ARTICLE IN PRESS

Steam and/or Semi-occluded Vocal Tract Exercise as Morning

Vocal Warm-up Strategy
Andrew Keltz, and Monica McHenry, Valhalla, NY, USA

Summary: Objective. This study was designed to evaluate the effectiveness of either steam, semi-occluded vocal
tract (SOVT) exercises, or a combination of both as a speaking voice warm-up strategy to be used at the start of the day.
Methods/Design. This prospective study assessed the impact of three different vocal warm-up conditions on
phonatory threshold pressure (PTP). The three conditions were: (1) Steam - breathing steam for 3 minutes; (2)
SOVT exercise - blowing bubbles through a straw into a cup of water while phonating /u/ for 3 minutes; and (3)
Steam + SOVT - both conditions 1 and 2. Participants were 12 females with a mean age of 24. They were assessed
on three different mornings, with one condition being tested each morning. Condition order and combination
order were counterbalanced. Each morning prior to arriving, participants were asked to be up for about an hour,
with no shower, no hot drinks or food, minimal voice-use, and no exercise. PTP was measured prior to each con-
dition and immediately after. Participants also qualitatively described the experience of each condition and pro-
vided their subjective impression of how their voice felt after each condition.
Results. There were 36 data points, reflecting change in PTP from before to after each condition. Results
reflected high variability within each individual and condition. Due to this variability, means and standard devia-
tions for each separate condition are meaningless, requiring deeper investigation into trends in the data. The
investigators eliminated all data points where the sound pressure level (SPL) in the pre-experimental measure
exceeded 67 dB; this was interpreted as the participant not performing the PTP task as softly as possible. First,
data were examined within each participant, excluding all data from any participant who exceeded 67 dB SPL in
any of the three pre-experimental measures. Of the seven participants remaining, steam was the best condition
for one, SOVT was the best for three, and Steam + SOVT was the best for three. Of these, only two people experi-
enced an improvement in PTP of greater than or equal to 0.5 cm H 2 O, both under the SOVT condition. Of the
same seven participants, steam was the worst condition for three, SOVT was the worst for one, and
Steam + SOVT was the worst for two. The three participants for whom steam was the worst reported strongly
disliking the condition. Only three people experienced a worsening of PTP greater than or equal to 0.5 cm H 2 O:
one in the SOVT condition; and two in the Steam + SOVT. It is typically expected that increases or decreases in
PTP and SPL will be systematically related. Since the goal of a warm-up is to increase phonatory efficiency, and
improve the viscosity of the vocal folds, a reduction in PTP after any condition was interpreted favorably. For
the 9 data points across all conditions where PTP and SPL both decreased, there was a mean decrease in PTP of
0.34 cm H2O (SD = 0.28 cm H2O ). Mean decrease in SPL was 2.00 dB (SD = 0.88 dB). This indicates that indi-
viduals were able to decrease PTP and SPL as expected after a warm-up strategy. Finally, a trend appeared in six
data points, where despite an increase in SPL, PTP decreased, potentially indicating improvement in vocal effi-
ciency. Of these data points the mean decrease in PTP was 0.36 cm H2O ( SD = 0.17 cm H2O ), with a mean
increase in SPL of 1.70 dB (SD = 1.21 dB). Of these six data points, indicating increased efficiency, three were
with steam, two with Steam + SOVT, and one with SOVT.
Conclusion. This study revealed that these strategies are not universally successful, and clinicians should recom-
mend them only after assessing their effectiveness for their client. Clinicians need to be custom tailoring these
exercises to their client’s goals and proclivities. Another consideration is the importance of teaching proper
SOVT technique, so it is done correctly without added tension. Even blowing bubbles into a cup of water with
phonation can be done poorly, in some cases yielding counterproductive results. Another interesting trend sug-
gests that the inclusion of steam in vocal warm-up may increase vocal efficiency. Future studies should explore
how time of day and vocal condition impact each strategy’s effectiveness, and which strategy may be most appro-
priate for different desired outcomes, such as vocal warmup versus vocal rescue.
Key Words: Superficial hydration−Professional voice user−Phonatory threshold pressure−SOVT.

