Glottal Area Research Articles

Treatment effectiveness for aging changes in the larynx.

To compare the effectiveness of injection augmentation and bilateral thyroplasty surgery in managing age-related changes of the larynx. Retrospective chart review of patients treated with bilateral thyroplasty and/or injection augmentation. We evaluated 22 patients before and after treatment using: 1) normalized glottal gap area and normalized true vocal fold width from endoscopic images; 2) patient self-rating questionnaires; and 3) acoustic and aerodynamic measures. Thyroplasty surgery resulted in 38% of patients demonstrating less bowing compared to 33% after injection, and 63% demonstrated less supraglottic activity compared to 43% after injection (P = 0.09). Change in mean Voice-Related Quality of Life (V-RQOL) scores was 25.5 after thyroplasty compared to -16.4 after injection (P < 0.05). Those exhibiting a greater than 20 change in V-RQOL after treatment were significantly more likely to report swallowing symptoms pretreatment. Patients postinjection did not rate themselves on any questionnaires as significantly better compared to pretreatment, whereas patients post-thyroplasty rated themselves as significantly improved on all questionnaires. Patients post-thyroplasty rated their voices as significantly closer to their best voice than patients postinjection. Likewise, 64% of patients who had thyroplasty surgery reported a significant treatment effect compared to 33% for injection augmentation. 4. Laryngoscope, 127:2572-2577, 2017.

High-Speed Imaging to Study an Auto-Oscillating Vocal Fold Replica for Different Initial Conditions

Experiments on mechanical deformable vocal folds replicas are important in physical studies of human voice production to understand the underlying fluid–structure interaction. At current date, most experiments are performed for constant initial conditions with respect to structural as well as geometrical features. Varying those conditions requires manual intervention, which might affect reproducibility and hence the quality of experimental results. In this work, a setup is described which allows setting elastic and geometrical initial conditions in an automated way for a deformable vocal fold replica. High-speed imaging is integrated in the setup in order to decorrelate elastic and geometrical features. This way, reproducible, accurate and systematic measurements can be performed for prescribed initial conditions of glottal area, mean upstream pressure and vocal fold elasticity. Moreover, quantification of geometrical features during auto-oscillation is shown to contribute to the experimental characterization and understanding.

Temporal Segmentation for Laryngeal High-Speed Videoendoscopy in Connected Speech

This study proposes a gradient-based method for temporal segmentation of laryngeal high-speed videoendoscopy (HSV) data obtained during connected speech. A custom-developed HSV system coupled with a flexible fiberoptic nasolaryngoscope was used to record one vocally normal female participant during reading of the "Rainbow Passage." A gradient-based algorithm was developed to generate a motion window. When applied to the HSV data, the motion window acted as a filter tracking the location of the vibrating vocal folds. The glottal area waveform was estimated using a statistical-based image-processing approach. The vocal fold vibratory frequency was computed by an autocorrelation-based extraction of the fundamental frequency (f0) from the glottal area waveform. Temporal segmentation was then performed based on the f0 contour and automatic detection of the epiglottic obstructions. Additionally, visual temporal segmentation was performed by viewing the HSV images frame by frame to determine the time points of the vocalization onsets and offsets, and the epiglottic obstructions of the glottis. The time points resulting from the automatic and visual temporal segmentation methods were cross-validated. The f0-contour patterns of rise and fall resulting from the automatic algorithm were found to be in agreement with the visual inspection of the vibratory frequency change in the HSV data. This study demonstrated the feasibility of automatic temporal segmentation of HSV imaging of connected speech, which allows for mapping the video content into onsets, offsets, and epiglottic obstructions for each vocalization. Automated analysis of HSV imaging of connected speech has significant clinical potential for advancing instrumental voice assessment protocols.

