Evaluating the Effectiveness and Efficiency of Voice

Therapy using Transnasal Flexible Laryngoscopy:

A Randomized Controlled Trial

*Helen J. Rattenbury, *Paul N. Carding, and †Paul Finn

*Newcastle upon Tyne and †Middlesbrough, United Kingdom

Transnasal flexible laryngoscopy (TFL) is an examination of laryngeal

anatomy and physiology using continuous light. TFL is being used increasingly
by voice pathologists in treatment but with little scientific evidence to support
it. The purpose of this study was to evaluate the effectiveness and efficiency
of TFL as a therapeutic tool. The study used a prospective randomized controlled
trial. Fifty dysphonic subjects were recruited and randomly assigned to
either a traditional treatment group or a TFL-assisted treatment group. The
effectiveness of voice therapy in both treatment groups was measured with
a package of voice outcome measures. Subjects in both treatment groups
demonstrated statistically significant improvements after voice therapy
(perceptual auditory rating of voice quality measurement p ⬍ 0.01; instrumental
electroglottographic measurement p ⬍ 0.01; patient questionnaire measurement
p ⬍ 0.01). The time taken to complete treatment in both groups was recorded.
The average (median) time taken to complete voice therapy in the TFL-
assisted treatment group was 2 hours less than in the traditional treatment
group (p ⬍ 0.01). Voice therapy with TFL as a therapy tool was effective and
more efficient than traditional voice therapy.
Key Words: Transnasal Flexible Laryngoscopy—Voice Therapy—Randomi-
sed Controlled Trial—Effectiveness—Efficiency.

INTRODUCTION a TFL examination by a voice pathologist are to

Voice pathologists have been using transnasal
flexible laryngoscopy (TFL) in their clinical prac-
tice for over 20 years.1 The main purposes of
Accepted for publication January 30, 2004.
From the *University of Newcastle, Newcastle upon Tyne,
UK; †University of Teesside, Middlesbrough, UK.
Address for correspondence: Professor Paul Carding, Depart-
ment of Speech, Voice and Swallowing, Otolaryngology, Free-
man Hospital, Freeman Road, Newcastle upon Tyne, NE7 7DN.
E-mail: paul.carding@ncl.ac.uk
Journal of Voice, Vol. 18, No. 4, pp. 522–533
0892-1997/$30.00
쑕 2004 The Voice Foundation
doi:10.1016/j.jvoice.2004.01.003
confirm the medical diagnosis,2,3 to understand the
physiological phonatory characteristics,4,5 and to
assist in the design of appropriate voice therapy
treatment.1,6 However, the scientific evidence to sup-
port this development is limited and anecdotal. This
is especially true with respect to the literature on
the therapeutic applications of TFL. These potential
therapy uses of TFL are described here.
TFL as a prognostic indicator
Specific voice therapy techniques can be used to
modify particular disorder phonatory patterns. TFL
can be used to quickly identify the most successful
voice therapy technique for a patient.5–8 The voice

