Original Paper

Folia Phoniatr Logop 2015;67:68–75 Published online: September 23, 2015

DOI: 10.1159/000437353

Do Different Semi-Occluded Voice Exercises Affect

Vocal Fold Adduction Differently in Subjects
Diagnosed with Hyperfunctional Dysphonia?
Marco Guzman a, b Carlos Calvache e, f Luis Romero a Daniel Muñoz c
Christian Olavarria d Sofia Madrid a Miguel Leiva d Cori Bortnem a
a
Department of Communication Sciences, University of Chile, b Voice Center, Las Condes Clinic, c Department of
Network Management, Barros Luco-Trudeau Hospital, and d University of Chile Hospital, Santiago, Chile;
e
Department of Communication Sciences, Universidad del Rosario, and f Department of Communication Sciences,
Corporación Universitaria Iberoamericana, Bogotá, Colombia

Key Words be recommended for decreasing glottal adduction. A straw

Semi-occluded vocal tract exercises · Tube phonation · submerged 10 cm below the water surface presented the
Voice therapy · Vocal fold adduction · Electroglottography · greatest CQ. A shallower depth led to a lower CQ, while
Contact quotient deeper submersion produced a higher CQ.
© 2015 S. Karger AG, Basel

Abstract
Objective: To observe the possible differential effects of 8
different semi-occluded vocal tract exercises on glottal con-
tact quotient (CQ) as a measure of vocal fold impact stress.
Patients and Methods: Eighty participants were divided into
two groups: an experimental group with hyperfunctional
dysphonia and a control group of vocally healthy subjects.
The participants were recorded before, during and after the
exercises. Electroglottographic samples were analyzed to
obtain CQ. Results: For the experimental group, all exercises,
except lip trills and tongue trills, had an overall significant
effect when conditions before, during and after the exercises
were compared. The CQ presented differently across the 8
semi-occluded postures during exercise for both groups. For
the experimental group, most exercises increased the CQ
during practice. Only lip and tongue trills demonstrated low-
er CQ during exercise. Conclusions: Different semi-occluded
exercises differentially affect vocal fold adduction. Lip and
tongue trills produced the lowest CQ. Therefore, they may
Introduction
Glottal contact quotient (CQ) is a quantitative param-
eter that can be obtained by electroglottography (EGG).
It is defined as the ratio of the duration of the contact
phase to the entire glottal cycle period [1, 2]. Earlier in-
vestigations support a possible association between EGG
CQ and the degree of vocal fold impact stress. Verdolini
et al. [3] conducted a study to observe the possible use of
the EGG CQ as a noninvasive method for estimating vo-
cal fold impact stress. The authors suggested that EGG
CQ strongly correlates with the degree of glottal impact
stress [3]. When the impact stress increases (stronger col-
lision during vibration), the vocal folds also tend to stay
together for longer intervals, thus increasing the CQ [3].
The CQ has also been reported to distinguish some modes
of phonation, e.g. resonant voice from pressed voice [4].
Moreover, Laukkanen et al. [5] presented a noninvasive
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© 2015 S. Karger AG, Basel Marco Guzman

