ARTICLE IN PRESS

Nasal Resistance (NR) Technique: A Novel Approach to

Improve Glottal Adduction
Nandhakumar (Nandhu) Radhakrishnan, Beaumont, Texas

Summary: Objective. Several techniques have been practiced in the field of voice therapy to balance glottal
pressures and improve glottal adduction. As such, Semioccluded Vocal Tract Exercises using narrow diameter
straws have shown promise as a technique to increase glottal contact as reflected by Closed Quotients (CQ) mea-
sured from electroglottograph (EGG). This study explored the effect of nasal resistance (NR) technique, a manu-
ally induced NR approach, on glottal adduction in phononormal subjects as a possible new therapeutic
technique to assist in glottal closure.
Subjects. Thirty-four vocally healthy adult females qualified for this study. All subjects were reportedly and
perceptually normal.
Methods. Subjects were instructed to perform tasks including (a) steady modal phonation, (b) straw phonation,
(c) humming, and (d) NR technique in a random order. EGG measures included calculation of the CQ and jitter
during the mid-section of each stimuli for a minimum of 10 EGG cycles. One-way repeated measures ANOVAs
and Bonferroni post-hoc comparisons were calculated to determine differences between each phonatory task for
the outcome measures of CQ and jitter.
Results. Analyses revealed that the mean CQ was significantly different in all the tasks performed with hum-
ming (33.99%) at the lowest and NR technique at highest (43.88%). Though the CQ of straw phonation (40.53%)
was higher than modal steady phonation (36.65%), jitter was found to be significantly lower for NR technique
(0.23%). Jitter during straw phonation (0.43%) did not differ significantly from modal phonation (0.44%).
Conclusion. These results provide preliminary evidence that NR technique can increase CQ with lower levels of
jitter compared to straw phonation using a narrow diameter of 2 mm. Future studies should expand enrollment
to men, larger age ranges, and patients with hypofunctional symptoms (eg, Parkinson disease) to evaluate the
potential benefits of NR as a therapeutic technique.
Key Words: Glottal adduction−Straw phonation−Glottal insufficiency−Glottal incompetency−Nasal resis-
tance−NR technique.

INTRODUCTION contact. This measure is referred to as EGG Width

Glottal adduction is mandatory for voicing. The thyroaryte-
noids, lateral cricoarytenoids, and interarytenoids (IA) play
a vital role in adducting the vocal folds. The former work in
adducting the anterior membranous portion and the latter
two increase medialization of the posterior glottis. Inade-
quate adduction leads to glottal insufficiency reflected by a
breathy voice quality. This could be due to various condi-
tions including functional issues such as muscle tension,
habitual use of husky/breathy voice, vocal fold atrophy, or
paresis/paralysis of vocal folds.1−3
Inadequate glottal closure can reflect abnormalities
across several measures of voice including perceptual,
acoustic, aerodynamic, electroglottographic, and endo-
scopic aspects. Electroglottograph (EGG) detects glottal
contact and the waveform is a plot of glottal contact across
time. The peak of this waveform reflects glottal contact.
The width of the waveform at specific levels from baseline,
that is, 25%, 50%, 75% have been used to interpret glottal
Accepted for publication April 28, 2020.
From the Department of Speech and Hearing Sciences, Voice Lab & Vocology
Clinic, Lamar University, Beaumont, Texas.
Address correspondence and reprint requests to Nandhakumar (Nandhu) Radhak-
rishnan, Voice Lab & Vocology Clinic, Lamar University, Beaumont, TX 77710. E-
mail: nandhu@lamar.edu
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.2020.04.020
(EGGW) at 25, 50, or 75th percent. It is a ratio between the
width and period of the waveform. EGGW* is a reliable
measure to infer glottal adduction.4,5
Literature reports several voice therapy techniques to
address glottal insufficiency. Almost all physiologic-based
approaches including Vocal Function Exercises, Resonant
Voice Therapy, and Semi-Occluded Vocal Tract exercises
(SOVTE) have reportedly been effective in balancing glottal
adduction, pressure, and flow aspects of voice production.
