Semi-occluded Vocal Tract Exercises

By creating a semi-occlusion at the level of the lips, tongue, or farther forward as with a straw, an optimal glottic configuration is achieved, with the vocal folds barely approximated. The rationale and physiologic underpinnings of these exercises are well described by Titze [13]. Self-sustained vocal fold oscillation occurs with the semi-occlusion, and voicing is produced with maximal output with minimal effort or strain. This can be effective in working with dysphonia related to hyperfunction (muscle tension dysphonia, vocal fold nodules) because it allows children to produce clear, functional voice without excessive impact forces. Conversely, it can also be helpful in achieving better vocal fold vibration in children with hypofunctional voice disorders (vocal fold paresis or paralysis, hyperfunctional underclosure, scar, reduced respiratory support) as it works to coordinate all three subsystems of voice for optimal voice quality. In working with children, semi-occluded vocal tract exercises are often approached through play. Straw phonation, blowing bubbles, and performing lip trills all create a semi-occlusion in the front of the vocal tract, resulting in improved efficiency of vibration at the level of the vocal folds, and more efficient sound with less effort.

These are all easily adapted to play situations. Examples of semi-occluded vocal tract exercises include phonation through a straw, blowing bubbles into water through a straw, humming, lip trills, tongue trills, and a “kazoo buzz” style sustained /u/. To adapt these to play, one can assign a sound to each vehicle when playing with cars – for example, a fire truck can be pitch glides, a plane can be a hum, a boat can be a lip trill, and a car can be a resonant “voomm” sound. With older children, these same exercises can act as turns in a game – for example, when playing Candy Land, you can do a lip trill for each purple, a hum for each yellow, etc. Many children find a game of “soccer” while moving a ball of paper or a ping-pong ball using straw phonation fun and motivating.

Resonant Voice Therapy

Resonant voice therapy is based on the work of Arthur Lessac [14] and was further developed into Lessac-Madsen Resonant Voice Training [15]. Resonant voice calls for a focus of vibratory sensations in the lips and face, with an absence of strain or effort in the throat. Typically, humming, chanting with nasal sounds, and nasal-loaded words and sentences are used to facilitate this production and generalize it into everyday speech. This is based on the concept that sensation of these vibrations, combined with easy phonation, reflects the optimal configuration of the vocal folds during vibration [16]. The configuration has been described as “minimally adducted, minimally abducted,” allowing for efficient, effective phonation without unnecessary effort. Even very young children can identify a sensation of “buzz” or “tickle” in their lips on a hum or /v/ sound, and this can be shaped into words with resonant voice. Training of this approach uses principles of motor learning to enable the child to learn to use their healthier voice all the time. As with semi-occluded vocal tract exercises, this approach can be effective both with hyperfunctional and hypofunctional voice disorders.

In adapting to children, we often create games with a focus on /m/ or /v/ loaded words, (e.g., moon, mouse, mine, milk, mail, very, vine, vase, violin). These can be as simple as “memory” or “go fish” with articulation cards, self-created Bingo games, or fishing with a magnetic pole. When moving into connected speech, I often use games requiring sentences, such as Guess Who (Hasbro), Headbanz (Spin Master), or 20 questions. Later, depending on the age, connected speech may take the form of imaginative play or a conversation.

Adventures in Voice

Adventures in Voice (AIV) is a resonant voice-based voice therapy program created by Katherine Verdolini Abbott and combines several of the approaches listed above with child-friendly games and activities, as well as a teaching style based on motor learning and child development [17, 18]. AIV is offered through in-person and webinar-based specialty training. This program was recently studied in a randomized prospective clinical trial, comparing AIV with vocal hygiene education only [3]. Both groups showed improvements in quality of life, acoustic, and perceptual measures, with no statistically significant difference in improvement between the groups. There were age-based differences in results, and younger children benefitted more from vocal hygiene, while older children benefitted more from a combined approach. Children recruited later in the protocol benefitted more from the AIV program than hygiene alone, which may indicate that the skill and experience of clinicians plays an important role in therapy success.

Vocal Function Exercises

Vocal function exercises are another form of voice production with a semi-occluded vocal tract. As described by Stemple and colleagues [19, 20], these exercises are designed to rebalance the subsystems of respiration, phonation, and resonance for optimal voice production. Similar to resonant voice therapy and semi-occluded vocal tract exercises, these can be used for both hyperfunctional and hypofunctional voice disorders. These are well described in multiple papers and texts, and typical adaptations are described as well. While not studied in children, vocal function exercises have shown effectiveness in improving voice quality and voice-related quality of life in adults with benign mass lesions [21].