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Maximum Phonation Time and s/z Ratio in a Large Child Cohort

Article in Journal of voice: official journal of the Voice Foundation · June 2012
DOI: 10.1016/j.jvoice.2012.03.001 · Source: PubMed

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Maximum Phonation Time and s/z Ratio in a Large
Child Cohort
*Elaine Lara Mendes Tavares, †Alcione G. Brasolotto, ‡Se
rgio A. Rodrigues, *Adriana Bueno Benito Pessin,
and *Regina Helena Garcia Martins, *yzS~ao Paulo, Brazil

Summary: Aim. The purpose of this study was to provide normal values for maximum phonation time (MPT) and the
s/z ratio by examining 1660 children aged 4–12 years and without vocal signs or symptoms.
Methods. The technique was based on the sustained emission of the /a/ vowel and fricatives /s/ and /z/.
Results. The average of the MPT in children of the different age groups was as follows: 6.09 seconds for the age group
4–6 years (males, 5.97; female, 6.21 seconds), 7.94 seconds for the age group 7–9 years (males, 8.07; females, 7.79 sec-
onds), and 8.98 for the age group 10–12 years (males, 9.05; females, 8.92 seconds). The overall average for males was
7.78 and females 7.64 seconds. The s/z ratio was near 1.0 in most children but above 1.2 in 133 children and below 0.8 in
133 children.
Conclusion. These values of MPT and s/z ratio can be used as normative in further pediatric studies.
Key Words: Maximum phonation time–s/z ratio–Child–Voice.

INTRODUCTION 6.79–11.11 seconds for males between 3 and 4 years and

The maximum phonation time (MPT) is the capacity of individ-
uals to control the aerodynamic, respiratory, and myoelastic
forces of the larynx during phonation.1–3 MPT represents the
maximum time that an individual can sustain the sound during
only one deep breath. Its measure is presumed to provide
a rough indication of respiratory support and phonatory
function. It is a noninvasive, fast, and an objective method.2,4
The values of the MPT vary according to age and gender, due
to the individual differences in the respiratory parameters and
phonatory control.5,6
The s/z ratio evaluates the time of vocal emission with or
without vibration of the larynx and can indicate lesions or dam-
ages in vocal folds.3,4 During the voiceless /s/ emission, the
control of respiratory support can be analyzed. On the other
hand, we can notice the condition of glottic closure4 during
the voiced /z/ emission. In individuals with normal voices, the
s/z ratio is near 1.0.3
The MPT values and s/z ratio are generally obtained during
a sustained emission of the vowel /a/, the fricatives /s/ and /z/,
and counting numbers.4,5 According to some authors, the
values of MPT increase as a function of age.5,6 Nevertheless,
some authors have registered very high values of MPT in
children. Beber et al7 considered as normal standards the MPT
between 9.28 and 20.59 seconds for males until 13 years and
8.7 and 20.15 seconds for females until 12 years. The authors
registered narrower age range of MPT during the emission of
the fricatives /s/ and /z/ (11.65 and 16.5 seconds for males;
10.75 and 15.14 seconds for females). Colton et al1 found out
Accepted for publication March 16, 2012.
From the *Department of Ophthalmology, Otorhinolaryngology and Head and Neck
Surgery, Botucatu Medical School, S~ao Paulo State University, S~ao Paulo, Brazil;
yDepartment of Speech-Language Pathology and Audiology, Bauru School of Dentistry,
University of S~ao Paulo, Bauru, S~ao Paulo, Brazil; and the zDepartment of Biostatistics,
Institute of Biosciences, S~ao Paulo State University, S~ao Paulo, Brazil.
Address correspondence and reprint requests to Regina Helena Garcia Martins, Disci-
plina de Otorrinolaringologia, Departamento de Oftalmologia, Otorrinolaringologia e
Cirurgia de Cabeça e Pescoço, Faculdade de Medicina de Botucatu, Distrito de Rubi~ao
Junior s/n, Botucatu, S~ao Paulo 18618-970, Brazil. E-mail: rmartins@fmb.unesp.br
Journal of Voice, Vol. 26, No. 5, pp. 675.e1-675.e4
0892-1997/$36.00
Ó 2012 The Voice Foundation
doi:10.1016/j.jvoice.2012.03.001
13.60–21.88 seconds for males between 5 and 12 years. Among
females, the authors recorded 5.70–9.30 seconds between 3 and
4 years and 11.20–18.84 seconds for 5–12 years.
Patients with laryngeal pathologies show a significantly poorer
phonation time than normal speakers because of the decrease
in glottal resistance. MPT is inversely related to the severity of
the vocal disorders and the degree of vocal fold adduction or
respiratory impairment.7,8 MPT has been used as an indicator
of vocal fold function. Some authors have examined MPT
before and after successful voice therapy.3 In children, these
values are controversial among the authors, and there is not a stan-
dard method to obtain the answers.
The purpose of the present study was to determine the MPT
values and s/z ratio among a large group of children with nor-
mal voice.
METHODS
The parents of 2000 children aged between 4 and 12 years
(4:0–6:11; 7:0–9:11; 10:0–12:0) and attending eight public
schools in Botucatu answered a questionnaire about their chil-
dren’s vocal quality and symptoms. Only children without
vocal signs or symptoms and normal auditory perceptive vocal
analysis were included in the study, totaling 1660 children. The
research was approved by the Human Research Ethics Commit-
tee of Botucatu Medical School (UNESP) (number 2136/2006).
All children were submitted to the vocal perceptive analysis,
which were carried out using GRBASI scale and applied by
three speech therapist experts in voice. The GRBASI scale
covers six parameters: G (Grade), R (Roughness), B (Breathi-
ness), A (Asthenia), S (Strain), and I (Instability). The tech-
nique was based on the sustained emission of the /a/ vowel
and fricatives /s/ and /z/. All children with vocal score above
1 to the parameter G from GRBASI scale were excluded from
the present study.
The MPT data were recorded in a quiet room. During each re-
cording, the children were instructed to perform a deep inspira-
tion, and then to prolong the vowel /a/ as long as possible, at
a comfortable pitch and loudness while sitting on a chair directly
in front of the system microphone. Then, the children were
675.e2 Journal of Voice, Vol. 26, No. 5, 2012

