Open Access Review

Article DOI: 10.7759/cureus.62041

Assessing the Effectiveness of Voice Therapy

Techniques in Treating Dysphonia: An
Review began 05/20/2024
Otolaryngological Review
Review ended 06/03/2024
Published 06/10/2024 Omair H. Al-Hussain 1

© Copyright 2024
Al-Hussain. This is an open access article 1. Otolaryngology - Head and Neck Surgery, Faculty of Medicine, Imam Mohammad Ibn Saud Islamic University,
distributed under the terms of the Creative Riyadh, SAU
Commons Attribution License CC-BY 4.0.,
which permits unrestricted use, distribution,
Corresponding author: Omair H. Al-Hussain, [email protected]
and reproduction in any medium, provided
the original author and source are credited.

Abstract
Dysphonia is a prevalent condition that can impact individuals across all age groups. It occurs when normal
voice quality is altered, caused by structural and/or functional issues. Evaluation and assessment from
clinicians are warranted if dysphonia persists for more than four weeks and/or is coupled with risk factors or
other concerning clinical manifestations. Additionally, voice disorders can increase the risk of depression
and anxiety disorders, as well as raise stress levels and lower self-reported health indicators. Dysphonia can
have a substantial influence on interpersonal interactions and lower overall quality of life since effective
communication relies significantly on spoken language. Hence, managing dysphonia is essential for
enhancing communication abilities, improving quality of life, maintaining vocational functioning,
promoting psychological well-being, and addressing underlying health concerns. Speech and language
therapy, medical management, surgery, or a combination of the aforementioned are all possible treatments
for dysphonia. Speech and language therapy is often the first-line treatment option for dysphonia patients
who do not meet the criteria for surgical intervention. Voice therapy is often beneficial and remains the first
line of treatment, even when patients approach with benign vocal fold nodules. A well-designed voice
therapy program improves both the quality of life and vocal performance. The majority of the studies in the
existing literature advocate for and report beneficial outcomes associated with voice therapy; however, more
research is needed to provide evidence-based findings to guide clinical practice and achieve optimal
outcomes. This comprehensive review elaborately highlights the utilization and efficacy of various voice
therapeutic modalities utilized for the management of dysphonia in light of current literature.

Categories: Other, Otolaryngology, Therapeutics

Keywords: ent, beneficial, treatment, voice therapy, dysphonia

Introduction And Background

Dysphonia, which includes the cardinal symptom of hoarseness, affects around 1% of all patients and has a
lifetime incidence of approximately 30% [1]. It refers to any voice impairment, including hoarseness,
restriction of vocal performance, or strained vocalization [1]. Hoarseness can stem from a range of factors,
such as acute and chronic laryngitis, laryngopharyngeal reflux, functional dysphonia caused by vocal strain
or misuse, vocal cord paralysis, and various laryngeal disorders and growths [2]. Hoarseness resulting from
acute and chronic laryngitis accounts for 42% and 10% of instances, respectively, while for functional
dysphonia the incidence is 30% [3]. Additionally, the percentages attributed to hoarseness caused by age-
related physiological changes in the voice and psychogenic factors are 2% and 2-2.2%, respectively, benign
(15%) and malignant tumors (3%), while vocal cord paresis is responsible for 5% of cases [1].

Voice disorders can lead to heightened susceptibility to depression and anxiety disorders, increased levels of
stress, and diminished self-reported indicators of health. Effective communication heavily relies on spoken
language, making dysphonia a significant challenge that can profoundly impact interpersonal interactions
and diminish the overall quality of life [4]. Dysphonia, a condition affecting vocalization, manifests in
various acoustic forms. Perello introduced a well-known classification of dysphonia into two categories:
organic and functional. Later on, Majdevac proposed a classification based on the primary etiological factors
[5]. Under Majdevac’s classification, dysphonias caused by primary functional disorders include hyperkinetic
dysphonia grades I and II, hypokinetic dysphonia, contact hyperplastic dysphonia, and dysodic dysphonia,
while dysphonias resulting from primary neurogenic disorders encompass central dysphonias
spasmodic/spastic dysphonia, dysphonia related to myasthenia gravis, dysphonia within skull base
syndromes, dysphonia due to unilateral/bilateral palsy of the inferior laryngeal nerve and dysphonia due to
palsy of the superior laryngeal nerve. Primary psychogenic disorders lead to psychogenic aphonia,
psychogenic dysphonia, and false mutation. Dysphonias caused by primary somatic disorders include those
resulting from vocal cord insufficiency, vocal cord edema, laryngitis secondary functional, cord-ventricular
voice, posttraumatic dysphonia, arthrogenic dysphonia, and presbyphonia [5].

