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Treatment for Vocal Polyps: Lips and Tongue Trill

Article · August 2016

DOI: 10.1016/j.jvoice.2016.07.003

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Daniela Vasconcelos Adriana Camargo Gomes

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Treatment for Vocal Polyps: Lips and Tongue Trill
*Daniela de Vasconcelos, †Adriana de Oliveira Camargo Gomes, and †Cláudia Marina Tavares de Araújo, *†Brazil

Summary: Vocal polyps do not have a well-defined therapeutic indication. The recommended treatment is often la-
ryngeal microsurgery, followed by postoperative speech therapy. Speech therapy as the initial treatment for polyps is a
new concept and aims to modify inappropriate vocal behavior, adjust the voice quality, and encourage regression of
the lesion. This study aimed to determine the effectiveness of the sonorous lips and tongue trill technique in the treat-
ment of vocal polyps. The sample consisted of 10 adults diagnosed with a polyp who were divided into two subgroups:
treatment and control. Ten speech therapy sessions were conducted, each lasting 30–45 minutes, based on the sono-
rous lips and tongue trill technique, accompanied by continuous guidance about vocal health. Speech therapy was effective
in three of the five participants. The number of symptoms presented by the participants decreased significantly after
voice therapy (P = 0.034) and vocal self-evaluation (P = 0.034). The acoustic evaluation showed improvements in pa-
rameters of noise values (P = 0.028) and jitter (P = 0.034). The size of the polyp and the degree of severity of dysphonia,
hoarseness, and breathiness showed a significant reduction after treatment (P = 0.043). Among the remaining two par-
ticipants, one opted out of laryngeal surgery, indicating that the improvement obtained was sufficient to avoid surgery.
The sonorous lips and tongue trill technique was thus considered effective in 60% of the participants, and as laryngeal
surgery was avoided in 80% of them, it should be considered a treatment option for vocal polyps.
Key Words: laryngeal diseases–vocal fold–dysphonia–voice–speech therapy.

INTRODUCTION and tongue trill technique was selected as a standard speech

Surgery is the predominant method of treatment of polyps on therapy protocol for further study.
the vocal folds,1 although presurgical vocal speech therapy may This technique, which is classed as a semi-occluded vocal tract
also be effective, reducing the edema associated with the polyp exercise, is indicated for patients with mass lesions in the vocal
or underlying areas and thus minimizing the area of interven- folds and individuals with occupational voice use as it pro-
tion in surgery.2 Speech therapy is indicated after surgery to suit vides smooth vocal emission and reduces the phonation effort.36–40
the vocal behavior and thus prevent recurrence of the lesion.3–6 This intervention study aimed to verify the effectiveness of
Other treatment alternatives that do not require surgery under the sonorous lips and tongue trill technique in the treatment of
general anesthesia have been reported with positive results.7–16 polyps, based on the vocal and polyp characteristics in patients
Speech therapy as the primary treatment of polyps with sub- before and after speech therapy, and to relate the result of the
sequent surgical indication in persistent hoarseness or treatment to the type and size of polyp.
dissatisfaction with the treatment outcome has also been
reported.17–21 The treatment of vocal fold polyps through speech METHODS
therapy is a noninvasive process that avoids the risks of laryn- Participants
geal surgery.22 The study sample was collected at the Clinical Hospital of Federal
Despite the growing number of publications and presenta- University of Pernambuco, during the period from April to Sep-
tions at scientific events on initial speech therapy in the treatment tember 2015, after approval by the research ethics committee
of vocal fold polyps23–29 that have demonstrated positive results of the institution (1445315). All participants provided their signed,
regardless of polyp classification, with full or partial resorp- informed consent.
tion of the injury, the standard medical intervention continues The sample consisted of 10 consecutive participants. The in-
to be surgical. 1 Other studies of different therapeutic ap- clusion criteria were patients diagnosed with polyps on the vocal
proaches have shown positive results in relation to the treatment folds and availability for speech therapy for 3 months. Patients
of vocal polyps through speech therapy.17–21,30–35 who demonstrated an inability to carry out the sonorous lips and
However, most of these studies had a retrospective design or tongue trill technique, had polyp recurrence, or had undergone
methodological biases that make it difficult to prove the effec- prior laryngeal surgery because of the possibility of iatrogenic
tiveness of speech therapy in the treatment of polyps on the vocal effects on the vocal folds that could interfere with the search
folds. Given this scientific scenario and the pressing need for results were excluded from the study.
publications with greater methodological rigor, the sonorous lips Participants were divided into two groups: treatment and
control. Each group was composed of two male and three female
participants, aged between 30 and 60 years old with a mean age
Accepted for publication July 7, 2016. of 44 years. The criteria for splitting the groups were the deci-
From the *Clinical Hospital, Federal University of Pernambuco, Brazil; and the †De- sion of the participants about surgery or speech therapy treatment.
partment of Speech Therapy, Federal University of Pernambuco, Brazil.
Address correspondence and reprint requests to Daniela de Vasconcelos, Avenida Professor The control group consisted of those who had opted for surgery.
Moraes Rego s/n, Cidade Universitária, Recife, PE, Brazil, CEP: 50670-901. E-mail:
daniela_vasconcelos@outlook.com
Journal of Voice, Vol. 31, No. 2, pp. 252.e27–252.e36 Procedures
0892-1997
© 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
All participants underwent an initial evaluation and were re-
http://dx.doi.org/10.1016/j.jvoice.2016.07.003 evaluated after 3 months. The assessment protocol consisted of
Daniela de Vasconcelos et al Lips and Tongue Trill as Treatment for Vocal Polyps 252.e28

