Journal of Otology & Rhinology

Kusunoki et al., J Otol Rhinol 2015, S1:1
http://dx.doi.org/10.4172/2324-8785.S1-015
Journal of Otology &
Rhinology
Research Article
A SCITECHNOL JOURNAL
A Simple Voice Training Method
for Inflammatory Laryngeal
Diseases by Relying on Abdominal
Respiration
Takeshi Kusunoki1*, Toshio Monjyu2, Mitsuhisa Fujimaki1 and
Katsuhisa Ikeda1
1Department
of Otorhinolaryngology, Juntendo University Faculty of Medicine,
Tokyo, Japan
2Monjyu
Voice Clinic, Osaka, Japan
*Corresponding
author: Takeshi Kusunoki, Department of Otorhinolaryngology,
Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo,
113-8421, Japan, Tel: + 81-3-5802-1229, Fax: +81-3-5840-7103; E-mail:
ttkusunoki001@aol.com
Rec date: Nov 18, 2014 Acc date: Mar 10, 2015 Pub date: Mar 14, 2015
Abstract
Background: It has been suggested that doctors should
perform voice therapy in cooperation with speech therapists,
but there are few speech therapists in Japan. Therefore, at our
hospital otorhinolaryngology out-patient clinic, voice therapy is
performed by a single doctor (first author) using a simple
method of voice training that relies on the abdominal type of
respiration.
Voice therapy is considered the first choice for vocal fold
nodules. We tried this voice training method for vocal fold
polyps and laryngeal granulomas with resistance to proton
pump inhibitor (PPI) as well as vocal fold nodules.
Methods: At our hospital otorhinolaryngology out-patient clinic,
voice therapy was performed using a simple method of voice
training that relies on abdominal respiration for inflammatory
laryngeal diseases.
Results: All 16 cases with vocal fold nodules showed
disappearance of symptoms by our method of voice training.
Nine of 12 cases with vocal fold polyps and 12 of 15 cases with
laryngeal granulomas showed disappearance or reduction of
symptoms.
Conclusions: These results suggested that our method of
voice training could be useful for some cases of both vocal fold
polyps and laryngeal granulomas in the same way as vocal fold
nodules.
Keywords: Abdominal type of respiration; Voice training; Vocal fold
nodule; Vocal fold polyp; Laryngeal granuloma
Abbreviations:
PPI: Proton pump inhibitor; GRBAS: Grade rough breathy asthenic
strained; LAR: Laryngeal adductor reflex; PVFM: Paradoxical vocal
fold movement; GRAD: Gastroesophageal reflux disease
Introduction
Methods of treatment for voice disorders include phonosurgery and
non-operative therapies. Because voice therapy is a non-operative
therapy, it is noninvasive and less of an economic burden to patients.
It has been suggested that doctors should perform voice therapy in
cooperation with speech therapists [1]. In fact, there are few speech
therapists in Japan. Therefore, Monjyu [2] designed a simple method
of voice training that relies on abdominal respiration for volcalization
relies with only a single doctor administering such training. At our
hospital otorhinolaryngology out-patient clinic, this voice therapy has
been performed by only one doctor, the first author. Although
abdominal respiration has been known to be useful for voice training,
no report has demonstrated concretely or in detail such a method of
voice training that relies on abdominal respiration. As a result, all our
patients could speak comfortably and in a relaxed manner after
mastering abdominal respiration.
Voice therapy is considered the first choice for vocal fold nodules in
Japan [3]. We tried this voice training for vocal fold polyps and
laryngeal granulomas that were resistant to proton pump inhibitors
(PPI) as well as for vocal fold nodules, and our voice training method
was assessed for its effectiveness for the above inflammatory laryngeal
diseases.
In Japan, evaluation of the effectiveness of voice therapy has widely
been done using the grade rough breathy asthenic strained scale
(GRBAS scale) [4]. The GRBAS scale has been considered the gold
standard for psychoacoustic voice evaluation in Japan, and is a
subjective rather than objective evaluation. Therefore, we tried to
make our evaluation as objective and clear as possible. The grade of
the effectiveness of our training was evaluated by using it for various
laryngeal diseases.