Partial neuromuscular block impairs arytenoid abduction during hypercarbic challenge in anesthetized dogs

ObjectiveTo evaluate the effect of two levels of partial neuromuscular block (NMB) on arytenoid abduction, tidal volume (VT) and peak inspiratory flow (PIF) in response to a hypercarbic challenge in anesthetized dogs. Study designProspective laboratory study. AnimalsEleven healthy male Beagle dogs aged 3–5 years. MethodsDogs were anesthetized with propofol and dexmedetomidine infusions. The rima glottidis was observed via an endoscope placed through a laryngeal mask airway. Atracurium infusion was titrated to obtain two levels of partial NMB. The normalized glottal gap area (NGGA; glottal gap area normalized to height squared of rima glottidis) at peak inspiration during a hypercarbic challenge (10% CO2 inspired for 1 minute) was measured at baseline, during mild [train-of-four (TOF) ratio 0.4–0.6] and shallow (TOF ratio 0.7–0.9) NMB, and 30 minutes after spontaneous recovery from NMB. The VT and PIF were measured at the same time points and compared using anova for repeated measures and Tukey’s post hoc tests. ResultsThe NGGA and VT were significantly lower than baseline during both levels of partial NMB with no difference between mild and shallow NMB (p < 0.05). They returned to baseline values after spontaneous recovery from NMB. PIF was not altered significantly during partial NMB. Conclusions and clinical relevanceThe NGGA and VT at peak inspiration in response to a hypercarbic challenge were reduced during partial NMB block, with decreased abduction of the arytenoid cartilages. This dysfunction was present even at shallow levels of NMB.

Glottal Gap tracking by a continuous background modeling using inpainting.

The visual examination of the vibration patterns of the vocal folds is an essential method to understand the phonation process and diagnose voice disorders. However, a detailed analysis of the phonation based on this technique requires a manual or a semi-automatic segmentation of the glottal area, which is difficult and time consuming. The present work presents a cuasi-automatic framework to accurately segment the glottal area introducing several techniques not explored before in the state of the art. The method takes advantage of the possibility of a minimal user intervention for those cases where the automatic computation fails. The presented method shows a reliable delimitation of the glottal gap, achieving an average improvement of 13 and 18% with respect to two other approaches found in the literature, while reducing the error of wrong detection of total closure instants. Additionally, the results suggest that the set of validation guidelines proposed can be used to standardize the criteria of accuracy and efficiency of the segmentation algorithms.

Dynamics of the Driving Force During the Normal Vocal Fold Vibration Cycle

Intraglottal pressure is the driving force of vocal fold vibration. Theoretically, simultaneous quantification of glottal area and transglottal airflow allows the calculation of the intraglottal pressure waveform during a single vibration cycle. In this study, we show that, by combining photoglottography (transglottal light transmission) and airflow (Rothenberg mask) measurements during sustained vocal emissions in vivo, the intraglottal pressure wave can be approximated in a way similar to what has been done in models. The results confirm in vivo that the intraglottal pressure is systematically larger during the opening phase than during the closing phase, so that over one whole cycle, the driving force performs net positive work, accounting for sustained vocal fold motion. A component of this driving force asymmetry is related to vocal tract inertance, which also accounts for the skewing of the airflow waveform compared with the area waveform. Furthermore, the intraglottal pressure ratio (opening:closing) increases with voicing intensity, reaches a maximum around 76 dB, and significantly decreases at higher intensities. This rise and fall suggests that there is a range of intensity values in which, mechanically, a maximum of the driving force is imparted to the vocal fold mass. This finding could have implications for voice economy in professional speakers.

Laryngeal evidence for the first and second passaggio in professionally trained sopranos.

IntroductionDue to a lack of empirical data, the current understanding of the laryngeal mechanics in the passaggio regions (i.e., the fundamental frequency ranges where vocal registration events usually occur) of the female singing voice is still limited.Material and methodsIn this study the first and second passaggio regions of 10 professionally trained female classical soprano singers were analyzed. The sopranos performed pitch glides from A3 (ƒo = 220 Hz) to A4 (ƒo = 440 Hz) and from A4 (ƒo = 440 Hz) to A5 (ƒo = 880 Hz) on the vowel [iː]. Vocal fold vibration was assessed with trans-nasal high speed videoendoscopy at 20,000 fps, complemented by simultaneous electroglottographic (EGG) and acoustic recordings. Register breaks were perceptually rated by 12 voice experts. Voice stability was documented with the EGG-based sample entropy. Glottal opening and closing patterns during the passaggi were analyzed, supplemented with open quotient data extracted from the glottal area waveform.ResultsIn both the first and the second passaggio, variations of vocal fold vibration patterns were found. Four distinct patterns emerged: smooth transitions with either increasing or decreasing durations of glottal closure, abrupt register transitions, and intermediate loss of vocal fold contact. Audible register transitions (in both the first and second passaggi) generally coincided with higher sample entropy values and higher open quotient variance through the respective passaggi.ConclusionsNoteworthy vocal fold oscillatory registration events occur in both the first and the second passaggio even in professional sopranos. The respective transitions are hypothesized to be caused by either (a) a change of laryngeal biomechanical properties; or by (b) vocal tract resonance effects, constituting level 2 source-filter interactions.