laryngoscopy, perceptual and acoustic voice assessment, ques- of the sound (because these parts show instability), leaving about
tionnaire of vocal habits and symptoms, and vocal self-assessment. 3 seconds of the recording. Acoustic measurements of jitter,
Laryngoscopy exams were performed by a single otorhino- shimmer, proportion of glottal signal/noise excitation (glottal-
laryngologist specialist with experience in laryngology to diagnose to-noise excitation—GNE), and phonatory deviation diagram
the polyp and its characteristics, such as its location in the vocal (PDD) were extracted from this record using the VoxMetria
fold, form of insertion of the lesion on the vocal folds, polyp program (CTS Informática, Pato Branco, PR, Brazil).
type, and lesion size. Examinations were conducted using a Watec The PDD was analyzed in relation to the quadrant location
WAT-231S 1/3 inch camera (Ultra Compact Color Camera) of phonation (1 = normal, 2, 3, and 4)41 and in relation to the
(Watec, Yamagata-Ken, Japan), a halogen light source (250 watts, density of the concentrated emission points (when the points are
Diagnor, Recife, PE, Brazil), and a rigid laryngoscope (8 mm, restricted to only a square PDD) or spread (when located in two
70°, Endoview, Recife, PE, Brazil). or more square PDD).42
The polyp size was assessed using ImageJ, an image pro- The vocal register protocol Consensus Auditory-Perceptual
cessing and analysis software (National Institutes of Health, Evaluation of Voice was used for perceptual assessment. The
Bethesda, MD, USA), which allows the extraction of measure- overall severity level of parameters was analyzed, including rough-
ments of the size of the vocal fold and the size of the polyp at ness and breathiness obtained as a percentage, as recommended
the same figure to correct the variability of lesion size based on by the Consensus Auditory-Perceptual Evaluation of Voice. The
the distance from the endoscope to the vocal folds. Thus, the overall degree of severity was classified as neutral (between 0 mm
polyp size was calculated as a ratio of lesion length and the length and 34 mm), mild (between 34.1 mm and 51 mm), moderate
of the vocal fold in abduction, as in Figure 1. (between 51.1 mm and 63.5 mm), intense (between 63.6 mm and
The participants underwent vocal register recording, per- 77.5 mm), and extreme (77.5 mm above), according to the ref-
formed by the same examiner, who was a voice expert, in a quiet erence study.43
environment: the voice room of the Hospital Speech Therapy The perceptual evaluation was carried out by three speech thera-
Service. pists with more than 10 years of clinical experience in independent
Voices were recorded on an HP Notebook personal comput- and blind trials. The judges had previously gone through a 4-hour
er (Hewlett-Packard Company, Califórnia, USA) using a Karsect training program for regulation and adjustment inter-judges. For
HT-2 microphone headset (Enping Karsect Eletronics Corpo- analysis purposes, the weighted average of the scores of the three
ration, Enping, China) plus a filtration and noise reduction evaluators for each participant was used. The intraclass corre-
equipment (Andrea PureAudio USB-SA, Andrea Electronics Cor- lation coefficient (ICC) was extracted for inter- and intra-judge
poration, New York, USA). The microphone was maintained at evaluation. The inter-judge ICC was considered excellent
a distance of approximately 4 cm from the mouth at an angle (ICC ≥ 0.75) based on the Fleiss rating44 for all parameters ana-
of about 45° with the participants seated with their hands resting lyzed, with the exception of grade of breathiness (ICC = 0.66),
on their legs. which was considered satisfactory. The intra-judge ICCs were
The participants were asked to produce a comfortable vowel 0.80 (judge 1), 0.93 (judge 2), and 0.91 (judge 3), which were
/ɛ/ sustained for about 5 seconds at a comfortable intensity and considered excellent.
frequency, and this was recorded directly on the computer. The A questionnaire about vocal habits and symptoms consisted
recording was then edited, disregarding the beginning and end of nine objective questions about occupation, inadequate habits,