1021–7762/15/0672–0068$39.50/0 Department of Communication Sciences
University of Chile
Gazi Üniversitesi
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E-Mail karger@karger.com
Av. Independencia 1027, Santiago (Chile)
www.karger.com/fpl
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measurement based on EGG CQ to quantify the cost of
voice production in terms of impact stress, the quasi-out-
put-cost ratio, defined as (sound pressure level/CQ from
EGG signal) × [period length (T)/T0]. This measure cor-
related inversely with CQ. The measure should therefore
reflect voice production-related mechanical vocal load-
ing [5].
Regarding vocal fold impact stress, it has been pro-
posed that a barely abducted or a barely adducted laryn-
geal configuration may be favorable in order to produce
a resonant voice (healthy voice production) [4]. This la-
ryngeal configuration has been proposed to produce
maximum vocal economy, defined as the maximized ra-
tio between voice output (in dB) and intraglottal impact
stress (measured in kPa) under constant subglottic pres-
sure and frequency conditions [6]. A previous study dem-
onstrated that vocally healthy subjects produced a reso-
nant voice with barely abducted or barely adducted vocal
folds, thus in a configuration within the range of those
producing maximum vocal economy [7]. Therefore, vo-
cal economy can be optimized as a function of glottal
width, and the barely abducted laryngeal configuration
could be a general target relevant for both subjects with
glottal hyperfunction and those with glottal hypofunc-
tion [6].
In the voice clinic, the degree of a patient’s impact
stress during phonation is one of the most relevant topics.
The softer tissues of the lamina propria are the structures
most likely to absorb a majority of the impact stress dur-
ing vocal fold vibration. Additionally, impact stress is the
main vocal loading and traumatizing factor during voice
production. In fact, impact stress is the main cause of vo-
cal fold nodules and other phonotraumatic lesions of the
superficial lamina propria [8, 9]. Vocal fold nodules are
considered to be a consequence of vocal trauma and,
more specifically, a tissue reaction to repeated localized
mechanical stress to vocal tissues [9, 10].
Due to the importance of vocal fold adduction in voice
production and voice rehabilitation, clinicians often in-
clude exercises or strategies which control this variable by
modifying the degree of impact stress during phonation.
This modification is usually dependent on a combination
of laryngeal muscle behavior, breathing function and res-
onance. Semi-occluded vocal tract postures are voice ex-
ercises that have been investigated and used in voice clin-
ics to affect vocal fold vibration and to change the pattern
of voice production. Some studies have reported a change
in CQ when semi-occlusion is compared to vowel phona-
tion [11–21]. Unfortunately, most studies investigating
the effects of semi-occlusion on CQ have small sample
Effect of Semi-Occluded Exercises on
Contact Quotient
sizes and have failed to produce clear effects. Some studies
have found decreased CQ during and after semi-occluded
exercises, while others have reported an increase.
The present study aimed to observe the possible dif-
ferential effects of 8 semi-occluded vocal tract exercises
on glottal CQ. Specifically, we attempted to answer two
questions: (1) Is there any influence of semi-occlusions
on vocal fold adduction that can be determined using CQ
values derived from electroglottographic signals? (2) Do
different semi-occluded voice exercises affect vocal fold
adduction differently? Based on previous data and clini-
cal observations, we hypothesized that semi-occlusions
with high degrees of airflow resistance (e.g. tube in the
water) should increase the degree of vocal fold adduction
(thus, impact stress), while semi-occlusions with low air-
flow resistance may produce a decrease in the degree of
adduction. In addition, the possible effect of semi-occlu-
sions during exercise may not necessarily be maintained
in post-exercise phonation. Different effects of semi-oc-
clusions were also expected when comparing normal and
dysphonic subjects.
Patients and Methods
Participants
Eighty participants were included in this study. They were di-
vided into two groups: an experimental group of subjects diag-
nosed with mild hyperfunctional dysphonia (n = 40; mean age 28
years, range 20–49) and a control group of vocally healthy subjects
(n = 40; mean age 27 years, range 22–47). Both groups were equal-
ly divided by gender. Inclusion criteria for the experimental group
included: (1) age range of 20–50 years and (2) laryngoscopic diag-
nosis of mild hyperfunctional dysphonia. Inclusion criteria for the
control group included: (1) the same age range as the experimental
group and (2) no current or past history of voice disorders. Par-
ticipants from both groups were native speakers of Spanish; no
vocally trained subjects were included.
Several definitions of laryngeal hyperfunction exist, but a re-
current feature in almost all descriptions is excessive laryngeal
musculoskeletal activity, force or tension [22]. The basic paradigm
for the evaluation of laryngeal hyperfunction is to look for com-
pression of the glottis and supraglottic structures during phona-
tion [23]. In the present study, the diagnosis of hyperfunctional
dysphonia was made based on this description. Furthermore, all
participants from the experimental group reported voice problems
for at least 1 year.
This study was reviewed and approved by the University of
Chile Faculty of Medicine Review Board and by the Ibero-Ameri-
can University. Informed consent was obtained from all partici-
pants.
Phonatory Tasks
Prior to electroglottographic assessment, all participants were
asked to undergo rigid videostroboscopy to confirm the diagnosis
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of mild hyperfunctional dysphonia (experimental group) or the
absence of laryngeal pathology (control group). Endoscopic laryn-
geal examinations were performed by 3 experienced laryngolo-
gists. No topical anesthesia was used during the endoscopic proce-
dures.
The participants were required to randomly select and produce