Some forms of SOVTE reported in the literature are straw
phonation, humming, LaxVox, hand over mouth, lip trills,
tongue trills, and tube phonation in air versus water. Effect
of SOVTE on glottal adduction and overall voice produc-
tion varies based on the type of exercises selected including
the number of locations of vibration or resistance offered
(single or double), length and diameter of the straw, and
depth of the tube in water.
Andrade et al studied the effect of seven SOVTEs on EGG
measures of 23 vocally healthy subjects. Closed Quotient (CQ)
though differed across all seven tasks, the values decreased
from comfortable phonation (44.15%). Among these, only lip
trills 38.57%, expressed statistically significant difference from
comfortable phonation. Straw phonation and LaxVox
*The software used for EGG analysis in this study performs EGGW50 calculations;
however, labels it as Closed Quotient.
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2020
decreased CQ to 41.33% and 43.54%, respectively. The sili-
cone tube used for LaxVox was 25 cm in length with a 9 mm
internal diameter. The straw reportedly had a measurement of
12.5 cm length and 4 mm diameter. Generalized inference
about the effect of straw phonation on CQ cannot be made
from this study alone because the diameter of the straw can
change the direction of this measure.6 Mills et al studied the
effect of short-duration (1 minute) and long-duration (10
minutes) exercises using different lengths of straws (7.5, 15,
and 30 cm) with a diameter of 2 cm on voice measures includ-
ing oral pressure, mean airflow, aerodynamic resistance, and
CQ. The subjects, 10 males and 10 females, of this study were
all vocally healthy. According to their results, long-duration
exercises revealed significant decrease in oral pressure, aerody-
namic resistance, and CQ and a significant increase in airflow.
The effect of change in length did not show significant differen-
ces in these measures. In this study, the diameter of the straws
was consistent (2 cm).7 Guzman et al investigated the effect of
straw phonation across different diameters and phonation
through tubes immersed in different depths of water. The par-
ticipants of this study belonged to four groups, (a) vocally nor-
mal without voice training, (b) vocally normal with voice
training, (c) patients with muscle tension dysphonia, and (d)
patients with unilateral vocal fold paralysis. This study
reported statistically significant increase in CQ for voicing
through a stirring straw with 2.7 mm inner diameter (3%
increase) and phonation using 55 cm straw with 10 mm inner
diameter submerged 10 cm in water (5% increase). Moreover,
the trend of change in parameters was not different based on
vocal health of the subjects.8 Based on interpretation of these
studies, effect of SOVTE on glottal adduction and overall
voice production varies based on the type of exercises selected
including the number of locations of vibration or resistance
offered (single or double), length and diameter of the straw,
and depth of the tube in water.
Titze explained the scientific rationale of SOVTE suggest-
ing that semiocclusion in the oral cavity improve the inter-
action between the source and filter thereby increasing the
mean intraglottal air pressure and supraglottal pressure
which may in turn raise the maximum flow declination rate
within the glottis.9 Though literature has described the prac-
tice of several types of SOVTEs including humming, manu-
ally induced nasal resistance (NR) during humming and its
effect on voice production has not been reported.
Humming, in isolation or combination, is reportedly used in
both therapy10−13 and vocal training.14,15 Humming report-
edly improves voice quality by stabilizing the vocal fold oscil-
lation, prephonatory positioning, and perception of
roughness.13,16,17 How does the low levels of vocal fold medial
compression and enhanced airflow during humming change
when manual resistance is offered? This needs to be studied.
NR TECHNIQUE
NR manually offered at the level of nostrils during humming is
a novel approach to increase glottal adduction. This approach
has not been reported. The rationale to recommend this
technique for hypofunctional voice disorders stems from pre-
liminary investigations by the Primary Investigator (PI). Prac-
tice recordings across several subjects showed an increase in
CQ when this technique was performed during humming.
Hence the claim is made that this technique may benefit
patients who have inadequate glottal contact. Performance of
this technique, reliability, and repeatability are discussed under
“Protocol of NR Technique” in Methods section.
