Immediate and Short-term Effects of Straw Phonation in Air or Water on Vocal Fold Vibration and Supraglottic Activity of Adult Patients with Voice Disorders Visualized with Strobovideolaryngoscopy: A Pilot Study

Published:November 18, 2021DOI:


      Purpose The first purpose of this study was to investigate and compare the short-term effects after a semi-occluded vocal tract (SOVT) therapy session consisting of straw phonation (SP) in air or water on vocal fold vibration and supraglottic activity of adult patients with voice disorders, visualized with strobovideolaryngoscopy (SVL). The second purpose of this study was to investigate and compare immediate changes in the patients’ vocal fold vibration and supraglottic activity during SP in air or water, visualized with SVL.
      Methods Twelve adult patients with voice disorders (eight women and four men, mean age 52 years) were assigned randomly to one of two study groups: SP in air or SP in water. Immediately before and after a therapy session of 15 min, participants underwent a rigid SVL to determine the short-term effects of the SP session. At the posttherapy examination, flexible SVL while performing SP was added to determine the effects occurring during SP. The visual-perceptual ratings were performed blindly and in random order by three laryngologists, using the Voice-Vibratory Assessment with Laryngeal Imaging rating form for stroboscopy.
      Results Short-term effects after SP: After the SP-in-air session, the supraglottic mediolateral compression decreased significantly. The SP-in-water session led to significantly increased left vibrational amplitude. Immediate effects during SP: During SP in air, a significantly increased left amplitude and mucosal wave, and significantly decreased mediolateral supraglottic activity, were found. SP in water tended to decrease the vibrational amplitude during performance of the task. A trend toward higher anteroposterior supraglottic compression was observed during both SP in air and water, being more prominent in the latter.
      Conclusion SP in air led to less false vocal fold adduction and consequently less hyperfunction. The small increment in anteroposterior supraglottic activity during SP in air and water might be related to epilarynx narrowing, an economic phenomenon associated with SOVT exercises. The effects on vibrational amplitude were rather ambiguous. The small reduction in amplitude during SP in water is expected to diminish vocal fold impact stress and therefore creates an ideal basis for voice therapy. The increment in amplitude and mucosal wave during SP in air might indicate insufficient supraglottic pressure to obtain the favorable effects of semi-occlusion. Whether or not the rise in amplitude after the SP-in-water session is due to voice efficiency or voice fatigue remains unknown. Future larger-scale investigation in subgroups of voice patients is needed to explore these hypotheses.

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        • Titze IR.
        Voice training and therapy with a semi-occluded vocal tract: Rationale and scientific underpinnings.
        J Speech Lang Hearing Res. 2006; 49: 448-459
        • Gaskill CS
        • Quinney DM.
        The effect of resonance tubes on glottal contact quotient with and without task instruction: a comparison of trained and untrained voices.
        J Voice. 2006; 26: e79-e93
        • Croake DJ
        • Andreatte RD
        • Stemple JC.
        Immediate effects of the vocal function exercises semi-occluded mouth postures on glottal airflow parameters: a preliminary study.
        J Voice. 2017; 31 (e9-245.e14): 245
        • Dargin TC
        • Searl J.
        Semi-occluded vocal tract exercises: aerodynamic and electroglottographic measurements in singers.
        J Voice. 2015; 29: 155-164
        • Kapsner-Smith MR
        • Hunter EJ
        • Kirkham K
        • et al.
        A randomized controlled trial of two semi-occluded vocal tract voice therapy protocols.
        J Speech Lang Hearing Res. 2015; 58: 535-549
        • Maxfield L
        • Titze I
        • Hunter E
        • et al.
        Intraoral pressures produced by thirteen semi-occluded vocal tract gestures.
        Logop Phonatr Vocol. 2015; 40: 86-92
        • Mills R
        • Hays C
        • Al-Ramahi J
        • et al.
        Validation and evaluation of the effects of semi-occluded face mask straw phonation therapy methods on aerodynamic parameters in comparison to traditional methods.
        J Voice. 2017; 31: 323-328
        • Smith SL
        • Titze IR.
        Characterization of flow-resistant tubes used for semi-occluded vocal tract voice training and therapy.
        J Voice. 2017; 31 (113.e1-113.e8)
        • Andrade AP
        • Wood G
        • Ratcliffe P
        • et al.
        Electroglottographic study of seven semi-occluded exercises: laxVox, straw, lip-trill, tongue-trill, humming, hand-over-mouth, and tongue-trill combined with hand-over-mouth.
        J Voice. 2014; 28: 589-595
        • Conroy ER
        • Henninck TM
        • Awan SN
        • et al.
        Effect of variations to a simulated system of straw phonation therapy on aerodynamic parameters using excises canine larynges.
