ARTICLE IN PRESS

How Do Tube Diameter and Vocal Tract Configuration Affect

Oral Pressure Oscillation Characteristics Caused by Bubbling
During Water Resistance Therapy?
*,†
Marco Guzman, ‡Christian Castro, §Karol Acevedo, IICamilo Moran, ¶Victor Espinoza, and
II
Camilo Quezada, *, yxk{Santiago, and zValparaiso, Chile

Summary: Purpose. The present study aimed at observing the effect of tube diameter and vocal tract configu-
ration on frequency, amplitude, and regularity of Poral oscillation caused by bubbling during water resistance
therapy (WRT). A secondary objective was to examine the degree of self-perceived sensation of massage-like
effect produced by bubbles during WRT.
Methods. Forty-two participants were included in this study. Assessment protocol included: (1) self-assessment
of massage-like sensation and (2) objective assessment of air pressure-related variables. In the first section, partic-
ipants were instructed to select and produce a sustained-vowel like phonation into three different tubes (varying
inner diameter) submerged 5 cm below the water surface. Also, two different vocal tract configurations were pro-
duced by all subjects: (1) horizontal position (regular vocal tract position), (2) vertical position (yawning position
with low vertical laryngeal position). Participants were asked to self-assess their massage-like sensation. In the
second section, objective measurements of air pressure-related variables were acquired during WRT exercises.
Results. Statistical differences were driven by tube inner diameter for oral pressure oscillation frequency, ampli-
tude, jitter and shimmer and self-perceived massage-like sensation. Vocal tract position generated differences for
medium-size tube and large-size tube only for self-perceived massage-like sensation.
Conclusion. Inner diameter of tube and configuration of vocal tract affect bubble characteristics and massage-
like sensation during WRT. Larger tube diameters and vocal tract volumes seem to produce more regular bub-
bles, lower bubble frequency, and larger bubble amplitude, causing a more evident massage-like sensation. There-
fore, control of these variables is apparently relevant to obtain the best effect in patients with voice disorders.
Key Words: Water resistance therapy−Tube phonation−Voice rehabilitation−Voice training.

INTRODUCTION variation of Poral during tube phonation in water has also

Bubbling produced during water resistance therapy (WRT)
voice exercises has been attributed to a massage-like effect
due to the oscillation in oral pressure (Poral) caused by bub-
bles during phonation.1-5 Patients usually report that water
bubbling positively impacts their voice production because
of the relaxing effect in both laryngeal and pharyngeal
areas.4 A massage-like effect with reduction of muscle
hypertension could be desirable in patients with voice disor-
ders, especially in subjects diagnosed with vocal hyperfunc-
tion. Previous data have showed improvement in muscle
relaxation sensation in subjects diagnosed with functional
dysphonia immediately after voice exercises with WRT and
after one week of home practice.4
Poral modulation during water bubbling has been estab-
lished at a frequency of 12-40 Hz.4-6 The magnitude of
This research was supported by grants from CONICYT (grant FONDECYT
11180291).
From the *Department of Communication Sciences and Disorders, Universidad de
los Andes, Chile; yDepartment of Otolaryngology, Voice Center, Las Condes Clinic,
Santiago, Chile; zDepartment of Communication Sciences and Disorders, Universi-
dad de Valparaiso, Valparaiso, Chile; xDepartment of Communication Sciences and
Disorders, Universidad San Sebastian, Santiago, Chile; kDepartment of Communica-
tion Sciences and Disorders, Universidad de Chile, Santiago, Chile; and the {Depart-
ment of Sound, Universidad de Chile, Santiago, Chile.
Address correspondence and reprint requests to Marco Guzmán, Department of
Communication Sciences and Disorders, Universidad de los Andes, Avenida Monse-