Specific aims of this research were to compare CQ and
EGG jitter during (a) steady phonation of /ɑ/ at modal
pitch, (b) straw phonation, (c) humming, and (d) humming
under NR technique. The following are the null hypotheses:
a. There is no significant difference in CQ between com-
fortable phonation /ɑ/, straw phonation, comfortable
humming, humming under NR technique.
b. There is no significant difference in jitter between com-
fortable phonation /ɑ/, straw phonation, comfortable
humming, humming under NR technique.
METHODS
This study was approved by the Institutional Review Board
at Lamar University.
Subjects
Among 49 volunteers, 34 phononormal females (speech lan-
guage pathology majors), between the ages 19−32 years
with a mean age of 23.82 years, met the following inclusion/
exclusion criteria and participated as subjects. Subjects pro-
vided informed consent to participate in this study.
Inclusion criteria
(a) Subjects should not have upper respiratory and/or
vocal complaints and are vocally healthy
(b) Subjects’ EGG trials should reveal clear EGG signals
Exclusion criteria
(a) Subjects had perceptually below normal voice quality
(b) Subjects’ EGG signals were not reliable
(c) Subjects had upper respiratory infection/discomfort,
including common cold
(d) Subjects are vocally trained
(e) Subjects had a history of voice disorders
The PI, who has more than 15 years of experience in clini-
cal voice, screened the subjects through auditory perceptual
evaluation.
Instrumentation
Electroglottography: Contact quotient was measured using
EGG Model 6103 by Pentax Medical (New Jersey, USA).
Electrode placement was facilitated using Spectra 360
 ARTICLE IN PRESS
Nandhakumar (Nandhu) Radhakrishnan Nasal Resistance (NR) Technique
electrode gel manufactured by Parker Laboratories (New
Jersey, USA). The output was connected to PowerLab
PL3516/P (ADInstruments, Colorado, USA) multi-signal
acquisition device at a sampling rate set to 16-bit, 20 KHz.
The use of EGG as a clinical and research tool has been
debated in the literature. Colton and Conture discussed the
common complications and downsides of this tool and clas-
sified the problems into four areas (a) instrumental, (b) pro-
cedural, (c) subject related, and (d) interpretation of the
signal. In short, EGG signals are affected by (i) low fre-
quency noise that masks the target waveform, (ii) electrode
placement, (iii) degree of contact between electrodes and
skin, (iv) movement of the larynx during speech, (v) neck
size, (vi) difference in length of vocal folds and angle of thy-
roid cartilage, as seen between adult males and females, (vii)
adipose tissue around anterior neck region, and (viii) inter-
pretation of the valley, open phase in a vibratory cycle.18
Low frequency noise in the signal is minimized by high-
pass filtering; however, if not done correctly, it can lead to
phase distortions that affect temporal aspects of the wave-
form.19 Rothenberg addresses this issue stating that it
depends on the filters selected and the effect is negligible in
high frequency voices of females and children.20
Incidentally, this research recruited only female subjects.
During data collection, care was taken to place the electro-
des after digital palpation of the larynx and identification of
the thyroid laminae. Electrode gel was used to improve skin
−electrode contact. The protocol included only steady pro-
longation of voice and not speech or pitch fluctuation.
Moreover, only subjects who could deliver strong and clear
EGG signals were included. In order to avoid the valley of
EGG waveform, the software measured CQ at location that
is at 50% of the y-axis (Image 1). This is also referred to
EGG width 50 (EGGW50) in literature.
Acoustic: Behringer ECM-8000 condenser microphone
(Willich, Germany) was placed 6-inches from the mouth of
the subjects. Focusrite Scarlett 2i2 preamp (High Wycombe,
England) was used to connect the microphone to PowerLab.
The sampling rate was set at 16-bit, 20 KHz. This acoustic
data was intended as back-up and not used for analysis.