INTRODUCTION
Accepted for publication August 28, 2020.
From the New York Medical College, Department of Speech-Language Pathology, Countless individuals rely on optimal vocal health in order
School of Health Sciences and Practice Building, 30 Plaza West, Valhalla, NY 10595, to perform their jobs effectively. Multiple factors can put a
USA.
Address correspondence and reprint requests to Andrew Keltz, Lakeshore Profes- person’s voice at risk. For musical theatre performers, the
sional Voice Center, 21000 Twelve Mile Rd., St. Clair Shores, MI 48081. physical stress of performing eight shows a week, requires
E-mail: [email protected]
Journal of Voice, Vol. &&, No. &&, pp. &&−&& constant care to maintain a voice that audiences pay to
0892-1997 hear. Teachers often have to speak loudly for many hours
© 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2020.08.037 each day with little opportunity for vocal rest.1 Of course,
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2020

each individual faces their own vocal challenges depending METHODS

on the circumstances of their life, profession, and environ- Participants
ment, which can result in vocal fatigue and possible injury. Participants were 12 female speech-language pathology
Many vocal warm-up and rescue strategies exist which are graduate students between the ages of 22 and 36 years old
anecdotal with no scientific basis; however, a few (mean age = 24 years). This study was part of the research
approaches have supporting evidence, including external component of a modular rotation in the graduate program.
hydration with steam and semi-occluded vocal tract (SOVT) Voice demands among participants consisted of providing
exercises. While drinking water provides systemic hydration, speech and language assessment and treatment to patients
steaming hydrates superficially, moistening the upper vocal across the lifespan at a variety of clinical sights, as well as
tract and vocal folds. This is crucial for performers who conversational interactions in quiet settings. No participants
experience desiccation in these areas through mouth breath- were involved in any activities that involved speaking loudly
ing in dry, dusty theatres. Environmental dryness and mouth over noise, nor were any professional or formally trained
breathing are also contributing factors for other vocational singers. There were no exclusion criteria since investigators
voice users, like an educator who teaches in a dry classroom. were interested in a variety of voices and each participant
Furthermore, individuals experiencing vocal fatigue are was acting as her own control. One participant demon-
even more susceptible to the negative impact of dryness.2 strated mild habitual muscle tension dysphonia (MTD).
Steaming is recommended by many speech-language pathol- Another participant reported that she received voice therapy
ogists as part of a comprehensive vocal hygiene regimen to as a child for vocal fold nodules, but that they had been
provide external hydration to the vocal fold mucosa,3 and resolved for some time.
some speech-language pathologists are advising their
patients to manage external hydration with nebulizers.4 In a
study inducing dehydration through 10 minutes of mouth Task and instrumentation
breathing, followed by rehydration with three minutes of The investigators sought the most functional warm-up
steam inhalation, objective measures of voice quality strategies that could be implemented with minimal time
showed significant improvement following steaming.5 commitment, accessible equipment, and minimal train-
There is more evidence to support the benefit of SOVT ing. To this end, the following three warm-up conditions
exercises. Vocal fold damage can result from high collision were examined: (1) Steam - breathing steam for 3
forces, where the vocal folds strike with excessive force dur- minutes; (2) SOVT exercise - blowing bubbles through a
ing loud phonation. These collisions can cause pathological straw into a cup of water while phonating /u/ for 3
tissue changes, leading to vocal nodules and voice quality minutes; and (3) Steam + SOVT - both conditions 1 and
changes. SOVT exercises optimize voice production with 2 for three minutes each. Participants were assessed on
slightly separated vocal folds, minimizing collision forces, three different mornings, with one condition being tested
while still allowing efficient vocal projection with reduced each morning. Condition order and combination order
phonatory threshold pressure (PTP), the minimum pressure were counterbalanced. Each morning prior to arriving,
required to initiate vocal fold vibration.6 There are many participants were asked to be up for about an hour, with
versions of SOVT exercises, from humming, to lip trills, to no shower, no hot drinks or food, minimal voice-use,
blowing bubbles through a straw into water while voicing. and no exercise. All reported complying with these
All are designed to increase intraoral pressure, improving requirements. PTP was measured prior to each condition
the impedance match at the level of the vocal folds. Some and immediately after.
SOVT exercises, like humming and hand-over-mouth with Five days prior to beginning the study, participants were
voicing, incorporate a single source of vibration occurring oriented to the tasks and instrumentation. They were
at the vocal folds. These exercises create a steady intraoral trained on how to properly produce the PTP task and were
pressure. Other SOVT exercises, like lip trills, tongue trills, given verbal instructions about how to use the personal
and blowing bubbles through a straw into water while steam inhaler and how to perform the SOVT exercise. They
voicing, encompass vibration at the vocal folds as well as each practiced the tasks briefly with coaching, as needed.
an additional source of vibration at the distal end of the Emails were sent the night before each testing day to remind
vocal tract. This creates a fluctuating intraoral pressure, the participants that the morning of the testing they needed
possibly imparting a massage effect on the laryngeal tis- to comply with the testing requirements.
sue.7 Improved aerodynamic efficiency occurs both during Upon arrival on each testing day, participants were asked
and immediately after completing SOVT exercises, making what they ate and/or drank prior to arrival. Then initial PTP
their implementation ideal for vocal warm-up and was obtained (Phonatory Aerodynamic System; PENTAX-
rescue.8,9 Medical). To acquire the data, the participant placed a mask
This study was designed to assess the effectiveness of morn- over their nose and mouth. A pressure sensing tube was
ing warm-up strategies with the goal of optimizing laryngeal placed just behind their lips and not touching the tongue or
function to prepare for the vocal demands of the day. It was teeth. Airflow was sensed by a pneumotachograph to ensure
hypothesized that SOVT exercises plus steam would enhance complete stoppage of air during /p/ production because
vocal function more than either strategy alone. incomplete bilabial closure would invalidate the intraoral air
 ARTICLE IN PRESS
Andrew Keltz and Monica McHenry Steam and/or Semi-occluded Vocal Tract Exercise 3