~or Alvaro
n del Portillo 12455, Santiago, Chile E-mail: guzmann.marcoa@gmail.com
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2020.03.004
been examined. In a modeling study by Horácek et al6 pho-
nation at conversational loudness resulted in 2.2 times larger
peak-to-peak pressure variation with the tube submerged
10 cm in water, compared with phonation on [u:]. Similarly,
an in vivo study by Radolf et al5 showed about two-four
times higher peak-to-peak variation in Poral with the tube
immersed 10 cm in water, compared with phonation on [u:].
A possible effect of bubbling on vocal folds oscillation has
also been explored. Enflo et al1 found that during phonation
with glass resonance tube in water, bubbles generate not
only modulations in Poral, but also in electroglottography
(EGG) and audio signals. Authors showed that oscillation
of oral pressure modifies the transglottal pressure (which
drives the vocal folds) and this, in turn, produces changes in
the EGG signal amplitude. Therefore, the modulation of
Poral during bubbling seems to have an effect on vocal fold
oscillation and possibly on vocal fold tissues.1 A high-speed
imaging study, designed to investigate tube phonation,
reported modulations of vocal fold vibration and EGG sig-
nal due to oscillation of back pressure during water bub-
bling.7 Andrade et al2 reported that voice exercises with a
secondary source of vibration (eg, bubbling during WRT)
significantly changes the behavior of the vocal folds. Specifi-
cally, the secondary source of vibration (bubbles) causes an
increment of both EGG contact quotient (CQ) range, and
fundamental frequency (F0) range. Authors suggest that a
larger CQ range is an indicator of greater variability of
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2 Journal of Voice, Vol. &&, No. &&, 2020
open and closed phases of the vocal fold vibration, and a
that larger F0 range indicates greater variability of the vocal
fold vibration frequencies.2
Characteristics of water bubbling frequency during voice
production have also been previously explored. Data sug-
gest that variables such as the inner diameter of the tubes
and airflow rate could have an impact on bubbling fre-
quency.6-8 Similarly, water depth also seems to have an
impact on both Poral oscillation frequency and amplitude
(mean difference between max. and min. Poral).4 It has
been showed that changes in bubbling frequency and ampli-
tude of Poral oscillation potentially affect the degree of mas-
sage-like sensation during voice exercises.5, 8
In a recent modeling study, Wistbacka et al9 found that
bubbling type is dependent on airflow rate. Authors
reported that with a low airflow rate (0.005 L/s), bubbles
were produced one by one in a regular pattern. When
increasing the flow to 0.013 L/s, the bubble pattern turned
to a bimodal version, with bubbles produced in periodic
pairs of two bubbles that merged into a mushroom-like
shape. When flow was increased to 0.05 L/s, the bubble pat-
tern turned chaotic without a regular visible pattern. Bubble
frequency increased with increasing airflow rate and the vol-
ume of the bubbles also increased for higher flow. Also,
researchers reported that larger back volumes (resembling
the vocal tract volume) produced lower bubble frequencies
and greater bubble volumes. To the best of our knowledge,
this study is the first one inspecting bubbling-formation
in the context of voice production with tubes submerged
into water.
To date, no studies have been designed to explore changes
in Poral oscillation characteristics (frequency, amplitude,
and regularity) produced by bubbling during different con-
ditions in humans. The following research aims guided the
investigation:
Specific aim 1: to observe the effect of tube diameter
and vocal tract configuration on frequency, ampli-
tude, and regularity of Poral oscillation caused by
bubbling during WRT. We hypothesized that larger
tube diameter and larger vocal tract volume produce
lower Poral oscillation frequency, greater amplitude,
more regular bubbling.
Specific aim 2: to observe the effect of tube diameter
and vocal tract configuration on the degree of self-per-
ceived sensation of massage-like effect produced by
bubbles during WRT. We hypothesized that larger
tube diameter and larger vocal tract volume produce
greater massage-like sensation.
METHODS
Participants
Adopted Inclusion criteria were: (1) age within the 20-
55 years range, (2) perceptually normal voice, (3) no current
or past history of voice disorders, (4) previous experience
with tube phonation (at least 1 year performing WRT
exercises, self-reported by participants), and (5) ability to
produce different vocal tract configurations (visually
assessed by experimenters). Perceptual auditory assessment
of voice for recruitment was conducted by one voice pathol-
ogist with 15 years of experience as a voice clinician. This
procedure was carried based on the parameter G (grade of
dysphonia) from the GRBAS scale. Only subjects with at
least G = 0 were included in the experiment. Forty-six par-
ticipants were initially enrolled in this study. Four subjects
were excluded because they did not meet inclusion criteria.
Forty-two participants were finally included in this study
(6 males and 36 females). Mean average age was 28 years,
with a 24-37 range. This study was reviewed and approved
by the Review Board of Universidad de los Andes.
Informed consent was obtained from all participants.
Assessment procedures
The entire assessment session lasted approximately 30
minutes per subject. It consisted of two different sections: (1)
self-assessment of massage-like sensation (vibration pro-
duced by water bubbling; 10 minutes approximately) and (2)
objective assessment of air pressure-related variables
(20 minutes approximately). During the whole examination,
participants were asked to sit comfortably upright on a chair.
In the first section, participants were instructed to select
and produce a sustained-vowel like phonation (using a com-
