ARTICLE IN PRESS

Computerized Tomography Measures During and After

Artificial Lengthening of the Vocal Tract in Subjects
With Voice Disorders
*,†Marco Guzman, ‡Gonzalo Miranda, §Christian Olavarria, *Sofia Madrid, ¶Daniel Muñoz, §Miguel Leiva,
‡Lorena Lopez, and *Cori Bortnem, *†‡§¶Santiago, Chile

Summary: Purpose. The present study aimed to observe the effect of two types of tubes on vocal tract bidimensional
and tridimensional images.
Methods. Ten participants with hyperfunctional dysphonia were included. Computerized tomography was per-
formed during production of sustained [a:], followed by sustained phonation into a drinking straw, and then repetition
of sustained [a:]. A similar procedure was performed with a stirring straw after 15 minutes of vocal rest. Anatomic
distances and area measures were obtained from computerized tomography midsagittal and transversal images. Vocal
tract total volume was also calculated.
Results. During tube phonation, increases were measured in the vertical length of the vocal tract, oropharyngeal area,
hypopharyngeal area, outlet of the epilaryngeal tube, and inlet to the lower pharynx. Also, the larynx was lower, and
more closure was noted between the velum and the nasal passage.
Conclusion. Tube phonation causes an increased total vocal tract volume, mostly because of the increased cross-
sectional areas in the pharyngeal region. This change is more prominent when the tube offers more airflow resistance
(stirring straw) compared with less airflow resistance (drinking straw). Based on our data and previous studies, it seems
that vocal tract changes are not dependent on the voice condition (vocally trained, untrained, or disordered voices),
but on the exercise itself and the type of instructions given to subjects. Tube phonation is a good option to reach ther-
apeutic goals (eg, wide pharynx and low larynx) without giving biomechanical instructions, but only asking patients
to feel easy voice and vibratory sensations.
Key Words: tube phonation–semi-occluded exercises–vocal tract–voice therapy–functional dysphonia.

INTRODUCTION
One aspect considered in voice therapy and training is the mod-
ification of vocal tract structures. These changes partially shape
the spectral energy distribution, and this in turn, can produce
different voice qualities or vocal timbres. It is generally agreed
among clinicians and voice trainers that vertical laryngeal po-
sition (VLP), pharyngeal width, and laryngeal constrictions are
important aspects that shape voice quality in both normal and
pathological voices.1–7 A wide variety of voice exercises are used
to accomplish modifications in these vocal tract features, one
being the semi-occluded vocal tract exercises.
Several effects have been attributed to semi-occluded vocal
tract postures. One of the effects that has been explored is the
modifications of vocal tract configuration during and after pho-
nation into different types of tubes used in voice therapy. Two
earlier investigations have been performed using computerized
tomography (CT). Guzman et al,8 in a single case study, re-
ported that during Finnish glass tube and stirring straw phonation,
hypopharyngeal area widened, the laryngeal position lowered,
and more closure was seen between the velum and the nasal
Accepted for publication January 4, 2016.
Disclosure: There is no financial support and the authors report no conflicts of interest.
From the *Department of Communication Sciences, University of Chile. Santiago, Chile;
†Department of Otolaryngology, Las Condes Clinic, Santiago, Chile; ‡Department of Ra-
diology, University of Chile Hospital, Santiago, Chile; §Department of Otolaryngology,
University of Chile Hospital, Santiago, Chile; and the ¶Department of Otolaryngology, Uni-
versity of Chile, Santiago, Chile.
Address correspondence and reprint requests to Marco Guzmán, Avenida Independencia
1027, Santiago, Chile. E-mail: guzmann.marcoa@gmail.com
Journal of Voice, Vol. ■■, No. ■■, pp. ■■-■■
0892-1997
© 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jvoice.2016.01.003
passage compared with open vowel phonation. All changes were
more prominent during stirring straw phonation than during glass
tube phonation in air. In another CT and finite-element model-
ing single case study, the most dominant change during phonation
into the tube was the expansion of the cross-sectional area of
the oropharynx and in the oral cavity due to a different tongue
position.9 CT images also revealed that the velum rose to seal
the nasopharyngeal port during tube phonation and also re-
mained raised after it.9 Moreover, the total volume of vocal tract
was considerably larger after phonation into the tube. Laukkanen
et al10 observed similar vocal tract modifications during glass
tube phonation in a female subject using magnetic resonance
imaging. All of the previously mentioned studies were carried
out with vocally trained participants without vocal fold pathology.
Vocal tract changes during eight different semi-occluded ex-
ercises were recently studied using flexible laryngeal endoscopy
in a group of patients diagnosed with hyperfunctional dyspho-
nia. Findings revealed that all exercises produced a lower VLP,
a narrower aryepiglottic opening, and a wider pharynx than resting
position.11
To the best of our knowledge, to date, no studies with semi-
occluded postures have been performed using CT in patients with
voice disorders. The present research aimed to observe the effect
on vocal tract bidimensional and tridimensional images of two
types of plastic tubes commonly used in voice therapy and train-
ing. Based on previous data, we hypothesize that during tube
phonation, the vocal tract should experience the following modi-
fications compared with open vowel production: (1) larger total
volume of the vocal tract, lower VLP, raised velum, and a wider
pharynx; (2) changes should be more prominent during narrow
 ARTICLE IN PRESS
2 Journal of Voice, Vol. ■■, No. ■■, 2016