Presentation of hoarseness is frequent in ENT clinics, with estimates suggesting that over 50,000 patients
seek care for dysphonia annually at otolaryngology/voice clinics [6]. Adequate vocal function is deemed

How to cite this article

Al-Hussain O H (June 10, 2024) Assessing the Effectiveness of Voice Therapy Techniques in Treating Dysphonia: An Otolaryngological Review.
Cureus 16(6): e62041. DOI 10.7759/cureus.62041
 necessary for approximately one-third of the workforce to effectively carry out their job responsibilities.
Evaluating and treating patients with hoarseness can be intricate and prolonged due to its often
multifactorial etiology [6]. Managing or treating dysphonia is essential for enhancing communication
abilities, improving quality of life, maintaining vocational functioning, promoting psychological well-being,
and addressing underlying health concerns.

Treatment initiation should prioritize voice rest, with particular emphasis on avoiding whispering, coupled
with interventions aimed at addressing potential underlying causes. For instance, hoarseness attributed to
reflux may warrant the use of proton pump inhibitors, while vocal abuse-related issues benefit from
adhering to proper vocal hygiene practices. However, in cases lacking clear indications, empirical use of
antibiotics, oral corticosteroids, or proton pump inhibitors for treating hoarseness is not recommended.
Visualization of the larynx and vocal folds should be conducted within three months if an etiology remains
unidentified or if conservative measures prove ineffective. Patients experiencing symptoms persisting
beyond two weeks, especially those with risk factors for dysplasia like tobacco or heavy alcohol use, may
necessitate an earlier laryngoscopic assessment. Voice therapy represents an effective means of enhancing
voice quality for individuals with dysphonia when conservative approaches prove inadequate, and it may
serve as a preventive measure for high-risk groups such as vocalists or public speakers. Surgical intervention
becomes necessary for addressing laryngeal or vocal fold dysplasia or malignancy, airway obstruction, or
benign pathology [7].

Moreover, voice therapy has been proven to demonstrate effectiveness in enhancing both self-assessed and
externally evaluated aspects of voice quality. Typically, after ruling out conditions necessitating surgical
intervention, patients are commonly directed to a speech and language therapist for voice therapy [8]. Voice
therapy treatments may be divided into three distinct categories: hygienic, which refers to modifying
behaviors that can cause vocal fold injury; symptomatic, which includes treating faulty voice quality in the
ensuing phonated voice; and physiologic, which is optimizing voice output [9]. A well-designed voice
therapy program improves both the quality of life and vocal performance. Short-term voice therapy (less
than three weeks) may be as effective as long-term programs, and telepractice voice therapy may be a
feasible option to improve therapy adherence [10]. Present clinical practice guidelines also advocate that
clinicians should recommend voice therapy for patients experiencing dysphonia stemming from conditions
suitable for voice therapy intervention [11]. Voice therapy is a recommended treatment for dysphonia, which
remains a prevalent condition encountered in clinical practice at otolaryngological clinics. Therefore,
assessing the efficacy of this modality is vital. Hence, we aim to conduct this review to comprehensively
analyze the existing literature to define the effectiveness of various voice therapeutic techniques utilized for
the management of dysphonia and provide evidence-based findings that can guide clinical practice, achieve
optimal outcomes for patients, and significantly improve their quality of life.

