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246 The Voice and Voice Therapy
13. Hierarchy Analysis
Kinds of Problems for Which the Approach Is Useful
In hierarchy analysis, the patient lists various situations in their life that ordinarily produce some
anxiety and arranges those situations in a sequential order from the least to the most anxiety
provoking. Individual patients may instead prepare a hierarchy of situations, ranging from those
in which they find their voices best to those in which they find them worst. This technique is
borrowed from Wolpe’s (1987 [later reported by Mansuri et al., 2018]) method of reciprocal
inhibition, which teaches the patient relaxed responses to anxiety-evoking situations. After identifying a hierarchy of anxiety-evoking situations, the patient begins by employing the relaxed
responses in the least anxious of them and, in therapy, works their way up the hierarchy, thereby
eventually deconditioning their previously established anxious responses. The identification of
hierarchical situations (less anxiety–more anxiety; worst voice–best voice) is a useful therapeutic
device for most patients with hyperfunctional voice problems, which by definition imply excessive
overreacting. Patients with functional dysphonia, or with dysphonias accompanied by nodules,
polyps, and vocal fold thickening, frequently report that their degrees of dysphonia vary with the
situation. Such patients may profit from hierarchy analysis. Case (2002) reports effective use of
hierarchy analysis for particular aspects of voice, such as pitch or loudness.
Procedural Aspects of the Approach
1. Begin by developing in the patient a general awareness of the hierarchical behavior to be
studied. If, for example, the patient is asked to identify situations in which they feel most
uncomfortable, discuss with the patient the symptoms of being uncomfortable. Or if the
patient is going to develop a hierarchy of situations in which they experience variation of
voice, discuss and give examples of a good voice or a bad voice. Explain that the patient
must develop a relative ordering of situations, sequencing them from “good” to “bad.” Some
patients are initially resistant to this sort of ordering, perhaps because they never realized that
there are relative gradations to their feelings of anxiety or relative changes in their quality of
voice. They may not be aware that the degree of their anxiety or hoarseness is not constant.
2. Although the majority of voice patients are soon able to arrange situations into a hierarchy,
a few require practice sequencing some neutral stimuli. On one occasion, a woman was
taught the idea of sequential order by arranging five shades of red tiles from left to right,
in the order of the lightest pink to the darkest red. Having done this, she was then able
to sequence her voice situations, proceeding gradually from those in which her voice was
normal to those in which it was extremely dysphonic.
3. As a home assignment, instruct the patient develop several hierarchies with regard to their
voice. One hierarchy might center on how the patient’s voice holds up with the family,
another on how it is related to work situations, and a third on what happens to it in
varying situations with friends. After these hierarchies have been developed by the patient
at home, review them in therapy.
4. In therapy, use the “good” end of the hierarchical sequence first. That is, begin by asking
the patient to recapture, if possible, the good situation. The goal of therapy is to duplicate
CHAPTER 7 Voice Facilitating Approaches 247
the feeling of well-being or the good voice that the patient experienced in the situation
rated as best. Efforts should be made in therapy to recall the good factors surrounding the
more optimum phonation. If the patient is successful in re-creating the optimum situation,
the patient’s phonation will sound relaxed and appropriate. The re-created optimum
situation thus serves as an excellent facilitator for producing good voice. After some success
in re-creating the first situation on the hierarchy, capturing completely their optimum
response (whether this is relaxation, phonation, or both), the patient will then be able to
continue with the second situation. Again, the goal is to maintain optimum response. The
rate of movement up the hierarchy depends entirely on how successfully the patient can
re-create the situations and maintain optimum responses. By using the relaxed response
in increasingly tense situations, the patient is conditioning themself to a more favorable,
optimum behavior.
5. Although some patients can re-create situations outside the clinic with relative ease, some
cannot. As soon as possible, have the patient practice the optimum response outside
the clinic under good conditions so that the patient will eventually be able to use it in
the real world in more adverse situations. The patient must not lose sight of the goal of
maintaining the good response in varying situations outside the clinic.