tube phonation compared with wide tube phonation; and (3) these
changes are not expected to remain after exercises.
METHODS
Participants
Ten participants were included in this study (six women and four
men). The average age of the subjects was 26 years, with a range
of 21–43 years. Inclusion criteria included (1) age range of 20–
45 years, (2) laryngoscopic diagnosis of mild hyperfunctional
dysphonia, and (3) no previous voice training or therapy. None
of the participants reported previous experience using tube pho-
nation or other semi-occlusions as vocal training or warm-up
exercises. Subjects did not report any known voice or hearing
pathology at the time of the experiment. Several definitions of
laryngeal hyperfunction exist, but a recurrent feature in almost
all descriptions includes excessive laryngeal musculoskeletal ac-
tivity, force, or tension. The basic paradigm for the evaluation
of laryngeal hyperfunction is to look for compression of the glottis
and supraglottic structures during phonation. In the present study,
diagnosis of hyperfunctional dysphonia was made based on the
previous description. This study was reviewed and approved by
the University of Chile Hospital Review Board. Informed consent
was obtained from all participants.
Laryngoscopic assessment
All participants were asked to undergo flexible laryngoscopy
(Olympus ENF-P4; Olympus, Center Valley, PA, USA) to confirm
the presence of functional dysphonia. Endoscopic laryngeal ex-
aminations were performed by two laryngologists who are
coauthors of the present study (C.O. and M.L.). Intranasal topical
anesthesia was used during trans-nasal endoscopy for all subjects.
strong as possible on the alveolar ridge, face, and head areas;
and to produce an easy voice during tube phonation. Each subject
was scanned once while producing each phonatory task. No more
repetitions were performed because of the maximum allowed
amount of radiation. Participants were asked to adopt a relaxed
posture in the CT scanner and exactly the same body and head
position was kept during the entire CT procedure. The head po-
sition was mechanically fixed in a frame during all experiments.
CT image analysis
Most of CT measures included in the present study were based
in a previous research.8 Five CT midsagittal images (five pho-
natory tasks × one repetition) were chosen from each subject to
perform a series of distance measurements (mm). Anatomic dis-
tances (Figure 1 ) of interest included (1) vertical length of the
vocal tract (which is indicative of the VLP) measured as the dis-
tance between the lowest point of the odontoid process of the
atlas and the vocal folds following a vertical line; (2) horizon-
tal length of the vocal tract measured as the distance between
the lowest point of the atlas and the narrowest point between
the lips, (3) lip opening measured as the distance between the
lower edge of the upper lip and the upper edge of the lower lip,
(4) jaw opening measured as the distance between the lower-
most edge of the jawbone contour and the anterior end of the
hard palate, (5) tongue dorsum height measured as the dis-
tance between the lowermost edge of the jaw bone and the
uppermost point of the tongue dorsum, (6) oropharynx width mea-
sured as the distance between the lowest point of the second
vertebra and the most posterior part of the tongue contour (to
ensure the same angle, we used a straight line from the anterior

