ARTICLE IN PRESS

Immediate Effects of the Semi-Occluded Ventilation Mask on

Subjects Diagnosed With Functional Dysphonia and Subjects
With Normal Voices
*Kharina Frisancho, †Lukas Salfate, ‡Karla Lizana, §,#Marco Guzman, ║Fernando Leiva, and ¶Camilo Quezada,
*Arequipa, Per
u, and y#║{Santiago, zOsorno, and xChile

Abstract: Purpose. The present study was designed to assess the immediate effects of the semi-occluded venti-
lation mask (SOVM) in subjects with functional dysphonia and subjects with normal voice.
Methods. Sixty-four participants were included in this study (48 women and 16 men). Thirty-one of them were
diagnosed with functional dysphonia and 33 with normal voice. All subjects were randomly assigned to one of
two conditions: an experimental condition using the SOVM (n = 33) and a control condition with participants
not using the SOVM (n = 31). Thus, within both conditions, participants could be either dysphonic or normal-
voiced. This produced a total of four different groups: (1) subjects with normal voice with SOVM (n = 17), (2)
subjects with normal voice without SOVM (n = 16), (3) dysphonic subjects with SOVM (n = 16), and (4) dys-
phonic subjects without SOVM (n = 15). All participants underwent aerodynamic, electroglottographic (EGG),
and acoustic assessments, and were also asked to assess their own voice, before and after voice exercises.
Results. Significant differences were found for aerodynamic, EGG, and acoustic variables when comparing
SOVM conditions (dysphonic and normal) against control. Cepstral peak prominence and EGG contact quotient
showed an increase among dysphonic participants with SOVM. L1-L0 showed an increase for all participants in
SOVM condition (dysphonic and normal). Self-perceived resonant voice quality showed an increase for both
groups in SOVM condition. Glottal airflow showed a decrease for the dysphonic participants in SOVM condi-
tion. Phonation threshold pressure and subglottic pressure showed a decrease for both groups in SOVM
condition.
Conclusion. The present study suggests that immediate positive effect could be produced by connected speech
phonatory tasks using the SOVM in both dysphonic subjects and subjects with normal voice, the change being
greater among the former. SOVM seems to promote an easy voice production and a more efficient phonation.
Key Words: Semi-occluded vocal tract−Voice therapy−Resonant voice−Voice training−Tube phonation.

INTRODUCTION
the glottal flow waveform (faster cessation of the glottal
Over the last decade, great importance has been given to semi-
flow).12,13 Therefore, vocal tract impedance can affect the
occluded vocal tract exercises (SOVTE) because of the benefits
voice source function in two ways: through an acoustic-aero-
they produce in voice training and voice rehabilitation. Physio-
dynamic interaction and through mechano-acoustic interac-
logical effects of SOVTE have been widely studied.1−5 In voice
tions.1,11−14,16
training with normal-voiced subjects, SOVTE have been used
The most commonly used SOVTE include phonation on
to improve voice quality and increase loudness in an effortless
voiced fricatives, nasals,17,18 lip and tongue trills,19,20 lessac y-
way. In voice therapy, SOVTE have been used to reduce
buzz,21,22 hand over mouth technique,23,24 cup phonation,25,26
hyperfunctional voice patterns and also to increase adductory
and phonation through tubes and straws 27−29 with the free
vocal folds activity in patients with hypofunctional phona-
end either in the air or submerged into a recipient filled with
tion.6−10 SOVTE increase the vocal tract impedance, resulting
water.30−32 These exercises have limitations stemming from
in changes in the inertive reactance,1,11−14 which brings favor-
the fact that subjects are precluded from producing connected
able effects to voice production by decreasing the phonation
speech during the exercise. This kind of exercises only allow to
threshold pressure (PTP)13−15 and by increasing skewing of
perform a single-phoneme task such as [b:], [a:], or [u:].
Borrog
an et al33 first proposed using a semi-occluded ventila-
Accepted for publication October 8, 2018. tion mask (SOVM), which allows overcoming this limitation,
From the *Department of EDUCATION, Universidad Nacional de San Agustin,
Arequipa, Per
u; yHospital Salvador, Department of otolaryngology, Santiago, Chile.;
achieving a more distal occlusion and allowing connected
zDepartment of Communication Sciences and Disorders, Universidad de Los Lagos, speech during voice therapy and training. SOVM produces an
Osorno, Chile; xUniversidad de los Andes, CHILE; #Department of Otolaryngology,
Voice Center, Las Condes Clinic, Santiago, Chile; ║Department of Communication
easier transition from the therapeutic process to the production
Sciences and Disorders, Universidad Pedro de Valdivia, Santiago, Chile; and the of daily speech, while still generating the same gains in effi-
{Department of Communication Sciences and Disorders, Universidad de Chile, San-
tiago, Chile.
ciency and vocal economy that traditional SOVTE generate.34
Address correspondence and reprint requests to Marco Guzm
an, Universidad Figures 1 and 2 show respectively the SOVM and how it is
de los Andes, Avenida Monse~

