Original Paper
Folia Phoniatr Logop 2014;66:237–243 Published online: February 5, 2015
DOI: 10.1159/000369167
Early Voice Therapy in Patients with
Unilateral Vocal Fold Paralysis
Manal El-Banna Gamal Youssef
Unit of Phoniatrics, Otorhinolaryngology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
Key Words
Early voice therapy · Unilateral vocal fold paralysis ·
Dysphonia Severity Index · Voice Problem Self-Assessment
Scale
Abstract
Objective: The purpose of this work was to study the efficacy
of early voice therapy in the management of patients with
unilateral vocal fold paralysis. Patients and Methods: Three
groups of patients suffering from unilateral vocal fold pa-
ralysis were subjected to a protocol of voice evaluation in-
cluding auditory-perceptual voice analysis, the Dysphonia
Severity Index (DSI) and the 20-item Voice Problem Self-As-
sessment Scale (VPSS-20). Patients were also examined us-
ing video laryngostroboscopy. The early voice therapy group
was enrolled in a voice therapy program for 16 sessions as
soon as the patients were diagnosed; the second group of
patients did not receive voice therapy during the course of
their ailment. The late voice therapy group was enrolled in a
voice therapy after a period of at least 6 months following
the onset of vocal fold paralysis. All studied patients were
reevaluated after a period of 2 months. Results: The early
voice therapy group showed better outcomes regarding
VPSS-20 scores, auditory-perceptual voice analysis as well as
© 2015 S. Karger AG, Basel
1021–7762/15/0666–0237$39.50/0
E-Mail karger@karger.com
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the DSI. Conclusion: Early onset of voice therapy may en-
hance the reduction in glottal gap and improvement of
voice quality by hindering the development of faulty hyper-
functional compensatory behaviors; early voice therapy may
therefore enhance the patient’s quality of life.
© 2015 S. Karger AG, Basel
Introduction
Unilateral vocal fold paralysis (UVFP) may alter pho-
nation, airway protection, breathing and stabilization of
the body core during physical activity. Weakness and
change of voice quality and dysphagia are consequences
of inadequate closure of the vocal folds. Dysphonia is the
main symptom that causes a patient to seek a phoniatri-
cian’s advice. The degree of voice complaints depends on
the amount of glottal incompetence and on the type of
compensatory behaviors the patient may employ to im-
prove vocal intensity [1]. The voice may be breathy and
rough, with restricted pitch and loudness variations as
well as short phonation time. Diplophonia can occur as
patients increase the effort to attain glottal closure [2].
Compensatory hyperfunctional behaviors, such as ante-
rior-posterior or lateral compression of the false vocal
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Dr. Gamal Youssef
Freie Universität Berlin
ENT Department, Dubai Hospital
ENT Voice Clinic, PO Box 7272
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Dubai (UAE)
E-Mail dr.gamal @ gmail.com
folds, can result in a rough, strained and low-pitched
voice. Vocal fatigue, globus sensation and neck discom-
fort are other symptoms that may be associated with
UVFP. This condition may have a negative impact on pa-
tients’ self-assessment of their voice problem [1, 2]. Man-
agement of UVFP includes surgical techniques such as
Teflon, collagen, hydroxyapatite or autogenous micron-
ized dermis, fat injection, type I thyroplasty, and nerve
pedicle transfer [3], but voice therapy is strongly recom-
mended for the management of UVFP with minimal glot-
tal gap. The main goal of voice therapy is to improve glot-
tal closure without causing supraglottic hyperfunction
while developing abdominal support for breathing and
improving the strength of intrinsic muscles [2]. The most
commonly used voice therapy approaches involve hard
glottal attack and pushing exercises, designed to narrow
the glottis to permit the buildup of subglottal pressure
which can then effectively vibrate the vocal folds for vow-
els production. These maneuvers should be avoided,
however, as they may induce supraglottic hyperfunction;
for this reason, glottal attack approaches have been rec-
ommended only as short-term therapies, at the outset of
treatment [4, 5]. Modified pushing is an isometric exer-
cise whereby sustaining vowels and gliding from the low-
est to the highest note, and vice versa, is practiced. This
approach encourages contraction of the thyroarytenoid
muscle [4, 6]. The Smith accent method has also been
suggested to improve auditory-perceptual and aerody-
namic parameters of UVFP patients [7].
Data regarding the efficacy of early-onset voice thera-