Oscillatory Onset and Offset in Young Vocally Healthy Adults Across Various Measurement Methods

This study aimed to investigate the relationship between (1) oscillatory onset-offset time across various approaches that use different measurement criteria and (2) oscillatory onset and offset times in vocally healthy young adults. Oscillatory onset-offset times were obtained from 71 vocally normal adults, using high-speed videoendoscopy. Comparisons between the different onset methods involved measurement of the oscillatory onset time (OOT), voice initiation period (VIP), and the phonation onset time (POT), and for offset methods involved computation of the oscillatory offset time (OOToff) and the phonation offset time. Correlation of the OOT with the VIP was 0.240 (P = 0.04) and with the POT form glottal area waveform was 0.248 (P = 0.04); however, correlation between the VIP and the POT glottal area waveform was 0.661 (P < 0.001). For offset, there was a moderate correlation (rS = 0.503, P < 0.001) across OOToff and vocal offset period. The onset time was longest for the OOT followed by the VIP and the POT. There was no correlation between onset and offset for all methods. A framework for quantification of oscillatory onset-offset time was developed for /hi/ tasks, which can be used for future measurements of disordered voice. A positive relationship was observed between VIP and POT and between OOToff and vocal offset period. There was a nonlinear relationship between the OOT, VIP, and POT measures. Onset-offset times are strongly influenced by the calculation method used, the pros and cons of which are discussed in this paper. Vibratory onset and offset represent physiologically different phenomena.

Relevant reduction effect with a modified thermoplastic mask of rotational error for glottic cancer in IMRT

The purpose of this study was to analyze the glottis rotational error (GRE) by using a thermoplastic mask for patients with the glottic cancer undergoing intensity-modulated radiation therapy (IMRT). We selected 20 patients with glottic cancer who had received IMRT by using the tomotherapy. The image modalities with both kilovoltage computed tomography (planning kVCT) and megavoltage CT (daily MVCT) images were used for evaluating the error. Six anatomical landmarks in the image were defined to evaluate a correlation between the absolute GRE (°) and the length of contact with the underlying skin of the patient by the mask (mask, mm). We also statistically analyzed the results by using the Pearson’s correlation coefficient and a linear regression analysis (P <0.05). The mask and the absolute GRE were verified to have a statistical correlation (P < 0.01). We found a statistical significance for each parameter in the linear regression analysis (mask versus absolute roll: P = 0.004 [P < 0.05]; mask versus 3D-error: P = 0.000 [P < 0.05]). The range of the 3D-errors with contact by the mask was from 1.2% - 39.7% between the maximumand no-contact case in this study. A thermoplastic mask with a tight, increased contact area may possibly contribute to the uncertainty of the reproducibility as a variation of the absolute GRE. Thus, we suggest that a modified mask, such as one that covers only the glottis area, can significantly reduce the patients’ setup errors during the treatment.

Characterization of Vocal Fold Vibration in Sulcus Vocalis Using High-Speed Digital Imaging.

The aim of the present study was to qualitatively and quantitatively characterize vocal fold vibrations in sulcus vocalis by high-speed digital imaging (HSDI) and to clarify the correlations between HSDI-derived parameters and traditional vocal parameters. HSDI was performed in 20 vocally healthy subjects (8 men and 12 women) and 41 patients with sulcus vocalis (33 men and 8 women). Then HSDI data were evaluated by assessing the visual-perceptual rating, digital kymography, and glottal area waveform. Patients with sulcus vocalis frequently had spindle-shaped glottal gaps and a decreased mucosal wave. Compared with the control group, the sulcus vocalis group showed higher open quotient as well as a shorter duration of the visible mucosal wave, a smaller speed index, and a smaller glottal area difference index ([maximal glottal area - minimal glottal area]/maximal glottal area). These parameters deteriorated in order of the control group and Type I, II, and III sulcus vocalis. There were no gender-related differences. Strong correlations were noted between the open quotient and the type of sulcus vocalis. HSDI was an effective method for documenting the characteristics of vocal fold vibrations in patients with sulcus vocalis and estimating the severity of dysphonia.