CT scanning
CT was carried out at the University of Chile Hospital, Depart-
ment of Imaging and Radiology. The CT images were acquired
using a SOMATOM Sensation 64 (Siemens Healthcare, Erlangen,
Germany) CT machine. The CT imaging parameters used to
provide images of the vocal tract were voltage of 100 kV, time
of the rotation of 0.4 seconds, and slice thickness of 1.2 mm.
In supine position inside the CT machine, subjects were asked
to produce the following phonatory tasks: (1) to sustain vowel
[a:] (baseline, condition pre), (2) to phonate a sustained vowel-
like sound into a drinking straw (tube 1) (5 mm of inner diameter
and 25.8 cm in length) for 15 minutes, and immediately after
that, (3) to produce another sustained vowel [a:] (condition post).
After 20 minutes of complete silence (vocal rest), subjects per-
formed phonation into a plastic stirring straw (tube 2) (2.7 mm
of inner diameter and 10.7 cm in length) for 15 minutes. Im-
mediately after that, participants were asked to produce another
sustained vowel [a:] (post condition). Subjects were allowed to
breathe normally during tube phonation. All phonations were
carried out at habitual loudness level and speaking pitch. Pitch FIGURE 1. Distances (mm) measured in computerized tomogra-
was kept constant during all phonatory tasks and it was percep- phy (CT) midsagittal images: (1) vertical length of the vocal tract,
tually controlled by one of the experimenters using an electronic (2) horizontal length of the vocal tract, (3) lip opening, (4) jaw opening,
keyboard. Participants were required to produce a stable sound (5) tongue dorsum height, (6) oropharynx width, (7) velum elevation,
with a good closure at the lips; to feel vibratory sensations as and (8) hypopharynx width.
 ARTICLE IN PRESS
Marco Guzman et al Computerized Tomography Measures During Tube Phonation
FIGURE 2. Areas (mm2) measured in computerized tomography (CT)
midsagittal images: oral cavity (A1), pharyngeal region (A2), and
epilaryngeal region (A3).
uppermost edge of the jawbone contour to the anterior lowest
point of the second vertebra), (7) velum elevation measured as
the distance from the posterior upper edge of the hard palate and
the anterior lowest point of the uvula, and (8) hypopharynx width
measured as the distance between the lowest point of the pharynx
and the internal edge of the epiglottis following a line from the
anterior uppermost edge of the jawbone contour to the lower point
of the pharynx. All CT distance measurements were per-
formed using OsiriX version 5.0.2 64-bit software.
Moreover, three cross-sectional areas (mm2) were measured
from the same five midsagittal CT images (Figure 2 ). The areas
were (1) oral cavity (A1) measured from the lips to the velum
(up to the line connecting the lowermost edge of the jawbone
contour and a break of declivity on the velum surface), (2) the
pharyngeal region (A2) measured from the line ending A1 down
to the horizontal line connecting the lower edge of opisthion (oc-
cipital bone) and the lowermost edge of the jawbone contour,
and (3) the epilaryngeal region (A3) measured from the line
ending A2, down to the vocal folds.
FIGURE 3. Areas (mm2) measured in computerized tomography (CT) transversal images: the inlet to the lower pharynx (Ap) and the outlet of
the epilaryngeal tube (Ae).
3
Additionally, from the transversal CT images, two areas (mm2)
were measured (Figure 3 ): (1) the inlet to the lower pharynx
(Ap) just above the collar of the epiglottis and (2) the outlet of
the epilaryngeal tube (Ae) just below the collar of the epiglot-
tis where the epilarynx and the piriform sinuses form three
separate tubes. Areas from transversal CT images were chosen
taking into account the bending of the vocal tract. A line from
backbone to jawbone through the tip of arytenoids in a parallel
way to the bottom line of the CT image was used to obtain Ae.
A line just above the tip of arytenoids, which was also parallel
to the bottom line, was used to obtain Ap.
Furthermore, volumetric measures of total vocal tract were
also performed. All volumetric measures were performed using
syngo MMWP version 31A software, with the semiautomatic
settings. Once the measures were computed, an experienced ex-
perimenter (coauthor of the present study) manually corroborated
all of the results.
Statistical analysis
Descriptive statistics were calculated for the variables, includ-
ing median and interquartile range. A generalized estimating
equation model was fitted to assess differences between pre,
during, and post tube use and also to assess the difference between
tubes. Spearman rank correlation coefficient was used to assess
statistical dependence between distance, area, and volumetric mea-
sures. All analyses were made using Stata 12.1 (StataCorp LP,
College Station, TX). A P value <0.05 was considered statisti-
cally significant, and all P values were two sided.
RESULTS
Table 1 shows values from distance measures for both se-
quences (tube 1 and tube 2). In general, it is possible to observe
that during use of both tubes there was an increased vertical
length, increased tongue dorsum height, a wider oropharynx,
higher velum position, and a wider hypopharynx compared with
vowel phonation pre and post tube exercise. However, only
changes in hypopharynx width were statistically significant for
both sequences. Moreover, modifications in tongue dorsum height,
oropharynx width, and velum elevation were statistically
significant only for tube 2 sequence. Even though vocal tract
changes were more prominent for tube 2 than for tube 1,
 ARTICLE IN PRESS
4 Journal of Voice, Vol. ■■, No. ■■, 2016

TABLE 1.
Median and interquartile range for anatomic distances (mm) calculated from the midsagittal images of the vocal tract
obtained from the CT measurements performed before, during, and after tube 1 and tube 2 phonations
During Post During Post Intratube 1 Intratube 2 Tube 1 Versus
Variables Pre Tube 1 Tube 1 Tube 2 Tube 2 (P Value) (P Value) Tube 2 (P Value)
Vertical length 61.89 70.56 60.59 71.84 61.97 0.27431 0.22941 0.8785
16.05 18.50 14.25 27.12 17.41
Horizontal length 93.59 97.73 93.73 94.44 94.41 0.36931 0.69948 0.3863
6.34 3.75 8.63 9.47 9.12
Lip opening 10.04 3.48 9.32 2.73 9.37 0.0001 0.0001 0.0745
5.55 1.56 7.48 1.02 8.50
Jaw opening 78.98 82.78 81.85 81.16 79.90 0.79505 0.71592 0.2411
10.14 11.12 8.11 10.46 7.33
Tongue dorsum height 54.78 66.03 57.08 67.48 58.64 0.05393 0.00436 0.0284
3.39 11.42 7.32 11.89 6.28
Oropharynx width 10.34 16.29 10.33 17.32 10.39 0.20584 0.01116 0.1141
5.42 7.85 5.35 6.63 4.07
Velum elevation 19.88 18.45 22.19 16.08 22.43 0.07454 0.03101 0.5076
6.22 4.90 5.51 4.90 5.04
Hypopahrynx width 20.71 24.81 22.19 26.02 22.32 0.03957 0.02771 0.0745
3.11 5.93 2.10 5.93 3.79
CT, computerized tomography.