a series of 3 semi-occluded vocal tract exercises from a list of 8 ex-
ercises: (1) straw phonation (5 mm of inner diameter and 25.8 cm
in length), (2) straw submerged 3 cm below the water surface, (3)
straw submerged 10 cm below the water surface, (4) lip trills, (5)
tongue trills, (6) Y-buzz, (7) hand over mouth, and (8) sustained
consonant [m:]. These specific exercises were chosen for compar-
ison with previous studies. The same straws were used in the sub-
mersion and air exercises. Y-buzz is described as a sound combina-
tion of the consonant [y:] as in the word ‘yonder’ and the vowel [i:]
as in the word ‘easy’. Before performing the experiment, the par-
ticipants received general instructions about the experimental pro-
cedures and how to perform the exercises. During the exercises,
the participants were asked to feel easy phonation and vibrations
in the front part of the face and alveolar ridge. Feedback was pro-
vided by the experimenters about these sensations. All exercises
were demonstrated to the participants before data collection by
trained speech-language pathologists, who were also experiment-
ers in the present study. To standardize the demonstrations of the
exercises, all experimenters participated in a 3-hour training ses-
sion. Each semi-occluded exercise was asked to be produced for 5
min. A 20-min voice rest was taken between exercises by all sub-
jects. No voice rest time was considered between 3 time points (e.g.
between phonation before and during exercise).
The participants were recorded 3 times (before, during and af-
ter vocal exercises). A sustained vowel /a/ was produced before and
after the semi-occluded exercises. Three repetitions were per-
formed for each time point (before, during and after). This result-
ed in a total sample number of 2,160 (80 subjects × 3 semi-occlud-
ed exercises × 3 time points × 3 repetitions). The subjects were
asked to phonate at a comfortable pitch and vocal loudness in all
phonatory tasks. They were asked to produce the same comfort-
able pitch produced in the first sequence for all trials. An electron-
ic keyboard was used to control the pitch, which was monitored
perceptually by the experimenters. Each recording session was
completed in approximately 1 h.
Equipment
EGG data were obtained with a 2-channel electroglottograph
(EG2; Glottal Enterprises, Syracuse, N.Y., USA) using a 20-Hz
high-pass filter (to exclude slow variations in the signal amplitude,
which could be due to articulatory movements of the larynx). Sam-
ples were recorded digitally in WAV files at a sampling rate of 44
kHz with 16 bits/sample quantization.
At the beginning of the examination, the participants were
asked to comfortably sit upright in a chair. Two surface electrodes
were attached over the thyroid cartilage by means of a lightweight
elastic band. The electrodes were attached with a Velcro strip,
wrapped comfortably around the participant’s neck – but as tight-
ly as possible to prevent movement of the electrodes throughout
the data collection. Readjustments of the elastic band and elec-
trodes were necessary in some participants until the EGG signal
was properly captured. The electrodes were cleaned with a slightly
wet tissue, and a thin layer of conductive gel was applied (Spectral
360 electrode gel; Parker Laboratories, Fairfield, N.J., USA).
70 Folia Phoniatr Logop 2015;67:68–75
DOI: 10.1159/000437353
Each electroglottographic sample captured before, during and
after an exercise was analyzed to obtain the glottal CQ. The EGG
CQ (the ratio of the duration of the contact phase to the entire glot-
tal period) was obtained with the software PhaseComp version
1.3.2 (Glottal Enterprises) from the middle section of each overall
EGG sample taken before and after exercises (each 3–5 s in length).
In the samples obtained during exercises, calculation of the CQ
value was performed at the beginning and in the middle and final
sections (each 3–5 s in length). A criterion level of 35% from the
peak-to-peak amplitude of the EGG signal was used.
Statistical Analysis
Numerical variables were described by means and SD, while
categorical variables were described as frequencies and percent-
ages and compared using the Kruskal-Wallis test. A generalized
linear model to observe the joint influence of the presence or ab-
sence of dysphonia, according to each phonatory exercise, was fit-
ted. All analyses were performed using Stata® 13.1 (StataCorp,
College Station, Tex., USA); p < 0.05 was considered to be statisti-
cally significant, and all reported p values are two-sided.
Results
Because each subject selected 3 of the 8 possible exer-
cises, the number of participants that produced each vo-
cal exercise varied. The distribution of choices was as fol-
lows: straw phonation (n = 24), straw 3 cm into the water
(n = 37), straw 10 cm into the water (n = 24), lip trills
(n = 31), tongue trills (n = 29), Y-buzz (n = 24), hand over
mouth (n = 43) and sustained consonant [m:] (n = 31).
Figure 1 shows a general comparison of CQ across the
3 time points (including experimental and control
groups) for the 8 semi-occluded exercises. Tables 1 and
2 report mean CQ values for each semi-occluded exercise
by time point for the experimental and the control group,
respectively. p values indicate for the experimental group
that all exercises except lip trills and tongue trills had sig-
nificant effects across time points (table 1; χ2 values for
rows). For the control group, only straw into the water
(3 and 10 cm) and the hand-over-mouth technique dem-
onstrated a significant overall effect across time points
(table 2).
Moreover, during the exercises, CQ presented differ-
ently between the 8 semi-occluded exercises for both the
experimental and the control group. For the experimental
group, most exercises (excepting lip trills and tongue
trills) increased the CQ. For the control group, 4 exer-
cises (straw phonation, lip trills, tongue trills and sus-
tained consonant [m:] production) decreased the CQ
compared to before exercising. The rest of the semi-oc-
clusions demonstrated increased CQ compared to before
exercising.
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 Color version available online
60