LabChart-v7 (ADInstruments, Colorado, USA) was used
to digitize and display the EGG waveform and acoustic
waveform as channel 1 and 2. Dell Optiplex 9010 desktop
computer was used to save the recorded data. EFxHist v2.0,
a software programmed by Mark Huckvale (University
College London, UK) was used to analyze EGG signals.
Protocol for NR technique
It is possible for subjects to perform NR technique on them-
selves; however, for this research, the PI performed it on
each subject. This technique was performed on subjects in
the following manner.
(a) Subjects were seated comfortably
(b) Subjects were asked to take a deep breath and hum at a
comfortable pitch and loudness
3
(c) After perceptually judging the effort, pitch, and loud-
ness, the PI placed his thumb and index finger at the
subject’s nostrils and offered resistance to the flow of
air. The other hand was positioned at the back of the
subject’s head for support. Latex-free medical gloves
were worn for protection.
(d) During the above task, subjects gave in to the resis-
tance and reduced the airflow and loudness of
humming
(e) At this point, instructions were given not to surrender
to the resistance and attempt to continue the same flow
and loudness. The PI monitored the authenticity by
sensing the pressure and flow at the nostrils and percep-
tion of not giving in
(f) The subjects were asked to perceptually register the
attempts they made to overcome this resistance
(g) After the PI was confident about the output, steps (b)
and (c) were repeated.
Reliability and repeatability of NR technique
Although the technique includes subjectivity with reference
to the amount of resistance offered at the level of nostrils,
perception of, pressure, and flow; similar to any other voice
therapy approach, this technique can be easily mastered.
The clinician should be watchful for the following:
(i) Humming, as demonstrated by the subject should be at
their comfortable effort, pitch, and loudness. The clini-
cian should give a demonstration, if needed.
(ii) During step (c), the resistance offered may not be suffi-
cient if the fingers are not adequately blocking the nos-
trils. The clinician should not offer 100% blockage.
The subject should be able to comfortably overcome
the resistance. If the fingers are smaller than the nostril
opening, the resistance may not be adequate; however,
this may be a rare case.
(iii) Instructions during step (e) is crucial. It was observed
that subjects were tempted to give in to the resistance.
Adequate instructions followed by clinicians’ monitor-
ing will produce desirable results.
Another approach to improve reliability and repeatability
would be to use visual feedback. A real-time EGG may be
beneficial. Such a software can show CQ during humming
and the change in value during NR technique.
Protocol for recording
Subjects performed the following tasks in a random order.
a. Comfortable phonation of /ɑ/. Instructions to phonate
at comfortable pitch and loudness for minimum 5 sec-
onds was given.
b. Straw phonation. Subjects phonated through a narrow
straw of 2 mm diameter (stirring straw). The PI moni-
tored the pitch, loudness, and effort level. The duration
of phonation was for minimum 5 seconds.
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2020
c. Comfortable humming: Subjects were asked to hum at
their comfortable pitch and loudness with their lips
sealed as in /m/.
Humming is predominantly used as a technique to decrease
glottal compression and improve easy onset in speech and
singing.12,21 Though the primary target of NR technique is
to increase CQ, this study has included humming as part of
the stimuli to show the change in CQ through NR offered
during humming.
d. Humming under NR technique: Authenticity of this
technique was established as mentioned in the section
describing the protocol.
The last 2 tasks were performed at the same exhalatory
phase to avoid difference in lung volume during initiation of
voicing. The subject started with comfortable hum and after
3 seconds NR technique was introduced. This approach
made sure that the subject did not phonate too long and
lose lung volume during humming. Care was also taken to
make sure that the technique was performed as per instruc-
tions and EGG signals were appropriate for analysis.
Recording was done only after the subject was clear about
the task. Each recording had all these four segments
Measures
EFxHist, the software used, refers to EGGW50 as CQ.
According to Mark Huckvaley, the EGG signal is bandpass
filtered (Butterworth) with a cut-off 80 −2000 Hz and the
phase is preserved during this process. This decreases any
low frequency artefacts in the signal. The jitter reported by
this software is also referred to as Point Perturbation Quo-
tient (PPQ) in literature. Each stimulus was identified for
every subject. The measures (CQ and Jitter) were calculated
at the mid-central section of each stimulus. The measures
were taken from a minimum of ten EGG cycles.