        J Voice. 2014; 28: 1-6
        • Titze IR
        • Verdolini Abbott K.
        Vocology: The Science and Practice of Voice Habilitation.
        National Center for Voice and Speech, Salt Lake City, UT2012
        • Guzman M
        • Jara R
        • Olavarria C
        • et al.
        Efficacy of water resistance therapy in subjects diagnosed with behavioral dysphonia: a randomized controlled trial.
        J Voice. 2017; 31: 385.e1-385.e10
        • Titze IR.
        Phonation into a straw as a voice building exercise.
        J Singing. 2000; 57: 27-28
        • Titze IR.
        How to use the flow-resistant straws.
        J Singing. 2002; 58: 429-430
        • Guzman M
        • Laukkanen AM
        • Krupa P
        • et al.
        Vocal tract and glottal function during and after vocal exercising with resonance tube and straw.
        J Voice. 2013; 27: 523.e19-523.e34
        • Ogawa M
        • Hosokawa K
        • Yoshida M
        • et al.
        Immediate effects of humming on computed electroglottographic parameters in patients with muscle tension dysphonia.
        J Voice. 2014; 28: 733-741
        • Hampaia V
        • Laukkanen AM
        • Guzman MA
        • et al.
        Vocal fold adjustment caused by phonation into a tube: a double-case study using computed tomography.
        J Voice. 2015; 29: 733-742
        • Dargin TC
        • DeLaunay A
        • Searl J.
        Semioccluded vocal tract exercises: changes in laryngeal and pharyngeal activity during stroboscopy.
        J Voice. 2016; 30: 377.e1-377.e9
        • Guzman M
        • Laukkanen AM
        • Traser L
        • et al.
        The influence of water resistance therapy on vocal fold vibration: a high-speed digital imaging study.
        Logop Phonatr Vocology. 2017; 42: 99-107
        • Verdolini K
        • Druker DG
        • Palmer PM
        • et al.
        Laryngeal adduction in resonant voice.
        J Voice. 1998; 12: 315-327
        • Berry DA
        • Verdolini K
        • Montequin DW
        • et al.
        A quantitative output-cost ratio in voice production.
        J Speech Lang Hearing Res. 2001; 44: 29-37
        • Guzman M
        • Calvache C
        • Romero L
        • et al.
        Do different semi-occluded voice exercises affect vocal fold adduction differently in subjects diagnosed with hyperfunctional dysphonia.
        Folia Phoniatr Logo. 2015; 67: 68-75
        • Guzman M
        • Acuña G
        • Pacheco F
        • et al.
        The impact of double source of vibration semioccluded voice exercises on objective and subjective outcomes in subjects with voice complaints.
        J Voice. 2018; 32: 770.e1-770.e9
        • Meerschman I
        • Van Lierde K
        • Ketels J
        • et al.
        Effect of three semi-occluded vocal tract therapy programmes on the phonation of patients with dysphonia: lip trill, water-resistance therapy and straw phonation.
        Int J Lang Commun Disord. 2019; 54: 50-61
        • Laukkanen AM
        • Geneid A
        • Bula V
        • et al.
        How much loading does water resistance voice therapy impose on the vocal folds? An experimental human study.
        J Voice. 2020; 34: 387-397
        • Story BH
        • Laukkanen AM
        • Titze IR.
        Acoustic impedance of an artificially lengthened and constricted vocal tract.
        J Voice. 2000; 14: 455-469
        • Titze IR
        • Finnegan EM
        • Laukkanen AM
        • et al.
        Raising lung pressure and pitch in vocal warm-ups: the use of flow-resistant straws.
        J Singing. 2002; 58: 329-338
        • Sampaio M
        • Oliveira G
        • Behlau M.
        Investigation of the immediate effects of two semi-occluded vocal tract exercises.
        Pro Fono. 2008; 20: 261-266
        • Costa CB
        • Costa LHC
        • Oliveira G
        • et al.
        Immediate effects of the phonation into a straw exercise.
        Braz J Otorhinolaryngol. 2011; 77: 461-465
        • Guzman M
        • Higueras D
        • Fincheira C
        • et al.
        Immediate acoustic effects of straw phonation exercises in subjects with dysphonic voices.
        Logoped Phoniatr Vocol. 2013; 38: 35-45
        • Guzman M
        • Rubin A
        • Muñoz D
        • et al.
        Changes in glottal contact quotient during resonance tube phonation and phonation with vibrato.
        J Voice. 2013; 27: 305-311
        • Guzman M
        • Castro C
        • Madrid S
        • et al.
        Air pressure and contact quotient measures during different semioccluded postures in subjects with different voice conditions.
        J Voice. 2015; 30: 759.e1-759.e10
        • Robieux C
        • Galant C
        • Lagier A
        • et al.