py in patients with UVFP are scant. We hypothesized that
patients in an early treatment group would exhibit a sta-
tistically significant improvement in the following vocal
function measures: auditory-perceptual assessment of
voice quality, Voice Problem Self-Assessment Scale
(VPSS), Dysphonia Severity Index (DSI) and glottal gap
size.
The aim of this work is to study the efficacy of early
voice therapy in improving voice quality in patients with
unilateral vocal fold paralysis using both objective and
subjective measures.
Method
Participants
The study included 42 patients diagnosed as having UVFP and
complaining of postoperative change of voice quality. The selec-
tion was restricted to patients with iatrogenic etiology to be able to
determine the time of onset of the paralysis. Patients with preop-
erative thyroid nodules were followed up immediately after sur-
238 Folia Phoniatr Logop 2014;66:237–243
DOI: 10.1159/000369167
gery to select those with unilateral vocal fold immobility. The par-
ticipants were 17 males and 25 females. The age range was 22–52
years (mean 35.38 years). The early voice therapy group included
22 patients (9 males and 13 females) with a mean age of 35 ± 7.17
years. The 15 patients (5 males and 7 females) who received no
voice therapy had a mean age of 35 ± 5.97 years. The late voice
therapy group consisted of 8 patients (3 males and 5 females) with
a mean age of 37 ± 9.24 years. Vocal fold paralysis affected the right
vocal fold in 19 patients and the left one in 33 patients. The dura-
tion of vocal fold paralysis at initial assessment ranged from 2 to 4
weeks, with a mean of 3.4 ± 1.6 weeks. In the late voice therapy
group, the mean time between onset of vocal fold paralysis and
onset of voice therapy ranged from 6 to 14 months, with a mean of
9.12 ± 2.6 months.
Patients included in the study were only those candidates for
voice therapy with a vocal fold in the paramedian position; patients
with clinically significant aspiration were excluded from the study,
as they had shown a large glottal gap, and other lines of interven-
tion were suggested. The early voice therapy group participants
were enrolled in voice therapy sessions as soon as they were re-
ferred and diagnosed postoperatively. The ‘no voice therapy’
group included patients who were unable or refused to attend reg-
ular voice therapy. The late voice therapy group included patients
who were enrolled in voice therapy sessions after >6 months fol-
lowing the onset of the insult. They refused voice therapy sessions
earlier, but were enrolled later when they were convinced about the
importance of voice therapy as an intervention strategy.
Voice Assessment
All groups were initially assessed using a protocol of voice as-
sessment, which included the following:
• Auditory-perceptual voice analysis using the modified Grade,
Roughness, Breathiness, Asthenia and Strain (GRBAS) scale
[8] was performed by 3 expert phoniatricians. Their assessment
of the voices was blinded, with no reference to the research
group.
• 20-Item VPSS (VPSS-20) [9] is a 4-point scale questionnaire
with a total score of 80. The total score of the VPSS-20 summa-
rizes the scores of 4 clusters which are the functional, physical,
emotional and phonathenic clusters. The VPSS-20, like the 30-
item Voice Handicap Index (VHI-30), is a reliable and valid
instrument that measures the impact of voice disorders on
Egyptian patients.
• The DSI was calculated using the following equation: DSI =
0.13 × MPT + 0.0053 × F0-high – 0.26 × I-low – 1.18 × jitter (%)
+ 12.4 [10]. The parameters used for the DSI are maximum
phonation time (MPT, in seconds), the highest frequency (F0-
high, in Hz), the lowest intensity (I-low, in dB SPL), and jitter
(in %).
The measurements were collected using the Multidimensional
Voice Profile and Visi-pitch. Participants were seated 30 cm from
the microphone, and the ambient noise level was 30 dB in the
room. Participants were asked to phonate /a/ as softly as possible
at a comfortable pitch to obtain the fundamental frequency. The
patients were asked to produce /a/ starting at a comfortable pitch
going up to the highest and then down to the lowest pitch to obtain
both F0-high and F0-low. To calculate jitter, the participants pho-
nated /a/ three times at a comfortable pitch and loudness for ap-
proximately 3 s. Jitter was calculated on a sample of 1 s from each
trial, starting half a second after voice onset. The lowest result of
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Freie Universität Berlin
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Table 1. Mean and standard deviation of the auditory-perceptual assessment of voice quality at the initial and final assessment for the
three studied groups