6. Not all patients can go all the way up the hierarchy, maintaining a good voice at each level.
Such patients should be advised that most people experience anxiety or poorer voice in
some situations, such as at the highest level of the hierarchy. Some practice might be spent
one step lower in the hierarchy where good performance is still maintained.
Typical Case History Showing Utilization of the Approach
Jamie was a 28-year-old transwoman who joined our clinic for gender-affirming voice and speech
treatment. In voice therapy, Jamie reported that her out-of-clinic voicing was continually changing,
“very dependent on what kind of situation I find myself in.” Jamie was employed as a full-time
receptionist for an area agency for aging. Her voice clinician worked with Jamie to develop this
nine-step hierarchy, in which she found she had the most desired voice all the way down to the
level of least desired voice:
Best Voice
1. I always have my best new voice with my mother.
2. The director of our agency. She is always a great listener to everyone.
3. I answer the phone at work with a very good voice.
4. The doctor at the clinic doesn’t listen as well as he should. He wants me to try harder to
work on pitch inflections.
5. Some salespeople are hard to talk to, especially car mechanics.
6. I think some people at the church are bigots.
7. I still date my old girlfriend who doesn’t understand me anymore.
8. Meeting new men tends to make me nervous and my speech breaks down.
9. Talking with my dad is the hardest. He won’t accept me and still calls me Jim.
248 The Voice and Voice Therapy
Evidence-Based Evaluation of the Approach
Many voice patients report great variability in voice quality, depending on how much they have
been using the voice, the time of day, and the psychodynamics of the speaking situations. Hierarchy analysis is often helpful for dealing with vocal inconsistencies experienced while talking
with different people in various situations (Hapner & Johns, 2004). By analyzing the hierarchical
situations in which voice deteriorates or improves, the patient develops an awareness of the situational cues that are causing voice changes. Hierarchy analysis is consistent with the cognitive
behavioral therapy approach to functional dysphonia described by Miller and colleagues (2014)
and van Leer (2021). Perhaps for the first time, the patient realizes that voice quality is not a
constant and that vocal quality fluctuations are somewhat dependent on how relaxed one feels or
how comfortable one is with their listeners. Therapy then focuses on using the best voice found
low on the hierarchy. The patient attempts to use that optimum voice in situations in which they
have previously experienced difficulty. Hierarchy analysis is consistently useful in voice therapy.
14. Inhalation Phonation
Kinds of Problems for Which the Approach Is Useful
Patients who have functional aphonia and functional dysphonia often profit from inhalation
phonation. Inhalation phonation is also called ingressive, inspiratory, and reverse phonation in the
literature. Inhalation phonation can be a helpful technique for the patient who often lapses into
using ventricular phonation and often demonstrates difficulty “getting out of it.” Likewise, it can
be helpful for the patient with functional dysphonia who has developed some maladaptive voice
that seems resistant to change. On videoendoscopy, when the voice patient is asked to produce
stretched position (lengthened in their respiratory length) suddenly adducted and set into vibration. It is the relative thinness of the folds on inspiration that seems to produce the high-pitched
voice. The ease with which most patients can produce the technique (inhaling with voice and
exhaling with a near-matched voice) makes the approach readily useful in establishing or reestablishing true vocal fold vibration. Inhalation phonation as a therapy technique for hyperfunctional
phonation has been explored by Lehman (1965), Rose and colleagues (2017), and Gordon and
Reed (2019). Robb and colleagues (2001) suggested that vowel articulation associated with reverse
phonation did not differ from expiratory phonation for the production of the /i/, although it
was affected for the production of the high and low back vowels. Therefore, it is suggested that
training be performed with the /i/. See the VFA tongue protrusion /i/ for additional benefits of
the high-front tongue position in voice therapy.