Methods
At our hospital otorhinolaryngology out-patient clinic, voice
therapy was performed from April 2011 to June 2013 using a simple
method of voice training by placing great importance on the
abdominal type of respiration. All patients received an explanation
about surgical or pharmacological treatments, as well as our voice
training method, but selected our method of voice training. Finally,
sixteen cases with vocal fold nodules, twelve cases with vocal fold
polyps and 15 cases with laryngeal granuloma underwent our voice
training. All 15 cases of laryngeal granuloma were unimproved by PPI
treatment for 8 weeks. All cases of vocal fold nodules, vocal fold polyps
and laryngeal granuloma were treated by our method of voice training
alone, using no other therapy (e.g., silent therapy, medicine,
operation). All patients gave their written informed consent and the
study was approved by the ethics committee of the Juntendo
University Faculty of Medicine.
In our method of voice therapy, new patients were instructed to
master the abdominal type of respiration at the first medical
examination as follows [2]. Patients practiced exhaling from the
mouth with inward abdominal movement and inhale nasally with
outward abdominal movement while relaxing the upper half of the
body. Next, patients practiced voice training with naturally relaxed
phonation using first “f” and gradually changing from “f” to “v”, while
exhaling with abdominal respiration. Our voice training is intended to
avoid excessive stress on the vocal fold due to inadvertently hard
All articles published in Journal of Otology & Rhinology are the property of SciTechnol and is protected by copyright
laws. Copyright © 2015, SciTechnol, All Rights Reserved.
Citation:
Kusunoki T, Monjyu T, Fujimaki M, Ikeda K (2015) A Simple Voice Training Method for Inflammatory Laryngeal Diseases by Relying on Abdominal
Respiration. J Otol Rhinol S1:1.
doi:http://dx.doi.org/10.4172/2324-8785.S1-015
laryngeal phonation. In additional to the home exercise program, all
patients received a detailed explanation of our voice training method,
and exercised twice or three times-daily for 10 minutes. Moreover, we
instructed them as follows. If patients sense that phonation during
daily conversation excessively stresses the vocal fold, they should
correct to naturally relaxed phonation by exhaling with the abdominal
type of respiration. Follow up evaluations were scheduled for every
month after their initial visit.
laryngeal granulomas by upper gastrointestinal endoscope. In twelve
of these 15 cases the laryngeal granulomas disappeared (5) or were
reduced (7) after using our method of voice training (Table 3). Nine
cases with hyperfunctional dysphonia at the first medical examination
showed improvement after using our method of voice training
together with reduced anterior-posterior contraction of the larynx
(Figure 3).
Evaluations of the effectiveness of this therapy for the laryngeal
disease itself were classified three categories as follows:
“disappearance”, “reduction”, “no change”. The criterion for
“reduction”was a disease volume less than one-half of that before voice
therapy.
Results
All 16 cases with vocal fold nodules showed disappearance after
using our method of voice training (Table 1 and Figure 1).
Figure 1: Endoscopic finding of vocal fold nodule, Left: Case with
vocal fold nodule at the first medical examination had hoarseness;
Right: After using our method of voice training for 4 months, the
vocal fold nodule and hoarseness disappeared. At phonation, a slit
between the right and left vocal folds could be reduced by this voice
training.
Nine of 12 cases with vocal fold polyps showed disappearance
(Table 2). Three of the cases with vocal fold polyps underwent our
method of voice training while waiting for surgery. Two of these cases
showed disappearance within 2 months (Figure 2). One case with
postoperative reoccurrence showed disappearance after using our
method of voice training.