Review
Almost 30% of the adult population will experience voice issues at some point in their lives, whether chronic
(21.5%) or acute (78.5%). Their voices will not perform or sound as usual, which may influence their
communication, work, and overall quality of life. Voice issues can have a significant detrimental influence
on a person’s social interactions, emotional state, and health, analogous to other chronic conditions such as
heart failure, angina, and chronic obstructive pulmonary disease. Behavioral voice therapy, directed by a
speech-language pathologist, is frequently advised as the primary strategy for treating voice abnormalities,
and when not, it is indicated in conjunction with medical or surgical treatment [12].

As it becomes more extensively understood that medical treatments should be reviewed scientifically,
paramedical therapies must also be objectively evaluated following current evidence-based medicine
standards. The evaluation of voice therapy falls under this rising focus. However, there have been relatively
few studies on the effects of voice therapy [13]. Van Stan et al. have developed a taxonomy of voice therapy
that organizes direct and indirect treatment into more specific components. Direct intervention is classified
into five categories: auditory, somatosensory, musculoskeletal, respiratory, and vocal function. The indirect
intervention comprises pedagogy and counseling elements. This taxonomy empowers clinicians and
researchers to contemplate therapeutic options based on physiological goals [14].

In the past decade, two systematic studies of large patient groups have provided promising evidence for the
efficacy of voice therapy. Ruotsalainen et al. conducted a systematic literature review and concluded that an
amalgamation of direct and indirect voice treatment is the best available solution for functional dysphonia
when compared to no intervention. However, these findings are based on three studies and only on self-
assessment measures: the Vocal Performance Questionnaire and the Voice-Related Quality of Life [15].
Speyer conducted a review of functional and organic dysphonia and discovered that direct voice therapy
produces better results than indirect voice therapy. This same review also found that when study
populations were restricted to groups of patients with specific diagnoses and assigned to well-defined voice
therapy techniques, they had more success compared to studies where groups and treatments were less
explicit [13]. Another review from recent times concluded that behavioral voice therapy often improves
voice outcomes; however, more research into the therapeutic significance of the results is required to
determine what the term effectiveness means in the context of voice therapy [12].

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 In this review, we analyzed the existing literature by performing an elaborate literature search to assess the
efficacy of various voice therapeutic techniques among dysphonia patients. The literature search yielded a
total of 17 potential studies, the details of which are illustrated and defined in Table 1 [16-32].

Voice therapy
Type of
Author modality utilized Outcome
dysphonia
for treatment

Chen et al. Positive effects on voice quality, vocal fold vibration, vocal fold closure, speaking flexibility,
Voice disorder Resonant therapy
[16] phonation effort, and functional communication

Vocal therapy is effective in treating dysfunctional dysphonia, with a high degree of

Morsomme et Dysfunctional satisfaction, particularly in improving vocal quality. There was a significant decrease in
Voice therapy
al. [17] dysphonia perceived handicap post-treatment, indicating the efficacy of vocal therapy in the long-term
management of dysfunctional dysphonias.

A considerable proportion of patients across different severity levels experienced an

improvement in voice disorder symptoms, with effect sizes indicating significant overall
Kleemola et al. Organic and improvement, which persisted after therapy. Functional and organic voice disorder patients
Voice therapy
[18] functional demonstrated similar improvement, although functional patients may have derived slightly
greater benefit from treatment, suggesting progressive and comparable efficacy of voice
treatment.

Group therapy as a service delivery model possesses many advantages from a psychosocial,
Law et al. [19] Voice disorder Group therapy
clinical, and health resources allocation perspective.

MTD or Significant improvements in the s/z ratio, maximum phonation time, sentence CPP, and VHI
Watts et al. Stretch-and-flow
phonotraumatic through therapy were observed, with large effect sizes observed for the s/z ratio and VHI and
[20] voice therapy
lesions moderate effect sizes for maximum phonation time and sentence CPP.

Humming and
subsequent um-
Immediate effect in adjusting the regularity of vocal fold vibration and augmenting the degree
Ogawa et al. hum phonation on
MTD of glottal contact in MTD patients as well as nondysphonic speakers, whereas humming
[21] the computed
alone increases the degree of glottal contact in MTD patients
parameters of
electroglottographic

Steppet al. Both the cycle and therapy phases significantly influence REF, with post-therapy REF
MTD Voice therapy: RFF
[22] measurements being significantly higher than pretherapy measurements.