required to prolong /s/ and /z/ during sustained phonation. Three

TABLE 2.
trials of each phoneme were elicited, and the longest value was MPT of the Vowel /a/
used. All procedures were instructed verbally in addition to a vis-
ible and audible trial performance by the researcher. Gender Boy Girl Total
Age
RESULTS (y:mo) MPT /a/ MPT /a/ MPT /a/
Age and gender 4:0–6:11 6.02 ± 1.77 aA 6.22 ± 1.99 aA 6.12 ± 1.89 a
The present study represents data from 1660 children 7:0–9:11 8.05 ± 1.98 bA 7.90 ± 1.98 bA 7.98 ± 1.98 b
(824 boys and 836 girls) across three age groups. Groups 10:0–12:00 9.22 ± 2.33 cA 9.05 ± 2.02 cA 9.14 ± 2.18 c
were of age 4–6 years (n ¼ 185 males and 204 females),
7–9 years (n ¼ 483 males and 473 females), and 10–12 years
(n ¼ 156 males and 159 females), Table 1. and for the girls was 15.79 seconds. The longest MPT mean
Tables 2–4 present the values of MPT during the emission of was recorded in the group of boys aged 15 years. MPT increased
the /a/ vowel and fricatives /s/ and /z/ in three age groups. The as a function of age. The latter author5 highlighted that the MPT
MPT values were similar in each age range and increased with performance could be enhanced by using repeated trials and also
age until 9 years. The MPT was not more variable among boys providing visual feedback. In this study, only 20% of children
or girls within a particular age group. The s/z ratio was near reached MPT by three trials, and most of them did not reach
1.0 in the three age groups, and it was slightly higher among maximum MPT until the ninth trial. However, more than three
girls aged 7–9 years (Table 5). trials are not useful in the clinical practice due to the lack of
cooperation from children.
MPT is directly related to vital capacity (VC), age, weight,
DISCUSSION
height, and laryngeal neuromuscular control. The gender influ-
MPT is a measure frequently used in voice assessment due to
ence is still controversial. The increase of MPT in males is cor-
the fact that it is noninvasive, fast, easy to obtain, and consid-
roborated by some authors,2,9–12 but in the present study, we
ered the objective evaluation of the efficiency of the respiratory
could not demonstrate statistical differences between males
mechanism during phonation.2 MPT is also used in the assess-
and females.
ment of degree of vocal dysfunction. Yet, Speyer et al2 high-
The respiratory contribution to MPT was researched by
lighted the importance of the training respiratory support
Solomon et al8 in 12 students with normal voices. Because
before the measures, mainly in children because subjects tend
they were monitored for lung volume during MPT task, the
to be more motivated to increase the length of phonation after
authors observed that such subjects used 90% of their VC for
repeated trials.9
their best MPT trial, and this parameter was not correlated
MPT reflects the mean of the three longest trials.5 However,
with VC to perform the task. Fabron et al6 demonstrated the lin-
some authors have recommended more than three trials.9 In an
ear correlation between the MPT as well as the height and VC in
interesting study by Lewis,9 children were instructed to sustain
children and also highlighted the importance of such parame-
the vowel /a/ for 20 consecutive trials, but only 2% of them pro-
ters in the MPT.13–15
duced their longest phonation by the third trial. Finnegan5
The MPT values increased with age until puberty.9,11,12,16,17
instructed 286 children, aged 3.6–17.11 years, to sustain the
In the present study, the lowest MPT values were recorded in
vowel /a/ for 14 trials to MPT measures. Children were posi-
children aged 4:0–6:11 years. The results are justified by
tioned in front of a monitor to visual control of their inhalation.
the minor pulmonary capacity and laryngeal muscular
The mean values of the MPT for the boys were 18.23 seconds
incoordination until these ages. Similar values of MPT were
recorded by Capellari and Cielo16 for the vowel /a/ and
TABLE 1.
Age (Years) and Gender
Gender TABLE 3.
MPT of the Fricative /s/
Boy Girl Total
Gender Boy Girl Total
Age (y:mo) n % n % n %
Age
4:0–6:11 185 47.56 aA 204 52.44 aB 389 100 (y:mo) MPT /s/ MPT /s/ MPT /s/
7:0–9:11 483 50.52 aA 473 49.48 aB 956 100
4:0–6:11 5.77 ± 1.94 aA 5.91 ± 1.88 aA 5.84 ± 1.91 a
10:0–12:00 156 49.52 aA 159 50.48 aB 315 100
7:0–9:11 7.47 ± 1.92 bA 7.74 ± 1.92 bA 7.61 ± 1.92 b
Total 824 49.64 836 50.36 1660 100 10:0–12:00 9.22 ± 2.23 cA 9.10 ± 1.96 cA 9.16 ± 2.10 c
Two frequencies followed by the same small letter do not differ concern- Two means followed by the same small letter do not differ concerning to
ing to the respective age groups (lines), fixing the gender (P > 0.05). the respective age groups (lines), fixing the gender (P > 0.05).
Two frequencies followed by the same capital letter do not differ concern- Two means followed by the same capital letter do not differ concerning to
ing to the genders (columns), fixing the age group (P > 0.05). the respective genders (lines), fixing the age group (P > 0.05).
Observation: Goodman test. Observation: Two-factor analysis of variance.
Elaine Lara Mendes Tavares, et al Maximum Phonation Time in Children 675.e3