522
 HELEN J. RATTENBURY ET AL
pathologist can visually observe the patient at-
tempting selected vocal manoeuvres and decide
which technique is the most successful at modifying
the aberrant physiology. In theory, this therapeutic
application of TFL should reduce the time spent
in the planning and trial stages of voice therapy.
Dejonckere and Lebacq8 report the clinical value of
prognostic indicators. Furthermore, Dejonckere and
Lebacq8 found a good correlation between success
with a voice therapy technique used as a prognostic
indicator and a full course of the same technique.
However, to date, there is very little scientific evi-
dence regarding this application of TFL.
TFL as a patient information tool
Several authors have reported the benefits of using
TFL to educate and motivate voice patients.9–11 En-
suring that the patient understands why and how his
or her voice is dysfunctional and how voice therapy
can remedy the situation is vital to the success of
treatment.3,6 Allowing the voice patient to observe
the TFL examination of his or her own vocal mecha-
nism on a television monitor (either in real time or
during video playback of the recorded examination)
can provide a more concrete concept of voice pro-
duction and understanding of the process of vocal
rehabilitation.12 A common understanding between
the voice patient and the voice pathologist promotes
better cooperation and a shared responsibility for
treatment.3
TFL as a visual laryngeal biofeedback tool
The use of TFL as a visual laryngeal biofeedback
tool allows the voice patient to view the direct results
of his or her attempts at specific voice therapy tech-
niques. The patient can try specific voice therapy
techniques with the scope in place while observing
the television monitor in real time. This application
of TFL gives the voice patient additional visual feed-
back to complement the proprioceptive and auditory
information received when phonating.1 Continued
visual laryngeal biofeedback also helps to ensure that
the patient is correctly carrying out the voice therapy
techniques. Casper and Colton13 reported that voice
patients (without the benefit of TFL) might attempt
to match the voice pathologist’s auditory model by
inadvertently ‘contorting’ their laryngeal mecha-
nism further, rather than reducing the inappropriate
523
vocal behaviours. Several benefits regarding the
use of TFL as a visual laryngeal biofeedback tool
have been reported in the literature,1,11,12 but, again,
there is little scientific evidence to prove its value.
Study goals
The purpose of this study was to evaluate TFL as a
therapeutic tool. We aimed to compare the effective-
ness and efficiency of traditional voice therapy tech-
niques and TFL-assisted voice therapy. The null
hypotheses were that voice therapy would not be effec-
tive in either treatment group and that TFL-assisted
voice therapy would offer no benefit in terms of effi-
ciency (time to complete therapy) compared with tra-
ditional voice therapy approaches.
METHODS
This study used a prospective randomized con-
trolled trial design comparing traditional voice ther-
apy and TFL-assisted voice therapy.
Subjects
Fifty consecutive subjects with muscle tension
dysphonia (MTD)14 were recruited for the study.
All subjects were diagnosed after joint medical and
voice pathology examination (including strobos-
copy) and were classified by using the Morrison
and Rammage14 criteria. Patients with minor vocal
fold lesions considered secondary to MTD (eg, minor
vocal nodules) were included. All subjects were at
least moderately perceptually dysphonic (defined as
an overall grade of at least ‘2’ on the GRBAS rating
scale15–Grade Roughness Breathiness Aesthenia
Strain, each parameter rated on a 0-3 scale). To
minimize the effect of other treatment variables,
voice patients were excluded if they exhibited any
of the following (adapted from previous prospective
voice therapy studies16): dysphonia lasting more
than 12 months,17 a medical history of significant
psychiatric or psychological illness,18 unwillingness
to attend for the complete treatment program, or
age less than 16 years.
Having satisfied the selection criteria, the voice
patients were asked to complete a consent form.
The subjects were then randomly allocated, on re-
cruitment, to 1 of the 2 treatment groups. A random
Journal of Voice, Vol. 18, No. 4, 2004
524 TRANSNASAL FLEXIBLE LARYNGOSCOPY
number generator19 was used to assign each subject
an identification number and a group (treatment
group 1 or 2). The initial 30 generated integers (of
a pool of 60) were assigned to treatment group
1 and the second 30 integers to treatment group 2.
The integers were then arranged in numerical order,
and the first subject recruited was assigned the
lowest integer and its associated treatment group.
This method allowed subjects to be randomly as-
signed into a treatment group on recruitment, ensur-
ing that equal numbers would be treated in each
group of the study.
Subjects assigned to treatment group 1 received
traditional voice therapy. Subjects assigned to treat-
ment group 2 received TFL-assisted voice therapy.
The same voice pathologist treated all subjects, re-