Mathur et al. Hyperfunctional Voice therapy in

Voice therapy improved voice quality.
[23] dysphonia teachers

Significant changes in perturbation (HNR) in the FE group after treatment were observed,
Nguyen and Vocal function indicating a reduction in voice perturbation and improved vocal quality. The FE group showed
MTD
Kenny [24] exercises increased size and speed of pitch change and fewer adverse effects. Both interventions
showed some degree of benefit.

An improvement was seen in various acoustic and auditory perceptual parameters after the
de Oliveira
Indirect and direct voice therapy intervention. A positive difference was observed for vocal jitter, which
Lemos et al. MTD
voice therapy decreased from 0.46% to 0.31% post-therapy, and shimmer, which decreased from 4.58% to
[25]
3.80% post-therapy.

Tierney et al. Voice therapy was effective in improving voice quality in most patients with FD: 84.7% of
FD Voice therapy
[26] patients achieved normal voice quality.

MCT, SOVTE, and DSI impairment levels and VHI scores showed significant improvement from the baseline to
Sarin and
MTD vocal hygiene both at six weeks and three months of VRT (p < 0.001). DSI and VHI scores even showed
Chatterjee [27]
program significant improvement between six weeks and three months of therapy.

Aerodynamic assessments, acoustic findings, and self-ratings demonstrated improvement

Voice therapy: flow
Kaneko et al. following voice therapy. Stroboscopic examinations conducted before voice therapy revealed
MTD phonation
[28] asymmetric vibration with a glottic gap, which showed improvement after voice therapy.
technique
Additionally, there was an increase in fundamental frequency (F0) post-therapy.

Patients experienced significant improvements in VHI-10 values, with mean scores

decreasing from 30.91 before treatment to 3.36 in the final follow-up examination.
Başer and Psychogenic DoctorVox voice
Additionally, grade, roughness, breathiness, asthenia, and strain scale scores decreased
Denizoğlu [29] dysphonia therapy
markedly post-treatment, indicating enhanced phonatory muscle function and therapy
adherence facilitated by multidimensional biofeedback mechanisms.

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 Treatment included cup-bubble blowing, gargling, and stretch and flow exercises. Voice
quality was significantly improved in both treatment groups, with trends toward better voice-
related quality of life. Although aerodynamic and acoustic measures did not significantly
Rangarathnam Flow phonation
MTD1 change, visual comparisons showed better laryngeal closure patterns in the flow phonation
et al. [30] voice therapy
voice therapy group. These findings suggest that flow phonation exercises can be beneficial
for individuals with MTD1, particularly in alleviating vocal hyperfunction and improving
auditory-perceptual measures.

The physiologic voice therapy group showed significant improvements in VHI, VoiSs, VTDS
(decrease), and self-perception of resonant voice quality (increase), along with significant
decreases in subglottic pressure, phonation threshold pressure, and glottal airflow across the
Guzman et al. Behavioral Physiologic voice implemented tasks. These findings suggest that physiologic voice therapy based on semi-
[31] dysphonia therapy occluded vocal tract exercises effectively enhances voice outcomes in individuals with
behavioral dysphonia, particularly in physical and functional aspects, with subglottic pressure
and phonation threshold pressure serving as sensitive indicators of phonatory effort reduction
post-therapy.

All groups undergoing VFTs, MCT, or combined VT demonstrated significant improvements

in the VTD scale and DSI scores post-treatment. Additionally, a significant difference was
observed between the groups (p ≤ 0.05), with the combined VT group showing the greatest
Khoddami et Combined VT with
MTD improvement in the VTD severity subscale and DSI scores (η2 = 0.99 and 0.98, respectively).
al. [32] other approaches
Notably, the interactive effect of treatment and time was significant, suggesting that combined
VT yielded the most substantial improvements in MTD teachers, emphasizing the potential
benefit of integrating various therapeutic approaches for the management of MTD.