Quality of voice Early voice therapy group No voice therapy group Late voice therapy group
IA FA IA FA IA FA

Overall grade of dysphonia 2.00 ± 0.75 1.50 ± 0.67 2.00 ± 0.95 1.92 ± 0.99 2.00 ± 0.75 1.75 ± 0.71
p value 0.001 0.586 0.170
Roughness 1.09 ± 0.68 0.82 ± 0.66 1.92 ± 0.90 1.00 ± 0.95 1.75 ± 0.46 1.62 ± 0.52
p value 0.030 0.339 0.351
Breathiness 2.00±.75 1.50 ± 0.67 1.08±.90 1.58 ± 1.08 1.75±.46 1.62 ± 0.52
p value 0.001 0.220 0.351
Asthenia 1.36 ± 0.49 1.18 ± 0.49 1.58 ± 0.79 1.33 ± 0.98 1.50 ± 0.53 1.50 ± 0.53
p value 0.104 0.191 –
Strain 0.72 ± 0.83 0.41 ± 0.59 0.67 ± 0.89 1.08 ± 1.50 1.50 ± 1.07 0.87 ± 1.25
p value 0.016 0.339 0.011

– = The correlation and t cannot be computed because the standard error of the difference is 0; IA = initial assessment; FA = follow-
up assessment.

the three calculations was used. To measure MPT, participants Follow-Up

were asked to inhale deeply and sustain /a/ for as long as possible
at a comfortable pitch and loudness. The MPT was recorded three
times, and the longest measured phonation time in seconds was
noted.
The digital video laryngostroboscopic assessment by Kay Pen-
tax was used to monitor the glottal gap. Glottal gap changes were
monitored and classified subjectively into three categories (re-
duced, no change and increased glottal gap). Three phoniatricians
were asked to judge changes in the glottal gap when viewing video
recordings, which were presented in random order and with no
reference to the studied group or assessment time.
Voice Therapy
Voice therapy was administered by one of the authors. It was
individualized, based on the degree of glottal incompetence as well
as on the type and degree of the compensatory behaviors used by
the patient. The adopted voice therapy program included modified
pushing exercises and the Smith accent method. The patients were
asked to produce a hard glottal attack with the addition of stretch-
ing the vowel while gliding down to a lower pitch. They practiced
modified hard glottal attack with vowels and words twice a day for
1 week. If progress was made, the patients incorporated isometric
push to the exercise program. Progress was judged using the audi-
tory-perceptual assessment, the patient’s subjective perception of
improvement and endoscopic monitoring. If progress was not ob-
served after the termination of voice therapy sessions, modified
hard glottal attack was tried for another week, after which the ac-
cent method was started. Patient performance was monitored to
guard against supraglottic hyperfunction using the auditory-per-
ceptual voice analysis and endoscopic signs of supraglottic hyper-
function. The Smith accent method was applied as 20-min sessions
twice weekly for 16 sessions [11].
All groups were reassessed, using the same protocol as de-
scribed above, after a period of 2 months to determine changes in
vocal performance.
Ethics
The Institutional Review Board at the Faculty of Medicine, Al-
exandria University, Egypt, approved the protocol of this study,
and written informed consent was obtained.
Statistical Analysis
The χ2 test was used to compare groups as regards qualitative
variables, for example, gender. The Kruskal-Wallis H test was per-
formed to compare the three studied groups, while paired t tests
were used to assess differences between means obtained at the ini-
tial and follow-up assessment of the same group. All statistical
analyses were performed using the SPSS software package version
13.0. p values <0.05 were considered significant.
Results
No significant differences between groups considering
age (p = 0.785) and gender (p = 0.981) were found.
The mean overall grade of dysphonia at the initial and
follow-up assessment for the three groups are presented
in table 1. A statistically significant difference was record-
ed in the early voice therapy group for the dimensions of
the GRBAS scale, between the initial and follow-up as-
sessment, except for asthenia (p = 0.104). No statistically
significant change was recorded comparing the initial
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 Table 2. Mean and standard deviation of the VPSS-20 total score and clusters at the initial and final assessment
for the three studied groups

