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Loreto Nercelles Carvajal
Address: Fernández Concha 700, Las Condes
Santiago. Chile. Zip Code: 7560356
loreto.nercelles@unab.cl
INTRODUCTION: Puberphonia is a voice disorder that begins in adolescence and is characterized by the use of a higher pitch after the period of vocal change. The causes are multiple, ranging from lack of adaptation of the laryngeal muscle to environmental and psychosocial influences.
OBJECTIVE: The objective of this study was to collect and analyze the current scientific evidence on the evaluation and treatment of puberphonia.
DATA SOURCE: A search for works published from 2008 to 2018 was carried out in the PubMed and LILACS (Latin American Literature) databases. The search terms used were puberphonia, mutational falsetto, voice change disorder 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 abstract did not include methodology, results or conclusions of the research.
DATA SYNTHESIS: The literature review revealed 16 articles that met the inclusion and exclusion criteria. The reviewed studies had a total sample size of 1 to 45 subjects with puberphonia, all male. Most of the sample designs were non-experimental and only two were experimental (case-control).
CONCLUSION: Puberphonia is a voice disorder characterized by the use of higher tones and vocal instability. Speech-language therapy is the most effective measure according to the literature review. However, type III thyroplasty is also an alternative surgical option, especially in cases where speech-language therapy does not produce good results.
INTRODUCTION
Throughout life, the voice undergoes various changes that are due to developmental factors, in which the nervous system and the hormonal system play a predominant role 1 . However, during puberty, a change occurs called the vocal change period. During this stage, especially in men, a series of important transformations occur, in which the adolescent abandons the characteristic high-pitched tone and moves on to an adult voice with a low tone. This change is usually the result of a morphological adaptation of the larynx to the development of the organism 2 .
The vocal change period represents a stage of imbalances, characterized by anatomical changes such as: increased neck length, lowering of the larynx, widening of the thorax, growth of the resonance cavities, trachea and lungs 3-5 . Voice change occurs in men around the ages of 13 to 15, while in women it occurs around the ages of 12 to 14 2,6 .
Structural modifications generate changes in vocal parameters, especially in the high 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 months 7, 8 . This process of vocal change does not always occur normally. There are occasions when the voice change is delayed or not completed, persisting with a childish voice 9 . These disorders are known as vocal change disorders or puberphonia, whose main symptomatology is a higher pitch of the voice. 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 of keeping the larynx in a high position 3,7,10-14 .
The causes of this condition are multiple, but are generally associated with muscular adaptation, environmental or psychosocial problems 11 . When the cause is a lack of muscular accommodation, the individual changes the entire vocal apparatus to maintain a childlike voice, commonly maintaining an elevated larynx 15 . Regarding environmental or psychosocial causes, some researchers have linked puberphonia to domineering mothers, overly demanding or overprotective fathers who do not allow their children to face adult responsibilities 2 . Others have associated it with a weak father figure 16 . Finally, cases have also been described in which the individual wants to retain his high-pitched voice due to identification with some childish character who has a high tone and whom he likes to imitate 17 .
OBJECTIVE
To collect and analyze scientific production on the evaluation and treatment of puberphonia.
METHODOLOGY
To achieve the objective of this study, an integrative literature search was carried out through an analysis of articles published between 2008 and 2018 in recognized databases (PubMed and LILACS). The following were used as subject descriptors in the advanced search: puberphonia, mutational falsetto and voice change disorder in Spanish, English and Portuguese in all their possible combinations.
A definition was subsequently developed applying exclusion criteria. Studies classified as literature review articles and those that did not present the methodology and conclusions or results of the investigation in their abstract were eliminated. The final number of selected articles was 16 studies.
RESULTS
The reviewed studies have a total sample that comprised between 1 and 45 individuals, all male. Table 2 shows the research designs, which mostly had non-experimental sample designs and only two were experimental (case-control).
Table 3 shows the different treatment techniques presented in the studies. Most of the studies that delved into the evaluation and therapy of subjects with puberphonia used speech therapy as the exclusive treatment resource (62.5%), and only five (31.2%) studies presented the surgical technique as a treatment for this vocal disorder.