The Influence of Vowels on Vocal Fold Dynamics in the Tenor's Passaggio

The influence of vowels on the frequency region where registration events in male voices usually occur (passaggio) has not yet been clarified. Particularly, for tenors who frequently have to sing across the passaggio, it might be assumed that the vowel quality has an influence on the stability of phonation. In this investigation, six professionally trained Western classical tenors performed a glide from A3 (220 Hz) to A4 (440 Hz) and were recorded using high-speed videoendoscopy at 20,000 fps via transnasal flexible endoscopy. The participants produced transitions (1) from modal register to falsetto and (2) from modal register to stage voice above the passaggio on the vowels [aː], [iː], and [uː]. Simultaneously, acoustic and electroglottographic (EGG) signals were recorded. The glottal area waveform (GAW) open quotient (OQ), the EGG OQ, and the sample entropy derived from the EGG were calculated and phonovibrograms were established. In comparison to [iː] and [uː], vowel [aː] showed lower values regarding the sample entropy and greater periodicity in the phonovibrograms during the passaggio. For [iː] and [uː], the falsetto showed greater GAW OQ than the stage voice above the passaggio but no great difference for vowel [aː]. There was a good agreement between GAW OQ and EGG OQ for GAW OQ values below .65. However, for values greater than .65, the EGG OQ showed greater disagreement. The data support the hypothesis that the vowel condition influences the phonatory stability concerning the passaggio, suggesting that vowel [aː] is associated with greater phonation stability.

Automatic and quantitative measurement of laryngeal video stroboscopic images.

The laryngeal video stroboscope is an important instrument for physicians to analyze abnormalities and diseases in the glottal area. Stroboscope has been widely used around the world. However, without quantized indices, physicians can only make subjective judgment on glottal images. We designed a new laser projection marking module and applied it onto the laryngeal video stroboscope to provide scale conversion reference parameters for glottal imaging and to convert the physiological parameters of glottis. Image processing technology was used to segment the important image regions of interest. Information of the glottis was quantified, and the vocal fold image segmentation system was completed to assist clinical diagnosis and increase accuracy. Regarding image processing, histogram equalization was used to enhance glottis image contrast. The center weighted median filters image noise while retaining the texture of the glottal image. Statistical threshold determination was used for automatic segmentation of a glottal image. As the glottis image contains saliva and light spots, which are classified as the noise of the image, noise was eliminated by erosion, expansion, disconnection, and closure techniques to highlight the vocal area. We also used image processing to automatically identify an image of vocal fold region in order to quantify information from the glottal image, such as glottal area, vocal fold perimeter, vocal fold length, glottal width, and vocal fold angle. The quantized glottis image database was created to assist physicians in diagnosing glottis diseases more objectively.

Sensitivity of Source-Filter Interaction to Specific Vocal Tract Shapes.

A systematic variation of length and cross-sectional area of specific segments of the vocal tract (trachea to lips) was conducted computationally to quantify the effects of source-filter interaction. A one-dimensional Navier-Stokes (transmission line) solution was used to compute peak glottal airflow, maximum flow declination rate, and formant ripple on glottal flow for Level 1 (aero-acoustic) interactions. For Level 2 (tissue movement) interaction, peak glottal area, phonation threshold pressure, and deviation in fo were quantified. Results show that the ventricle, the false-fold glottis, the conus elasticus entry, and the laryngeal vestibule are the regions to which acoustic variables are most sensitive. Generally, any narrow section of the vocal tract increases the degree of interaction, both in terms of its length and its cross-sectional area. The closer the narrow section is to the vocal folds, the greater the effect.

Comparison of Videostroboscopy to Stroboscopy Derived From High-Speed Videoendoscopy for Evaluating Patients With Vocal Fold Mass Lesions.

Videostroboscopy (VS) uses an indirect physiological signal to predict the phase of the vocal fold vibratory cycle for sampling. Simulated stroboscopy (SS) extracts the phase of the glottal cycle directly from the changing glottal area in the high-speed videoendoscopy (HSV) image sequence. The purpose of this study is to determine the reliability of SS relative to VS for clinical assessment of vocal fold vibratory function in patients with mass lesions. VS and SS recordings were obtained from 28 patients with vocal fold mass lesions before and after phonomicrosurgery and 17 controls who were vocally healthy. Two clinicians rated clinically relevant vocal fold vibratory features using both imaging techniques, indicated their internal level of confidence in the accuracy of their ratings, and provided reasons for low or no confidence. SS had fewer asynchronous image sequences than VS. Vibratory outcomes were able to be computed for more patients using SS. In addition, raters demonstrated better interrater reliability and reported equal or higher levels of confidence using SS than VS. Stroboscopic techniques on the basis of extracting the phase directly from the HSV image sequence are more reliable than acoustic-based VS. Findings suggest that SS derived from high-speed videoendoscopy is a promising improvement over current VS systems.