VPSS-20 Initial Follow-up d.f. t Sig.

assessment assessment

Early voice therapy group 21

Functional cluster 10.68 ± 6.09 7.14 ± 4.35 5.14 0.000
Physical cluster 12.64 ± 6.18 7.04 ± 4.42 5.20 0.000
Emotional cluster 8.23 ± 5.69 4.91 ± 3.39 4.63 0.000
Phonasthenic cluster 1.23 ± 5.33 6.18 ± 3.80 6.05 0.000
Total 42.64 ± 16.18 25.27 ± 10.55 8.08 0.000
No voice therapy group 11
Functional cluster 9.5 ± 5.56 9.08 ± 5.52 1.16 0.269
Physical cluster 10.92 ± 4.81 10.83 ± 4.74 0.23 0.820
Emotional cluster 8.33 ± 5.30 8.17 ± 4.82 0.32 0.754
Phonasthenic cluster 12.50 ± 3.12 11.58 ± 2.78 1.14 0.277
Total 40.58 ± 16.93 39.67 ± 16.58 0.43 0.673
Late voice therapy group 7
Functional cluster 11.00 ± 6.82 10.00 ± 57.69 1.53 0.170
Physical cluster 13.75 ± 2.87 11.25 ± 2.76 2.04 0.081
Emotional cluster 6.62 ± 6.99 5.37 ± 5.68 1.26 0.250
Phonasthenic cluster 12.25 ± 4.33 8.75 ± 5.39 2.93 0.022
Total 44.50 ± 8.40 35.37 ± 12.45 3.13 0.017

d.f. = Degree of freedom.

The boxplots in figure 1 represent the initial and final

Initial assessment Follow-up assessment assessment of all groups for the total VPSS-20 score. Ta-
80 ble 2 shows the VPSS-20 scores obtained at the initial and
final assessment for the three studied groups. Statistically
60
significant differences between the initial and follow-up
VPSS-20 total score

assessment for the total VPSS-20 score and its clusters

were recorded for all parameters in the early voice thera-
40
py group. Statistically significant differences were not re-
corded for the no-voice therapy group, while the late
20 voice therapy group showed a statistical difference in total
VPSS-20 score (p = 0.017) and in the phonasthenic clus-
0
ters (p = 0.022).
22 22 12 12 8 8 DSI means and standard deviations for the three
Early voice therapy No voice therapy Late voice therapy groups are presented in table 3. The early voice therapy
group group group
group revealed a significant change from the initial to the
final assessment (p = 0.003), while the no-voice therapy
Fig. 1. Boxplots of total VPSS-20 scores in the three studied groups and the late voice therapy groups did not reveal a signifi-
at the initial and follow-up assessment. cant change (p = 0.735 and p = 0.311, respectively).
Videoendoscopic assessment showed a reduction in
gap size in the majority of the studied groups; these re-
ductions were more evident in the early voice therapy
and follow-up assessment of the no-voice therapy group. group (fig. 2). Seven patients in the early voice therapy
The late voice therapy group recorded significant statisti- group revealed adequate phonatory closure following
cal improvement only for strained voice quality (p = voice therapy.
0.011).
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 Table 3. Mean and standard deviation of the DSI at the initial and final assessment for the three studied groups

DSI Initial assessment Follow-up assessment d.f. t Sig.