nor Alvaro del Portillo, 12455 Santiago, Chile.
E-mail: guzmann.marcoa@gmail.com
typically used during voice exercises.
Journal of Voice, Vol. &&, No. &&, pp. 1−12 Two recent studies have explored the effects of the
0892-1997
© 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
SOVM.34,35 Mills et al34 presented a validation and evalua-
https://doi.org/10.1016/j.jvoice.2018.10.004 tion of the effects of the SOVM on excised canine larynx.

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 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2018
FIGURE 1. Semi-occluded ventilation mask.
Authors reported that SOVM techniques lead to the same
decreases in phonation threshold flow and PTP that have
been reported using traditional methods (eg, tube phona-
tion). Fantini et al35 conducted a study with acoustic analy-
sis and self-assessment of voice in contemporary
commercial music singers using SOVM. Significant benefi-
cial changes were found after exercises in jitter, shimmer,
FIGURE 2. Subject performing connected speech phonatory
tasks using the semi-occluded ventilation mask.
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and singing power ratio. Self-assessment of voice showed
significant higher phonatory comfort and better voice qual-
ity after exercises with SOVM.
To the best of our knowledge, there are no studies
assessing the possible effects of SOVM in subjects diag-
nosed with voice disorders. The purpose of the present
study was to assess the immediate effects of SOVM in
subjects diagnosed with functional dysphonia and sub-
jects with normal voice. We hypothesized that (1) voice
exercises with SOVM would promote both more eco-
nomic voice production and a more resonant voice
quality among participants, whether dysphonic or nor-
mal-voiced; (2) these beneficial effects would be captured
both by objective (aerodynamic, electroglottographic,
and acoustic) measures and subjective measures. Specifi-
cally, based on previous findings, it is expected a reduc-
tion of the perceived phonatory effort, more resonant
voice production, decreased PTP, decreased glottal air-
flow, and an increased acoustic output due to a more effi-
cient phonation.
METHODS
Participants
Sixty-four participants were included in this study (48 women
and 16 men). They were recruited by advertisings in private
clinics and social networks. Thirty-one of them were diag-
nosed with functional dysphonia (individuals with any
organic vocal fold pathology were excluded) and 33 with nor-
mal voice and larynx. Dysphonic subjects were chosen from a
population of participants who had no history of voice
complaint and who were confirmed to be auditory-perceptu-
ally dysphonic (breathy voice) by the two speech and
language pathologists. Dysphonic patients were not
receiving voice therapy at the time of the study. All subjects
(dysphonic and normal) were randomly assigned to one of
two conditions: an experimental condition with participants
using the SOVM (n = 33) and a control condition with partic-
ipants not using the SOVM (n = 31). Thus, within both con-
ditions, participants could be either dysphonic or normal-
voiced. This produced a total of four different groups: (1)
subjects with normal voice with SOVM (n = 17), (2) subjects
with normal voice without SOVM (n = 16), (3) dysphonic
subjects with SOVM (n = 16), and (4) dysphonic subjects
without SOVM (n = 15). The inclusion criteria for all partici-
pants were (1) age within 18-45 years range, and (2) auditory
perceptual diagnosis by 2 speech-language pathologists with
more than 15 years of experience, and (3) laryngeal strobo-
scopic diagnosis of behavioral dysphonia or normal voice.
The exclusion criteria included: (1) diagnosis of psychiatric
pathology, (2) diagnosis of hearing loss, (3) pregnancy, and
(4) presence of influenza or allergic conditions at the time of
examination. Exclusion criteria were confirmed via self-
report. All participants were native speakers of Spanish. This
study was reviewed and approved by an institutional review
board, and all participants signed informed consent forms
before the experiments.
 ARTICLE IN PRESS
Kharina Frisancho, et al Immediate Effects of the Semi-Occluded Ventilation Mask
Laryngoscopic assessment
Before the aerodynamic, electroglottographic, and acousti-
cal assessments, all subjects were asked to undergo rigid
laryngeal videostroboscopy (Digital videostroboscopy
system Atmos Strobo 21 Led; ATMOS MedizinTechnik,
Lenzkirch, Lenzkirch, Germany) to confirm diagnosis of
functional dysphonia and normal larynx. Laryngoscopic
examinations were performed by one experienced voice
pathologist who coauthors the present study. No topical
anesthesia was used during endoscopic procedure.
Equipment and data collection
All samples were digitally recorded twice (before and after
voice exercises). All participants underwent aerodynamic,
EGG, and acoustic assessments. The Phonatory Aerodynamic
System (PAS model 4500, KayPENTAX, Lincoln Park, NJ)