55

Mean CQ
50

45

40

Before During After

Straw phonation Straw into the water (3 cm)

Straw into the water (10 cm) Lip trills

Fig. 1. General comparison between CQ Tongue trills Y-buzz

averages by semi-occluded exercise and Hand over mouth Humming
time point.

Table 1. Comparison between CQ averages by semi-occluded exercise and time point for the experimental group

Before exercise During exercise After exercise χ2; p value*

Straw phonation 48.32 ± 10.86 60.27 ± 14.76 43.75 ± 8.13 21.34; 0.0220
Straw into the water (3 cm) 47.93 ± 5.5 54.03 ± 7.72 47.49 ± 7.11 33.10; 0.0005
Straw into the water (10 cm) 48.41 ± 5.66 61.01 ± 11.17 47.83 ± 9.91 32.98; 0.0006
Lip trills 48.70 ± 6.70 46.03 ± 9.56 45.93 ± 6.92 3.41; 0.2989
Tongue trills 45.54 ± 7.71 41.59 ± 3.88 45.37 ± 5.89 11.55; 0.1269
Y-buzz 48.58 ± 7.14 56.71 ± 10.91 49.99 ± 8.36 19.75; 0.015
Hand over mouth 47.84 ± 6.08 52.80 ± 9.08 49.11 ± 10.70 24.42; 0.0098
Sustained consonant [m:] 45.98 ± 5.94 52.41 ± 7.72 45.64 ± 10.33 27.59; 0.0062
χ2; p value* 2.66; 0.91462 29.75; 0.00011 4.49; 0.72151

Values represent means ± SD. * Kruskal-Wallis test.