TABLE 1: Outcomes of included studies

CPP, cepstral peak prominence; FD, functional dysphonia; FE, full vocal exercise protocol; DSI, Dysphonia Severity Index; HNR, harmonics-to-noise ratio;
MCT, manual circumlaryngeal therapy; MTD, muscle tension dysphonia; NR, not reported; PE, partial vocal exercise protocol; RFF, resonant voice
therapy; ref, relative fundamental frequency; VFT, vocal function exercises; VHI, Voice Handicap Index; VRT, vocal rehabilitation therapy; VT, vocal
therapy; VTD, vocal tract discomfort

The majority of the reported dysphonia cases were muscle tension dysphonia, followed by functional,
organic, dysfunctional, behavioral, psychogenic, and voice disorder cases. Almost all of the included studies
demonstrated the effectiveness of voice therapy in the treatment of dysphonia. Chen et al. defined that with
the utilization of resonant voice therapy, positive effects on voice quality, vocal fold vibration, vocal fold
closure, speaking flexibility, phonation effort, and functional communication were observed [16]. Similarly,
findings from a study by Morsomme et al. demonstrated that vocal therapy is effective in treating
dysfunctional dysphonia, with a high degree of satisfaction, particularly in vocal quality improvement [17].
Kleemola et al. indicated that a considerable proportion of patients across different severity levels
experienced improvement in voice disorder symptoms, with effect sizes indicating significant overall
improvement, which persisted after therapy [18]. Watts et al. observed that with stretch and flow voice
therapy, there were significant improvements in the s/z ratio, maximum phonation time, sentence cepstral
peak prominence, and Voice Handicap Index (VHI), with large effect sizes observed for the s/z ratio and VHI
and moderate effect sizes for maximum phonation time and sentence cepstral peak prominence [20]. Ogawa
et al. noted that with humming and subsequent um-hum phonation on the computed parameters of
electroglottography, an immediate effect was seen in adjusting the regularity of vocal fold vibration and
augmenting the degree of glottal contact in muscle tension dysphonia patients as well as non-dysphonic
speakers, whereas humming alone increases the degree of glottal contact in muscle tension dysphonia
patients [21]. Stepp et al. reported that both the cycle and therapy phase significantly influence the relative
fundamental frequency, with post-therapy relative fundamental frequency measurements being significantly
higher than pre-therapy measurements [22]. Mathur et al. further agreed that voice therapy improved the
voice quality of patients suffering from hyperfunctional dysphonia [23]. While Nguyen and Kenny observed
that with vocal function exercises, voice quality significantly improved, along with a reduction in voice
perturbation [24], de Oliveira Lemos et al. also reported that with direct and indirect voice therapy,
improvement in various acoustic and auditory perceptual parameters was observed [25]. A study from
Tierney et al. further added that voice therapy was effective in improving voice quality in most patients [26],
while findings from a study by Kaneko et al. added more evidence in this context by reporting that
aerodynamic assessments, acoustic findings, and self-ratings demonstrated improvement following voice
therapy [28]. Sarin and Chatterjee reported that, in addition to the vocal hygiene program, manual
circumlaryngeal therapy also resulted in significant improvements [27].

Findings of a present study by Başer and Denizoğlu highlighted the efficacy of voice therapy in the
management of dysphonia as patients experienced significant improvements in VHI-10 values, with mean
scores decreasing from 30.91 before treatment to 3.36 in the final follow-up examination [29]. Additionally,

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 Rangarathnam et al. suggested that flow phonation exercises can be beneficial for individuals with muscle
tension dysphonia, particularly in alleviating vocal hyperfunction and improving auditory-perceptual
measures [30]. Guzman et al. observed in their study that physiologic voice therapy based on semi-occluded
vocal tract exercises effectively enhances voice outcomes in individuals with behavioral dysphonia,
particularly in physical and functional aspects, with subglottic pressure and phonation threshold pressure
serving as sensitive indicators of phonatory effort reduction post-therapy [31]. Ribeiro et al. further agreed in
this context, as the authors described that voice therapy utilizing semi-occluded vocal tract exercises
yielded beneficial outcomes concerning voice quality, symptoms, and musculoskeletal discomfort in females
experiencing behavioral dysphonia. Rooted in the taxonomy of voice therapy, this approach appears to have
fostered phonatory equilibrium, muscle release, and enhancement in vocal resilience among this
demographic [33]. Another study by Khoddami et al. noted that combined voice therapy yielded the most
substantial improvements in muscle tension dysphonia among teachers, emphasizing the potential benefit
of integrating various therapeutic approaches for the management of muscle tension dysphonia [32].

