Puberphonia and its management

From Otolaryngology Online


Mutational falsetto, Voice break.


The persistence of adolescent voice even after puberty in the absence of organic cause is known as Puberphonia. This condition is commonly seen in males. This is uncommon in females because laryngeal growth spurt occurs commonly only in males. According to Banerjee the incidence of Puberphonia in India is about 1 in 900,000 population.


In infants the laryngotracheal complex lies at a higher level. It gradually descends. During puberty in males this descent is rapid, the larynx becoming larger and unstable and on top of it the brain is more accustomed to infant voice. The boy may hence continue to use a high pitched voice or it may break into higher and lower pitches.



1. Emotional stress

2. Delayed development of secondary sexual characters

3. Psychogenic

4. Hero worship of older boy or sibling

5. Excessive maternal protection

6. Non fusion of thyroid laminae


1. Unusual high pitched voice persisting beyond puberty

2. Hoarseness of voice

3. Breathy voice

4. Inability to shout

5. Vocal fatigue

Examination of these patients should include a complete physical examination including a genital examination also. Secondary sexual characters should be assessed, hypogonadism should be ruled out. A complete psychological profile of the patient in question should be built to rule out psychological causes. If psychological causes could be identified they treating it should take precedence over other modalities.

These patients speak in a double voice, both in high pitch and low pitch.

Goals of treatment of Puberphonia:

1. The patient should be taught to phonate at a low pitch

2. The patient should be taught to fully utilise the Phonatory and Respiratory musculature

3. The patient must be convinced that the new low pitch should be used instead of the old high pitch voice

Treatment modalities available:

1. Voice therapy

2. Larynx manipulation

3. Surgery

Voice therapy includes:

1. Cough

2. Speech range masking

3. Glottal attack before a vowel

4. Relaxation techniques to relax the laryngeal musculature

5. Visi pitch

6. Lowering of larynx to appropriate position

7. Humming while sliding down the scale

8. Half swallow Boom technique


Patient is taught to cough with pressure over the adams apple. This maneuver shortens the length of the vocal cord there by reducing its vibrating pitch. The patient is advised to perform this exercise at home. This will enable the patient to get used to a lower basic speech frequency.

Speech range masking:

This procedure is known to improve the quality of voice. It has been established that speaking in a noisy background has profound effects on how an individual speaks. It can alter the quality of speech of an individual. This procedure also makes the voice clearer and louder. For this purpose an instrument known as the facilitator is used. The masking bandwith is between 100 - 8000 Hz. The advantage of using this frequency is that it covers the speech range and masking is possible at much lower sound levels when compared to a white or pink noise which are commonly used for purposes of masking. A tape recording of the voice of the patient during and after masking is provided to the patient and the patient should try to match the voice generated during masking on a consistent basis.

Glottal attack before a vowel:

Vowel is a very important sound in speech. It is also easily amenable to therapy / change. Glottal attack involves bringing both vocal cords into close approximation. The patient is asked to breathe in, build air pressure in the subglottic area. This causes increased muscular tension in the laryngeal area. The vowel is uttered as the air is breathed out. This procedure enables a patient with puberphonia to settle down to their basic fundamental frequency of voice.

Relaxation techniques to relax laryngeal musculature:

Laryngeal muscles can be relaxed using the following relaxing procedures:

Yawn technique:

The patient is advised to practice yawning, followed by generation of a sighing sound. This procedure reduces the tension on the vocal folds.

Chewing technique:

First the act of chewing in an exaggerated manner is practiced. Then gradually random sounds, words and sentences are added to this task. This act reduces the tension of the laryngeal muscles.

/M/ warm up:

To warm up the vocal cords the consonent M is spoken or sung before the words. This helps to produce a gentle air flow through the larynx as phonation begins.


This instrument is commonly used by speech pathologists to treat various speech disorders. This machine helps in extraction of Critical speech and voice parameters and displays them in true real-time to help clients achieve therapy goals with visual feedback. This machine helps in training the patient in nuances of normal speech production.

Boone's technique of larynx lowering: This method is also known as "Yawn - sigh" method. The patient is asked to simulate a yawn and while yawning is in progress asked to sigh. This manuver not only lowers the larynx it also relaxes it.

Humming while sliding down the scale:

In this exercise the patient is taught to hum in the highest pitch possible and the humming is continued by lowering the pitch. This exercise helps not only in tuning the vocal cords it also relaxes the laryngeal muscles.

Half swallow Boom technique:

In this technique the patient is asked to swallow. While swallowing is in progress the patient is asked to say "Boom". Then the patient is asked to turn to one side and say "BOOM". The same exercise is repeated by turning the head to the opposite side.

The patient is then asked to lower the chin, and say Boom. The patient is taught to add words to the BOOM. The swallow procedure is known to maximise the closure of larynx. The sound Boom is produced by posterior pressure to the larynx. The patient gradually learns to lower the pitch of his voice.

Antero posterior compression of thyroid cartilage: Compression is applied to the Adam's apple area in the neck using the thumb and the patient is asked to speak. This procedure relaxes the vocal cord and lowers its basic pitch. The patient is instructed to repeat this exercise frequently while attempting to speak. This helps in reducing the basic pitch of the patient's vocal cord.

Laryngeal manipulation:

This is a quite recent method in the treatment of puberphonia. This was first reported by Sudhakar vaidya in Laryngoscope journal in 1995. Patient was asked to come nil by mouth for six hours before the procedure in the ENT outdoor. Patient was examined under xylocaine spray anesthesia by anesthesiologist’s intubation laryngoscope (Macintosh). Long blade of laryngoscope was put in valleculae and patient was asked to speak a long eeeee. Pressure over the valleculae stretched the vocal cords. Sometimes-additional pressure was applied by a laryngeal biopsy forceps over the anterior commisure. The external digital pressure over the thyroid cartilage also helped in improvement of the voice quality.The procedure was repeated 3-4 times in a single sitting.