was used to collect aerodynamic data. The EGG signal was
captured with an electroglottograph (model 6103, KayPEN-
TAX). The EGG signal quality was monitored using a real-
time oscillogram that was incorporated in the EGG software.
Both aerodynamic and EGG devices were connected to an
interface (Computerized Speech Lab, model 4500, KayPEN-
TAX), which in turn was connected to a desktop computer
running a real-time oscillogram (model 6600, version 3.4, Kay-
PENTAX). All aerodynamic and EGG samples were cap-
tured digitally at a rate of 22.1 KHz with 16 bits/sample
quantization. Calibration of the air pressure and airflow sig-
nals was performed before data acquisition in accordance with
the manufacturer's instructions.
Aerodynamic and electroglottographic assessment
Each participant was asked to produce the same three phona-
tory tasks for aerodynamic and electroglottographic assess-
ments, before and immediately after voice exercises (both
with and without SOVM): (1) to produce a sustained speak-
ing vowel [a:], (2) repeat of the syllable [pa:], and (3) read a
242-word phonetically balanced text (The Grandfather text).
Participants were asked to keep a comfortable speaking pitch
and loudness during phonatory tasks. Three repetitions were
asked for the first and second phonatory tasks during pre and
post assessments. The sustained vowel [a:] was used to mea-
sure the transglottal airflow rate. The syllable [pa:] was used
to estimate the subglottic pressure (Psub) from the oral pres-
sure (Poral) during the occlusion of the voiceless consonant
[p:]. A silicone tube inserted into the mouth was used to
acquire oral pressure. Participants were asked not to touch
the tube with their tongue or any other oral structure so as to
not block the airflow. PTP was also obtained. Participants
were asked to produce repetitions of the syllable [pa:]. The
aim was to obtain the Psub from Poral, but with the softest
voice possible without whispering. Additionally, participants
read the text for approximately 60 seconds to obtain the
transglottal airflow during connected speech.
All samples were analyzed with the real-time aerody-
namic and EGG analysis software. A criterion level of 25%
from the peak-to-peak amplitude of the EGG signal was
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3
used for CQEGG analysis. Only the most stable part from
the middle section (onset and offset of voice were removed)
of each sustained vowel and repetition of the syllable [pa:]
sample was analyzed (approximately 5 seconds). This crite-
rion was used only for sustained vowel [a:] and repetition of
the syllable [pa:] samples. Once the stable sections were
selected, the following variables were obtained:
1. Mean SPL (dB).
2. Mean fundamental frequency (F0) (Hz).
3. Glottal airflow (Lit/sec).
4. Mean EGG contact quotient (CQEGG) (%).
5. Subglottic pressure (Psub) (cm H2O).
6. Phonation threshold pressure (PTP) (cm H2O).
Acoustic assessment
After the aerodynamic and EGG assessment, participants
were recorded acoustically while engaged in two phonatory
tasks: (1) producing a sustained speaking vowel [a:] three
times and (2) reading aloud a phonetically balanced text
(the same used for aerodynamic assessment). The micro-
phone was positioned 30 cm from the mouth of participants,
who remained standing. An omnidirectional condenser
microphone (AKG-Perception-120, AKG Acoustic,
Vienna, Austria) connected to a DAT interface (Marantz
PMD 671; Marantz, Mahwah, NJ) was used. Recordings
took place in an acoustically treated room, and the samples
were recorded digitally at a sampling rate of 44.1 kHz and
with 16 bits. The Software Pro Tools 9.0 (Avid Corpora-
tion, Burbank, CA) was used to make voice recordings.
Audio samples were edited with the Audacity software, ver-
sion 2.1.2. (Freeware) Acoustical analysis with long-term aver-
age spectrum (LTAS) and Cepstrum analysis (CPP) was
performed. The LTAS spectra were obtained by Praat software,
version 5.3.60 (Paul Boersma and David Weenink of Institute of
Phonetics Sciences of the University of Amsterdam, The Nether-
lands). Before performing LTAS analysis, unvoiced sounds and
pauses were eliminated from the samples by the Praat software
using the pitch-corrected LTAS version with standard settings.
CPP was obtained through computerized speech lab (CSL),
model 4500, (KayPENTAX, Lincoln Park, NJ).
The obtained acoustical variables were:
1. Alpha ratio (from sustained vowel and text) (dB),
which is a measurement that represents overall spectral
slope. The sound level differences were between 50-
1000 Hz and 1000-5000 Hz.
2. L1-L0 (from sustained vowel and text) (dB), which is
associate with the degree of vocal fold adduction. The
sound level differences were between 50-300 Hz and
300-800 Hz.
3. Cepstral peak prominence (from sustained vowel) (dB).
Self-assessment of voice quality
Participants were asked to individually and autonomously
self-assess their perception of resonant voice quality. Resonant
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2018