pressure measure. After obtaining the pretreatment PTP, par- Statistical analysis
ticipants engaged in one of the three conditions. Due to high variability of results within each individual and
In the steam condition, participants used a steam inhaler condition, analyzing means and standard deviations proved
(Vick’s) with the vents in their most open position. The meaningless. As such, formal statistical analyses were not
steam inhaler was turned on prior to participants’ arrival to performed. Instead, data were examined with the goal of
ensure that the water was bubbling and maximal steam was identifying any patterns or trends.
being produced during inhalation. Participants were
instructed to sit in a comfortable position, place their face
over the mask and breathe calmly for three minutes. There RESULTS
was some variability in the participants’ ability to tolerate There were 36 data points reflecting change in PTP from
the steam and keep their face touching the mask, so partici- before to after each condition, which are presented in
pants were also allowed to hover approximately one inch Table 1. Changes in sound pressure level (SPL) are included
above the mask during this condition. as well.
For the SOVT condition, participants were each given their Results reflected high variability within each individual
own reusable hard plastic cup with a lid and a straw. The cup and condition. The focus, therefore, was to uncover mean-
was filled with water to a depth of approximately 10 cm. The ingful trends in the data. Upon analysis, the investigators
straws were submerged at approximately 2 cm below the sur- observed that some SPL data points in the pre-experimental
face of the water. Each straw had a ridge 2 cm from the bot- measure were greater than or equal to 67 dB. This could be
tom of the straw designed to prevent it from falling out of the interpreted in two ways: first, the participant did not per-
cup. This ridge was used as a guide for the submersion depth, form the PTP task as softly as possible; or second, the par-
and the straw was held in place with a rubber band. ticipant performed the PTP task as softly as possible at a
Participants were instructed to blow bubbles through the higher SPL because the current physiological state of their
straw and phonate /u/ on a single comfortable pitch with vocal folds precluded the production of soft voicing. Fur-
comfortable loudness for one minute. After the first minute, ther investigation led the researchers to determine that it
they were instructed to switch to producing comfortable was likely the former; the participant was not performing
pitch glides on /u/ up and down the scale for the remaining the PTP task as softly as possible. For the five people who
two minutes. demonstrated pre-experimental SPL higher that 67 dB, four
Of the many SOVT exercises, this one was chosen for a of them did so on the first, or first and second experimental
variety of reasons. First, an SOVT exercise with two sources condition. By the second or third day of the experiment,
of vibration (dual source) may have a massaging effect on their pre-experimental SPL dropped to below 67 dB, sug-
the vocal folds due to fluctuations in intraoral pressure.7 gesting newly acquired comfort and familiarity with the
The present investigators hypothesized that the potential task. Though the researchers provided training on the PTP
massaging effect would be useful during morning warm-up task five days prior to beginning the experiment, SPL was
to facilitate the dissipation of fluid within the vocal folds. not objectively assessed at that time. Judging by these
Second, among the dual source SOVT exercises like lip trills results, more training was warranted while monitoring SPL
and tongue trills, blowing bubbles into water while phonat- objectively. With these considerations in mind, the investi-
ing was likely to be easier to teach and implement by most gators eliminated all data points where the SPL in the pre-
people. Anecdotally, there are many individuals for whom experimental measure exceeded 67 dB.
lip trills are difficult to produce. After eliminating all data from any participant who
In the Steam + SOVT condition, participants completed exceeded 67 dB SPL in any of the three pre-experimental
conditions 1 and 2: three minutes of steam and three minutes conditions, seven participants remained. Regardless of
of SOVT. Order was counterbalanced across participants. whether PTP increased or decreased in the postexperimental
After completion of the prescribed condition assigned for condition, researchers evaluated all three conditions for
that testing day, participants’ PTP was obtained again. Par- each person and determined which condition was the best
ticipants were also asked to subjectively report how they felt and which was the worst for that person. Best was defined
during each condition and how their voices felt after each as the largest reduction in PTP or the smallest increase in
condition. Pressure traces were measured by eliminating the PTP when comparing all three warm-up conditions. Even if
first and last syllables of each syllable train, verifying com- a participant’s PTP increased after each of the conditions, a
plete lip closure based on airflow, assessing the overall con- best and a worst condition for each individual was identi-
sistency of pressure peaks, and taking the average of those fied. Of the seven participants, steam was the best condition
remaining as the prevailing pressure. Pressure peaks were for one, SOVT was the best for three, and Steam + SOVT
deleted if complete bilabial closure was not achieved, and was the best for three. Of these, only two people experienced
the remaining pressure peaks were used for calculation. an improvement in PTP of greater than or equal to 0.5 cm
Twenty-five percent of data points were remeasured to H2O, both in the SOVT condition. Of the same seven partic-
determine reliability. The mean difference for both inter- ipants, steam was the worst condition for three, SOVT was
and intrajudge reliability across all conditions was 0.05 cm the worst for one, and Steam + SOVT was the worst for
H2O. two. The three participants for whom steam was the worst
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2020