FIGURE 1. Length of vocal fold and polyp from ImageJ. On the left is the length of the vocal fold (A), corresponding to 148.95 μm, and on the
right is the length of the polyp (B), corresponding to 49.74 μm. In this example, the polyp was equivalent to 33.39% of the length of the vocal
fold, as described below:

a → 100%
b ∗ 100 49, 74 ∗ 100
b → x% x= x= x = 33, 39%
a 148, 95
252.e29 Journal of Voice, Vol. 31, No. 2, 2017

hydration, main symptoms, duration of symptoms, and time of Wilcoxon test as appropriate. In all statistical analyses, we adopted
laryngeal polyp diagnosis. The self-assessment of the degree of a significance level of less than 5% (P < 0.05).
dysphonia was analyzed using a visual analog scale (VAS)
of 100 mm, where zero corresponds to normal and 100 to a severe RESULTS
vocal problem. The characteristics of the treatment group and control group are
shown in Table 1. There was no difference between groups with
Treatment regard to gender, occupational use of the voice, hydration, du-
Speech therapy consisted of 10 sessions of 30–45 minutes long, ration of symptoms, or time of diagnosis of the polyp.
once a week. At each meeting, activities related to vocal health Table 2 presents the results of the laryngology evaluation, which
guidelines were performed, and participants were given con- demonstrated that all polyps were located in the middle third
ducts regarding daily exercises. and freeboard of the vocal folds. Polyps classified as having an
The vocal health guidelines were conducted through aware- indefinite location were those that occupy more than one third
ness of the pathophysiology of the polyp, physiology of the lips of the vocal fold, including the middle third. The control group
and tongue trill technique, vocal self-perception, and factors that included the only cases of pedicle and fibrous polyp within the
interfere negatively in vocal production throughout the treat- study population.
ment period. For this purpose, we used videos, pictures, and a The findings of the auditory perceptual and acoustic voice as-
preestablished protocol specially designed for this study. sessment are shown in Tables 3 and 4, respectively. The evaluation
The vocal exercises were performed in the sitting position, with showed vocal homogeneity between the groups, with the ex-
hands resting on legs, for the longest phonation time that was com- ception of mild vocal severity and the PDD quadrant.
fortable, and at habitual frequency and intensity. The participant The results of analysis of differences between the initial as-
was instructed to perform each exercise for 3 minutes. In between sessment and the reassessment after treatment are shown in
exercises, the participant was instructed to drink water and to report Table 5. There was a significant difference in vocal self-
any physical or perceptual symptoms and ask any questions. assessment, polyp size, perceptual evaluation, and acoustic
During the sessions, the patient underwent 3 minutes of each assessment in the treatment group after the intervention.
variation of the sonorous lips trill or tongue trill technique, start- The main characteristics and individual changes in the study
ing with comfortable continuous production (without variation participants are shown in Table 6. After speech therapy, the polyps
of frequency or intensity), evolving into variations such as cra- in patients 2 and 4 had completely regressed and their vocal pa-