Table 2. Comparison between CQ averages by semi-occluded exercise and time point for the control group

Before exercise During exercise After exercise χ2; p value*

Straw phonation 46.43 ± 5.18 43.96 ± 9.98 42.31 ± 5.01 10.65; 0.2663
Straw into the water (3 cm) 47.09 ± 4.47 50.21 ± 8.41 44.92 ± 6.01 36.92; 0.0053
Straw into the water (10 cm) 46.74 ± 6.20 54.70 ± 7.06 46.51 ± 7.96 38.71; 0.0002
Lip trills 48.65 ± 5.36 44.58 ± 6.84 47.16 ± 6.41 9.98; 0.1345
Tongue trills 47.85 ± 5.34 43.18 ± 8.29 41.88 ± 5.77 4.18; 0.4726
Y-buzz 45.98 ± 6.37 47.47 ± 11.26 45.55 ± 7.09 5.13; 0.4956
Hand over mouth 45.70 ± 6.79 47.96 ± 7.13 45.03 ± 7.18 31.87; 0.0335
Sustained consonant [m:] 49.07 ± 8.02 47.43 ± 7.32 47.53 ± 7.48 4.45; 0.5317
χ2; p value* 2.009; 0.95932 42.95; 0.0001 10.15; 0.1796

Values represent means ± SD. * Kruskal-Wallis test.

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Effect of Semi-Occluded Exercises on Folia Phoniatr Logop 2015;67:68–75 71

Contact Quotient DOI: 10.1159/000437353
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 Color version available online
Phonatory task
Straw phonation
Straw into the water (3 cm)
Straw into the water (10 cm)
Lip trills
Tongue trills
Y-buzz
Hand over mouth
Humming

Voice status
Normal voice
Fig. 2. Multivariate linear regression model Dysphonic voice
including CQ as the outcome and semi-oc-
0 10 20 30 40 50
cluded exercise and voice condition as pre- Regression coefficients
dictive variables.

Table 3. Multivariate linear regression model including CQ as the outcome and semi-occluded exercise and voice
condition as predictive variables

Coefficient (95% CI) SE t p value

Phonatory task
Straw phonation reference
Straw into the water (3 cm) 35.46 (29.39 – 41.54) 3.08 11.51 <0.001
Straw into the water (10 cm) 39.31 (31.55 – 47.07) 3.93 9.98 <0.001
Lip trills 28.88 (22.34 – 35.43) 3.31 8.70 <0.001
Tongue trills 28.38 (20.30 – 36.46) 4.10 6.92 <0.001
Y-buzz 32.58 (23.20 – 41.96) 4.76 6.84 <0.001
Hand over mouth 34.43 (28.02 – 40.84) 3.25 10.59 <0.001
Sustained consonant [m:] 35.51 (28.55 – 42.47) 3.53 10.06 <0.001
Voice status
Dysphonic voice 16.12 (11.88 – 20.37) 2.15 7.48 <0.001