Statistical analysis
IBM SPSS 24.0 (SPSS Corporation, Chicago, Illinois ) for
Windows was used to perform one-way repeated measures
ANOVA to compare the means of target measures (CQ and
Jitter) followed by post hoc Bonferroni test to analyze if the
difference is significant (P = 0.01). All statistical assump-
tions were met for ANOVA.
RESULTS
Table 1 shows the CQ and jitter obtained from the subjects for
the four tasks. The average and standard deviation for CQ and
jitter is shown in Figures 1 and 2. A one-way repeated meas-
ures ANOVA indicated that the mean CQ was different across
the four tasks, thus rejecting the null hypothesis related to CQ:
yMark Huckvale is the programmer of EFxHist. The information given here was
requested through personal email communication.
Wilks’ Lambda = 0.051, F(3,31) = 193.45, P < 0.01, Effect
size or partial h2 = 0.95. Bonferroni post-hoc tests revealed sta-
tistically significant difference (P < 0.01) between CQ across
all four tasks with humming (33.99%) at the lowest and NR
technique at highest (43.88%). Straw phonation (40.53%) was
higher than modal phonation (36.65%). Similarly, mean jitter
was different across the four tasks, thereby accepting the alter-
nate hypothesis related to jitter: Wilks’ Lambda = 0.361, F
(3,31) = 18.32, P < 0.01, partial h2 = 0.64. Though Bonferroni
post-hoc tests revealed significant difference in jitter measures
(P < 0.01) between straw phonation (0.43%), humming
(0.34%), and NR technique (0.23%), there was no statistical
difference between modal phonation (0.44%) and straw pho-
nation (P > 0.01). The larger effect size (partial h2) for both
CQ and jitter analysis suggests that the difference is substan-
tial. Cumming suggests the use of Cohen’s dav as a measure of
effect size. This is the ratio between the difference of means
during pairwise comparison and the average of their standard
deviations. The subscript indicates average. Based on the
value, effect size can be estimated as small (0.2−0.5), medium
(0.5−0.8) or large (0.8 or more).22 Table 2 shows Cohen’s dav
pairwise comparisons between the four tasks and target meas-
ures CQ and jitter.
The increase in CQ measures during straw phonation
using a narrow (coffee stirring) straw complemented Guz-
man et al (2016) study that compared voice measures of
phononormal and patients with muscle tension dysphonia.
Reduced levels of CQ and jitter during humming comple-
ments the effects of humming during speech and singing
described in literature.
DISCUSSION
The results of this study show an increase in CQ and decrease
in jitter during NR technique. The rationale for this approach
to demonstrate these results can be interpolated from available
literature on SOVTE. Titze’s research explaining the scientific
rationale of SOVTE suggests that semi-occlusion increases the
mean intraglottal air pressure and supraglottal pressure which
may increase the maximum flow declination rate within the
glottis.9 Laukkanen et al recorded electromyography signals
of a single subject during demonstration of SOVTE. electro-
myography data showed an increased thyroarytenoid activity
when compared to cricothyroid and lateral cricoarytenoids.
This was in response to increased vocal tract impedance during
tube phonation.23 This indicates that SOVTE can increase
activity of laryngeal adductors that can in turn increase CQ.
Guzman et al study investigated activity of the laryngeal and
pharyngeal area in 20 patients diagnosed with hyperfunctional
dysphonia during different types of SOVTE including tubes
varying in diameter (narrow and wide) both in air and water.
Tubes with narrow diameter (3 mm) resulted in a decreased
vertical laryngeal position, narrower aryepiglottic opening,
and a wider pharyngeal area than resting position. This indi-
cates that SOVTE using narrow straws can lower the larynx
and widen the pharynx for better source filter interaction.24
NR technique does reduce the size of opening at the nostrils
 ARTICLE IN PRESS
Nandhakumar (Nandhu) Radhakrishnan Nasal Resistance (NR) Technique 5

TABLE 1.