dling (simulating frequency variations needed when singing a rameters were normal. Patient 3 showed vocal adaptation after
baby’s lullaby), siren (modulating variation between two com- speech therapy, despite the absence of total polyp regression. Thus,
fortable frequencies, simulating the sound of an ambulance siren), speech therapy was effective for three of the five participants
and singing the tune of “Happy Birthday To You.” These changes who presented with vocal adaptation.
were introduced gradually, so that at the end of the second session,
the patient was performing the four techniques for 3 minutes each. DISCUSSION
None of the participants showed any symptoms of vocal fatigue The treatment group and the control group, each consisting of
or related laryngeal discomfort. five participants, showed very similar population characteris-
Participants pledged to carry out the lips trill or tongue trill tics (Table 1). These differences were centered on the number
in the reported sequence, three to five times a day, every day and type of symptoms presented and the vocal self-evaluation
of the week, and to keep a daily record according to the prees- (VAS). The number of symptoms was higher in the treatment
tablished protocol. The average output was 3.2 times daily. group, although the impact of dysphonia was more intense in
the control group (VAS). The high perception of dysphonia in
Therapeutic evaluation the control group may have played a decisive role in favor of
At the end of 10 sessions, participants underwent vocal and la- immediate laryngeal surgery. In contrast, the average number of
ryngeal reevaluation following the same protocols applied at the associated symptoms, which was higher in the treatment group,
first assessment. They also answered the questionnaire of vocal was not high enough to indicate the surgical option in this group,
habits and symptoms and performed the vocal self-evaluation. who preferred the initial speech therapy treatment.
For the data analysis, speech therapy was considered an ef- As in the vocal self-evaluation, the control group showed
fective treatment of polyps on the vocal folds when the following greater severity of voice alteration than did the treatment group
were observed: total regression of polyp (no injury) and vocal (Table 3). Roughness and breathiness were the most affected pa-
adaptation (neutral severity of dysphonia); total regression of polyp rameters in both groups, as reported by Cielo et al.45 Vibratory
and vocal improvement (mild severity of dysphonia); or partial irregularity of the affected vocal fold causes the characteristic
regression of polyp (decrease in lesion size) and vocal adaptation. roughness, whereas injury to the glottis causes breathiness.46
In the review study conducted by Cielo et al,45 the main level
Statistical treatment of dysphonia was moderate, whereas in this study, four out of
All data were stored in SPSS Statistics Base 18 (IBM, Armonk, five respondents (80%) were classified as having moderate to
NY, USA). The distribution of normality was verified using the severe dysphonia (Table 3). This divergence could be linked to
Shapiro-Wilk test, and comparisons between groups were made the classification model used. The current study used the
using the parametric paired Student t test or nonparametric International Classification of Functioning, Disability and Health,
Daniela de Vasconcelos et al Lips and Tongue Trill as Treatment for Vocal Polyps 252.e30