fortable pitch) into three different tubes (varying inner
diameter) submerged 5 cm below the water surface: (1) tube
1 (0.5 cm in inner diameter and 30 cm in length), (2) tube 2
(1 cm in inner diameter and 30 cm in length), tube 3 (2 cm
in inner diameter and 30 cm in length). Also, two different
vocal tract configurations were produced by all subjects: (1)
horizontal position (regular vocal tract position), (2) vertical
position (yawning position with low vertical laryngeal posi-
tion). Based on previous data, it was assumed that vertical
vocal tract configuration (lower vertical laryngeal position
and raised velum) causes an increase total vocal tract vol-
ume.10-12 Therefore, six different combinations were used
(3 tube diameters £ 2 vocal tract configurations). Participants
were asked to maintain the same pitch during all phonatory
tasks. An electronic keyboard was used to cue their pitch,
which was also auditorily monitored by the four experiment-
ers who participated in experimental procedures. Control of
pitch was performed as many times as needed by each subject
in all phonatory tasks. The sequence of tubes and vocal tract
configurations was individually randomized for each subject.
When performing the exercises, the participants were required
to phonate with an easy voice (not to put tension or excessive
pressure in the throat and neck areas). Easy phonation was
auditory perceptually assessed by experimenters both at the
beginning of task presentation and throughout the tasks.
Before data collection all the exercises were shown and
explained to the participants by a trained Speech-Language
Pathologists. To standardize assessment procedures, all
experimenters underwent a 2-hour training period (conducted
by the first author of the present study) before data collection.
 ARTICLE IN PRESS
Marco Guzman, et al How Do Tube Diameter and Vocal Tract Configuration
FIGURE 1. Image showing real-time control of Psub level targeted at 10-15 cm H2O during acquisition of air pressure-related variables.
Participants were asked to self-assess their massage-like sensa-
tion (vibration produced by bubbling) immediately after every
phonatory task (tube + vocal tract configuration). Self-assess-
ment was performed using a 100-mm visual analog scale with
0 = no massage sensation at all and 100 = very intense mas-
sage sensation. Degree of massage-like sensation during bub-
bling was the only dependent variable in this first section of
experimental procedures.
In the second section of the experiment, objective measure-
ments of air pressure-related variables were acquired. Partici-
pants were required to produce the same phonatory tasks
produced in the first experimental section. The sequence of
tubes and vocal tract configurations was randomized in the
same manner as in the first section. The free end of tubes was
submerged 5 cm below the water surface while samples were
recording. Subglottic pressure level was visually controlled by
experimenters and participants using a real-time software with
a target of 10-15 cm H2O (KayPENTAX, Model 6600, version
3.4, KayPENTAX, Lincoln Park, NJ) (Figure 1). Each voiced
segment lasted approximately 5 seconds. Three repetitions
were performed for each phonatory task. This totaled 756 sam-
ples (42 subjects £ 6 postures £ 3 repetitions). Each aerody-
namic recording session took approximately 15 minutes. While
phonating into the water, the outer end of the tube was rapidly
closed fully with a finger every 1.4 seconds (a metronome set at
40 beat per seconds was used). This shuttering procedure allows
for estimating the subglottic pressure (Psub) from Poral during
phonation into the tube in order to visually control the Psub at
target of 10-15 cm H2O by experimenters and subjects.
Dependent variables obtained from the second section of
experimental procedures (objective measures) were: (1) Fun-
damental frequency (F0) (Hz) from acoustic signal (from
the repetition of syllable [pa:]), (2) Poral oscillation fre-
quency (Hz) estimated from oral pressure during manual
3
shuttering of the end of the tube submerged in water, (3)
Poral oscillation amplitude (% of deviation) (mean differ-
ence between max. and min. Poral) estimated from oral
pressure during manual shuttering of the end of the tube
submerged in water, (4) Poral oscillation Jitter (% of devia-
tion) (average absolute difference between consecutive peri-
ods, divided by the average period) estimated from oral
pressure during manual shuttering of the end of the tube
submerged in water, and (4) Poral oscillation Shimmer
(% of deviation) (average absolute difference between ampli-
tudes of consecutive periods, divided by the average ampli-
tude) estimated from oral pressure during manual
shuttering of the end of the tube submerged in water.
Aerodynamic data were collected with a Phonatory Aero-
dynamic System (PAS; KayPentax, model 6600, KayPEN-
TAX, Lincoln Park, NJ). All samples were sampled at 22.1
KHz with 16 bits/sample quantization. The Poral was cap-
tured with a pressure transducer (incorporated into the PAS)
connected to a thin flexible plastic tube (13 cm in length).
The tube was inserted into the corner of the mouth, extend-
ing a few millimeters behind the lips, without touching the
tongue or any other oral structure. Calibration of the air
pressure was performed according to the manufacturer’s
instructions. A nose clip was used for all participants during
data collection to avoid air leakage through the nose. Oral
airflow leakage was controlled by one of the experimenters
by placing the hand near participant’s lips during each pho-
natory task. If researchers noticed any leakages, the task was
repeated with a firmer closure at the lips.
Aerodynamic sample analysis
Aerodynamic measures were obtained using a semiauto-
mated procedure. Using a custom Matlab script, a trained-
user estimated the peaks pressure during the consonant /p/
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4 Journal of Voice, Vol. &&, No. &&, 2020