TABLE 1.
Results Summary Showing PTP in cm H2O and SPL in dB Before and After Each Condition for Each Participant
Participant Condition PRE PTP POST PTP Difference PTP Pre SPL Post SPL Difference SPL
1 STEAM 4.44 4.2 0.24 67.52 65.42 2.1
1 SOVT 4.86 5.42 0.56 67.46 67 0.46
1 STEAM + SOVT 4.99 4.43 0.56 62.07 65.9 3.83
2 STEAM 3.45 3.86 0.41 63.91 63.69 0.22
2 SOVT 3.75 4.12 0.37 64.67 64.55 0.12
2 STEAM + SOVT 3.7 3.63 0.07 66.76 63.52 3.24
3 STEAM 4.1 4.01 0.09 61.71 63.45 1.74
3 SOVT 3.81 4.31 0.5 61.43 63.88 2.45
3 STEAM + SOVT 4.42 4.08 0.34 63.95 61.22 2.73
4 STEAM 4.56 4.86 0.3 61.29 68.55 7.26
4 SOVT 4.7 3.73 0.97 61.49 60.86 0.63
4 STEAM + SOVT 3.9 3.53 0.37 63.28 60.38 2.9
5 STEAM 3.48 3.68 0.2 61.36 60.66 0.7
5 SOVT 4.14 3.59 0.55 62.78 60.55 2.23
5 STEAM + SOVT 3.63 3.16 0.47 61.33 63.23 1.9
6 STEAM 4.7 4.06 0.64 76.1 67.94 8.16
6 SOVT 3.87 4.17 0.3 61.21 62.99 1.78
6 STEAM + SOVT 3.62 3.43 0.19 66.55 65.05 1.5
7 STEAM 4.09 3.93 0.16 62.36 61.41 0.95
7 SOVT 4.81 4.38 0.43 61.07 62.43 1.36
7 STEAM + SOVT 4.5 4 0.50 67.45 62.71 4.74
8 STEAM 5.47 5.49 0.02 65.72 63.18 2.54
8 SOVT 3.38 3.76 0.38 63.69 65.39 1.7
8 STEAM + SOVT 5.3 5.31 0.01 62.12 66.17 4.05
9 STEAM 3.57 3.35 0.22 62.84 60.86 1.98
9 SOVT 3.16 2.99 0.17 63.45 61.63 1.82
9 STEAM + SOVT 3.27 3.97 0.7 60.86 65.72 4.86
10 STEAM 4.13 3.75 0.38 65.49 65.66 0.17
10 SOVT 4.05 3.86 0.19 67.5 64.11 3.39
10 STEAM + SOVT 4.7 4.98 0.28 68.55 69.05 0.5
11 STEAM 5.08 4.86 0.22 63.68 64.88 1.2
11 SOVT 5.91 5.62 0.29 69.9 64.34 5.56
11 STEAM + SOVT 5.13 5.17 0.04 70.71 68.75 1.96
12 STEAM 3.83 4.3 0.47 61.2 61.2 0
12 SOVT 3.76 3.78 0.02 62.07 66.04 3.97
12 STEAM + SOVT 3.25 3.88 0.63 61.94 61.34 0.6
Difference in PTP and SPL are also included, with a negative number indicating a decrease in the postcondition.