Procedural Aspects of the Approach
1. This particular approach is better demonstrated than explained. Demonstrate inhalation
phonation by phonating a high-pitched sound with your palms upturned. It is important
to time the initiations of the inhalation with palms upturned. Turn them up so you can
mark for the patient the contrast between inhalation (palms upturned) and exhalation
(palms turned down).
CHAPTER 7 Voice Facilitating Approaches 249
2. After demonstrating several separate inhalations with phonation, say, “Now, I’ll match the
high-pitched inhalation voice with an expiration voice.” Inhale and then exhale in a high
pitch several times.
3. Ask the patient to generate an inhalation phonation. The patient should repeat the
inhalation phonation several times. Now again repeat the inhalation–exhalation matched
phonation, taking care to make the associated palms-up and palms-down movements.
4. After the patient has produced the matching hum, say, “Now, let us extend the expiration
like this.” Demonstrate a continuation of the high pitch, sweeping down from your falsetto
register to your regular chest register on one long, continuous expiration. Repeat this
several times. Then say to the patient, “Once I’ve brought my vocal cords together at the
high pitch, I then sweep down, keeping them together, to the pitch level of my regular
speaking voice.”
5. If the patient is unable to produce this shift from high to low, repeat the first four steps.
If the patient can make the shift down to the regular speaking register, say, “Now you’re
getting your vocal cords together for a good-sounding voice.” Take care at this point not to
rush the patient into using the “new” voice functionally. Rather, have the patient practice
some similar hum phonations. After some practice just phonating the hum, give the patient
a word list containing single nasal-glide words, advancing to nasal-glide phrases.
6. Once the patient can produce inspiration–expiration without difficulty, the patient should
be instructed to stop using the pronounced palms-up and palms-down movements.
7. Stay at the single-word and short phrase practice level until normal voicing is established.
We often spend several therapy periods practicing the new phonation as a motor practice
drill without attempting to make the voice conversationally functional. You might say,
“Now we’re getting the vocal folds together the way we want them.” This places the
previous aphonia or ventricular phonation “blame” on the mechanism rather than on the
patient. Counseling with the patient at this time is important. The motor practice gives the
patient time to adjust to the more optimum way of phonating.
Typical Case History Showing Utilization of the Approach
Derek, a 5-year-old boy, was found to have small bilateral vocal nodules. His speech clinician
placed him on complete voice rest, which unfortunately was enforced for 5 continuous months.
At the end of 5 months, the nodules had disappeared, and Derek was instructed by both the
physician and the speech clinician to resume normal phonation. Despite all his efforts, Derek
could only whisper. He became completely aphonic but whispered easily to all people with much
animation and relative comfort. This functional aphonia remained for 2 months, after which he
was instructed, “Go back and talk the normal way.” Derek gestured that he wanted to use his voice
but could not “find it.” Therapy efforts for restoring phonation began about 7 months after Derek’s
phonations had ceased. Inhalation phonation was initiated, and at the first therapy session Derek
was able to produce a high-pitched inhalation sound and to follow his clinician well by matching
the inhalation with an expiration sound. He was able to use an expiration phonation, appropriate
in both quality and pitch, by the end of the first therapy session. He was scheduled for two other
appointments within a 24-hr period, during which he practiced producing his regained normal
voice. He was counseled that his “voice is working now, and you’ll never have to lose it again.”
250 The Voice and Voice Therapy
Derek continued to have normal phonation. Counseling to curb yelling and other vocal abuses
appeared to be successful, because Derek did not experience return of the bilateral vocal nodules.
Evidence-Based Evaluation of the Approach
Some patients who experience either aphonia, dysphonia, or ventricular phonation for any length
of time often lose their ability to initiate normal true fold phonation. The longer the aphonia or
dysphonia persists, the harder it might be to use normal voice. Inhalation phonation is an effective
way to “reset” hyperfunctional musculature by lowering the larynx, increasing the lumen of the
hypopharynx, and decreasing the anteroposterior constriction at the glottis (Gordon & Reed,
2019; Moerman et al., 2017). The high-pitched voice on inhalation probably results from the folds
being longer in their inhalation posture, and even though they may adduct on command, they
remain in their longer configuration. This elongated posture thins them, resulting in the higherpitched phonation (Robb et al., 2001). The important part of the approach, however, is matching
the inhalation voicing with exhalation voicing. Once the patient can produce the exhalation voice
without the inhalation prompt, the inhalation practice is no longer needed.