Early voice therapy group –4.59 ± 2.01 –3.10 ± 2.58 21 –3.43 0.003
No voice therapy group –4.68 ± 2.15 –4.33 ± 2.15 11 –0.352 0.735
Late voice therapy group –4.08 ± 1.58 –3.92 ± 2.61 7 –1.06 0.311

d.f. = degree of freedom.

Discussion
Increased glottal gap No change in glottal gap
Vocal fold paralysis is a debilitating condition affect- Reduced glottal gap
ing an individual’s general health and quality of life [12]. 120
Voice therapy is strongly recommended for the manage- 4% 8% 0%
100
ment of UVFP with a minimal glottal gap. The need for
intervention depends on many factors, the most impor- 80 23%

Participants (%)
33% 50%
tant of which is the patient’s vocal requirements, based on
60
his or her occupational and social demands [13, 14].
Voice therapy efficacy studies indicate a significant posi- 40
73%
tive impact of voice therapy, in case of vocal fold paralysis, 59%
50%
on VHI scores [5, 7, 12, 15, 16], voice quality, aerody- 20

namic values, and vibratory pattern [7]. 0

Monitoring the patient’s quality of life as well as objec-
tive measures are complementary when monitoring suc-
cess (or lack thereof) during and after treatment [2, 17].
The present study included clinician-based (GRBAS and
DSI) as well as patient-based (VPSS-20) outcome mea-
sures. The study revealed a significant advantage for the
early voice therapy group over the other studied groups.
A significant difference in voice quality using the GRBAS
scale was reported in the early voice therapy group except
in the asthenic nature of voice. This may be explained by
the fact that the people enrolled in early voice therapy
were still not confident about their voice use and were still
suffering from surgical pain hindering powerful, loud
phonation. The late voice therapy group showed a sig-
nificant reduction in the strained quality of voice only;
this finding supports the usefulness of voice therapy in
reducing hyperfunctional compensatory vocal behaviors,
but with little effect on the overall voice quality. The
group that did not receive therapy showed improvement
in their ability to sustain phonation, but suffered signs of
a supraglottic hyperfunctional state which caused strained
voice quality and poor breath control.
The voice quality improves as the patient learns to use
a softer confidential speaking voice while developing ab-
dominal support for breathing and improving intrinsic
muscle strength; this results in improvements in the per-
Early voice therapy No voice therapy Late voice therapy
group group group
Fig. 2. The distribution of participants in the three groups as re-
gards glottal size changes.
son’s adaptations to social and occupational life. Voice
therapy may also have helped the reduction in voice gap
and respiratory phonatory control causing, in general, a
reduction in effort for voice production. These positive
physical effects were sensed early by patients through ear-
ly voice therapy and helped elevate the participants’ mo-
tivation encouraging them to complete the voice therapy
program. The effect of voice therapy on physical symp-
toms translates to real life and may persist for a prolonged
period [18]. Also, the use of a direct therapeutic approach,
such as the Smith accent technique, has been implicated
as producing improvements on voice-related quality of
life measures [19].
The VHI score of patients with untreated UVFP tends
to reveal greater perceived vocal dysfunction, particularly
in the physical subscale, compared with patients with dys-
phonia from other causes. It was suggested that this find-
ing is probably due to the experience of a sudden, severe
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voice change [15]. This aspect of physical difficulties en-
countered in cases of UVFP was evident in the present
study as a significant difference in physical as well as
phonasthenic manifestations as markedly revealed by
VPSS-20 scores in patients subjected to intervention us-
ing voice therapy. Previous studies applied the VHI as a
patient’s self-perception tool to assess this ailment. The
VPSS-20, used in the present study, is a questionnaire
constructed to suit Egyptian patients. It was subjected to
reliability and validity measures. Its scoring cannot be
compared to VHI scoring as it includes, for example, the
phonasthenic cluster, which is not present in the VHI.