        Direct measurement of pressures involved in vocal exercises using semi-occluded vocal tracts.
        Logoped Phoniatr Vocol. 2015; 40: 106-112
        • Ramos LA
        • Gama ACC.
        Effect of performance time of the semi-occluded vocal tract exercises in dysphonic children.
        J Voice. 2017; 31: 329-335
        • Mills RD
        • Rivedal S
        • DeMorett C
        • et al.
        Effects of straw phonation through tubes of varied lengths on sustained vowels in normal-voiced participants.
        J Voice. 2018; 32: 386.e21-386.e29
        • Kang J
        • Scholp A
        • Tangney J
        • et al.
        Effects of a simulated system of straw phonation on the complete phonatory range of excised canine larynges.
        Eur Arch Otorhinolaryngol. 2019; 276: 473-482
        • Kang J
        • Xue C
        • Chou A
        • et al.
        Comparing the exposure-response relationships of physiological and traditional vocal warm-ups on aerodynamic and acoustic parameters in untrained singers.
        J Voice. 2019; 33: 420-428
        • Kang J
        • Xue X
        • Lou Z
        • et al.
        The therapeutic effects of straw phonation on vocal fatigue.
        Laryngoscope. 2020; 130: E674-E679
        • Tangney J
        • Scholp A
        • Kang J
        • et al.
        Effects of varying lengths and diameters during straw phonation on an excised canine model.
        J Voice. 2021; 35: 85-93
      1. Manjunatha U, Nayak PS, Bhat JS. Can straw phonation be considered as vocal warm up among speech language pathologists? J Voice. Available online 9 September 2020. In Press

        • Kang J
        • Xue C
        • Piotrowski D
        • et al.
        Lingering effects of straw phonation exercises on aerodynamic, electroglottographic, and acoustic parameters.
        J Voice. 2019; 33: 810.e5-810.e11
      2. Keltz A, McHenry M. Steam and/or semi-occluded vocal tract exercise as morning vocal warm-up strategy. J Voice. Available online 26 September 2020. In Press.

        • Laukkanen AM
        • Horáček J
        • Krupa P
        • et al.
        The effect of phonation into a straw on the vocal tract adjustments and formant frequencies. A preliminary MRI study on a single subject completed with acoustic results.
        Biomed Signal Proc. 2012; 37: 75-82
        • Guzman M
        • Miranda G
        • Olavarria C
        • et al.
        Computerized tomography measures during and after artificial lengthening of the vocal tract in subjects with voice disorders.
        J Voice. 2017; 31: 124.e1-124.e10
        • Guzman M
        • Castro C
        • Testart A
        • et al.
        Laryngeal and pharyngeal activity during semioccluded vocal tract postures in subjects diagnosed with hyperfunctional dysphonia.
        J Voice. 2013; 27: 709-716
        • Poburka BJ
        • Patel RR
        • Bless DM.
        Voice-vibratory assessment with laryngeal imaging (VALI) form: reliability of rating stroboscopy and high-speed videoendoscopy.
        J Voice. 2017; 31: 513.e1-513.e14
        • Hallgren KA.
        Computing inter-rater reliability for observational data: An overview and tutorial.
        Tutor Quant Methods Psychol. 2012; 8: 23-34
        • Koo TK
        • Li MY.
        A guideline of selecting and reporting intraclass correlation coefficients for reliability research.
        J Chiropractic Med. 2016; 15: 155-163
        • Light RJ.
        Measures of response agreement for qualitative data: Some generalizations and alternatives.
        PsycholBulletin. 1971; 76: 365-377
        • Landis JR
        • Koch GG.
        The measurement of observer agreement for categorical data.
        Biometrics. 1977; 33: 159-174
        • Cicchetti DV.
        Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology.
        Psychol Assess. 1994; 6: 284-290
        • Menezes MH
        • de Campos Duprat A
        Olival Costa H. Vocal and laryngeal effects of voiced tongue vibration technique according to performance time.
        J Voice. 2005; 19: 61-70
        • Schwarz K
        • Cielo CA.
        Vocal and laryngeal modifications produced by the sonorous tongue vibration technique.
        Pró-Fono Revista de Atualização Científica. 2009; 21: 161-166
        • Cordeiro GF
        • Montagnoli AN
        • Tsuji DH.
        Comparison among phonation of the sustained vowel /ε/, lip trills, and tongue trills: the amplitude of vocal fold vibration and the closed quotient.
        Otolaryngology. InTech, Rijeka, Croatia. 2012; : 129-148
        • Laukkanen AM
        • Pulakka H
        • Alku P
        • et al.
        High-speed registration of phonation-related glottal area variation during artificial lengthening of the vocal tract.