15. Laryngeal Massage
Kinds of Problems for Which the Approach Is Useful
This particular approach follows the procedures, modified slightly, for manual circumlaryngeal
therapy, as first presented by Aronson (1990), and further advanced by Roy (2008), Van Lierde
and colleagues (2004), and Tomlinson and Archer (2015), among others. Laryngeal massage
involves the gentle manipulation and massage of the larynx. The approach is recommended for
use with patients with functional voice disorders in which structural or neurogenic causal factors
cannot be identified. While the most used professional term for such voice disorders is functional dysphonia, a few authors have recommended that these functional disorders be classified as
psychogenic dysphonia (Aronson, 1990) or MTD (Morrison & Rammage, 1994). As introduced
in Chapter 3, we use the term functional dysphonia generically to include hoarseness without
identified structural or organic cause, ventricular dysphonia, puberphonia, falsetto, and voicing
with discomfort (pain, scratchy throat, etc.). Stress, psychological conflict, and overall systemic
tension often appear to worsen the symptoms of functional dysphonia. Manual circumlaryngeal
therapy offers gentle laryngeal manipulation and massage, resulting in lower laryngeal carriage and
greater intrinsic–extrinsic laryngeal muscle relaxation.
Past studies report reductions of hyperfunctional voice symptoms and improved vocal quality
after a single or multiple therapy session using this laryngeal manipulation–massage therapy
(Angsuwarangsee & Morrison, 2002; Anhaia et al., 2014; Van Lierde et al., 2004). Although
the present authors can report good results with this technique, we have also achieved lower
laryngeal postures with greater muscle relaxation using the yawn-sigh technique. Indeed, in a
systematic review assessing laryngeal manual therapies for behavioral dysphonia, Vies Ribeiro
and colleagues (2018) found that the effectiveness of laryngeal manipulation was equivalent to
other direct voice therapy interventions. The other direct therapies identified were tongue or lip
trills, humming, overarticulation, and chewing techniques. Therefore, in our clinical practice, we
CHAPTER 7 Voice Facilitating Approaches 251
employ yawn-sigh first for the patient with a high larynx and laryngeal tension. If the patient is
not successful employing the yawn-sigh followed by focus, our next approach is the use of manual
circumlaryngeal massage (VFA 15).
Procedural Aspects of the Approach
1. This approach should only be undertaken after the voice clinician has studied the anatomy
and physiology of the head and neck and has been mentored by an expert in laryngeal
massage. The first step is a screen for a high larynx and likely excessive laryngeal–neck
muscle tension. If neither of these are present, other VFAs are used. If either one or both
are present, we continue.
2. The yawn-sigh (see VFA 25) is attempted first. If a lower larynx and greater muscle
relaxation are achieved by using the yawn-sigh, we do not apply laryngeal manipulation
and massage.
3. We follow Aronson’s (1990) procedures for reducing “musculoskeletal tension associated
with vocal hyperfunction”:
a. Encircle the hyoid bone with the thumb and middle finger. Work back posteriorly until
the major horns are felt.
b. Apply light pressure with the fingers in a circular motion over the tips of the hyoid
bone.
c. Repeat this procedure with the fingers from the thyroid notch, working posteriorly.
d. Find the posterior borders of the thyroid cartilage (medial to the sternocleidomastoid
muscles) and repeat the procedure.
e. With the fingers over the superior borders of the thyroid cartilage, begin to work the
larynx gently downward and laterally at times.
f. Ask the patient to prolong vowels during these procedures and note changes in quality
or pitch. Clearer voice quality and lower pitch indicate relief of tension. Because of
possible fatigue, rest periods should be provided.
g. Improvement in voice is immediately reinforced. Practice should be given in producing
voice in vowels, words, phrases, and sentences.
h. Discuss with the patient how voice tension has been reduced. Repeat the procedures.