FIGURE 2. Image showing estimation of the peaks pressure. In blue, the raw pressure signal. In black, the average pressure of vowel seg-
ment [a:]. In red (circle), the peak value of pressure during consonant segment /p/.

by targeting (with the mouse cursor) on the recorded pres-
sure waveform in Matlab (Matlab, Mathworks, Natick,
MA) (Figures 2-4). To improve accuracy, a custom algo-
rithm chose the peak pressures from the neighbor points
entered by the user. Between the points mentioned above
(ie, the vowel segment [a:]), the average minimum flow is
estimated for each segment. Voice fundamental frequency
was determined from the power spectral density of the [a:]
segments, choosing the best candidate for the fundamental
frequency and then averaging for each waveform. As the
bubbling frequency is expected to be lower than the voice
fundamental frequency, the voice segments were lowpass fil-
tered at 30 Hz with an eighth order zero-phase Butterworth
filter after windowing (Tukey window with alpha = 0.1) to
avoid termination discontinuities. After this filtering, a peak-
valley detector was used to determine each time-period and
amplitude for the segments. Bubble frequency (in Hz), and
time-amplitude deviations were estimated (in percentage) for

FIGURE 3. Power spectral density (PSD) for the voiced segments. Bubbling frequency and voice fundamental frequency are clearly
showed. Note around voice fundamental frequency that two frequency components appear as evidence of frequency modulation due to
bubbles.
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Marco Guzman, et al How Do Tube Diameter and Vocal Tract Configuration 5

FIGURE 4. Thirty hertz low-pass filtered segment to estimate bubble frequency. Peaks and valleys are illustrated to visualize amplitude
and time variation for each cycle.