While further analyzing the current literature, the results of a study by Mansuri et al. reported that after
undergoing voice therapy, notable enhancements were noted in the acoustic attributes such as jitter,
shimmer, and harmonics-to-noise ratio (p < 0.05). In terms of auditory-perceptual evaluation, there was a
marked decrease in overall severity, roughness, and breathiness (p < 0.05). Thus, voice therapy appears to be
efficacious in diminishing the occurrence and intensity of vocal tract discomfort in individuals with muscle
tension dysphonia while also enhancing voice quality [34]. Manzoor et al. further highlighted the efficacy of
this technique since the majority of the patients were satisfied with their voice therapy and deemed it easy
to communicate after that [35]. Moreover, Ohlsson et al. described the long-term benefits of behavioral voice
treatment, particularly in a group environment [36]. Another study by Trajano et al. also advocated that
group voice therapy significantly reduced vocal discomfort and anxiety in patients with dysphonia [37].
Cohen and Garrett also agreed that voice therapy is an excellent first-line treatment for hoarseness in people
with vocal fold polyps and cysts. Patients with translucent polyps, objective muscular tension dysphonia,
and complete vocal fold closure on videostroboscopy may react better to voice therapy [38]. Similarly,
among our included studies, Law et al. emphasized that group voice therapy as a service delivery model
possesses many advantages from the psychosocial, clinical, and health resources allocation perspective [19].
Additionally, findings of a study by Cantarella et al. also reported that some dysphonia patients may benefit
from group voice therapy, which can enhance perceptual, acoustic, aerodynamic, and self-evaluated
characteristics. This form of treatment may help to reduce the expenditures and waiting lists connected with
rehabilitative care while also increasing patients’ motivation and compliance [39]. Our review provides deep
insights into the efficacy and utilization of various voice therapeutic modalities for dysphonia patients.
However, our analysis of the current literature identified the dearth and scarcity of studies in this regard;
moreover, the intrinsic characteristics and heterogeneity among the included studies may limit the
generalizability of our results. This underscores the need for further research in this domain. Furthermore,
to comprehensively characterize the outcomes of various voice therapy techniques in dysphonia treatment,
particularly in comparison with traditional approaches, large-scale prospective investigations are
imperative. Additionally, systematic reviews and meta-analyses can provide more conclusive findings about
the effectiveness of these interventions. By synthesizing data from multiple studies, these analyses would
provide robust evidence regarding the efficacy and effectiveness of different therapeutic modalities, thereby
facilitating informed decision-making in clinical practice and advancing our understanding of optical
therapies and treatment strategies for dysphonia.

Conclusions
Dysphonia significantly impairs the quality of life of patients and increases the risk of depression and
anxiety due to problems in communication; therefore, early diagnosis and prompt management are vital for
the well-being of patients. Voice therapy is beneficial for the treatment of dysphonia, which does not
necessitate surgical intervention and is proven to exhibit improvement and optimal outcomes, thus
improving the quality of life of these patients. However, the evidence available in the literature is limited,
which necessitates further research to address and analyze the efficacy of various voice therapeutic
techniques among dysphonia patients, specifically so more evidence-based findings from recent times are
available to guide clinical practice.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of the
work.

Concept and design: Omair H. Al-Hussain

Acquisition, analysis, or interpretation of data: Omair H. Al-Hussain

Drafting of the manuscript: Omair H. Al-Hussain

2024 Al-Hussain et al. Cureus 16(6): e62041. DOI 10.7759/cureus.62041 5 of 7

 Critical review of the manuscript for important intellectual content: Omair H. Al-Hussain

Supervision: Omair H. Al-Hussain

Disclosures
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

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