voice quality considers two main aspects: (1) vibratory sensa-
tions in the front part of the mouth and face, and (2) sensation
of easy voice production. Self-assessment was asked before
and immediately after voice exercises, using a 100 mm visual
analog scale, where 0 = not resonant at all, and 100 = very res-
onant. Prior self-assessment of resonant voice quality and a
detailed explanation about sensations (vibration and easy
voice) were provided to participants by one of the experiment-
ers. Self-assessment was required both before and after voice
exercises with or without SOVM for experimental and control
groups, respectively. Subjects were asked to perform any con-
nected speech task while rating voice quality using the
100 mm visual analog scale.
Voice exercises
Immediately after initial voice assessment, all participants
were required to engage in a 5-minute session of voice exer-
cises (counting numbers). Subjects from the two experimen-
tal groups were required to use a SOVM (Figure 1) (Air
Cushion Face Mask, Teleflex Medical; Research Triangle
Park, NC) while counting. Subjects from the two control
groups performed the same phonatory task without SOVM.
SOVM was placed over the nose and mouth and it was hand-
held by all participants while counting (Figure 2). Before per-
forming each task, all participants were given instructions aimed
at granting an adequate performance and avoid muscle tension
while speaking. Participants from all groups were asked to pro-
duce an easy voice quality during exercises. Feedback/guidance
from the experimenters was provided if necessary during count-
ing numbers. The entire exercise sequence lasted 5 minutes.
Statistical analysis
Data were processed with R software. Summary of results
and plots are presented for implemented tasks, for audio
signal, and for visual analog scale. A Mixed-Factorial
ANOVA was conducted on all variables (experimental con-
dition as four-level between-group factor, Pre/Post as
two-level within-group factor). Consistent with objectives,
two-tailed paired nonparametric Wilcoxon tests were con-
ducted on all variables comparing Pre and Post measures
for each group to gauge the effect of implemented condi-
tions. Reported statistical significance for the contrasts is
based on 95% confidence intervals of the median of the
differences between the two measures, with standard non-
zero criterion for the interval. P values are also provided.
No between-group comparisons were conducted on any
measures because of lack of relevance for this study. Consis-
tently, between-group main effects of condition are not
reported. Main effects for within measure are not reported
either. However, whenever the ANOVA’s interaction term
was found to be significant for a given variable, its P value
is reported to properly gauge simple effects. A small amount
of data was missing at random for some subjects on a few
variables, whether on Pre or Post measures. Missing data
percentage varied depending on variables, ranging from 0%
to 9.3%. Since the amount was overall rather small, missing
data were imputed by means of an expectation-maximiza-
tion method. This method completes missing values by con-
structing a latent variable from the original data set,
generating an initial set of probable values, and iteratively
evaluating them until convergence on a final probable solu-
tion is reached. For simplicity, only significant Pre/Post con-
trasts are reported (ie, nonzero CIs). A detailed graphical
account of results is provided in the Appendix Figures 1-4.
RESULTS
Table 1 and Appendix Figure 1 display results from acousti-
cal analysis. Significant results were only observed for Ceps-
tral peak prominence variable L1-L0. Table 2 and
Appendix Figure 2 show the significant contrasts results for
the variables included in the sustained phonation phonatory
task. A trend-wise result was also observed for the condition
Normal with SOVM (P = 0.05, CI 0.00004 0.03994). Table 3
and Appendix Figure 3 show the significant contrasts for
variables included in the repetition of the syllable [pa:] pho-
natory task. A trend-wise result was also observed for Dys-
phonic with mask condition on subglottic pressure (P =
0.06, CI 0.006 1.613). Table 4 and Appendix Figure 4 pro-
vide significant results for variables included in Running
Speech phonatory task. Finally, Table 5 and Appendix
Figure 5 show significant contrast for self-assessment of res-
onant voice quality.
DISCUSSION
The present study assessed the immediate effects of the
semi-occluded ventilation mask on subjects diagnosed with