Concerning laryngeal granulomas (Table 3), the chief complaint in
only four of 15 cases was hoarseness. Five of 15 cases had no
pharyngo-laryngeal symptoms, although they had occasionally shown
Volume S1 • Issue 1 • S1-015
Figure 2: Endoscopic finding of vocal fold polyp, Left: Vocal fold
polyp case at the first medical examination had hoarseness. This
patient underwent our method of voice training while waiting for
surgery. Middle: This voice training for 1 month could reduce the
vocal fold polyp. Right: With voice training for 2 months, the vocal
fold polyp disappeared. Therefore, we cancelled her surgery.
Figure 3: Endoscopic finding of laryngeal granulomas, Left:
Laryngeal granuloma case with hyperfunctional dysphonia at the
first medical examination showed severe anterior-posterior
contraction resulting in contact between the aryteoid and laryngeal
side of the epiglottis; Right: Our method of voice training for 16
weeks caused the laryngeal granuloma to disappear and improved
the hyper-functional dysphonia, while reducing the anteriorposterior contraction of the larynx.
All patients felt comfortable speaking after mastering the abdominal
respiration. All patients were checked carefully about abdominal
respiration at every medical examination. Some patients with
inadequate abdominal respiration underwent retraining. Finally, all
patients could master voice according to abdominal respiration There
was no correlation between the time required to master our voice
method and the results of therapy.
• Page 2 of 5 •
Citation:
Kusunoki T, Monjyu T, Fujimaki M, Ikeda K (2015) A Simple Voice Training Method for Inflammatory Laryngeal Diseases by Relying on Abdominal
Respiration. J Otol Rhinol S1:1.
doi:http://dx.doi.org/10.4172/2324-8785.S1-015
Case
Period of hoarseness
Period of voice training
Effectiveness
26 years F
6 years
4 months
disappearance
25 years F
6 months
4 weeks
disappearance
30 years F
3 months
2 months
disappearance
61 years F
2 months
5 months
disappearance
77 years F
1 years
2 months
disappearance
74 years F
3 months
4 weeks
disappearance
67 years M
3 months
4 weeks
disappearance
68 years M
*
2 weeks
disappearance
77 years F
5 years
4 weeks
disappearance
47 years F
2 months
3 months
disappearance
23 years F
3 months
8 weeks
disappearance
17 years F
2 months
4 months
disappearance
24 years F
9 months
11 weeks
disappearance
44 years F
4 months
4 weeks
disappearance
75 years F
1 months
6 weeks
disappearance
37 years F
1 months
6 weeks
Disappearance
Note: F: Female; M: Male; *Case 8 had no hoarseness. However, vocal fold nodules were found by gastrointestinal endoscope.
Table 1: Voice training for vocal fold nodules.
Case
Period of hoarseness
Period of voice training
Effectiveness
61 years M
Unknown
4 months
disappearance
29 years M*
5 years
2 months
disappearance
37 years F
8 months
2 months
disappearance
64 years M
11 days
4 months
disappearance
59 years M**
6 months
3 months
No change
71 years M
2 months
5 months
disappearance
31 years F
1 year
3 months
disappearance
23 years F
3 months
4 weeks
disappearance
79 years M
2 years
3 months
No change
51 years F
2 months
6 months
disappearance
70 years F
4 months
5 months
disappearance
44 years M
6 months
3 months
No change
Note: M: male; F: Female; * In Case 2, the postoperative recurrence had disappeared by voice training; **Case 5 underwent laryngomaicrosurgery after voice training.
Table 2: Voice training for vocal fold polyp.
Volume S1 • Issue 1 • S1-015
• Page 3 of 5 •
Citation:
Kusunoki T, Monjyu T, Fujimaki M, Ikeda K (2015) A Simple Voice Training Method for Inflammatory Laryngeal Diseases by Relying on Abdominal
Respiration. J Otol Rhinol S1:1.