Can the patient maneuver their own larynx to a lower position?
4. We determine whether the patient can experience the same lowering of the larynx with
muscle relaxation by producing the yawn-sigh (VFA 25). We discuss how both can be used
when excessive laryngeal tension is experienced.
Typical Case History Showing Utilization of the Approach
Carl was a 23-year-old graduate student in speech and hearing sciences who complained to his
clinical supervisor that in certain situations he experienced “such tightness in my throat, I can
hardly get my voice out.” A subsequent voice evaluation found him to have unnecessarily high
carriage of his larynx accompanied by some evidence of functional dysphonia. He was asked to read
Aronson’s description of therapy for “musculoskeletal tension (vocal hyperfunction)” (Aronson,
1990, p. 339). Subsequently, the supervisor conducted a full 1-hr manual circumlaryngeal therapy
252 The Voice and Voice Therapy
session with Carl that had an immediate result of lowering his laryngeal posture and relaxing his
voice, resulting in “a voice that was always there with greater intensity and less perturbation.”
Carl was followed over an 18-month period (while in graduate school) and was able to maintain
a normal voice following the one session of laryngeal manipulation and massage.
Evidence-Based Evaluation of the Approach
The literature on laryngeal manual therapy shows positive results (Barsties et al., 2024; Toles
et al., 2023). One only has to see a demonstration of this manipulation–massage technique to
be impressed with its sudden effectiveness in reducing muscular tension and producing a more
relaxed, lower-pitched, resonant voice. We have been impressed with the results of laryngeal
massage, including findings from Silverio and colleagues (2014), who found significantly lower
reported incidence and intensity of pain in the anterior and posterior neck after the laryngeal
massage technique. A similar manipulation approach called the cricothyroid visor maneuver
focuses primarily on relieving tension in the cricothyroid space (Mokhlesin et al., 2023).
16. Masking
Kinds of Problems for Which the Approach Is Useful
Patients with functional aphonia are often able to produce normal phonation under conditions
of auditory masking. Using masking with patients who have functional dysphonia often reveals
a “window” of improved phonation. It appears that many such patients produce faulty voices
because of poor real-time auditory monitoring. The use of masking as a stimulability probe during
the voice assessment often reveals changed phonation states that can then be recorded and used
as voice models in subsequent therapy. The masking VFA uses a voicing–reflex test, which audiologists administer as the Lombard test (Newby, 1972). The Lombard effect is believed to be
an unconscious reflex that occurs when a speaker is trying to make themself more intelligible
by becoming louder to listeners in a speaking situation with a loud background, such as a noisy
restaurant (Lau, 2008; Luo et al., 2018). The normal hearing patient increases voice loudness
reflexively when hearing a masking noise. In fact, the Lombard test was first introduced as a
method of finding voice in patients with functional aphonia. When asked to phonate in a loudnoise background, patients with functional aphonia sometimes used light voice.
In the voice–reflex situation, the patient wears earphones and is asked to read a passage aloud.
As the patient is reading, a masking noise is fed into the earphones. The louder the masking,
normally the louder is the patient’s voice. At increased masking levels, the patient cannot monitor
well either the loudness or the quality of their voice. Care should be given to the intensity of
masking intensity that is used. The reader is encouraged to investigate the following research
studies for their approaches to masking (Castro et al., 2022; Ishikawa et al., 2023).
Procedural Aspects of the Approach
The masking approach is best used without any prior explanation. The increased voicing experienced under masking conditions is produced on a reflexive, nonvolitional basis.