gardless of treatment group to minimize treatment/
therapist variables. The treating clinician had 15
years of experience treating voice patients and
8 years experience of independent TFL examina-
tions. For obvious reasons, treatment could not be
blind from the treating clinician. However, the treat-
ment goal was similar for all patients in the study:
to maximize vocal output to produce a healthy and
“normal” voice for the patient in as few sessions as
possible.
Treatment programs
The main aim of voice therapy for muscle tension
dysphonia is to correct faulty function and to modify
care and use of the vocal mechanism.20 Patients in
treatment group 1 (traditional voice therapy) were
given a combination of indirect and direct voice therapy
techniques as described elsewhere.16,21,22 Indirect
voice therapy techniques aim to manage the patient’s
voice problem by improving understanding of voice
production and encouraging modifications of sur-
roundings and lifestyle to provide ideal conditions
for good voice production. Descriptions of broad cate-
gories and specific indirect treatment techniques
are listed in Appendix 1.
‘Direct’ voice therapy techniques are designed to
modify the specific laryngeal pathophysiology being
exhibited by the voice patient (eg, specific suprag-
lottic contraction). These techniques require instruc-
tion to the patient to carry out specific laryngeal
movements aimed at reducing the disordered pattern
of phonation. Previous voice therapy studies have
Journal of Voice, Vol. 18, No. 4, 2004
used many ‘direct’ voice therapy techniques.16,21,22
These are listed in Appendix 2.
For patients in treatment group 1, the selection,
duration, and order of these voice therapy techniques
followed “traditional” and routine clinical practice.
The specific design of a MTD therapy treatment
program can be influenced by a number of factors
including the severity of the voice problem,3 the
personality of the patient,23 the patient’s understand-
ing of the problem,23 response to therapy strategies,6
therapy “trial and error” outcome,24 and the prefer-
ences of the treating voice therapist.23
Patients in treatment group 2 (TFL-assisted voice
therapy) received treatment techniques selected from
the same indirect and direct voice therapy techniques
options. However, the voice therapy techniques cho-
sen depended upon the patient’s response to the
trial of prognostic indicators. The list of prognostic
indicators and the associated voice trial techniques
are detailed in Appendix 3. In addition, the initial
TFL examination was played back to the subjects
in the TFL-assisted treatment group and the pertinent
phonatory features discussed in detail. Direct com-
parison was made to a TFL examination of a non-
dysphonic voice sample to allow the subject to further
understand his or her aberrant vocal features. Fur-
ther TFL examinations were used throughout the
therapy process in the TFL-assisted treatment group
at the discretion of the voice pathologist. The total
number of TFL procedures used with subjects in the
TFL-assisted treatment group varied depending upon
each subject’s tolerance of the scope. However, all
patients in treatment group 2 received a minimum of
2 TFL examinations during the therapy process (not
including the pretherapy diagnostic examination and
the posttherapy assessment examination).
Voice outcome measures
A package of voice-related outcome measures
was used before and after treatment to measure the
effect of voice therapy. The 2 primary voice out-
come measures were the relative change of an inde-
pendent perceptual rating of voice quality and the
patient’s report of his or her own vocal perfor-
mance. The secondary outcome measurement was
electroglottograph (EGG) analysis measurements of
frequency and amplitude perturbation (% jitter and
% shimmer).
 HELEN J. RATTENBURY ET AL
To perform the perceptual ratings of voice quality,
the subjects’ voices were recorded in a soundproofed
room with a Sony Digital Audio Tape Deck (DTC
690) with a Kenwood Stereo Integrated Amplifier
KA-3020 (Long Beach, Calif). A lapel microphone
(ECM 144, Sony, Tokyo, Japan) fixed at 10 cm from
the subject’s mouth was used to record the signal
onto the digital audiotape. The subjects were asked
to produce a sustained vowel /a:/ for several seconds
at a comfortable pitch and volume, say the days of
the week, and read the standard passage, “The Rain-
bow Passage” (Fairbanks 1960).30
Perceptual ratings of voice quality were con-
ducted with the GRBAS scale.15 The GRBAS scale is
considered by many authors to be the most reliable
auditory perceptual scale currently available for
use as an outcome measure.25,26 The GRBAS overall
parameter of ‘Grade’ has been found to demonstrate
a high level of interrater reliability (0.7)25 and has
produced a moderate test-retest correlation (0.7).26
In this study, the samples of recorded speech were
randomized, copied onto a CD, and presented to a
voice pathologist familiar with the GRBAS scale
but not associated with the study. This rater was blind
to the identity and treatment group of each sample on
the CD. Each sample was approximately 3 minutes
in duration, and the rater could listen to each sample
up to 3 times.