both peak and valleys points for each segment and then aver- RESULTS
aging, that is, jitter and shimmer calculations. Repeated measures ANOVA for Poral oscillation frequency
was highly significant: F(5, 195) = 48.42, P ≤ 0.001,
MSE = 1.41, GES = 0.45. Post hoc Tukey contrast revealed
Statistical analysis three distinctly different groups (Table 1): Small tube verti-
Data were analyzed and plotted with statistical software R cal (c), Small tube horizontal (c), Medium tube vertical (b),
(R Core Team 2019, Wickham, 2016). Given the design of Medium tube horizontal (b), Large tube vertical (a), and
the study, 2 £ 3 within factor analysis of variances Large tube horizontal (a). In other words, statistical differ-
(ANOVAs) were first conducted on all dependent variables. ences were driven by tube size, with no effect of tube posi-
Results showed that no interaction terms were significant in tion. Results are plotted in Figure 5.
any tests. Also, no main effects for vocal tract configuration As for Poral oscillation amplitude difference, the con-
were observed for any objective measures. A main effect of ducted repeated measures ANOVA was also significant:
position was, however, observed for visual analogue scale F(5, 195) = 34.55, P ≤ 0.001, MSE = 0.00, GES = 0.32.
(VAS). Given this, one-way repeated measures ANOVAs Post hoc Tukey contrast revealed two different groups
were conducted on each variable of interest comparing the (Table 2): Small tube vertical (a), Small tube horizontal (a),
six possible combinations of the two inspected factors. As Medium tube vertical (b), Medium tube horizontal (b),
will be discussed below, this was done to provide a fine-
grained view of effects on VAS. Whenever Mauchly’s test for
sphericity was significant, corrected P values are reported
TABLE 1.
(either Greenhouse-Geisser or Huynd-Feldt depending on
Post Hoc Tukey Contrast Grouping for Poral Oscillation
epsilon’s value). Generalized ETA Squared (GES) is pro- Frequency
vided as an effect size measure, given the exclusive presence
of repeated measures. GES is to be interpreted as follows: a b c
0.02 small, 0.13 medium, and 0.26 large. Also, since the Small horizontal X
observed independent variable was a within-group factor, Small vertical X
post hoc Tukey contrasts were conducted by fitting multiple Medium horizontal X
mixed-effects models (Maximum Likelihood method) with Medium vertical X
one single predictor nested within subjects. Post hoc contrasts Large horizontal X
are reported based on the Tukey-corrected grouped P values, Large vertical X
considering a 0.05 alpha level.
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6 Journal of Voice, Vol. &&, No. &&, 2020

FIGURE 5. Results from Poral oscillation frequency. Error bars represent 95% CI for the mean of the variable in each condition.

Large tube vertical (b), and Large tube horizontal (b). Repeated measures ANOVA for Poral oscillation
Again, statistical differences were driven by tube size, with shimmer revealed a significant general effect: F(5,
no effect of tube position. Results are plotted in Figure 6. 195) = 61.88, P ≤ 0.001, MSE = 415, GES = 0.56. Post
Repeated measures ANOVA for Poral oscillation jitter hoc Tukey contrast showed two different groups
revealed a significant general effect: F(5, 195) = 55.52, P ≤ (Table 4): Small tube vertical (b), Small tube horizontal
0.001, MSE = 56.2, GES = 0.53. Post hoc Tukey contrast (b), Medium tube vertical (a), Medium tube horizontal
showed two different groups (Table 3): Small tube vertical (a), Large tube vertical (a), and Large tube horizontal
(b), Small tube horizontal (b), Medium tube vertical (a), (b). Statistical differences were found for tube size, but
Medium tube horizontal (a), Large tube vertical (a), and no effect for tube position was observed. Results are
Large tube horizontal (b). Statistical differences were found plotted in Figure 8.
for tube size, but no effect for tube position was observed. Finally, repeated measures ANOVA for VAS (self-per-
Results are plotted in Figure 7. ceived massage-like sensation) was also significant: F(5,
195) = 72.18, P ≤ 0.001, MSE = 251, GES = 0.53. Post hoc
Tukey contrast revealed four groups (Table 5): Small tube
vertical (a), Small tube horizontal (a), Medium tube vertical
TABLE 2. (cd), Medium tube horizontal (b), Large tube vertical (d),
Post Hoc Tukey Contrast Grouping for Poral Oscillation
and Large tube horizontal (bc). Vocal tract position does
Amplitude
generate differences for Medium-size tube and Large size
a b tube. However, tube position has no effect when observing
Small horizontal X small tube. Results are plotted in Figure 9.
Small vertical X
Medium horizontal X
Medium vertical X DISCUSSION
Large horizontal X The present study aimed at observing the effect of tube
Large vertical X diameter and vocal tract configuration on frequency, ampli-
tude, and regularity of Poral oscillation caused by bubbling
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Marco Guzman, et al How Do Tube Diameter and Vocal Tract Configuration 7