doi:http://dx.doi.org/10.4172/2324-8785.S1-015
Case
Motivation of Consult
Hyperfunctional
dysphonia
before voice training
Period of voice training
Effectiveness
60 years M
Hoarseness
−
9 months
reduction
70 years M
Point out by GIF
−
7 months
reduction
45 years M
Point out by GIF
−
16 weeks
reduction
50 years M
Throat discomfort
+
7 weeks
disappearance
70 years M
Point out by GIF
+
3 weeks
disappearance
62 years M
Point out by GIF
−
7 months
reduction
62 years M
Hoarseness
−
8 weeks
reduction
64 years M
Throat discomfort
+
16 weeks
disappearance
42 years M
Throat discomfort
−
9 months
No change
70 years F
Hoarseness
+
5 weeks
disappearance
68 years M
Point out by GIF
+
3 months
disappearance
56 years M
Throat discomfort
+
2 months
No change
60 years M
Point out by GIF
+
4 months
reduction
67 years F
Hoarseness
+
3 months
No change
56 years M
Throat discomfort
+
3 months
No change
Note: M: male; F: Female.
GIF: Gastrointestinal Endoscope
Table 3: Voice training for laryngeal granulation with resistance to PPI.
Discussion
Voice therapy is the first choice for vocal fold nodules in Japan [4].
All of our 16 cases with vocal fold nodules showed disappearance by
our method of voice training. Surgery has been the first choice for
vocal fold polyps. Yamaguchi [3] reported that the first choice for
vocal fold polyps was surgery, followed by protection against
postoperative recurrence by voice training. Three of our cases with
vocal fold polyps underwent our method of voice training while
waiting for surgery. Two of these cases showed disappearance within 2
months. Umeno [5] described that 25% of vocal fold polyp cases
treated by voice training alone showed disappearance. In nine of our
12 cases with vocal fold polyps treated by our method of voice
training, the polyps had disappeared. Our method of voice training
was very effective for vocal fold polyps as well as vocal fold nodules.
The postoperative recurrence of a vocal fold polyp disappeared after
using our method of voice training. Therefore, our method of voice
training may be the first choice for some cases with vocal fold polyps
as well as vocal fold nodules. In most cases, laryngeal granulomas are
observed on the vocal process, but not the vocal fold [6,7]. Therefore,
such cases generally have a low grade of hoarseness and subjective
symptoms. In only four of 15 cases with laryngeal granulomas was the
chief complaint hoarseness. Some researchers [8,9] have insisted that
gastroesophageal reflux disease (GERD) is an increasingly important
factor in laryngeal granulomas. Laryngeal granulomas have been
treated by PPI as the main therapy [10]. In fact, it is known that not all
cases can be completely improved by PPI alone [11]. None of our cases
with laryngeal granulomas were completely improved by PPI
Volume S1 • Issue 1 • S1-015
treatment for 8 weeks. Murry [11] that patients with the primary
complaint of cough and laryngeal adductor reflex (LAR) following the
diagnosis of paradoxical vocal fold movement (PVFM) exhibited
improvement in the laryngeal sensation with an associated resolution
of PVFM and chronic cough after treatment with PPI and retraining
by abdominal respiration, despite the persistence of cough when
treated with PPI alone. The results of the present study suggest that the
cough associated with PVFM might be attributed to the decreased
mechano-sensitivity resulting from receptors buried in the edematous
mucosa. This is a hallmark of LPR and can be expected to improve
with treatment. In those with PVFM, although the PPI might reduce
the edema, the behavioral response (cough) required further treatment
with behavioral methods, namely respiratory retraining. Decreased
mechano-sensitivity and chemosensitivity of the laryngopharyngeal
mucosa from chronic acid irritation results in the increased collection
of particulate or irritants in the laryngopharyngeal mucosa, and the
chronic cough reflex might be simply an adaptive mechanism that has
evolved through habit to clear the larynx. The paradoxical adduction
of the vocal folds during inspiration in this context might serve as a
protective response to prevent further inhalation of particulate matter
in patients whose cough is not controlled by pharmacological
treatment alone. Hyperfunctional dysphonia as well as GRAD and
chronic cough are thought to be causes of laryngeal granuloma [4,12].