CHAPTER 7 Voice Facilitating Approaches 253
1. Masking should be presented with the patient wearing headphones and not presented in an
open-air field. The patient is asked to read aloud and to keep reading no matter what kind
of interruption the patient may hear. We typically have the patient read (or very young
children are asked to count) about 10 s, introduce masking for 5 s, go back to reading
without masking, then reintroduce masking. We record the patient’s oral reading, and on
playback we can hear the changes in voice that are introduced when masking occurs.
2. A recording should be made as the patient reads aloud. An aphonic patient’s whisper
may change to voice under conditions of masking. It is important to have recorded
the emergence of voice, which the patient can use in Step 5. The dysphonic patient
(functional, ventricular, or puberphonic) should also be recorded while using the masking
approach. Marked differences in voice quality between the absence and presence of
masking conditions will probably be evident.
3. Five- or 10-s exposures to masking are introduced to the patient bilaterally. The intensity
levels should be more than 70 dB sound pressure level, which is sufficiently loud to mask
out the patient’s own voicing attempts. Whenever an aphonic patient hears the loud
masking, the patient may attempt some vocalization. Under masking, a dysphonic patient
will produce a louder voice and often a voice with more normal vocal quality as well.
4. Do not use the masking method beyond the trial stage with those few voice patients
who do not demonstrate the voice–reflex effect. If it works well and produces voice
improvement, the method may be used as part of every therapy period. One might then
experiment by having the patient listen to recordings of themself to see whether the patient
can volitionally match their voice under masking conditions. Recordings can then be made
contrasting the voice without masking (attempting to re-create the same voice as heard
before masking) and the voice with masking. Work with the patient to try to match the
voice under the masking condition.
5. A patient may profit from reading aloud under masking conditions, and then having the
masking abruptly ended to see if the patient can maintain the better voice. Many other
variations using the masking noise can be initiated by inventive clinicians.
Typical Case History Showing Utilization of the Approach
Lillian was a 9-year-old girl who had a history of vocal nodules that had been previously treated
successfully with voice therapy. Several months after therapy had been terminated (because it
was successful: no nodules, normal voice), Lillian developed a severe URI that left her aphonic.
She was completely aphonic and could communicate only by whispering and using good facial
expressions and gestures. The aphonia continued for 1 month (over the December holiday break)
before she returned to the voice clinic. The masking approach was used with Lillian after attempts
at modeling and request for voice failed. Lillian was asked to read aloud under conditions of
70-dB masking. Her reading attempts were recorded on a smartphone. As soon as masking was
introduced, light phonation was heard and recorded. The masking and oral reading were stopped,
and Lillian was asked to hear her good voice on playback. The child clapped her hands in joy
that she now had a returned voice. Further masking followed by ear training was used as her
vocalizations became stronger. After two follow-up therapy sessions, Lillian was discharged with
a normal voice and instructed to retain the voice files on her smartphone for later reference. She
254 The Voice and Voice Therapy
was encouraged to play these files should she again experience aphonia. Studies have suggested
that target behaviors often improve with audio feedback when modeled by the patients themselves
(Bandura & Hall, 2018).
Evidence-Based Evaluation of the Approach
The masking approach is based on the theory that speakers modify their speech in the presence of
noise in such a way that acoustic contrasts between speech and background noise are enhanced,
thus increasing speech audibility (Garnier & Henrich, 2014). We have found masking the most
helpful with aphonic and puberphonic patients. It is also effective for patients with dysarthria,
notably of the hypokinetic type. Richardson and colleagues (2022) found that masking for individuals with Parkinson’s disease revealed increases in loudness. Although we have used masking in
the past for patients with functional dysphonia, we recommend that the approach be used with
caution. Castro and colleagues (2022) found a persistence of the Lombard state in those with
nonphonotraumatic vocal hyperfuncton after being exposed to masking noise in the experimental
condition. Clinicians should use the masking approach with some degree of eclecticism — that is,
if the approach works, use it; if it does not, abandon it.