Table 4 summarizes the main aspects of the articles found, separated by author, year, article, objective, sample, methodology and results.
The results were then grouped according to the assessment, speech therapy, surgical therapy and treatment time.
1) Puberphonia assessment
Regarding the assessment and reassessment of puberphonia, the literature review indicates that it is important to complement the perceptual or auditory measurement performed by the speech therapist with objective voice analysis using software such as MDVP 18 , Speech Range Profile (SRP) 19 , electroglottography 20,21 and to measure aerodynamic performance 22 .
The assessment guidelines that analyze information about the physically, emotionally and socially disabled should also be applied at the beginning and end of therapy. The most commonly used assessment was the reduced version of the Vocal Inability Index (VHI-10) 21-23 .
Regarding the otorhinolaryngological assessment, the literature recommends ruling out organic lesions of the vocal folds, auditory pathologies and endocrinological dysfunctions 21 . The recommended instrumental examination was videostroboscopy 21,24 .
The need for a psychological evaluation or intervention is also indicated to provide more information about the adolescent’s emotional state and to explore whether there is any component that interferes with normal vocal change 25,26 .
2) Speech therapy
The evidence studied establishes that speech therapy of the voice is successful and can reduce the tone of the voice from high to low, and the fundamental frequency stabilizes after therapy 27,28 . Other studies add achievements regarding the stability of the intensity 29 .
In speech therapy, various methods and techniques are described to address the vocal change disorder. It is worth noting that the techniques used during therapy will depend on the type of patient and their vocal needs or requirements. In addition, these will be chosen according to the comfort and criteria of each therapist. Manual laryngeal repositioning therapy has shown to be an effective and efficient method for lowering the tone of the voice 30 . Furthermore, research describes that visual feedback should be added so that the patient can better understand the variations in tone that he or she must perform 31 . Likewise, therapy with DoctorVox is highly effective for the treatment of puberphonia 21 .
3) Surgical therapy
Surgical therapy, specifically type III thyroplasty, was the most indicated when speech therapy fails to achieve significant progress. In this surgery, the vocal cords are shortened by incising the anterior segment of the cartilage. During this procedure, two portions of the thyroid cartilage are removed, retracting the anterior commissure toward the posterior region of the glottis. As a consequence, there will be a decrease in vocal cord tension, which will produce a deeper voice 23,24,28,29,32,33 . Another study refers to a case of surgery applying bilateral laryngoplasty through the injection of hyaluronic acid, which allowed the voice frequency to be lowered bilaterally and immediately 28 .
4) Optimal therapy time and duration of progress
It is estimated that changes in the voice could be achieved in four weeks of therapy. This time is shorter for subjects with vocal hyperfunction. Likewise, subjects without hyperfunction may require more therapy time 22 . Regarding the duration of therapeutic progress, there are studies that perform between 6 and 24 months of follow-up after speech therapy, maintaining the frequency values 18,21,28 .
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, a surgical option can be sought. The recommended surgery is type III thyroplasty. On the other hand, research shows that the therapy is very efficient in relation to the number of sessions, since consistent changes in the voice could be obtained in the same month.
Among the limitations found, the lack of information about puberphonia in women stands out. Although most of the changes occur in men according to the bibliography, it would be interesting to investigate what happens in the evaluation and therapy of the hyperacute female voice. In addition, it would be important to have more studies with larger samples and a greater number of publications with experimental and case-control or cohort designs to provide greater reliability to the results.
CONCLUSION
Puberphonia is a voice disorder characterized by the use of higher pitch, bitonalities and vocal instability. The reviewed bibliography highlights speech therapy as an excellent therapeutic measure. In addition, other studies present type III thyroplasty as the most commonly used surgical alternative, especially in cases where speech therapy does not yield good results.
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5. Marinho A, Costa H, Duprat A, Eckley C. Dysphonia and hormonal changes. Pediatric laryngology. Sao Paulo: Roca; 1999. p. 23-38.
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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.
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