corroborate these findings. The production of /z/ may involve

TABLE 4.
MPT of the Fricative /z/
lower glottal airflow rates and may increase glottal efficiency.
The /s/ production may yield substantially greater airflow and
Gender Male Female Total reduce efficiency because of an open glottal configuration.3
Average Average Average So, the s/z ratio is an indicator of glottal efficiency. Several
Age
(y:mo) MPT /z/ MPT /z/ MPT /z/ studies indicated an s/z ratio less than 1.0 in normal voice.3,21
However, patients with laryngeal lesions have difficulty in
4:0–6:11 6.01 ± 2.05 aA 6.17 ± 1.86 aA 6.09 ± 1.95 a
prolonging the sound /z/ as long as /s/ because of a decrease
7:0–9:11 8.05 ± 2.30 bA 8.00 ± 2.20 bA 8.02 ± 1.95 b
in glottal efficiency.3,4 Tait et al12 in a study of children (aged
10:0–12:00 9.35 ± 2.27 cA 9.15 ± 2.11 cA 9.26 ± 2.19 c
from 5 to 9 years) found out that /z/ duration was slightly longer
Two means followed by the same small letter do not differ concerning to
the respective age groups (lines), fixing the gender (P > 0.05).
than /s/, and the s/z ratios increased with the age (0.88 for 5
Two means followed by the same capital letter do not differ concerning to years, 0.74 for 7 years, and 0.92 for 9 years). The higher s/z ratio
the respective genders (lines), fixing the age group (P > 0.05). can suggest laryngeal lesion.3,4,20
Observation: Two-factor analysis of variance.
In this study, the s/z ratio was near the unit, corroborating by
figures of other authors.2,7,8,12 When the values of /z/ are
identical or higher than the values of /s/, the most probable
phonemes /s/ and /z/ in 23 children aged 4, 5, and 6 years corre- condition is the hypercontraction of vocal folds during
sponding to 7.42, 6.35, and 7.19 seconds, respectively. Harden phonation and results in a decrease of the s/z ratio, keeping it
and Looney11 found out higher values in children without voice lower than 0.8.2 The s/z ratio higher or equal to 1.2 may indicate
disorders with a mean of age 6.2 years (10.4 ± 5.1 seconds to a default in the vocal fold closure during phonation. According
males and 10.6 ± 6.3 seconds to females) than the other authors. to Salom~ao,21 s/z ratio of 1.3 can indicate the presence of a dis-
In children with voice disorders, they have found 7.8 ± 3.5 sec- order of vocal fold vibratory behavior and/or inability in the
onds to males and 7.6 ± 4.5 seconds to females. glottic closure.
In our study, the higher values of the MPT were recorded in
ages from 10 to 12 years. The duration of /z/ was mildly longer
than /s/. Oliveira18 checked varied values of the MPT in chil- CONCLUSION
dren aged 7–11 years and without vocal symptoms, between Our larger study population is inconsistent with smaller sample
6.5 and 23 seconds for boys and between 4 and 27 seconds studies for values of MPT and the s/z ratio, being slightly lower.
for girls. Between age 7 and 9 years, this author found out the These values can be used as normative in further pediatric
following mean values to the vowel /a/ and fricatives /s/ and studies.
/z/: 7.98 ± 1.98, 7.61 ± 1.92, and 8.02 ± 1.95 seconds.
Westlake and Rutherford19 indicated that a normal child
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