FIGURE 6. Results from Poral oscillation amplitude. Error bars represent 95% CI for the mean of the variable in each condition.

during WRT. A secondary purpose was to examine the Effect of tube diameter on bubble frequency and
degree of self-perceived sensation of massage-like effect pro- amplitude
duced by bubbles during WRT. Results seem to support the Findings showed that the greater the tube diameter, the
effect of tube diameter on all air pressure-dependent varia- lower the frequency and the larger the amplitude calculated
bles included in the present study. Significant differences from the oscillation of Poral. In a previous physical model-
were found for Poral oscillation frequency, amplitude, jitter ing study aimed to examine water bubble formation during
and shimmer when comparing the three tube diameters. phonation, similar findings were found regarding the effect
Degree of massage-like sensation was also significantly of tube diameter.9 Authors reported that bubbling fre-
affected by tube diameter. Vocal tract configuration does quency was significantly higher for the 8-mm tube than for
not seem to significantly affect objective air pressure-related the 9-mm tube. Moreover, they also showed that bubble
variables, but only subjective sensation of massage. volumes were smaller for the 8-mm tube than for the 9-mm
tube.9 The Poral is directly affected by the bubble’s charac-
teristics. Thus, the oscillations in the Poral should give a
reliable estimation of the bubble frequency and amplitude.7
Based on that, it is suitable to state that our results are in
line with the abovementioned modeling experiment.9 This
TABLE 3.
Post Hoc Tukey Contrast Grouping for Poral Oscillation
assumption could also be supported by the fact that previ-
Jitter ous findings have also shown higher values of oscillating
component of Poral for larger diameters than for smaller
a b diameters.9 When comparing Horácek et al6 and Granqvist
Small horizontal X et al7 studies, it is possible to observe that in the former
Small vertical X study bubbling frequency was in average 18 Hz, while in the
Medium horizontal X latter study, frequency was about 10-12 Hz. The difference
Medium vertical X might be due to differences in inner diameter of the glass res-
Large horizontal X onance tubes; in Granqvist et al6 study tubes with 9 mm
Large vertical X inner diameter were used, while Horácek et al used tubes
with an inner diameter of 6.8 mm. Tyrmi et al8 compared
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8 Journal of Voice, Vol. &&, No. &&, 2020

FIGURE 7. Results from Poral oscillation jitter. Error bars represent 95% CI for the mean of the variable in each condition.