TABLE 1.
Significant Contrasts and Descriptives for Variables Included in the Acoustic Analysis. Significance for Interaction Term of
ANOVA Test Is Also Provided. Ninety-Five Percent Confidence Intervals Are Significant Whenever the Interval Does Not
Include Zero
Acoustical Analysis
Condition Pre Post P CI (95%) Interaction
CPP (db)
Dysphonic with SOVM 75.82 (1.76) 77.51 (2.21) < 0.001 ¡2.398 ¡1.041 P < 0.001
L1-L0 (dB)
Dysphonic without SOVM 0.87 (5.67) -0.34 (6.8) 0.01 0.235 1.435 NS

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 ARTICLE IN PRESS
Kharina Frisancho, et al Immediate Effects of the Semi-Occluded Ventilation Mask 5

TABLE 2.
Significant Contrasts and Descriptives for Variables Included in the Sustained Vowel [a:] Phonatory Task. Significance for
Interaction Term of ANOVA Test Is Also Provided. Ninety-Five Percent Confidence Intervals Are Significant Whenever the
Interval Does Not Include Zero
Sustained Phonation
Condition Pre Post P CI (95%) Interaction
Mean SPL (db)
Normal with SOVM 79.06 (5.02) 76.85 (5.08) 0.004 0.781 3.543 NS
Glottal airflow (lt/sec)
Dysphonic with SOVM 0.2 (0.05) 0.16 (0.05) 0.002 0.016 0.051 0.008