        Logop Phonatr Vocol. 2007; 32: 157-164
        • Vilkman E
        • Lauri ER
        • Alku P
        • et al.
        Effects of prolonged oral reading on F0, SPL, subglottal pressure and amplitude characteristics of glottal flow waveforms.
        J Voice. 1999; 13: 303-312
        • Solomon NP
        • DiMattia MS.
        Effects of a vocally fatiguing task and systemic hydration on phonation threshold pressure.
        J Voice. 2000; 14: 341-362
        • Chang A
        • Karnell MP.
        Perceived phonatory effort and phonation threshold pressure across a prolonged voice loading task: a study of vocal fatigue.
        J Voice. 2004; 18: 454-466
        • Enflo L
        • Sundberg J.
        Vocal fold collision threshold pressure: An alternative to phonation threshold pressure?.
        Logop Phonatr Vocology. 2009; 34: 210-217
        • Enflo L
        • Sundberg J
        • Romedahl C
        • et al.
        Effects on vocal fold collision and phonation threshold pressure of resonance tube phonation with tube end in water.
        J Speech Lang Hearing Res. 2013; 56: 1530-1538
        • Paes SM
        • Behlau M.
        Dosage dependent effect of highresistance straw exercise in dysphonic and nondysphonic women.
        CoDAS. 2017; 29e20160048
        • Menezes MHM
        • Ubrig-Zancanella MT
        • Cunha MGB
        • et al.
        The relationship between tongue trill performance duration and vocal changes in dysphonic women.
        J Voice. 2011; 25: e167-e175
        • Radolf V
        • Laukkanen AM
        • Horáček J
        • et al.
        Air-pressure, vocal folds vibration and acoustic characteristics of phonation during vocal exercising, part 1: measurement in vivo.
        Eng Mech. 2014; 21: 53-59
        • Echternach M
        • Raschka J
        • Kuranova L
        • et al.
        Immediate effects of water resistance therapy on patients with vocal fold mass lesions.
        Eur Arch Oto-Rhino-L. 2020; 277: 1995-2003
        • Echternach M
        • Köberlein M
        • Gellrich D
        • et al.
        Duration of biodynamic changes associated with water resistance therapy.
        Logop Phoniatr Vocol. 2020; 25: 1-8
        • Sundberg J.
        Articulatory interpretations of the singing formant.
        J Acoust Soc Am. 1974; 55: 838-844
        • Titze IR
        • Story BH.
        Acoustic interactions of the voice source with the lower vocal tract.
        J Acoust Soc Am. 1997; 101: 2234-2243
        • Laukkanen AM
        • Horáček J
        • Havlík R.
        Case-study magnetic resonance imaging and acoustic investigation of the effects of vocal warm-up on two voice professionals.
        Logoped Phoniatr Vocol. 2012; 37: 75-82
        • Titze IR
        • Laukkanen AM.
        Can vocal economy in phonation be increased with an artificially lengthened vocal tract? A computer modeling study.
        Logoped Phonatr Vocol. 2007; 32: 147-156
        • Stager SV
        • Bielamowicz SA
        • et al.
        Supraglottic activity: evidence of vocal hyperfunction or laryngeal articulation.
        J Speech Lang Hearing Res. 2000; 43: 229-238
        • Oliveira Maia MA
        • Oliveira Maia M
        • Côrtes Gama AC
        • et al.
        Immediate effects of the high-pitched blowing vocal exercise.
        J Soc Bras Fonoaudiol. 2012; 24: 1-6
        • Granqvist S
        • Simberg S
        • et al.
        Resonance tube phonation in water: High-speed imaging, electroglottographic and oral pressure observations of vocal fold vibrations - a pilot study.
        Logoped Phoniatr Vocol. 2015; 40: 113-121
        • Sovijärvi A
        • Häyrinen R
        • et al.
        Aänifysiologisten Kuntoutusharjoitusten Ohjeita [Instructions for voice exercises].
        Helsinki: Publications of Suomen Puheopisto, 1989
        • De Bodt MS
        • Clement G
        • et al.
        The impact of phonation mode and vocal technique on vocal fold closure in young females with normal voice quality.
        J Voice. 2012; 26: 818e1-818e4
        • Nam IC
        • Kim SY
        • et al.
        Effects of voice therapy using the lip trill technique in patients with glottal gap.
        J Voice. 2019; 33 (949.e11-949.e19)
        • Romak JJ
        • Heuer RJ
        • Hawkshaw MJ
        • et al.
        In Sataloff Rt. Professional Voice: The Science and Art of Clinical Care.
        4th edition. Plural Publ, San Diego, CA2017: 405-438
      3. Boles RW, Gao WZ, et al. Flexible versus rigid laryngoscopy: a prospective, blinded comparison of image quality. J Voice. Available online 26 March 2021. In Press.