Our cases with disappearance had hyper-functional dysphonia at
the first medical examination but were improved after using our
method of voice training. In our study, the causes of the laryngeal
granulomas in each case could not be determined whether among
• Page 4 of 5 •
Citation:
Kusunoki T, Monjyu T, Fujimaki M, Ikeda K (2015) A Simple Voice Training Method for Inflammatory Laryngeal Diseases by Relying on Abdominal
Respiration. J Otol Rhinol S1:1.
doi:http://dx.doi.org/10.4172/2324-8785.S1-015
GRAD, chronic cough and hyperfunctional dysphonia. Hyodo [13]
reported that the effective rates of PPI and operation for laryngeal
granulomas were 27% (4/15) and 42% (11/26). Nevertheless, all of our
cases of laryngeal granulomas with resistance to proton pump
inhibitors (PPI) that did not undergo other therapies (e.g, silent
therapy, medicine, operation) showed an effective rate of 80% (12/15)
with disappearance or reduction after using our method of voice
training. The above reports and our results would suggest that our
method of voice training might be useful for laryngeal granulomas due
to chronic cough with GRAD and hyperfunctional dysphonia.
In our study approximately 80% of the cases with both, vocal fold
polyps and laryngeal granulomas as well as vocal fold nodules showed
improvement after using our method of voice training. The above
results suggested that our method could be used for both vocal fold
polyps and laryngeal granulomas as well as vocal fold nodules.
Our study did not examine the physiological or aerodynamic
mechanisms by which the vocal fold nodules, laryngeal granulations,
and even polyps had disappeared. Since all patients could speak
comfortably after mastering abdominal respiration; vocalization using
abdominal respiration may have reduced stress on the vocal fold and
thereby contributed to the disappearance or reduction of the
inflammatory laryngeal disease symptoms.
Conclusions
At our hospital otorhinolaryngology out-patient clinic, voice
therapy for inflammatory laryngeal diseases was performed using a
simple method of voice training that relies on abdominal. These
results suggested that our method of voice training could be useful for
some cases of both vocal fold polyps and laryngeal granulomas in the
same way as for vocal fold nodules.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Kusunoki T, Monju, Ikeda K (2013) Effectiveness of a simple
voice training method by placing great importance on abdominal
type of respiration. Pract Otol (Kyoto) 106: 455-461.
Yamaguchi H (1992) Voice therapy for vocal fold polyp. JOHNS
8: 505-510.
Japan ORLSo (2010) Oto-rhino-laryngological dictionary (1st
edn) Kyoto, Kinpodo.
Umeno H, Tanaka S, Terasawa R, Hirano M (1993) Vocal fold
polyp-Retrospective study of 601 cases for 10 years. Pract Otol
(Kyoto) 62: 20-62.
Cherry J, Margulies SI (1968) Contact ulcer of the larynx. The
Laryngoscope 78: 1937-1940.
Oda M (1985) Investigations of pathogenesis of post-intubation
laryngeal granulomas. Otologica Fukuoka 31: 295-314.
Delahunty JE, Cherry J (1968) Experimentally produced vocal
cord granulomas. The Laryngoscope 78: 1941-1947.
Jackson C, Jackson CL (1935) Contact ulcer of the larynx.
Archives of otolaryngology 22: 1-15.
Wani MK, Woodson GE (1999) Laryngeal contact granuloma.
The Laryngoscope 109: 1589-1593.
Murry T, Branski RC, Yu K, Cukier-Blaj S, Duflo S, et al. (2010)
Laryngeal sensory deficits in patients with chronic cough and
paradoxical vocal fold movement disorder. Laryngoscope 120:
1576-1581.
Feder RJ, Michell MJ (1984) Hyperfunctional, hyperacidic, and
intubation granulomas. Archives of otolaryngology 110: 582-584.
Hyodo M, Taguchi A, Kobayashi J (2004) J The Larynx Japan 16:
102-105.
References
1.
Niimi S (2011) Vocal rehabilitaion. J Jpn Brochoesophagol Soc
62: 433-439.
Volume S1 • Issue 1 • S1-015
• Page 5 of 5 •