Closed Quotient and Jitter Values Across Target Stimuli Comfortable Phonation (Modal), Comfortable Humming (Hum),
Straw Phonation (SOVTE), and Humming Under NR (NR)
No. Modal CQ Modal Jitter SOVTE CQ SOVTE Jitter Hum—CQ Hum—Jitter NR—CQ NR Jitter
1 38.4 0.54 43.5 0.46 33.6 0.36 44.6 0.12
2 37.1 0.52 41.8 0.33 34.2 0.3 43.5 0.22
3 30.3 0.25 32.5 0.42 28.6 0.3 37.8 0.2
4 38.1 0.63 39 0.99 36.3 0.33 43.5 0.15
5 39.4 0.26 40.6 0.36 38 0.21 44.2 0.18
6 45.9 0.58 47.2 0.61 42.5 0.54 50.2 0.23
7 38.2 0.55 43.5 0.46 33.6 0.36 44.6 0.18
8 37.3 0.52 41.8 0.33 35.2 0.3 43.5 0.28
9 30.1 0.25 32.5 0.45 28.2 0.3 37.8 0.18
10 37.9 0.26 40.2 0.28 35.1 0.21 44.5 0.18
11 40.1 0.58 44.5 0.61 36.2 0.54 50.2 0.21
12 37.6 0.55 43.5 0.46 33.6 0.36 44.6 0.18
13 32.1 0.52 41.8 0.33 30.1 0.3 43.5 0.18
14 38.1 0.25 32.5 0.39 33.4 0.3 38.9 0.26
15 31 0.26 40.6 0.32 30.5 0.21 42.3 0.18
16 38.4 0.58 43.5 0.61 36.4 0.54 50.2 0.28
17 37.1 0.55 43.5 0.46 33.6 0.36 44.6 0.22
18 30.3 0.52 36.1 0.33 30 0.3 43.5 0.25
19 38.1 0.25 32.5 0.36 33.4 0.3 39.2 0.18
20 39.4 0.26 40.6 0.29 38 0.21 45 0.33
21 38 0.58 47.2 0.61 36 0.54 50.2 0.18
22 37.2 0.55 43.5 0.46 33.6 0.36 44.6 0.38
23 31.5 0.52 38.7 0.33 30.1 0.3 43.5 0.18
24 38.4 0.25 32.5 0.35 33.4 0.3 38.2 0.4
25 37.1 0.26 40.6 0.14 36.5 0.21 45.2 0.34
26 30.3 0.58 40.1 0.61 29.8 0.54 48 0.22
27 38.1 0.55 43.5 0.46 33.6 0.36 44.6 0.34
28 39.4 0.52 41.8 0.33 37.6 0.3 43.5 0.18
29 38.4 0.25 40.5 0.2 33.4 0.3 39.2 0.18
30 37.1 0.26 40.6 0.3 36.2 0.21 42.3 0.3
31 30.3 0.58 41.1 0.61 30.5 0.54 48.8 0.18
32 38.1 0.55 43.5 0.46 33.6 0.36 44.6 0.4
33 39.4 0.52 41.8 0.33 37.6 0.3 43.5 0.18
34 37.8 0.25 41 0.45 33.4 0.3 39.5 0.15
Avg 36.65 0.44 40.53 0.43 33.99 0.34 43.88 0.23
SD 3.67 0.15 4.01 0.16 3.10 0.11 3.52 0.08

50.00
NR CQ
0.70 45.00 43.88
0.60 SOVTE CQ
Closed Quotient (%)

40.00 40.53
0.50 Modal CQ
Modal Jitt SOVTE Jitt
Jitter (PPQ)

0.44 35.00 36.65 Hum CQ

0.40 0.43
Hum Jitt 33.99
0.30 0.34
30.00
0.20
NR Jitt 25.00
0.10
0.23
0.00 20.00
Modal Jitt SOVTE Jitt Hum Jitt NR Jitt Modal CQ SOVTE CQ Hum - CQ NR - CQ

FIGURE 1. Jitter values (%) obtained from EGG signal for the FIGURE 2. Closed Quotient values based on EGG signal for the
four target stimuli. The error bars indicate one standard deviation. four target stimuli. The error bars indicate one standard deviation.