glass resonance tube (9 mm diameter) and Lax Vox flexible immersion. This may suggest that people tend to lower the
tube (10 mm diameter). The amplitude of Poral oscillation flow rate when Poral rises. Water depth has also been
tended to be higher and the frequency of the oscillation reported to impact on Poral amplitude of oscillation during
tended to be lower with Lax Vox tube. This may be related bubbling. The largest values of Poral oscillation amplitude
to wider tube diameter in Lax Vox tube. This difference has been found to plateau around 5-6 cm H2O and occurred
may corroborate that the oscillation frequency decrease and for water depths of 3-7 cm, suggesting that the oscillating
oscillation amplitude increase with the tube diameter. Poral will not change with greater depths than 3 cm. Wist-
Another factor that could have an impact on bubble fre- backa et al9 have suggested that submersion of the tube end
quency is the depth of immersion. Granqvist et al7 reported deeper than 3 cm will not increase Poral oscillation ampli-
that the bubble frequency decreased with increasing water tude considerably. This is concordant to Guzman et al4 who
depth. Authors estimated bubble frequency from Poral reported that the amplitude of Poral modulation (mean dif-
oscillation, modulation of the glottal area signal, and modu- ference between max. and min. Poral) caused by bubbling
lation of the EGG signal. These results are consistent with did not show significant differences when comparing tube
findings by Tyrmi et al.8 Authors stated that, on average, immersion depths of 3 cm and 10 cm in water. Since water
the frequency of Poral variation is lower with deeper depth has been reported to impact bubble characteristics, it
was not included as an independent variable in the present
TABLE 4. study, but it was controlled during all experiments keeping
Post Hoc Tukey Contrast Grouping for Poral Oscillation it constant at 5 cm below the water surface.
Shimmer
a b Effect of tube diameter on bubble regularity
Small horizontal X Findings from the present study also showed that the greater
Small vertical X the tube diameter, the lower the jitter and shimmer, indicat-
Medium horizontal X ing that a more regular Poral oscillation during bubbling is
Medium vertical X obtained when phonating into a wider tube. No previous
Large horizontal X studies have explored the effect of tube diameter on bubble
Large vertical X regularity (jitter and shimmer). However, bubble regularity
could also be affected by other variables. Granqvist et al7 in
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Marco Guzman, et al How Do Tube Diameter and Vocal Tract Configuration 9

FIGURE 8. Results from Poral oscillation shimmer. Error bars represent 95% CI for the mean of the variable in each condition.