differences between them were not significant. Figures 4 and 5
show distance changes for tube 1 and tube 2, respectively.
Table 2 summarizes the results from area measurements for
both sequences (tube 1 and tube 2). In general, outlet of the
epilaryngeal tube (Ae), inlet to the lower pharynx (Ap), pha-
ryngeal region (A2), and epilaryngeal region (A3) tended to be
greater during phonation into both tubes. However, none of
abovementioned changes were statistically significant. Further-
more, comparison of vocal tract area changes between both tubes
did not show significant differences. Figures 6 and 7 show area
changes during tube 1 and tube 2 for Ap and Ae, respectively.
Results from volumetric measures of vocal tract are dis-
played in Table 3 . During both tube exercises, there was an
increased total volume. Nevertheless, statistically significant dif-
ferences were obtained only for the tube 2 sequence. No
significant differences were found when both sequences were
compared. Figures 8 and 9 show sagittal and coronal views
respectively for volumetric measures for tube 2. From a coronal
view (Figure 9), it is possible to observe a clear increase of the
piriform sinuses and valleculas.
Correlation analysis for tube 1 demonstrated strong linear re-
lation between Ap and A3 (rho = 0.904; P = 0.000), Ae
and Ap (rho = 0.948; P = 0.000), Ae and A3 (rho = 0.805;
P = 0.005), hypopharyngeal width andAe (rho = 0.799; P = 0.006),
hypopharyngeal width and Ap (rho = 0.726; P = 0.017),
hypopharyngeal width and A3 (rho = 0.662; P = 0.037), oropha-
ryngeal width andAe (rho = 0.652; P = 0.041), tongue dorsum height
and oropharyngeal width (rho = 0.704; P = 0.023), tongue dorsum
height and A1 (rho = −0.908; P = 0.025), and total volume and
A3 (rho = 0.732; P = 0.016).
Correlation analysis for tube 2 demonstrated strong linear
relation between Ap and A3 (rho = 0.881; P = 0.001), Ae and
Ap (rho = 0.903; P = 0.000), Ae and A3 (rho = 0.710; P = 0.021),
hypopharyngeal width and Ae (rho = 0.778; P = 0.008),

FIGURE 4. Midsagittal images of the vocal tract. Before (left), during (middle), and after tube drinking straw (right) phonations. The two most
evident changes are the higher velum, the lower laryngeal position, and wider pharynx during straw phonation.
 ARTICLE IN PRESS
Marco Guzman et al Computerized Tomography Measures During Tube Phonation 5

FIGURE 5. Midsagittal images of the vocal tract. Before (left), during (middle), and after tube stirring straw (right) phonations. The two most
evident changes are the higher velum, the lower laryngeal position, and wider pharynx during straw phonation.

TABLE 2.
Median and interquartile range for anatomic areas (mm2) calculated from the midsagittal and transversal images of the
vocal tract obtained from the CT measurements performed before, during, and after tube 1 and tube 2 phonations
During Post During Post Intratube 1 Intratube 2 Tube 1 Versus
Variables Pre Tube 1 Tube 1 Tube 2 Tube 2 (P Value) (P Value) Tube 2 (P Value)
Outlet of the epilaryngeal tube (Ae) 1.39 1.61 1.46 1.53 1.47 0.46048 0.50916 0.6098
0.34 0.37 0.54 0.88 0.28
Inlet to the lower pharynx (Ap) 4.65 5.60 4.62 6.19 4.99 0.12865 0.11880 0.4446
1.95 0.95 1.35 2.35 1.34
Oral cavity (A1) 12.38 11.11 14.33 11.93 11.65 0.23299 0.74513 0.8785
2.90 3.86 6.11 2.90 3.76
Pharyngeal region (A2) 3.92 3.99 4.03 4.04 3.86 0.79710 0.59856 0.9594
1.00 0.75 1.64 1.39 1.07
Epilaryngeal region (A3) 4.95 7.11 5.51 7.13 5.42 0.13015 0.10632 0.3329
3.06 2.26 3.28 5.02 3.29
CT, computerized tomography.

hypopharyngeal width and Ap (rho = 0.713; P = 0.021), DISCUSSION

oropharyngeal width and volume (rho = 0.633; P = 0.049), jaw Voice exercises to produce an open throat have been common-
opening and tongue dorsum height (rho = 0.834; P = 0.003), ly used to reduce muscle tension in the pharyngeal and laryngeal
total volume and A3 (rho = 0.807; P = 0.005), and total volume areas, in both normal and pathological voices.3,12,13 Moreover,
and Ap (rho = 0.62; P = 0.05). Titze,14 and Titze and Story15 stated that the “wide pharynx”

FIGURE 6. Transversal images of the vocal tract. Before drinking/stirring straw (left), during drinking straw (middle), and during stirring straw
(right) phonations. Ap increased during both drinking straw and stirring straw phonations compared with open vowel phonation. The increment
was slightly larger during stirring straw phonation than during drinking straw phonation.
 ARTICLE IN PRESS
6 Journal of Voice, Vol. ■■, No. ■■, 2016

FIGURE 7. Transversal images of the vocal tract. Before drinking/stirring straw (left), during drinking straw (middle), and during stirring straw
(right) phonations. Ae increased during both drinking straw and stirring straw phonations compared with open vowel phonation.

TABLE 3.
Median and interquartile range for volumetric measures (mm3) obtained from the CT samples performed before, during,
and after tube 1 and tube 2 phonations
During Post During Post Intratube 1 Intratube 2 Tube 1 Versus
Variables Pre Tube 1 Tube 1 Tube 2 Tube 2 (P Value) (P Value) Tube 2 (P Value)
Total volume vocal tract 57.94 68.21 58.31 76.91 56.41 0.13325 0.01326 0.5748
18.20 29.43 17.06 18.86 18.98
CT, computerized tomography.

