.

5. Marinho A, Costa H, Duprat A, Eckley C. Disfonias e alterações hormonais. Laringologia pediátrica. Sao Paulo: Roca; 1999. p. 23-38.

6. Spiegel JR, Sataloff RT, Emerich KA. The young adult voice. Journal of Voice. 1997;11(2):138-43.

7. Fuchs M, Fröehlich M, Hentschel B, Stuermer IW, Kruse E, Knauft D. Predicting mutational change in the speaking voice of boys. Journal of Voice. 2007;21(2):169-78.

8. Alcantara MOS, Pechula JMM, de Campos A D, Olival HC, Benatti BA. A interferência da muda vocal nas lesões estruturais das pregas vocais. Brazilian Journal of Otorhinolaryngology. 2007;73(2).

9. Boone DR, McFarlane SC, Von Berg SL, Zraick RI. The voice and voice therapy: Pearson Higher Ed; 2013.

10. Dagli M, Sati I, Acar A, Stone R, Dursun G, Eryilmaz A. Mutational falsetto: intervention outcomes in 45 patients. The Journal of Laryngology & Otology. 2008;122(03):277-81.

11. Aronson AE, Bless D. Clinical voice disorders. New York: Thieme; 2011.

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13. Morrison MD, Nichol H, Rammage L. The management of voice disorders. New York: Springer; 2013.

14. Wojciechowska A, Obrebowski A, Studzińska K, Swidziński P. Mutation voice disorders conditioned by psychic factors. Otolaryngologia polskaThe Polish otolaryngology. 2010;64(1):51.

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19. Gokdogan C, Gokdogan O, Tutar H, Aydil U, Yilmaz M. Speech Range Profile (SRP) Findings Before and After Mutational Falsetto (Puberphonia). Journal of voice: official journal of the Voice Foundation. 2016;30(4):448-51.

20. Chernobelsky S. The use of electroglottography in the treatment of deaf adolescents with puberphonia. Logopedics, phoniatrics, vocology. 2002;27(2):63-5.

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23. Remacle M, Matar N, Verduyckt I, Lawson G. Relaxation thyroplasty for mutational falsetto treatment. The Annals of otology, rhinology, and laryngology. 2010;119(2):105-9.

24. Jiménez LH, Barreto T. Laringoplastia de relajación o tiroplastia de tipo III. Universitas Médica. 2012;53(1):86-93.

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30. Roy N, Peterson EA, Pierce JL, Smith ME, Houtz DR. Manual laryngeal reposturing as a primary approach for mutational falsetto. The Laryngoscope. 2017;127(3):645-50.

31. Franca MC, Bass-Ringdahl S. A clinical demonstration of the application of audiovisual biofeedback in the treatment of puberphonia. International journal of pediatric otorhinolaryngology. 2015;79(6):912-20.

32. Nakamura K, Tsukahara K, Watanabe Y, Komazawa D, Suzuki M. Type 3 thyroplasty for patients with mutational dysphonia. Journal of voice: official journal of the Voice Foundation. 2013;27(5):650-4.

33. Wang LP, Zhou Y, Zhang YF, Li GD. Relaxation laryngoplasty in the management of mutational falsetto. Zhonghua er bi yan hou tou jing wai ke za zhi.QChinese journal of otorhinolaryngology head and neck surgery. 2009;44(9):749-52.
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