TABLE 1.
Study Population Characteristics
Study Population
Treatment Group Control Group
N=5 N=5
Variables n % Mean n % Mean
Sex
Male 2 40 2 40
Female 3 60 3 60
Age (y) 49.0 38.8
30–49 3 60 5 100
50–69 2 40 — —
Occupational voice use 3 60 3 60
Inadequate habits* 2.6 2.0
Tabagism 1 20 — —
Intensive use of voice 4 80 3 60
Vocal abuse 5 100 4 80
Sing with effort 3 60 3 60
Signals and 4.8 3.6
symptoms*
Hoarseness 5 100 5 100
Hawk 3 60 3 60
Dry throat 4 80 2 40
Pharyngeal globus 5 100 2 40
Dry cough 3 60 — —
Pain — — 1 20
Burn 3 60 1 20
Fatigue 2 40 4 80
Hydride consumption/day (L) 1.4 1.5
Duration of symptoms (mo) 11.4 11.0
Time of laryngeal diagnosis (mo) 4.2 4.0
Vocal self-evaluation (VAS) (%) 52 62
* For more than one case, there were several inadequate habits and various symptoms.
Abbreviation: VAS, visual analog scale, 100 mm.

which is based on the measurement of a problem on a five- Importantly, the participant with early moderate dysphonia had
point scale,43 whereas most of the studies analyzed by Cielo et mild dysphonia after treatment and presented results of 36%
al45 probably used the four-point Grade, Roughness, Breathiness, degree of overall severity of dysphonia, nearly to the normal cutoff
Asthenia, Strain (GRBAS) scale, which is widely used clini- of 34% used in the study, including normal roughness values
cally and in vocal research. and breathiness. These data can best be seen in Table 6. This
The overall severity of dysphonia, roughness, and breathiness participant did not achieve complete regression of the lesion or
showed a significant change after speech therapy in our study voice adaptation, but he chose not to undergo laryngeal surgery
(P = 0.043), as reported by other authors.31,33,34 After speech as he considered his voice to be satisfactory after treatment. His
therapy, of the three patients with moderate to intense dyspho- final vocal self-evaluation confirmed his view, if we consider the
nia, only one stayed at the moderate level (Table 6). Thus, three same cutoff point used for the normal range of vocal quality in
participants (60%) had vocal adaptation (neutral level) and one the perceptual evaluation.
(20%) showed light vocal changes, giving an overall signifi- Regarding the acoustic analysis, the treatment group and the
cant result when considering the average for the treatment group control group were homogenous, with less than 20% variation
after the intervention (P = 0.043) in which all parameters (overall in all parameters except the PDD quadrant (Table 4). For this
severity of dysphonia, roughness, and breathiness) were within parameter, the control group was concentrated in quadrants 2
the normal range, whereas the same parameters remained un- and 3, whereas the treatment group was distributed in all quad-
changed in the control group (Table 5). Similarly, Iwaki et al31 rants. It is noteworthy, however, that one patient in the treatment
reported an improvement in voice perceptual evaluation after vocal group was located in quadrant 1, considered normal,41 at the time
therapy in patients with polyps, mainly in terms of roughness, of the initial evaluation. By the time of reevaluation, all members
and Schindler et al33,34 reported an improvement in the overall of the treatment group were in quadrant 1, whereas in the control
severity of dysphonia. group no cases of normalcy were observed (Table 5), which
252.e31 Journal of Voice, Vol. 31, No. 2, 2017