configuration is an acoustic way to enhance the first formant and
this increases the overall sound level. The present study found
statistically significant measures of increase in the hypopharyngeal
width during phonation with both tubes, which simultaneously
increased measures of the inlet to the lower pharynx (Ap) and
the epilaryngeal region (A3).
Correlations were found between Ap and A3 for both tubes,
hypopharyngeal width and Ap for both tubes, and hypopharyngeal
width and A3 for tube 2. Additionally, an increased oropharyn-
geal width was observed for both tubes (only stirring straw was
significant) compared with baseline vowel phonation. A similar
study was previously performed (using trans-nasal laryngeal en-
doscopy) in participants with voice disorders.11 Authors reported
that the eight assessed semi-occluded postures increased pha-
ryngeal width differently throughout, with more prominent
changes during phonation into stirring straw and tube sub-
merged into the water (so-called water resistance therapy).11 Earlier
research has demonstrated similar results with normal subjects
and trained participants.8–10 Guzman et al found that during stir-
ring straw phonation (similar to tube 2 in the present study), the
hypopharynx became 38% wider compared with its size before
tube phonation, Ap area increased both during Finnish glass tube

FIGURE 8. Volumetric images from a sagittal view. Before drinking/stirring straw (left), during stirring straw (middle), and after stirring straw
(right).
 ARTICLE IN PRESS
Marco Guzman et al Computerized Tomography Measures During Tube Phonation
FIGURE 9. Volumetric images from a coronal view. Before drinking/stirring straw (left), during stirring straw (middle), and after stirring straw
(right). Most clear changes are observed in piriform sinuses, valleculae, and oral cavity.
(9%) and stirring straw phonations (91%), and the epilaryngeal
region (A3) became larger during both glass tube (13%) and stir-
ring straw (73%) phonations compared with vowel phonation
before exercise. Laukkanen et al in a case study observed a greater
cross-sectional area (67%) in the pharyngeal region during pho-
nation into a tube compared with vowel phonation before using
the tube.
Although, no significant differences were detected, vertical
length of the vocal tract tended to be larger during phonation
into both tubes. This change is likely caused by two observed
modifications: the lowering of the larynx and the elevation of
velum during exercises. In the present study, all participants dem-
onstrated an important modification in the velum position, which
rose to seal the nasopharyngeal port during the tube and stir-
ring straw phonations. Larger changes were observed during the
latter. However, after tube phonations, the velum was not as high
as during tube phonations. This change has been previously re-
ported in three studies.8–10 Nevertheless, in all of the previous
studies, the velum remained elevated after tube phonation, con-
trary to the current study.
Most participants (eight) evidenced a lower VLP during use
of both tubes in our study. Variable results have been previ-
ously reported regarding VLP during different semi-occluded
exercises. Most studies have encountered a lower VLP during
semi-occluded tasks,8,11,16,17 whereas others have reported the
opposite.18.19 Considering that people diagnosed with hyper-
functional voice disorders (as subjects in the present study)
commonly present a high VLP,20 semi-occluded vocal tract ex-
ercises may be a useful therapeutic tool. Sovijärvi et al21 and
Simberg and Laine22 stated that one of the positive effects of pho-
nation into a tube submerged in water (another commonly
used semi-occluded exercise) is the lowering of the larynx.
Sovijärvi23–25 stated that the length of the tube and depth into
the water should be chosen so that a clear lowering of the larynx
would occur during the exercise. Nevertheless, the goal after the
7
exercise is to have a normal voice production with the larynx
in a neutral position.23–25
Constriction of the outlet of the epilaryngeal tube (Ae) (ie, anterior-
posterior laryngeal compression or aryepiglottic compression) has
been an important topic in the laryngology field, especially when
it is assessed as a sign of laryngeal hyperfunction. This supra-
glottic laryngeal activity is often considered a sign of abuse or
misuse of the vocal mechanism.26–30 It is commonly reported in
patients presenting with voice disorders, particularly nonorganic
voice disorders, such as muscle tension dysphonia.31 Although
anterior-posterior compression has been accepted as an endo-
scopic sign of vocal dysfunction, some studies have demonstrated
that it may be present in normal speaking7,31–34 and singing35–40 voice
production. Our data showed that during both tube exercises, Ae
tended to increase compared with vowel production before tube
phonation (although no significant differences were found). Similar
findings were reported in a single case study performed with CT.8
The Ae area became larger during stirring straw phonation (65%).
Vampola et al showed no changes of the epilaryngeal tube diam-
eter during tube phonation. Differently, Guzman et al in a study
designed for laryngoscopic observation of supraglottic activity,
showed that all semi-occluded exercises produced a narrowing of
the outlet of the epilaryngeal tube. This modification was more
prominent during semi-occlusions that have the highest degree of
airflow resistance (tube into water 3 and 10 cm and stirring straw