High-speed Videolaryngoscopy: Quantitative Parameters of Glottal Area Waveforms and High-speed Kymography in Healthy Individuals

We conducted a study to obtain quantitative parameters of the vocal dynamic using high-speed videolaryngoscopy and to characterize the vocal fold vibration pattern of healthy individuals by analyzing glottal area waveforms and high-speed kymography. Laryngeal images of 45 healthy individuals were captured using high-speed videolaryngoscopy. The open and speed quotients of the glottal area waveforms and high-speed kymography were obtained and statistically analyzed according to the gender of each individual. Glottal area waveforms revealed average values of 0.85 and 1.16 for open and speed quotients, respectively, for women, and 0.70 and 1.19 for men. Using high-speed kymography, quantitative parameters of open and speed quotients for women were 0.62 and 1.02, respectively, and for men were 0.57 and 1.12. By gender, a significant statistical difference emerged for open quotients obtained from both glottal area waveforms (P = 0.004) and high-speed kymography (P = 0.013). Obtained by using computational tools specifically for analyzing laryngeal images from high-speed videolaryngoscopy, quantitative parameters of glottal area waveforms and high-speed kymography in healthy individuals provide reference data and normality for future studies.

Relationship Between Acoustic Voice Onset and Offset and Selected Instances of Oscillatory Onset and Offset in Young Healthy Men and Women

This study aimed to investigate the relationship between (1) onset of the acoustic signal (X1a) and prephonatory phases associated with oscillatory onset and (2) offset of the acoustic signal (X2a) with the postphonatory events associated with oscillatory offset across vocally healthy adults. High-speed videoendoscopy was captured simultaneously with the acoustic signal during repeated production of /hi.hi.hi/ at typical pitch and loudness from 56 vocally healthy adults (aged 20-42 years; 21 men, 35 women). The relationships between the acoustic sound pressure signal and oscillatory onset and offset events from the glottal area waveforms (GAWs) were statistically investigated using a multivariate linear regression analysis. The X1a is a significant predictor of the onset of first oscillatory motion (X1g) and onset of sustained oscillations (X2g). X1a as well as gender are significant predictors of the first medial contact of the vocal folds (X1.5g). The X2a is a significant predictor of the first instance of oscillatory offset (X3g), first instance of incomplete glottal closure (X3.5g), and complete cessation of (vocal fold) oscillatory motion (X4g). The acoustic signal onset is closely related to the X1.5g, but the latency between these events is longer for women compared to men. The X2a occurs immediately after incomplete glottal adduction. The emerging normative group latencies between the onset and offset of the acoustic and the GAW from this study appear promising for future investigations.

Effects of Volume, Pitch, and Phonation Type on Oscillation Initiation and Termination Phases Investigated With High-speed Videoendoscopy

This study aimed to investigate the effects of varying volume, pitch, and phonation types on the initiation and termination phases of vocal fold oscillation using high-speed digital videoendoscopy. Specifically, it addressed the effects of the variation of volume, pitch, and phonation type (normal, pressed, and breathy) on the transient duration of the vibrating glottal length (length transient duration, Tlen), the transient duration of the glottal area waveform (area transient duration, Tarea), the time offset between the beginning (or the end) of the full-length vibration and the full-amplitude vibration, TΔ, and the variation of the fundamental frequency during the vocal fold oscillation initiation and termination segments (pitch instability, %PI). A female subject with no voice problem produced voices with varying pitch and loudness, including comfortable pitch and comfortable loudness, normal pitch loud, high pitch and comfortable loudness, and high pitch and loud. Breathy and pressed phonations were also recorded. Each of the six phonation types was recorded six times, which resulted in 72 transient segments (each recording included both initiation and termination phases). Mixed model statistical analyses were employed to the five objective high-speed digital videoendoscopy parameters. Preliminary findings demonstrated significant findings for voice type effects for the length and area transient durations for the oscillation initiation segment but not for the oscillation termination segment. This study demonstrates that voice types appear to influence vibration initiation patterns more than the vibration termination patterns.