a human study reported that the modulation of the glottal because of high level of bubbling irregularity (chaotic oscil-
area caused by water bubbling is more regular at 2 cm water lation) caused by high airflow.9 The experimental setting of
depth than at greater depths. They suggested that less regu- our study did not allow to directly control airflow rate dur-
lar bubbles are created at deeper depths of immersion. ing phonation. Since airflow rate during voice production is
Earlier modeling studies have reported that bubble regu- dependent on subglottic pressure and glottal airflow resis-
larity is also affected by airflow rate. Davidson and Amick13 tance, an indirect way to control airflow rate throughout the
demonstrated that bubbles at low flows are produced one by different conditions in the present study was to visually con-
one in a periodic manner; at medium flows, the bubbles are trol Psub level by experimenters and subjects using a real-
emitted in pairs, resulting in a mushroom-like shape, and at time software with a target of 10-15 cm H2O. All partici-
high flows, the bubbles are created in a chaotic manner.13 pants were required to keep Psub constant throughout all
Similarly, Wistbacka et al9 showed that the bubble fre- phonatory tasks.
quency increased for higher flow. Experimenters reported
that measure of bubble frequency is sometimes not possible
Effect of vocal tract configuration on Poral-related
variables
Bubble frequency and volume as a function of the back vol-
TABLE 5.
ume was previously explored by Bistbacka et al9 Authors
Post Hoc Tukey Contrast for Self-Perceived Massage-
Like Sensation
used different back volumes in their physical model resem-
bling different human vocal tract volumes caused by differ-
a b cd bc d ent vocal tract configurations. Their results showed that
Small horizontal X lower bubble frequencies are produced at larger back vol-
Small vertical X umes. Furthermore, the bubble volume increased with
Medium horizontal X increasing back volume. In our experimental setting, two
Medium vertical X different vocal tract configurations were produced by all
Large horizontal X subjects: (1) horizontal position (regular vocal tract posi-
Large vertical X tion), (2) vertical position (yawning position with low verti-
cal laryngeal position). The former representing a small
 ARTICLE IN PRESS
10
FIGURE 9. Results from degree of massage-like sensation. Error bars represent 95% CI for the mean of the variable in each condition.
back volume and the latter a large back volume as was pre-
sented in Wistbacka et al study.9 Outcomes showed that
vocal tract configuration (horizontal or vertical) as an inde-
pendent variable does not have a statistical significant effect
on Poral oscillation variables. However, vertical position
tended to produce lower Poral oscillation frequency and
more regular bubbles (lower jitter and shimmer).
Effect of tube diameter and vocal tract configuration
on degree of massage-like sensation
Regarding the self-perceived degree of massage-like sensa-
tion, interesting results were also shown. Larger tube diame-
ters produced a significantly greater massage-like sensation
felt by participants. Therefore, it seems that a more regular
Poral oscillation (low jitter and shimmer), a lower frequency
and a larger amplitude produce a more intense massage-like
sensation when performing WRT. In a recent study aimed
to compare glass resonance tube and Lax Vox, it was sug-
gested that a higher Poral oscillation of Lax Vox could pro-
mote a more effective massage-like effect when doing
WRT.8 This could be attributed to the fact that the ampli-
tude of Poral oscillation tended to be higher with Lax Vox
tube (10 mm diameter) compared to resonance tube (9 mm
diameter). Furthermore, findings from the present study
revealed that vertical vocal tract configuration produced a
significantly higher degree of massage-like sensation
Journal of Voice, Vol. &&, No. &&, 2020
compared to horizontal vocal tract shape (regular shape)
for medium and large tube diameters. No prior studies have
explored the effect of vocal tract configuration of massage-
like sensation. Nevertheless, it is likely that conditions pro-
moting a lower bubble frequency, a greater bubble ampli-
tude, and a more regular bubbling (eg, large tube diameter
and vocal tract volume) are the main cause of a greater mas-
sage-like sensation. The vertical vocal tract configuration
(used in our study) could be comparable to the large back
cavity volume used in the Wistbacka et al modeling study.9
As mentioned above, significant lower bubble frequency
and larger bubble volumes were found with increasing back
volume.
Although the oscillating component of Poral has earlier
been referred to as providing the massage-like effect, there
is little evidence showing that Poral oscillation is really
capable to produce laryngeal and/or pharyngeal tissue
mobilization. In a recent high-speed digital imaging study,
Laukkanen et al14 demonstrated that the Poral oscillation
created during water bubbling was also reflected in the
movement of laryngeal tissues. They also observed that the
amplitude of the bubbling-induced vibration of the larynx is
higher than that caused by the fundamental frequency of
phonation. Moreover, there are some studies showing indi-
rectly this effect on tissues. Oscillation of Poral has been
demonstrated to affects the glottal area and fundamental
frequency.7 The vocal fold oscillations are highly influenced
 ARTICLE IN PRESS
Marco Guzman, et al How Do Tube Diameter and Vocal Tract Configuration
by the glottal airflow, which in turn, depends on the trans-
glottal pressure. If the subglottal pressure is reasonably con-
stant, any fluctuation in Poral will directly influence the
transglottal pressure and hence the vocal fold vibration.
Comparable findings were presented by Enflo et al.1 They
reported modulations in the audio and EGG time-derivative
signals during water bubbling.
Practical implications
Considering that our results showed higher degree of mas-
sage-like sensation when phonating into wider tube diame-
ters and when using larger vocal tract volumes, it is likely
that subjects with voice complaints (including high degree
of muscle tension and/or symptoms of vocal fatigue) could
benefit more when using larger tube diameters and vertical
position of the vocal tract. Physically, this effect seems to be
attributed to more regular bubbling, low frequency and
large amplitude of bubbles.
CONCLUSION
Inner diameter of tube and configuration of vocal tract
affect bubble characteristics and massage-like sensation dur-
ing WRT. Larger tube diameters and vocal tract volumes
seem to produce more regular bubbles, lower bubble fre-
quency, and larger bubble amplitude, causing a more evi-
dent massage-like sensation. Therefore, control of these
variables is apparently relevant to obtain the best effect in
patients with voice disorders.
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