TABLE 2. TABLE 4.
Vocal Polyp Characteristics Acoustical Assessment of Voice
Vocal Polyp Vocal Quality
Treatment Control Treatment Control
Group Group Group Group
N=5 N=5 Total N=5 N=5 Total
Variables n % n % % Variables n % n % %
Location Jitter
Anterior third — — — — — Normal (0.0%–0.6%) 2 40 2 40 40
Medium third 5 100 3 60 80 Altered (>0.6%) 3 60 3 60 60
Posterior third — — — — — Shimmer
Indefinite — — 2 40 20 Normal (0.0%–6.5%) 3 60 2 40 50
Position Altered (>6.5%) 2 40 3 60 50
Superior surface — — — — — GNE
Freeboard 5 100 5 100 100 Normal (0.5dB–1.0dB) 3 60 2 40 50
Inferior surface — — — — — Altered (<0.5dB) 2 40 3 60 50
Form PDD—quadrant*
Sessile 5 100 4 80 90 1 (Normal) 1 20 — — 10
Pediculate — — 1 20 10 2 2 40 2 40 40
Kind 3 1 20 3 60 40
Gelatinous 2 40 1 20 30 4 1 20 — — 10
Fibrous — — 1 20 10 PDD—density†
Angiomatous 3 60 3 60 60 Concentrated (Normal) 1 20 1 20 20
Size* Spread 4 80 4 80 80
Small (<25%) 2 40 1 20 30 * Classified according to Pifaia et al.41
Medium (≥25% ≤ 33.3%) 1 20 — — 10 †
Classified according to Madazio et al.42
Large (>33.3%) 2 40 4 80 60
* Classified according to Cho et al.30

a graphical representation of vocal quality.41 Modification of these

corroborates the effectiveness of speech therapy on vocal quality original patterns by speech therapy interferes with the graphi-
in participants in this study. cal representation of the PDD, changing the location of the vocal
The PDD is a VoxMetria feature that uses combined acous- register on the graph. It is expected, therefore, that improve-
tic parameters (jitter, shimmer, correlation, and GNE) to produce ment in acoustic parameters will be reflected in closer positioning

TABLE 3.
Perceptual Assessment of Voice
Vocal Quality
Treatment Control
Group Group
N=5 N=5 Total
Variables n % n % %
Overall degree of severity*
Neutral (≤34 mm) — — — — —
Mild (>34 mm ≤ 51 mm) 2 40 — — 20
Moderate (>51 mm ≤ 63.5 mm) 2 40 2 40 40
Intense (>63.5 mm ≤ 77.5 mm) 1 20 3 60 40
Extreme (>77.5 mm) — — — — —
Roughness†
Normal (≤34 mm) — — — — —
Altered (>34 mm) 5 100 5 100 100
Breathiness†
Normal (≤34 mm) 1 20 1 20 20
Altered (>34 mm) 4 80 4 80 80
* Classified according to Martins et al.43
†
Normal cutoff point according to Martins et al.43
Daniela de Vasconcelos et al Lips and Tongue Trill as Treatment for Vocal Polyps 252.e32

TABLE 5.
Main Variables at Time of Initial Assessment and Reassessment
Treatment Group Control Group
Assessment Reassessment Assessment Reassessment
Variables Mean Mean P Value Mean Mean P Value
Number of symtoms 5 2 0.034* 4 5 0.374†
Vocal self-evaluation (%) 52 30 0.034* 62 64 0.317*
Polyp size (%) 28 8 0.043* 44 54 0.366†
Perceptual voice Evaluation
Global severity (%) 53 29 0.043* 67 63 0.500*
Roughness (%) 52 28 0.043* 65 63 0.893*
Breathiness (%) 38 15 0.043* 53 52 0.500*
Acoustic voice Evaluation
Jitter (%) 2.00 0.19 0.043* 2.18 2.15 1.000*
Shimmer (%) 8.37 3.78 0.152† 9.10 9.52 0.849†
GNE (dB) 0.54 0.79 0.028† 0.43 0.40 0.853†
n n n n
PDD—quadrant‡ 0.066† 0.317*
1 (Normal) 1 5 — —
2 2 — 2 1
3 1 — 3 4
4 1 — — —
PDD—density§ 0.083* 0.317*
Concentrated (Normal) 1 4 1 —
Spread 4 1 4 5
n = number of subjects.
Values in bold correspond to P < 0.05.
* Wilcoxon test.
†
Student t test.
‡
Classified according to Pifaia et al.41
§
Classified according to Madazio et al.42