reported strongly disliking the condition. Only three people suggesting merits in all three strategies. Results after elimi-
experienced a worsening of PTP greater than or equal to nating those whose pre-SPL was greater than 67 dB and
0.5 cm H2O: one in the SOVT condition; and two in the whose PTP and SPL decreased are presented in Table 2,
Steam + SOVT. organized by condition.
It is typically expected that increases or decreases in PTP A trend appeared in six data points, where despite an
and SPL will be systematically related. Since the goal of a increase in SPL, PTP decreased, potentially indicating
warm-up is to increase phonatory efficiency, and improve improvement in vocal efficiency. Of these data points the
the viscosity of the vocal folds, a reduction in PTP after any mean decrease in PTP was 0.36 cm H2O (SD = 0.17 cm
condition was interpreted favorably. For the nine data H2O), with a mean increase in SPL of 1.70 dB (SD =1.21
points across all conditions where PTP and SPL both dB). Of these six data points, indicating increased efficiency,
decreased, there was a mean decrease in PTP of 0.34 cm three were with steam, two with Steam + SOVT, and one
H2O (SD = 0.28 cm H2O). The mean decrease in SPL was with SOVT. These results are displayed in Table 3.
2.00 dB (SD = 0.88 dB). This indicates that individuals were Finally, for participant 2 who had a history of pediatric
able to decrease PTP and SPL as expected after a warm-up vocal fold nodules, both steam and SOVT alone resulted in
strategy. Each of the three warm-up strategies demonstrated an increase in PTP, however her PTP decreased slightly
the potential to reduce PTP while also reducing SPL, with the Steam + SOVT condition. For participant 8 who
 ARTICLE IN PRESS
Andrew Keltz and Monica McHenry Steam and/or Semi-occluded Vocal Tract Exercise 5

TABLE 2.
Results After Eliminating Those Whose Precondition SPL was Greater Than 67 dB and Whose PTP and SPL Decreased,
Organized by Condition
Condition PRE PTP POST PTP Difference PTP PRE SPL Post SPL Difference SPL
STEAM + SOVT 3.9 3.53 0.37 63.28 60.38 2.9
STEAM + SOVT 4.42 4.08 0.34 63.95 61.22 2.73
STEAM + SOVT 3.62 3.43 0.19 66.55 65.05 1.5
STEAM + SOVT 3.7 3.63 0.07 66.76 63.52 3.24
SOVT 4.7 3.73 0.97 61.49 60.86 0.63
SOVT 4.14 3.59 0.55 62.78 60.55 2.23
SOVT 3.16 2.99 0.17 63.45 61.63 1.82
STEAM 3.57 3.35 0.22 62.84 60.86 1.98
STEAM 4.09 3.93 0.16 62.36 61.41 0.95
Mean (SD) 0.34 (0.28) 2.00 (0.88)
PTP is presented in cm H2O and SPL in dB.