 ARTICLE IN PRESS
6 Journal of Voice, Vol. &&, No. &&, 2020
TABLE 2.
Effect Size Based on Cohen’s dav. According to Cohen (1988) d = 0.2 is Small, 0.5 is Medium, and is Large
CQ
Cohen’s dav
Modal-SOVTE 1.01
Modal-Hum 0.78
Modal-NR 2.01
SOVTE-Hum 1.84
SOVTE-NR 0.89
Hum-NR 2.99
* Post-hoc Bonferroni test (P < 0.01) indicated insignificant difference.
and this may lead to findings suggested by Guzman et al.
Moreover, the decreased levels of jitter during NR technique
can be explained from summaries of Antti Sovij€ arvi’s Finnish
studies that suggest phonating into tubes submerged in water
can result in lowering of the larynx and “stabilization” of vocal
fold vibration.25 SOVTE involving tubes in water have resis-
tance offered at two levels, (a) at the level of lips and (b) at the
end of the tube in water. NR technique may be considered to
have two locations of resistance as well. The first level is the
natural resistance offered by the narrow path of the nasal cav-
ity and the second is the resistance offered by the thumb and
index finger at the nostrils. This may be the added advantage
compared to straw phonation that has resistance only at lip
level. Moreover, NR technique starts with humming. Endo-
scopic views of humming reportedly shows decreased supra-
glottic tension/compression, onset of voice with decreased
medial compression of vocal folds, and good mucosal wave.26
This may contribute to the lower levels of jitter during NR
technique. Though some of the SOVTE techniques that use
wider straws decreased CQ and were suitable to reduce muscle
tension, NR technique may only be used in conditions that
have lower levels of CQ. MTD that has a spindled shaped
glottic configuration, presbyphonia, unilateral vocal fold
paralysis are some examples.
As far as the PI’s knowledge, NR technique has not been
investigated or reported. The source vs filter interaction,
aerodynamic adjustments, and acoustical interactions dur-
ing this approach will be an interesting area to explore using
models, aerodynamic measurements of oral-nasal pressure
and flow, and endoscopy. This needs further investigation.
Accurate delivery of this technique is mandatory to see favor-
able results. The PI has noticed better results when the clinician
receives training in mastering this approach. Similar to the effi-
cacy of resonance-based voice training, twang exercises, yawn-
sigh approaches reported in literature, this technique also, if
practiced, can transfer the results to spontaneous speech.
LIMITATIONS
Basic science behind this approach needs investigation. This
research is based on vocally healthy female subjects of a par-
ticular age range only. Future research should focus on
comparing objective and subjective voice measures on
Jitter
Cohen’s dav
Modal-SOVTE 0.08*
Modal-Hum 0.78
Modal-NR 1.87
SOVTE-Hum 0.66
SOVTE-NR 1.70
Hum-NR 1.22
males, a wider age range, performance voice, and patients
with hypofunctional voice disorders such as Parkinson’s dis-
ease, presbyphonia, vocal fold paralysis etc.
CONCLUSION
NR technique, that initiates with easy onset via humming,
followed by resistance at the nostrils, has shown to increase
CQ as well as decrease jitter during vocal fold vibration.
Reliability and repeatability can be achieved if the approach
is followed as prescribed. Future research should be directed
to study the efficacy and long-term effects of this technique.
ACKNOWLEDGMENTS
The author would like to thank Dr. Indika Rathnathunga-
lage, Assistant Professor, Department of Mathematics,
Prairie View A&M University for his assistance in statistics.
SUPPLEMENTARY DATA
Supplementary data related to this article can be found
online at https://doi.org/10.1016/j.jvoice.2020.04.020.
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