Control of the glottal configuration in ex vivo human models: quantitative anatomy for clinical and experimental practices.

The objective of this paper was to identify the determining factors of the glottal prephonatory configuration from the point of view of the resulting muscular actions (i.e., arytenoids adduction, membranous vocal fold adduction, and tension). 21 human non-embalmed excised larynges (12 females and 9 males) were studied. Experiment A (11 larynges) studied four conditions of adduction of the vocal folds and arytenoids. Experiment B (10 larynges) studied the effect of cricothyroid approximation on the vocal fold length and the cricothyroid angle. Experiment A: The mean glottal area significantly decreased from 41.2mm2 mean with no adduction, to 10.2mm2 mean with arytenoid adduction, to 9.2mm2 with membranous vocal fold adduction, and down to 1.1mm2 with the combination of arytenoid and membranous adduction. The effect of the task was statistically significant. Experiment B: The length of vocal folds increased from 13.61mm median to 14.48mm median, and the cricothyroid angle decreased of 10.05 median along with cricothyroid approximation. The results of experiment A emphasize the sub-division of adductor intrinsic muscles in arytenoids adductors (i.e., LCA and IA), and membranous vocal fold adductor (i.e., TA). The results of experiment B quantify the effect of cricothyroid approximation on the vocal folds length. The implications of these results can be useful in both clinical practice and experimental studies.

Oscillatory Characteristics of the Vocal Folds Across the Tenor Passaggio

Recent research has revealed that classically trained tenors tend to constrict epilaryngeal structures when singing in and above the passaggio (ie, the frequency region where register events typically occur). These constrictions complicate visibility of vocal fold oscillatory patterns with transoral rigid high-speed video endoscopy, thus limiting the current understanding of laryngeal dynamics in the passaggio region of tenors. This investigation analyzed seven professionally trained western classical tenors using high-speed digital imaging (HSDI) at 20,000 frames per second via transnasal flexible endoscopy. The participants produced transitions (a) from modal to falsetto register and (b) from modal to stage voice above the passaggio (SVaP) during ascending pitch glides from A3 (220 Hz) to A4 (440 Hz) on vowel /i/. HSDI data were complemented by simultaneous acoustic and electroglottographic recordings. For many subjects both transition types were associated with constrictions of the epilaryngeal structures during the pitch glide. These constrictions appeared to be more distinct for the SVaP than for falsetto. No major irregularities of vocal fold oscillations in the sense of fundamental frequency jumps were observed for either transition type. However, during the transitions, the open quotient derived from the glottal area waveform (OQGAW) increased; in falsetto, the OQGAW was greater and the electroglottographic cepstral peak prominence was lower than in SVaP. Epilaryngeal constrictions should be considered typical for tenors singing at high fundamental frequencies. Vocal fold oscillatory patterns are changing not only for the register shift from modal to falsetto but also for the transition from modal to SVaP, indicating a need for laryngeal adjustments during these transitions.

The influence of water resistance therapy on vocal fold vibration: a high-speed digital imaging study

Purpose: This study investigated the influence of tube phonation into water on vocal fold vibration.Method: Eight participants were analyzed via high-speed digital imaging while phonating into a silicon tube with the free end submerged into water. Two test sequences were studied: (1) phonation pre, during, and post tube submerged 5 cm into water; and (2) phonation into tube submerged 5 cm, 10 cm, and 18 cm into water. Several glottal area parameters were calculated using phonovibrograms.Results: The results showed individual differences. However, certain trends were possible to identify based on similar results found for the majority of participants. Amplitude-to-length ratio, harmonic-to-noise ratio, and spectral flatness (derived from glottal area) decreased for all tube immersion depths, while glottal closing quotient increased for 10 cm immersion and contact quotient for 18 cm immersion. Closed quotient decreased during phonation into the tube at 5 cm depth, and jitter decreased during and after it.Conclusion: Results suggest that the depth of tube submersion appears to have an effect on phonation. Shallow immersion seems to promote smoother and more stable phonation, while deeper immersion may involve increased respiratory and glottal effort to compensate for the increased supraglottal resistance. This disparity, which is dependent upon the degree of flow resistance, should be considered when choosing treatment exercises for patients with various diagnoses, namely hyperfunctional or hypofunctional dysphonia.