presented with mild habitual MTD, an increase in PTP was Table 3 shows data points where PTP decreased while
noted for all three conditions, though for the steam and SPL increased, indicating a possible improvement in vocal
Steam + SOVT conditions the increase was negligible efficiency. Of the six data points for which this trend was
(increase of 0.02 cm H2O for steam, increase of 0.01 cm observed, five included steam (three were with steam alone
H2O for Steam + SOVT). and two were with Steam + SOVT). This may point to the
potential of steam to improve vocal efficiency. For those
who saw benefits from the steam and Steam + SOVT condi-
DISCUSSION tions, it can be hypothesized that starting the day with a hot
A morning vocal warm-up strategy is designed to establish shower will result in improvements in vocal efficiency and
optimal laryngeal function and prepare an individual for function. It must be noted, however, that the steam gener-
the vocal demands of their day. This study was designed to ated from a shower is more dissipated than that produced
determine the effectiveness of steam, SOVT, and a combina- by a steamer and may be less impactful. For participant 2
tion of the two as a morning vocal warm-up. Results who had a history of pediatric vocal fold nodules and for
revealed that these strategies are not universally successful, participant eight who presented with mild habitual MTD,
and clinicians should recommend them only after assessing Steam + SOVT was the best condition. This finding war-
their effectiveness for each client. Clinicians need to custom rants further investigation to examine the effectiveness of
tailor these exercises to their client’s goals and proclivities. these strategies for people with past or present voice disor-
Some participants hated the steam, finding it difficult to tol- ders, especially determining the impact of combining steam
erate for the full three minutes. Others loved it and found it with other exercises and strategies.
calming and enjoyable. Some found the SOVT exercise to Additionally, of the data points that were analyzed, very
be taxing and tension producing, while others found it easy. few reflected an increase or decrease in PTP of greater that
For some, steaming resulted in a reduction of PTP, while 0.5 cm H2O. This finding calls into question the degree to
for others it was counterproductive, resulting in increased which these strategies are making a difference either posi-
PTP. The same pattern was observed for all three condi- tively or negatively. Furthermore, all PTP values obtained
tions; each condition worked well for some participants, during this investigation were within the normal limits of
and each condition was not helpful for some. 3.0 to 6.0 cm H2O. This may have contributed to the small

TABLE 3.
Those Who Increased SPL and Reduced PTP
Participant Condition PRE PTP POST PTP Difference PTP PRE SPL POST SPL Difference SPL
7 SOVT 4.81 4.38 0.43 61.07 62.43 1.36
3 STEAM 4.1 4.01 0.09 61.71 63.45 1.74
10 STEAM 4.13 3.75 0.38 65.49 65.66 0.17
11 STEAM 5.08 4.86 0.22 63.68 64.88 1.2
1 STEAM + SOVT 4.99 4.43 0.56 62.07 65.9 3.83
5 STEAM + SOVT 3.63 3.16 0.47 61.33 63.23 1.9
Mean (SD) 0.36 (0.17) 1.70 (1.21)
PTP is presented in cm H2O and SPL in dB.
 ARTICLE IN PRESS
6 Journal of Voice, Vol. &&, No. &&, 2020