The range of scores referring to severity is also different,
including no severity scoring scale for each cluster. These
modifications have made literal comparison between
both questionnaires difficult. In spite of these differences,
the strong implication of the present study that early
voice therapy affects the patients’ self-perception of qual-
ity of life positively cannot denied.
Mattioli et al. [16] suggested that using voice therapy
early in the occurrence of UVFP helps recovering motil-
ity, whatever the etiology and position of the paralyzed
fold. Their study referred to a similar, positive effect of
early onset of voice therapy on acoustic measures, as in
the present study. Unfortunately, Mattioli et al. were un-
able to assert with certitude the efficacy of voice therapy
in terms of motility recovery and vocal improvement
since no studies with a control group of patients were per-
formed [16]. The present study adds to their finding as
the results of patients undergoing early voice therapy
were compared to those undergoing no voice therapy
mostly for logistic causes.
The present study revealed positive changes of the DSI
in both the early and late voice therapy groups, but statis-
tically significant differences were recorded only for the
early voice therapy group. It is worth mentioning that the
DSI for Egyptian patients ranged from +3 to –4. This in-
dex and its correlation to the overall grade of dysphonia
differ from those obtained by Wuyts et al. [10]. This may
reflect differences in voice quality between Dutch and
Egyptian patients and is worthy of further investigation.
Strobovideolaryngoscopic findings do not always cor-
respond to the degree of vocal impairment and thus can-
not be used as an objective reference to improvement
[12]. The present study revealed that a reduction in the
glottal gap was observed with the highest percentages of
studied participants in the early voice therapy group. The
improvement in glottal closure may be due not only to
adequate compensation of the contralateral vocal fold,
but also to the paralyzed vocal fold advancing to the mid-
242 Folia Phoniatr Logop 2014;66:237–243
DOI: 10.1159/000369167
line, owing to the activity of the interarytenoid muscle or
to passive lengthening induced by the cricothyroid mus-
cle. Moreover, glottal closure may improve due to the
compensatory activity of the inferior pharyngeal con-
strictor muscle [2]. Application of early voice therapy
may enhance these muscle actions. Glottal closure in the
present study improved even with no voice therapy, but
this may be due to spontaneous neural recovery. The im-
provement noticed in the late voice therapy group and in
those who received no voice therapy may be explained by
residual innervations and unpredictable reinnervation
and synkinesis, which maintain vocal bulk and tonus, and
may sometimes lead to spontaneous vocal recovery even
in the absence of restored vocal fold motion [20–22].
The confirmation of these suggestions would have re-
quired the use of electromyographic studies, which cannot
be denied as a potential explanation for improvements in
the early voice therapy group of the present study.
The previous findings support the hypothesis that ear-
ly intervention may enhance the results of voice therapy.
D’Alatri et al. [2] further suggested that the use of early
and appropriate behavioral voice treatment may avoid
the need for surgery in many UVFP patients, without ex-
posure to unnecessary risks.
The early voice therapy group showed better outcomes
regarding voice VPSS-20 scores and auditory-perceptual
analysis as well as DSI rates. This may indicate a powerful
relationship between the previous three aspects of out-
come measures. Early voice therapy helps using airflow to
increase the sound pressure level without increasing its
fundamental frequency, by improving the control of in-
trinsic and extrinsic laryngeal muscles, thus positively al-
tering acoustic and aerodynamic voice parameters [7].
Early onset of voice therapy may enhance the reduc-
tion in the glottal gap and the improvement of voice qual-
ity by hindering the development of hyperfunctional
compensatory behaviors; indeed, early voice therapy may
positively affect a patient’s quality of life.
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