TABLE 3.
Significant Contrasts and Descriptives for Variables Included in the Repetition of the Syllable [pa:] Phonatory Task. Signif-
icance for Interaction Term of ANOVA Test Is Also Provided. Ninety-Five Percent Confidence Intervals Are Significant
Whenever the Interval Does Not Include Zero
Repetition of Syllable
Condition Pre Post P CI (95%) Interaction
Mean CQ
Dysphonic with SOVM 55.02 (8.4) 56.94 (8.57) 0.04 ¡3.915 ¡0.005 NS
Glottal airflow (lt/sec)
Dysphonic with SOVM 0.2 (0.05) 0.15 (0.04) 0,03 0.021 0.070 NS
Psub
Normal with SOVM 7.19 (1.71) 6.33 (1.54) < 0.001 0.279 1.488 NS
Normal without SOVM 6.48 (1.29) 5.84 (0.86) 0.03 0.021 1.241
PTP
Dysphonic with SOVM 7.89 (1.67) 6.21 (1.38) < 0.001 0.996 2.405 P = 0.01
Normal with SOVM 5.04 (0.93) 4.41 (0.98) < 0.001 0.300 0.918

TABLE 4.
Significant Contrasts and Descriptives for Variables Included in Running Speech Phonatory Task. Significance for Interac-
tion Term of ANOVA Test Is Also Provided. Ninety-Five Percent Confidence Intervals Are Significant Whenever the Inter-
val Does Not Include Zero
Running Speech
Pre Post P CI (95%) Interaction
Glottal airflow (lt/sec)
Dysphonic with SOVM 0.17 (0.06) 0.15 (0.04) 0.01 0.009 0.044 NS
Normal with SOVM 0.13 (0.05) 0.11 (0.05) 0.002 0.010 0.030

TABLE 5.
Significant Contrasts and Descriptives for Self-Assessment of Resonant Voice Quality. Significance for Interaction Term of
ANOVA Test Is Also Provided. Ninety-Five Percent Confidence Intervals Are Significant Whenever the Interval Does Not
Include Zero
Running Speech
Condition Pre Post P CI (95%) Interaction
Dysphonic with SOVM 48.69 (19.14) 73.56 (16.57) < 0.001 ¡29.999 ¡20.499 P < 0.001
Dysphonic without SOVM 51.36 (24.9) 40.29 (23.55) 0,02 1.999 20.499
Normal without SOVM 62.5 (20.51) 86.72 (11.45) < 0.001 ¡32.999 ¡16.499