17. Nasal-Glide Stimulation
Kinds of Problems for Which the Approach Is Useful
Clinicians frequently note that in voice therapy, certain stimulus sounds seem to facilitate an
easier- produced, often better-sounding voice. If we harken back to our phonetics textbooks, we
recall that nasals and glides are classified as sonorants. Sonorants entail little to no obstruction of
voiced energy in the nasal and oral cavities; therefore, these sounds are very easy to produce. This
is particularly true with children and adults having problems of vocal hyperfunction. Watterson
and colleagues (1993) have found, in studying 15 adult voice patients with vocal hyperfunction and 15 matched control subjects, that nasal and glide consonants facilitated better voicing
patterns and were judged by the hyperfunctional subjects as “easier” to produce. The concept of
differences in vocal effort has also been investigated by Bickley and Stevens (1987) and Baken
and Orlikoff (1988), generally finding that supraglottal resonance–articulatory postures have a
direct relationship to laryngeal physiology and function. Using words that contain many nasal and
glide consonants, usually coupled with other therapy techniques, often helps the patient produce
desired target vocalizations. Using nasal-glide consonants as therapy stimuli is particularly useful
for patients with functional dysphonia, spasmodic dysphonia, and dysphonias related to fold
thickening, nodules, and polyps (see Video 7–3).
Procedural Aspects of the Approach
Most therapy techniques require the patient to say something. For example, in the open-mouth
approach or in practicing focus, the patient is given a few stimulus words to say. Words that
contain nasal or glide consonants often produce the best-sounding voice or the voice that appears
made with the least amount of effort (as compared with words containing other consonants).
CHAPTER 7 Voice Facilitating Approaches 255
Video 7–3. Nasals, glides, and liquids
are phonemes that take little effort to
produce, unlike fricatives, affricates, and
stops. They are voiced and produced with
a relatively open vocal tract, and they are
easy to sustain. Using words that contain
many nasals and glides/liquids, usually
coupled with other techniques, helps the
clients in the video produce desired target
vocalizations (e.g., my name means money).
Grand Rounds: The m, n, ny, and w sounds
also have a forward focus. How might these
forward-produced sounds help reduce
muscle tension at the larynx?
1. The clinician can find a number of monosyllabic and polysyllabic words containing nasal
consonants for the patient to practice saying as the response when using various VFAs.
Here are a few examples: man, moon, many, morning, many men, moon man, manual
lawnmower, Miami millionaire, morning singing.
2. A variation of the technique is to use nasal monosyllabic words and introduce an /a/
between each word. Ask the patient to say three words in a row with the neutral /a/ between
each word, for example, “man a man a man” or “wing a wing a wing.”
3. We use the same procedure for words containing glide consonants. It has been found,
however, that nasal consonants combine very well with the /l/ and /r/ phonemes, and many
of our glide words contain nasal consonants: loll, lil, rare, rah, lilly, arrow, marrow, married,
married women, one lonely memory, Laura ran around, remember many lawmen.
4. Using monosyllabic /l/ and /r/ words with an /a/ between them, such as “lee a lee a lee” or
“rah a rah a rah,” seems to produce good voice.
Typical Case History Showing Utilization of the Approach
Louise was a 66-year-old housewife who was forced to divorce her husband of some 42 years. She experienced a number of somatic symptoms following the divorce, including a severe functional dysphonia.
Endoscopic–stroboscopic examination revealed a high carriage of the larynx with moderate vocal fold
compression. The yawn-sigh approach was found to be effective in lowering her larynx and encouraging
a more optimal vocal fold approximation. Under the sigh condition, she was asked to say various
words. It was found that words with many nasal and glide consonants facilitated the easiest to produce
and best-sounding voice. Intensive self-practice and twice weekly voice therapy for 9 weeks, supplemented by concurrent psychological counseling, resulted in a good functional return of normal voice.
Evidence-Based Evaluation of the Approach
Clinicians are always looking for voicing tasks that facilitate good voice production. Research has
validated that certain sounds, particularly nasal and glide consonants, facilitate easy voice production,