Results from a multivariate linear regression model Discussion

including CQ as the outcome measure and semi-occlud-
ed exercise and voice status as predictive variables are
presented in table 3 and figure 2. Only scores during ex-
ercises were considered in this analysis, due to the ab-
sence of significant differences between pre- and post-
phonation values. Considering phonatory tasks, straw
phonation was taken as a reference point. All semi-oc-
cluded exercises produced a significant difference in CQ
compared to the reference point. Straw submerged 10 cm
below the water surface produced the highest value for
CQ, while tongue trills had the lowest value. Further-
more, participants diagnosed with hyperfunctional dys-
phonia evidenced a greater CQ than vocally healthy sub-
jects.
Only one previous study has explored the effect of a
large number of semi-occluded postures on CQ [21]. This
study compared CQ between comfortable vowel phona-
tion before and during exercise. Nevertheless, the CQ af-
ter practice was not measured. The present investigation
compared the effect of 8 semi-occluded vocal exercises on
CQ, including both dysphonic and healthy subjects (n =
80 in total), and also compared conditions before, during
and after exercise.
The results revealed that the CQ outcome changed
during phonation depending on the semi-occluded exer-
cise used. Four exercises increased the CQ (straw sub-
merged 3 cm below the water surface, straw submerged
10 cm below the water surface, Y-buzz and hand over
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mouth) for both groups. Only lip trills and tongue trills
decreased the CQ during exercise compared to vowel
phonation for both groups. In fact, these two exercises
demonstrated the lowest CQ. However, they did not show
significance. Andrade et al. [21] found that lip trills and
tongue trills produced the lowest CQ when compared to
the other semi-occluded postures. Gaskill and Erickson
[13] also found a decrease in CQ during phonation with
lip trills. The authors explained that in order to sustain
simultaneous vibration of the lips and vocal folds, the
amount of vocal fold adduction should be reduced to
have sufficient air flow. When there is a high glottal ad-
duction, vibration of the lips is harder or even not possi-
ble due to the low glottal airflow [13]. Hence, exercises
such as lip trills or tongue trills may be appropriate when
vocal fold adduction is needed to be low (e.g. in patients
with hyperadduction). A decrease in vocal fold adduction
should cause a decrease in EGG CQ. Blowing a raspberry
could also produce a similar effect on CQ, since it involves
tongue and lip trills at the same time. Additionally, Ham-
dan et al. [18] explored the impact of Mediterranean
tongue trills on CQ. A decrease during exercise compared
to sustained vowel phonation was found. Only one previ-
ous study has shown different data [17]. The CQ was
greater during lip trills when the voice was produced at
high intensity. However, since an increment in subglottic
pressure and glottal adduction is required to produce a
high vocal intensity, it may be expected that the CQ would
increase even while lip trills are being produced. Even
though our data only show a trend toward a decreased CQ
during lip and tongue trills, based on previous data it
seems that these 2 exercises could be useful when the ther-
apy’s target is decreased glottal adduction.
One of the most frequently used semi-occluded exer-
cises in the voice clinic is tube phonation with the free end
in the air. For this exercise, the present study demonstrat-
ed a significant increase in CQ during exercising for par-
ticipants with hyperfunctional dysphonia, but no signifi-
cant change for vocally healthy subjects. No earlier inves-
tigations have explored CQ in dysphonic subjects during
semi-occlusion. Most studies performed on vocally
healthy subjects have shown a decrease in CQ during tube
phonation into the air [11, 12, 15, 16, 19, 20]. Gaskill and
Erickson [15] and Gaskill and Quinney [16] stated that
the CQ tends to be lower with tube phonation compared
to vowel production. Titze et al. [11] and Bickley et al. [12]
reported similar findings in their EGG studies using reso-
nance tubes. Moreover, Guzman et al. [20] found that the
CQ decreased using different types of tube. These inves-
tigations were carried out in vocally trained people,
Effect of Semi-Occluded Exercises on
Contact Quotient
whereas in the present study no trained participants were
included. Perhaps vocal training status is a determinant
variable that should be considered. Furthermore, it is pos-
sible that the degree of glottal adduction during tube pho-
nation is also dependent on individual compensatory ad-
justments.
Our data show for both groups that the highest value
of CQ was obtained with a straw submerged 10 cm below
the water surface. This type of vocal exercise is common-
ly called ‘water resistance therapy’ [24]. In a high-speed
digital imaging study designed to explore the influence of
tube phonation into the water on vocal fold vibration,
Guzman et al. [25] suggested that the deeper the immer-
sion, the greater the CQ. Similarly, Radolf et al. [26] com-
pared EGG CQ between phonation into a resonance tube
with the outer end in the air, a tube submerged 2 cm be-
low the water surface and a tube submerged 10 cm below