into air). The same three phonatory tasks caused the widest pharynx
and the lowest laryngeal position. In fact, a high correlation between
all these variables was found. Correlation analysis from our data
demonstrated a strong positive correlation between Ae and the
other pharyngeal areas (Ap, A3, and hypopharynx width) for both
tube exercises.
Because semi-occluded exercises have been demonstrated to
increase vocal tract reactance,41 and narrowing of the epilaryngeal
tube has been reported as the most contributing factor for the
raised vocal tract reactance,42,43 one may expect that tube phonation
 ARTICLE IN PRESS
8 Journal of Voice, Vol. ■■, No. ■■, 2016
plus narrowing of epilaryngeal tube would be a good combina-
tion during and after exercise. Most previous investigations have
not demonstrated this combination. Nevertheless, it has also been
stated that wider vocal tract (increased diameter) could have the
same effect of a narrowed diameter of epilaryngeal tube.43 In
this regard, the Vampola et al study showed that the subject was
able to increase the vocal tract input reactance and makes the
vocal tract more inertive by expanding the space of oropharyn-
geal and oral cavities rather than narrowing the epilaryngeal tube.
The ratio between these two areas (epilaryngeal tube diameter
and pharyngeal width) has been suggested to be an important
factor for the singer’s formant cluster production (a prominent
spectrum envelope peak near 3 kHz associated with the “ringing”
voice quality). Sundberg44 stated that when the cross-sectional
area in the pharynx is at least six times wider than that of the
laryngeal tube opening, the epilaryngeal tube is acoustically un-
linked from the rest of the vocal tract acting as a separate
resonator. Therefore, an extra formant would be added to the vocal
tract transfer function. Guzman et al found a greater Ap/Ae ratio
after stirring straw phonation (5.5) compared with vowel pho-
nation before straw phonation. This value is close to the value
suggested by Sundberg (6).44 Interestingly, acoustic results from
the same data showed the largest increase in the energy of the
speaker/singer’s formant cluster region after straw phonation.
In the present study, the total volume of the vocal tract was
larger during both tube exercises compared with baseline, but
it was significantly different only during use of the stirring straw.
This change did not remain after tube phonation. Only one earlier
study has explored changes in vocal tract volume during tube
phonation.9 Contrary to our data, authors revealed that the total
volume increased 38.5% after phonation into the tube when com-
pared with vowel phonation before tube phonation. According
to Vampola et al,9 the increase in volume was mostly due to trans-
versal expansion of the vocal tract. From our results, similar
modifications could be the main cause for the increased total
volume during tube phonation. In fact, total volume obtained a
good correlation with A3 and Ap during both tube exercises.
Therefore, it seems that changes in vertical length of the vocal
tract are not the main cause of increased total volume, but changes
in cross sectional areas.
Vocal tract changes such as wider pharynx, lower larynx, and
raised velum are likely due to the increased oral air pressure
(Poral) during tube phonation. Several earlier studies have re-
ported that during occlusion at the lip and or artificial lengthening
of the vocal tract, oral pressure increased compared with open
vowel production.45–49 Titze et al45 stated that when airflow re-
sistance is increased because of occlusion, the intraoral
(supraglottal) pressure is positive, and this in turn would reduce
the transglottal pressure (difference between subglottic and oral
pressure), unless the subglottic pressure is raised.45 A recent in-
vestigation aimed to assess the static back pressure (oral pressure)
and airflow for different tubes commonly used for voice therapy,
reported that changes in the diameter of straws affect Poral con-
siderably more compared with the same amount of relative change
in length.46 Radolf et al47 found that the mean Poral increased
(compared with vowel phonation) during voice production into
a resonance tube submerged 10 cm below the water surface.
Maxfield et al48 created a rank ordering by measuring the in-
traoral pressure produced by 13 semi-occlusion exercises
commonly used in voice therapy. The highest values of Poral
were found in straw submerged in water, raspberries, and stir-
ring straw with the free end in air. Guzman et al,49 in a study
performed using subjects with different voice conditions (normal
trained, normal untrained, with functional dysphonia, and with
vocal fold paralysis) using five different semi-occluded exer-
cises, reported that all exercises had a significant increase in oral
pressure, with phonation into a silicon tube submerged 10 cm
in water and phonation into a stirring straw as the exercises having
the highest values of Poral compared with baseline (repetition
of syllable [pa:]) for all vocal status. In the present study, vocal
tract changes were more prominent during tube 2 phonation (stir-
ring straw) than during tube 1 (drinking straw) phonation, likely
because of the higher airflow resistance that stirring straw offers
compared with drinking straw. This in turn should have pro-
duced greater Poral during the former.
The most observed changes in our present study are also the
common goals in voice therapy. It is generally accepted that a
low VLP, a raised velum, and a widened pharynx (A1, A2, A3,