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 ARTICLE IN PRESS
6 Journal of Voice, Vol. &&, No. &&, 2018
functional dysphonia and subjects with normal voices.
Aerodynamic, electroglottographic, acoustic, and self-
assessment analyses were performed pre- and postvoice
exercises. The results showed positive significant differences
for both groups in SOVM condition (dysphonic and nor-
mal-voiced). Cepstral peak prominence (CPP) and electro-
glottographic contact quotient (CQEGG) showed an
increase for dysphonic subjects with SOVM. The self-per-
ceived resonant voice quality showed an increase for both
groups in SOVM condition. Glottal airflow showed a
decrease for the dysphonic experimental group. PTP and
Psub showed a decrease for groups in SOVM condition.
Electroglottographic contact quotient
CQEGG showed a significant increase after the SOVM exer-
cises in subjects with dysphonia. Many studies have explored
the possible physiological effects of SOVTE on the vocal fold
adduction through the CQEGG.19,27,28,36−42 These studies
reported different results regarding CQEGG. Changes in
CQEGG depend on the type of SOVTE observed and the
degree of airflow resistance during the exercise.42,43 For exam-
ple, findings show that a tube submerged 10 cm into water
causes high airflow resistance and tends to produce a high
CQEGG.19,41−43 Conversely, the Finnish glass tube with the
distal end in the air, and tongue and lip trills have been shown
to cause airflow low resistance and a low CQEGG.19,41−43
Hence, it seems that SOVM generates a high airflow resistance
similar to the straw submerged in the water. The fact that the
glottal airflow showed a significant decrease after SOVM exer-
cises in dysphonic and normal subjects in the present study
could be considered a confirmation of a possible increased
glottal adduction, as reflected by increased CQEGG.
Glottal airflow rate
Regarding the significant decrease in glottal airflow in dys-
phonic subjects after SOVM exercises, previous studies have
shown a decreased rate of glottal airflow after voice therapy
with some physiologic programs such as vocal function exer-
cises (VFE)44−46 and the accent method (AM).47 An increased
maximum phonation time reported after VFE and after AM
could also be a consequence of the reduction in airflow rate.44
−47
Sabol et al48 also found a reduction in glottal airflow rate
after VFE in a group of singers. Authors believe that this reduc-
tion may stem from an improved balance between subglottic
pressure and glottal adduction.44−48 After voice exercises, a
reduced glottal airflow is a desirable outcome in subjects with
breathy voice, as is the case with those included in the present
study. If this reduction in glottal airflow was produced simulta-
neously with an increased vocal fold adduction (with easy pho-
nation) and a decreased Psub, speculating that SOVM tends to
promote a more efficient voice production immediately after
exercises does not seem too far-fetched.
Self-perceived resonance voice quality
Self-perceived resonance voice quality showed a significant
increase after SOVM exercises in both groups using mask.
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Similar results have been found in previous studies conducted
with physiological voice therapy programs such as Resonant
Voice Therapy (RVT)17,49,50 VFE,51,52 and AM.53 Results
have also shown that tube phonation protocols positively
impact on self-assessment outcomes.31,32,54−58 Guzman et al32
showed a significant increase in self-perceived resonance voice
quality after 8 weeks of voice treatment with water-resistance
therapy in subjects diagnosed with behavioral dysphonia. Ver-
dolini-Marston et al17 showed similar results in a group of
patients diagnosed with vocal nodules. Subjects reported a
decrease in the self-perceived phonatory efforts after 2 weeks
of voice treatment with RVT. Sauder et al52 found comparable
results, less self-perceived phonatory efforts after 6 weeks of
treatment in a group of subjects diagnosed with aging voice.
Fantini et al35 reported similar data in a group of contempo-
rary commercial music singers treated with SOVM.
Phonation threshold pressure
Significant decrease in PTP was detected when comparing Pre/
Post conditions for both groups treated with SOVM (dys-
phonic and normal subjects). PTP is defined as the minimum
Psub required to initiate and sustain phonation, and it has
been linked to the degree of phonatory effort.1,2,11,43,59 There-
fore, decrease in PTP in the present study seems to be in line
to the increment found in self-assessment of resonant voice
quality in the present study. Previous studies exploring the
effect of other SOVTE have reported a decrease of PTP during
exercises.1,34,35,60 Chen et al61 showed a significant reduction
of PTP after RVT in subjects with voice complaints. Guzman
et al32 showed a significant decrease in PTP after 8 weeks of
voice treatment with water-resistance therapy in subjects with
behavioral dysphonia. Hor
acek et al62 in a study with a glass
resonance tube applied to a physical model of human voice
production found similar results in PTP measures. Modeling
studies have linked the PTP reduction to the increased vocal
tract inertance that occurs during SOVTE,1,11−15,63 which is,
in turn, linked to low phonatory effort.11,60,64 Additionally,
our findings showed a trend to increase PTP for dysphonic
subjects without mask. These results may support the idea,
previously discussed, that SOVT shape could be more favor-
able for a healthy voice production compared to an open vocal
tract shape. Recall that an inertive vocal tract (long and semi-
occluded vocal tract) through its mechano-acoustic interaction
brings favorable effects to voice production by decreasing the
PTP.13−15 Thus, is suitable to speculate that the opposite (and
open vocal tract shape) may produce a decreased mechano-
acoustic interaction.
Subglottic pressure
Psub also showed a significant decrease after SOVM exercises
for normal subjects and a clear trend-wise result (decrease) for
dysphonic with mask condition. Previous studies32,53,65 observ-
ing the behavior of Psub, after several weeks of voice therapy
with AM, have also reported a decrease in this variable.65 Com-
parable results were found by Bassiouny53 and Guzman et al.32
Since the degree of air pressure measures during phonation has
 ARTICLE IN PRESS
Kharina Frisancho, et al Immediate Effects of the Semi-Occluded Ventilation Mask 7