to the normal pattern in PDD (quadrant 1),42 as observed in our that polyps located in the anterior third of the vocal folds or pe-
study (Table 5). dunculated polyps interfere less in the vibration of the vocal folds,
With regard to the density phonation represented in PDD, the however have better noise measurements. We were unable to make
adapted voices have concentrated density as altered voices have similar inferences in our study because no polyp was located
spread density similar to than in Madazio et al.42 In our study, in the anterior third (Table 2). Nevertheless, the noise values
the treatment group had concentrated density after speech therapy (GNE) after speech therapy were within the normal range in the
in four of the five patients (80%), whereas in the control group treatment group, with a significant increase in the GNE average,
all members showed spread density in the reevaluation (Table 5), whereas in the control group, the GNE remained altered (Table 5).
corroborating the proposition of Madazio et al.42 Our results are consistent with those of Dursun et al.47
The acoustic measurements that showed significant changes Regarding the effect of speech therapy on the regression of
after speech therapy were jitter and GNE (Table 5), as reported injury, whereas the size of the polyp in the treatment group sig-
in other studies.33,46 The average value of shimmer in the treat- nificantly decreased (P = 0.043) (Table 5), it increased in two
ment group was within the normal range after speech therapy, patients in the control group, doubling in size in one of them.
although the change in this parameter following treatment was The lack of modification of vocally inappropriate behavior owing
not considered significant, whereas it remained altered in the to the absence of speech therapy may have led to greater fric-
control group. A similar result was reported by Schindler et al,34 tion between the vocal folds and the consequent increase in the
where shimmer showed a significant improvement in patients size of the lesion in the two aforementioned cases. This fact high-
with polyps after speech therapy. lights the importance of modification of vocal behavior for those
According to Dursun et al,47 jitter values may be altered slightly waiting for surgery or other treatments such as medication or
in patients with small polyps and to a greater extent in larger acupuncture.
polyps, because the polyp size directly affects the intensity of In our study, the two polyps that showed complete regres-
the vibration of the vocal fold irregularity. Thus, a reduction in sion after speech therapy were initially large (37.0% and 38.0%)
polyp size with speech therapy should lower jitter values to within and also showed the most effective results in relation to vocal
the normal range, as observed in this study. The authors also stated quality after the intervention (neutral degree of vocal alteration),
 252.e33
TABLE 6.
Main Variables per Patient
Variables Patient 1 Patient 2 Patient 3 Patient 4 Patient 5
Sex Female Male Male Female Female
Polyp type Gelatinous Angiomatous Angiomatous Gelatinous Angiomatous
Assessment Reassessment Assessment Reassessment Assessment Reassessment Assessment Reassessment Assessment Reassessment
Number of symptoms 5 2 4 1 4 1 5 3 6 3
Polyp size (%) 18 15 37 0 22 15 38 0 26 12
Polyp size classification* Small Small Large Absent Small Small Large Absent Medium Small
Vocal characteristics
Vocal self-evaluation (%) 71 51 41 20 50 21 52 29 48 29
Dysphonia classification† Moderate Moderate Mild Neutral Mild Neutral Intense Neutral Moderate Mild
Global severity (%) 58 55 41 17 44 7 69 30 55 36
Roughness (%) 56 55 40 17 42 7 68 29 53 32
Breathiness (%) 44 34 29 0 35 0 35 10 49 33
Jitter Altered Normal Normal Normal Normal Normal Altered Normal Altered Normal
Shimmer Altered Altered Normal Normal Normal Normal Altered Normal Normal Normal
GNE Normal Normal Normal Normal Altered Normal Normal Normal Altered Normal
PDD quadrant‡ 2 1 1 1 4 1 2 1 3 1
PDD density§ Spread Concentrated Spread Concentrated Concentrated Concentrated Spread Concentrated Spread Spread
* Classified according to Cho et al.30