the water surface and phonation into a very thin straw.
The outcomes showed that the CQ was highest when a
tube was submerged 10 cm below the water surface. It
seems that the degree of flow resistance, specifically the
depth of immersion, played an important role in glottal
adduction. A shallower depth tended to lead to a lower
CQ, while deeper submersion tended to result in a higher
CQ. Likewise, when the supraglottic load increased, a
higher subglottic pressure and a compensatory glottal ad-
duction were produced, no matter what the vocal status
of the participants was. To date, only one study has re-
ported opposing results [27]. Practical applications could
arise from our findings regarding water depth and glottal
adduction. Possibly, for subjects with low glottal adduc-
tion or a considerable glottal gap, such as those with vocal
fold paralysis or with presbyphonia, deeper immersion
may help to improve glottal function. Similar practical
recommendations for voice therapy were made by Sovi-
järvi et al. [28] and Sovijärvi [29].
It has been proposed that semi-occluded exercises can
be divided into two different groups depending on wheth-
er they have one or two sources of vibration [21]. The
primary source of vibration in all cases is vocal fold oscil-
lation. The added, secondary source of vibration may be
lip vibration, tongue vibration or water bubbling. The
changes in intraoral pressure required by these exercises
could cause a massage-like effect in laryngeal and pharyn-
geal tissues [21]. Therefore, exercises such as lip trills,
tongue trills, phonation in water and blowing raspberries
may be useful for patients with high muscle tension not
only because the CQ is lowered (as demonstrated in ear-
lier studies), but also because of the massage-like effect.
Enflo et al. [30] reported that during phonation into the
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resonance tube in water, variation of oral pressure modi-
fies the transglottal pressure (which drives the vocal
folds), and this, in turn, causes changes in the EGG sig-
nal amplitude. In a high-speed and electroglottographic
study, a modulation effect on vocal fold vibration when
producing bubbles was also observed [27].
Regarding the CQ obtained after semi-occluded exer-
cises, not all exercises maintained the direction of change
compared to the CQ during exercising. No clear pattern
was observed for either group of participants. Few of the
earlier studies have considered measurements of CQ after
semi-occlusion [15, 16, 20, 28]. Gaskill and Erickson [15]
and Gaskill and Quinney [16] reported no significant
changes when comparing samples before and after exer-
cise. In a single-case study, Guzman et al. [20] found a
decreased CQ compared to the baseline condition. In an
investigation to describe changes in aerodynamic and
electroglottographic measures, Dargin and Searl [31]
found that, in general, EGG CQ tended to increase after
practicing. Overall, the studies more clearly support the
change in CQ during semi-occluded exercises, but not
after practicing. More studies are needed to identify any
pattern in CQ change after exercise.
Conclusions
Various semi-occluded vocal tract exercises have dif-
ferent effects on vocal fold adduction as measured by elec-
troglottographic CQ during exercise in both participants
with hyperfunctional dysphonia and in vocally healthy in-
dividuals. After exercise, the results produced no clear
patterns. Lip trills and tongue trills generated the lowest
CQ; therefore, they may be recommended to decrease
glottal adduction during practicing. A straw submerged
10 cm below the water surface presented the greatest CQ.
A shallower depth tends to lead to a lower CQ, while deep-
er submersion tends to produce a higher CQ. Thus, for
subjects with low glottal adduction, e.g. patients with vo-
cal fold paralysis or presbyphonia, deeper immersion may
help improve glottal function. Furthermore, similar be-
havior occurs in dysphonic and normal subjects regarding
differential effects of the various semi-occluded exercises.
Acknowledgments
This study was supported by the Comité de Ciencia y Tec-
nología de la Corporación Universitaria Iberoamericana (grant
No. 1533). Special thanks are due to Karen Gonzalez Gutierrez,
Gina Pacheco Urrego, Alexa Salinas and Luis Miguel Galdino.

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Erratum

In the paper by Guzman et al., entitled ‘Do different semi-occluded voice exercises affect
vocal fold adduction differently in subjects diagnosed with hyperfunctional dysphonia’
[Folia Phoniatr Logop 2015;67:68–75, DOI:10.1159/000437353], a co-author was omitted.
The correct listing is as follows:

M. Guzmana, b C. Calvachee, f L. Romeroa D. Muñozc C. Olavarriad S. Madrida

M. Leivad C. Bortnema J. Pinoa
aDepartment of Communication Sciences, University of Chile, bVoice Center, Las Condes Clinic, cDepartment
of Network Management, Barros Luco-Trudeau Hospital, and dUniversity of Chile Hospital, Santiago, Chile;
eDepartment of Communication Sciences, Universidad del Rosario, and fDepartment of Communication Sciences,

Corporación Universitaria Iberoamericana, Bogotá, Colombia

149.126.78.49 - 2/13/2016 7:44:53 AM

Effect of Semi-Occluded Exercises on Folia Phoniatr Logop 2015;67:68–75 75

Contact Quotient DOI: 10.1159/000437353
Gazi Üniversitesi
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