and Ap) are important goals during voice therapy for patholog-
ical voices. These desired changes in our study were attained
without giving any biomechanical instructions to the partici-
pants (eg, “raise your velum,” “lower your larynx,” or “open your
throat”). Participants were simply asked to feel vibratory sen-
sation as strong as possible on the alveolar ridge, face, and head
areas, and to produce an easy voice during tube phonation. Voice
therapy and singing training in many institutions and practices
tend to focus on a conscious, mechanical control of voice pro-
duction (eg, “move your tongue,” “open your mouth,” or “relax
your shoulders”). To be sure, some patients improve perfor-
mance with instructions like these, but recent studies in perceptual
motor learning have shown that subjects who receive instruc-
tions about the biomechanics (internal focus of attention) of vocal
control showed poorer learning than those who were given no
instruction at all.50,51 According to Titze and Verdolini,52 verbal
instructions about the biomechanics of a task are inadequate de-
scriptors of action and often exceed a patient’s processing
capability. Perceptual-motor learning principles suggest that an
external focus, especially oriented to effect an action, is better
for motor learning than an internal focus on the mechanics of
actions. Our current study may confirm this learning principle
and supports earlier findings.52,53 Even though no verbal biome-
chanical instructions were given to our subjects, they all showed
the desired anatomical vocal tract changes when using tube pho-
nation. Hence, it is reasonable to state that semi-occluded vocal
exercises using an external focus of attention are appropriate,
reproducible, and valuable therapeutic tools in the treatment of
dysphonic voice.
CONCLUSION
Tube phonation causes an increased total vocal tract volume,
mostly due to the increased cross-sectional areas in the pharyn-
geal region. This change is more prominent when a tube offers
more airflow resistance (stirring straw) than when a tube offers
less airflow resistance (wider drinking straw). Based on our data
 ARTICLE IN PRESS
Marco Guzman et al Computerized Tomography Measures During Tube Phonation
and earlier studies, it appears that vocal tract changes during voice
therapy are not dependent on the voice condition (vocally trained,
untrained, or disordered voices), but on the exercise itself and
the type of instructions given to subjects. Tube phonation is a
good option to reach therapeutic goals (eg, wide pharynx and
low larynx) without giving biomechanical instructions, but only
asking to feel easy voice and vibratory sensations during pho-
nation. Changes obtained during tube phonation will not
necessarily remain after it.
REFERENCES
1. Aronson A. Clinical Voice Disorders. An Interdisciplinary Approach.
New York, NY: Thieme Medical Publishers; 1985.
2. Colton R, Casper J. Understanding Voice Problems. A Physiological
Perspective for Diagnosis and Treatment. Baltimore, MD: Lippincott
Williams & Wilkins; 1990.
3. Boone DR. The Voice and Voice Therapy. Englewood Cliffs, NJ: Prentice
Hall; 1977.
4. Mitchell HF, Kenny DT, Ryan M, et al. Defining open throat through content
analysis of experts’ pedagogical practices. Logoped Phoniatr Vocol.
2003;28:167–180.
5. Mitchell HF, Kenny DT. The effects of open throat technique on long term
average spectra (LTAS). Logoped Phoniatr Vocol. 2004;29:99–118.
6. Stager SV, Bielamowicz S, Gupta A, et al. Quantification of static and
dynamic supraglottic activity. J Speech Lang Hear Res. 2001;44:1245–
1256.
7. Stager S, Bielamowicz S, Regnell J, et al. Supraglottic activity: evidence
of hyperfunction or laryngeal articulation? J Speech Lang Hear Res.
2000;43:229–238.
8. Guzman M, Laukkanen A-M, Krupa P, et al. Vocal tract and glottal function
during and after vocal exercising with resonance tube and straw. J Voice.
2013;27:305–311.
9. Vampola T, Laukkanen A-M, Horacek J, et al. Vocal tract changes caused
by phonation into a tube: a case study using computer tomography and
finite-element modeling. J Acoust Soc Am. 2011;129:310–315.
10. Laukkanen A-M, Horacek J, Krupa P, et al. The effect of phonation into a
straw on the vocal tract adjustments and formant frequencies. A preliminary
MRI study on a single subject completed with acoustic results. Biomed Signal
Process Control. 2010;7:50–57.
11. Guzman M, Castro C, Testart A, et al. Laryngeal and pharyngeal activity
during semioccluded vocal tract postures in subjects diagnosed with
hyperfunctional dysphonia. J Voice. 2013;27:709–716.
12. Mitchell HF, Kenny DT, Ryan M, et al. Defining open throat through content
analysis of experts’ pedagogical practices. Logoped Phoniatr Vocol.
2003;28:167–180.
13. Mitchell HF, Kenny DT. The effects of open throat technique on long term
average spectra (LTAS) of female classical voices. Logoped Phoniatr Vocol.
2004;29:99–118.
14. Titze I. Voice research: the wide pharynx. J Singing. 1998;55:27–28.
15. Titze IR, Story BH. Acoustic interactions of the voice source with the lower
vocal tract. J Acoust Soc Am. 1997;101:2234–2243.
16. Fant G. Acoustic Theory of Speech Production. With Calculations Based
on X-ray Studies of Russian Articulations. 2nd ed. The Hague,
The Netherlands: Mouton; 1970.
17. Laukkanen AM, Takalo R, Vilkman E, et al. Simultaneous videofluorographic
and dual-channel electroglottographic registration of the vertical laryngeal
position in various phonatory tasks. J Voice. 1999;13:60–71.
18. Laukkanen A-M, Lindholm P, Vilkman E, et al. A physiological and acoustic