PTP changes observed. Nonetheless, a critical conclusion of variables of the SOVT exercise may be an important factor
this study is the importance of exploring the internal evi- in maximizing its effects and optimizing laryngeal function.
dence for each client. No strategy was universally better The current investigation also explored external hydra-
than the others. Larger studies might seek to identify partic- tion. Beyond the use of a personal steam inhaler, there are
ular patient characteristics that make one strategy more other methods of superficial hydration of the vocal tract,
effective than another. such as a humidifier, that may be appropriate for certain
An additional consideration is the importance of teaching individuals. In a 2014 study, researchers induced vocal tract
proper SOVT technique, so it is done correctly without dehydration by requiring participants to complete 2-hours
added tension. Even blowing bubbles into a cup of water of mouth-breathing in low-humidity (16%−27%).13 After a
with phonation can be done poorly, in some cases yielding 5-minute break in ambient humidity, participants were
counterproductive results. The SOVT exercise employed in given a 2-hour treatment of mouth-breathing in moderate
this study was chosen for its presumed ease of production as to high humidity (62%−80%). The researchers found that
compared to lip or tongue trills. This SOVT exercise also PTP increased significantly after dehydration and returned
has the added benefit of visual and acoustic feedback to con- to around baseline PTP after the humidification treatment.
firm adequate and consistent airflow; the person can hear Given that the humidification treatment lasted for two
and see the bubbles popping. If the bubbles become inter- hours, this intervention would not be ideal as part of a quick
mittent or erratic, the client knows they must increase or vocal warm-up strategy, however it may be an appropriate
produce airflow more consistently. While this exercise may recommendation for voice users to incorporate into their
be easier to produce than others, it still requires guidance everyday environments to facilitate more optimal vocal
and coaching for the client to produce it accurately without tract hydration.
adding tension. It is worth noting that during this SOVT An alternative method for external laryngeal hydration is
exercise, the cups were used with lids. We noted anecdotally the use of a nebulizer with isotonic saline. In a series of stud-
that blowing bubbles into cups with lids provides increased ies, investigators in Brazil examined the use of nebulizer
resistance as compared to cups without lids, and may result treatments with isotonic saline for teachers.14,15 Over the
in hyperfunction in some individuals. course of four weeks, participating teachers received 5-min-
SOVT literature supports the idea that no single tech- ute nebulization treatments with isotonic saline after 10
nique is appropriate for all patients. Variations in the minutes of desiccation through mouth breathing. This inter-
parameters of an SOVT exercise (eg, tube length, tube diam- vention resulted in improvements in self-perceived voice
eter, depth that tube is submerged in water) can impact the quality as well as improvements in objective voice quality
effectiveness of the intervention depending the individual.10 measures. In another study, researchers compared the use of
Phonating through a glass tube into water was introduced nebulized isotonic saline with nebulized sterile water in clas-
in the 1960s by Professor Antti Sovij€ arvi at the Department sically trained sopranos.16 There were no statistically signifi-
of Phonetics at the University of Helsinki.11 He determined cant changed in PTP after the desiccation challenge,
the appropriate tube length for a client by palpating the lar- however self-perceived phonatory effort (PPE) increased
ynx during phonation through the tube and feeling for the significantly postdesiccation. PPE returned to baseline for
relationship between tube length and laryngeal lowering. In those treated with isotonic saline, whereas for sterile water
singers, his choice of tube length also corresponded to vocal and no intervention, PPE remained above baseline during
category. This Finnish tradition of using the resonant tube the two hours postdesiccation. The nebulization treatment
method also highlights different submersion depths depend- in this study took place within a 10-minute period, which
ing on the etiology of the voice problem. For hyperfunc- makes it a viable alternative to steam inhalation as a com-
tional voice users, the tube is submerged 1−2 cm below the ponent of a quick vocal warm-up or rescue protocol.
water surface; whereas hypofunctional voice users might The findings in the present study depended on valid mea-
increase the submersion depth of the tube to between 5 and surement of PTP. As mentioned earlier, despite a practice
15 cm below the surface of the water to increase resistance session, a number of data points were eliminated due to
and thus improve vocal fold adduction. Another factor SPL of greater than 67 dB, as this was interpreted as the
impacting effectiveness in singers is vocalizing. In a more participant not voicing as softly as possible without whisper-
recent study examining resonant tube phonation in water ing. In future investigations, an area that may warrant more
with singers, expert listeners perceived a greater improve- practice for clients is accurately producing the soft voicing
ment in voice quality after the SOVT exercise for less experi- required for the PTP measure.
enced singers and those who did not practice daily, than for Future studies should explore how time of day and cur-
more experienced singers and those who did practice daily.12 rent level of vocal function impact each strategy’s effective-
These investigators posited that the experienced singers who ness, and which strategy may be most appropriate for
practiced daily already achieved their target phonatory con- different desired outcomes, such as vocal warm-up versus
dition regularly and thus might not benefit noticeably from vocal rescue. A vocal warm-up strategy is designed to opti-
this short and simple exercise. As such, experienced singers mize laryngeal function, whereas a vocal rescue strategy is
might need modified exercises to match their goals. The cur- designed to assist the voice user in healthily meeting their
rent investigation supports the idea that customizing the vocal needs despite their voice already being taxed.
 ARTICLE IN PRESS
Andrew Keltz and Monica McHenry Steam and/or Semi-occluded Vocal Tract Exercise 7

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