Journal of Voice, Vol. 31, No. 2, 2017

†
Classified according to Martins et al.43
‡
Classified according to Pifaia et al.41
§
Classified according to Madazio et al.42
Daniela de Vasconcelos et al Lips and Tongue Trill as Treatment for Vocal Polyps 252.e34

as can be seen in Table 6 (patients 2 and 4). This illustrates that the vocal folds,60 improves mucus wave motion,54,59 provides more
speech therapy can be extended to larger polyps, whereas it is periodic vibrations,36 and optimizes the circulation of fluid in
currently recommended mainly for small polyps.19–21,30 the tissue of vocal folds,61 thus making the observed outcome
There was no relationship between polyp size and voice quality possible.
in participants in our study. Whereas patients 3, 4, and 5 showed The differential of this study is therefore focused on the pro-
a trend for a relationship between the size of the polyp and the spective design and controlled intervention, along with
vocal quality during the evaluation (Table 6), opposite situa- consideration of vocal adequacy associated with regression of
tions were observed in patients 1 and 2, with the presence of the polyp following treatment, although the sample size was so
moderate dysphonia and a small polyp in patient 1, and mild small that other studies are required using the same methodology.
dysphonia and a large polyp in patient 2. At the time of reevalu- The patient’s choice with regard to the possibilities of treat-
ation, small polyps were associated with mild and moderate ment must also be taken into consideration. As mentioned by
dysphonia in two participants (1 and 5). These differences dem- Garret and Francis,49 the principal is not to define which treat-
onstrate that voice quality is a multidimensional condition that ment is more effective, but to give the patient the choice of
differs from individual to individual, depending on numerous conservative treatment (nonsurgical) that could produce satis-
factors such as the intensity and frequency of inappropriate factory results.
vocal behavior or influence of associated disorders (allergy, It is important to note that the participant who showed partial
pharyngolaryngeal reflux, hormonal changes). It cannot be related regression of lesion size and improved voice quality declined
to a single interfering factor such as the size of the lesion. laryngeal surgery after considering his vocal improvement to be
On this basis, it was not possible to infer a relationship between satisfactory. Thus, speech therapy removed the need for laryn-
vocal quality in the initial evaluation and treatment outcome. The geal surgery in four of the five study participants, and may, in
small sample size considered in this study may have prevented fact, be selected as first-line treatment for angiomatous or ge-
the finding of the relationship between polyp size and voice latinous polyps.
quality referred to in other studies.30,45,46,48–50
Similarly, there seems to be no relation between the type of CONCLUSIONS
polyp and the result of speech therapy, although Cohen and Improvement in the parameters of severity of dysphonia, rough-
Garret17 suggested a greater response to speech therapy in ge- ness, breathiness, jitter, GNE, PDD, vocal self-evaluation, and
latinous polyps (translucent). In our study, total resorption after polyp size indicated the potential of the sonorous lips or tongue
speech therapy as well as regression were observed in both ge- trill for use in speech therapy to treat polyps on vocal folds.
latinous and angiomatous polyps (Table 6). Most studies When considering the change in polyp size and voice quality,
addressing the effectiveness of speech therapy for polyps on the we found that speech therapy as the initial treatment for polyps
vocal folds were limited in the type of polyp analyzed, making on vocal folds was effective in three of the five participants (60%),
it difficult to establish comparisons with regard to this and prevented laryngeal surgery in four (80%) of them.
characteristic.19,20,30–35 Based on the data in this study, speech therapy should be con-
It is noteworthy that several previous studies on speech therapy sidered an initial treatment option for polyps on vocal folds,
for vocal polyps did not address voice assessment.17,19–21,30 This regardless of the type and size of the polyp.
fact commits the results of these studies were based only on vocal
self-evaluation or polyp size to establish the effectiveness of treat-
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