been linked to the degree of phonatory effort, the decrease of
both Psub and PTP in the present study could be directly related
to the increase in the self-perceived resonant voice quality. Thus,
SOVM seems to be able to produce positive immediate effects,
similar to what has been observed from other SOVTE.
Acoustic variables
A strong CPP (high value) is produced from a voice charac-
terized by a well-defined harmonic structure (normal
voice).66 On the other hand, a breathy and hoarse voice has
a poorly defined harmonic structure; therefore, the cepstral
peak is weak (low value).66 CPP value has been considered
the best predictor of overall dysphonia.67−71 Our data
showed a significant increase in CPP for dysphonic subjects
after exercises with SOVM. No differences were found
when comparing pre and post measured without mask. Our
results are consistent with Watts et al71 who reported that
CPP increased moderately after applying a 2-week stretch-
and-flow voice therapy for patients with hyperfunctional
voice disorders. Guzman et al72 showed an increase in CPP
after traditional voice therapy combined with neuromuscu-
lar electrical stimulation in patients with suspected superior
laryngeal nerve paresis.
In the present study, acoustic, aerodynamic, electroglot-
tographic and self-perceived resonance voice quality showed
positive changes immediately after the SOVM exercises,
especially in subjects with voice complaints. However, more
studies are needed to assess long-term follow-ups and be
able to analyze the therapeutic efficacy of a physiologic
voice therapy program based on SOVM.
CONCLUSION
Results from the present study suggest that immediate positive
effect can be produced by connected speech phonatory tasks
using the SOVM in both dysphonic subjects and subjects with
normal voice, with stronger effects among dysphonic subjects.
Our data indicate that SOVM seems to promote an easy voice
production and a more efficient phonation. These findings
may support the idea that connected speech could be an
important part of both voice rehabilitation and voice training.
This practice may also be used as a transition between SOVTE
with sustained vowel and spontaneous running speech.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found on
line at https://doi.org/10.1016/j.jvoice.2018.10.004.

APPENDIX FIGURE 1. Interaction plot for variables included in the acoustic analysis. Error bars represent one unit of standard error.

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8 Journal of Voice, Vol. &&, No. &&, 2018

APPENDIX FIGURE 2. Interaction plot for all variables included in the sustained vowel [a:]. Error bars represent one unit of standard
error. Error bars represent one unit of standard error.

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Kharina Frisancho, et al Immediate Effects of the Semi-Occluded Ventilation Mask 9

APPENDIX FIGURE 3. Interaction plot for variables included in the repetition of the syllable [pa:]. Error bars represent one unit of stan-
dard error.

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10 Journal of Voice, Vol. &&, No. &&, 2018

APPENDIX FIGURE 4. Interaction plot for variables included in running speech. Error bars represent one unit of standard error.

APPENDIX FIGURE 5. Interaction plot for self-assessment of resonant voice quality. Error bars represent one unit of standard error.

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Kharina Frisancho, et al Immediate Effects of the Semi-Occluded Ventilation Mask
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