study on voiced bilabial fricative /ß:/ as a vocal exercise. J Voice.
1996;10:67–77.
19. Laukkanen A, Titze I, Hoffman H, et al. Effects of a semi-occluded vocal
tract on laryngeal muscle activity and glottal adduction in a single female
subject. Folia Phoniatr Logop. 2008;60:298–311.
20. Aronson AE. Clinical Voice Disorders. 3rd ed. New York, NY: Thieme
Stratton; 1990.
9
21. Sovijärvi A, Häyrinen R, Orden-Pannila M, et al. Aänifysiologisten
kuntoutusharjoitusten ohjeita [Instructions for voice exercises]. Helsinki:
Publications of Suomen Puheopisto; 1989.
22. Simberg S, Laine A. The resonance tube method in voice therapy: description
and practical implementations. Logoped Phoniatr Vocol. 2007;32:165–
170.
23. Sovijärvi A. Die Bestimmung der Stimmkategorien mittels Resonanzröhren.
Int Kongr Phon Wiss. 1965;532–535.
24. Sovijärvi A. Äänifysiologiasta ja artikulaatiotekniikasta [On Voice Physiology
and Articulatory Technique]. Helsinki, Finland: Department of Phonetics,
University of Helsinki press; 1966.
25. Sovijärvi A. Nya metoder vid behandlingen av röstrubbningar. Nordisk
Tidskrift for Tale og Stemme. 1969;3:121–131.
26. Hillman RE, Holmberg EB, Perkell JS, et al. Objective assessment of vocal
hyperfunction: an experimental framework and initial results. J Speech Hear
Res. 1989;32:373–392.
27. Koufman JA, Blalock PD. Functional voice disorders. Otolaryngol Clin North
Am. 1991;24:1059–1073.
28. Morrison MD, Rammage LA, Belisle GM, et al. Muscular tension dysphonia.
J Otolaryngol. 1983;12:302–306.
29. Roy N, Ford CN, Bless DM. Muscle tension dysphonia and spasmodic
dysphonia: the role of manual laryngeal tension reduction in diagnosis and
management. Ann Otol Rhinol Laryngol. 1996;105:851–856.
30. Dworkin JP, Meleca RJ, Abkarian GG. Muscle tension dysphonia. Curr Opin
Otolaryngol Head Neck Surg. 2000;8:169–173.
31. Behrman A, Dahl L, Abramson A, et al. Anterior-posterior and medial
compression of the supraglottis: signs of nonorganic dysphonia or normal
postures? J Voice. 2003;17:403–410.
32. Sama A, Carding PN, Price S, et al. The clinical features of functional
dysphonia. Laryngoscope. 2001;111:458–463.
33. Stager S, Bielamowicz SA, Gupta A, et al. Quantification of static and
dynamic supraglottic activity. J Speech Lang Hear Res. 2001;44:1245–
1256.
34. Guzman M, Ortega A, Olavarría C, et al. Comparison of supraglottic activity
and spectral slope between theater actors and vocally untrained subjects.
J Voice. 2016; doi:10.1016/j.jvoice.2015.10.017.
35. Lawrence V. Laryngological observations on belting. J Res Singing.
1979;2:26–28.
36. Yanagisawa E, Estill J, Kmucha S, et al. The contribution of aryepiglottic
constriction to “ringing” voice quality: a videolaryngoscopic study with
acoustic analysis. J Voice. 1989;3:342–350.
37. Pershall K, Boone S. Supraglottic contribution to voice quality. J Voice.
1987;1:186–190.
38. Mayerhoff R, Guzman M, Jackson-Menaldi C, et al. Analysis of supraglottic
activity during vocalization in healthy singers. Laryngoscope. 2014;124:504–
509.
39. Guzman M, Lanas A, Olavarria C, et al. Laryngoscopic and spectral analysis
of laryngeal and pharyngeal configuration in non-classical singing styles.
J Voice. 2015;29:130.e21–130.e28.
40. Guzman M, Barros M, Espinoza F, et al. Laryngoscopic, acoustic perceptual,
and functional assessment of voice in rock singers. Folia Phoniatrica et
Logopedica. 2013;65:78–86.
41. Story BH, Laukkanen AM, Titze IR. Acoustic impedance of an artificially
lengthened and constricted vocal tract. J Voice. 2000;14:455–469.
42. Titze IR. Voice training and therapy with a semi-occluded vocal tract:
rationale and scientific underpinnings. J Speech Lang Hear Res.
2006;49:448–459.
43. Titze IR, Laukkanen AM. Can vocal economy in phonation be increased
with an artificially lengthened vocal tract? A computer modeling study.
Logoped Phoniatr Vocol. 2007;32:147–156.
44. Sundberg J. Articulatory interpretation of the singing formant. J Acoust Soc
Am. 1974;55:838–844.
45. Titze I, Finnegan E, Laukkanen A, et al. Raising lung pressure and pitch
in vocal warm-ups: the use of flow-resistant straws. J Singing. 2002;58:329–
338.
46. Amarante P, Wistbacka G, Larsson H, et al. The flow and pressure
relationships in different tubes commonly used for semi-occluded vocal tract
exercises. J Voice. 2016;30:36–41.
 ARTICLE IN PRESS
10
47. Radolf V, Laukkanen A-M, Horáček J, et al. Air-pressure, vocal fold
vibration and acoustic characteristics of phonation during vocal exercising.
Part 1: measurement in vivo. Eng Mech. 2014;21:53–59.
48. Maxfield L, Titze I, Hunter E, et al. Intraoral pressures produced by thirteen
semi-occluded vocal tract gestures. Logoped Phoniatr Vocol. 2015;40:84–
90.
49. Guzman M, Castro C, Madrid S, et al. Air pressure and contact quotient
measures during different semi-occluded postures in subjects with
different voice conditions. J Voice. 2016; doi:10.1016/j.jvoice.2015.09
.010.
Journal of Voice, Vol. ■■, No. ■■, 2016
50. Wulf G, Weigelt C. Instructions about physical principles in learning a
complex motor skill: to tell or not to tell. Res Q Exerc Sport. 1997;68:362–
367.
51. Yiu EM, Verdolini K, Chow L. Electromyographic study of motor
learning for a voice production task. J Speech Lang Hear Res.
2005;48:1254–1268.
52. Titze I, Verdolini K. Vocology. The Science and Practice of Voice
Habilitation. New York, NY: National Center for Voice and Speech; 2012.
53. Wulf G, McNevin N, Fuchs T, et al. Attentional focus in complex motor
skill learning. Res Q Exerc Sport. 2000;71:229–239.