The patient’s report of his or her own vocal perfor-
mance was measured by using the Patient Vocal
Performance Questionnaire (VPQ).27 This is a short,
valid, and reliable measure28 and has been used in
several other substantial studies of voice therapy
effectiveness.16,29 The VPQ consists of 12 multiple-
choice questions. A total score is calculated by
summing the responses: the greater the total score
(maximum 60) the greater the impact of the voice
problem on the patient’s quality of life.
EGG measurements were made with the Laryngo-
graph processor (Laryngograph Ltd, London, United
Kingdom). This system allows analysis of both sus-
tained vowel and connected speech samples. By
using both neck electrodes and a lapel microphone,
the speech and glottal signals were measured at
the time of audio recording for samples of a sus-
tained vowel /a:/ and a sentence of the Rainbow
Passage.30 A Carrera personal computer was used
525
with the Laryngograph software to analyze the sig-
nals. Percentage jitter and shimmer for both the
vowel and connected speech samples were com-
pared before and after therapy as part of the voice
outcome measures package.
Transnasal flexible laryngoscopy (TFL)
An Olympus ENF-L3 flexible nasendoscope
(Olympus America Inc, Melville, NY) was used to
view the laryngeal structures in this study. This scope
has a field of view of 85⬚, an angulation of 130⬚,
and a distal diameter of 4.2 mm. The nasendoscope
was connected to a Sharplan iSight (8010) Digital
High Definition Camera (Lumenis, Inc, New York,
NY). A Karl Storz-Endoskope Laryngoscope
(Model 8020) (Karl Storz Gmbtt & Co KG, Tuttlingen,
Germany) was used to produce the continuous
light source (150W tungsten-halogen lamp). A
Panasonic SVHS Video Cassette Recorder/Player
(Model AG-7700, Matsushita Electric, Osaka, Japan)
recorded the image from the camera to allow replay
to the subjects and provide a permanent record of
each subject’s progress. The video monitor was
placed, for ease of viewing, to the side of the exam-
iner to allow subjects in the TFL treatment group
to observe the live examination (subjects in the tradi-
tional treatment group could not view their assess-
ment TFL examinations).
The efficiency of voice therapy
The effectiveness of voice therapy in each treat-
ment group was measured by using the above pack-
age of outcome measures. Once this measure had
been made, the relative efficiency of both treatment
approach was measured. The amount of contact time
with each subject was documented throughout the
therapy process. Each 5-minute unit of time was
broadly categorized into ‘indirect’ and ‘direct’ ther-
apy for further analysis. The total time taken for each
subject to reach the discharge criteria was calculated.
The average time for the traditional treatment group
was compared to the average time taken in the TFL-
assisted group.
Completion of voice therapy and discharge were
based on a combination of the judgment of the clini-
cian and the opinion of the subject.23 In all cases,
there was agreement between both parties that the
subject’s voice was within normal limits or had
Journal of Voice, Vol. 18, No. 4, 2004
526 TRANSNASAL FLEXIBLE LARYNGOSCOPY
made sufficient progress to allow the subject to fully
participate in vocal activities.
Statistical analysis
The statistical power of this study was calculated
before recruitment and showed that, to observe a
clinically significant result, a minimum of 10 sub-
jects per treatment group was required. The outcome
measurements before and after therapy were com-
pared, each subject being his or her own control, to
measure the effectiveness of voice therapy for each
subject. The GRBAS data were categorical (0–3),
and the nonparametric paired samples statistical test
of the Wilcoxon signed rank test was used. The VPQ
data were continuous rather than categorical, and
therefore the parametric paired samples statistical test
of the paired samples t-test was used. A number of
‘censored observations’ were necessary when ana-
lyzing the EGG data* as some signals were too
dysphonic for the Laryngograph to process before
therapy. This data, although continuous in nature, no
longer had a normal distribution, and therefore the
nonparametric Wilcoxon signed rank test was used.
For the efficiency calculations, the total amount of
contact time was summed, and the median time
taken to reach discharge in each treatment group
was calculated. Despite the fact that the data were
continuous (time), equal variances could not be
assumed between the 2 groups, and therefore a nonpara-
metric statistical test was used for independent
samples, the Mann Whitney U test.
RESULTS
Fifty dysphonic patients were recruited to the
study; 26 were randomly assigned to the traditional
*In some cases, the Laryngograph could not calculate jitter or
shimmer before therapy due to the aperiodicity of the signal in
the more dysphonic voices. It is possible that a voice that was
‘unanalyzable’ before therapy became more periodic after ther-
apy producing analyzable EGG values. It was important to in-
clude these results. The statistical method applied was that of
censored observations. The ‘unanalyzable’ cases before therapy
were assigned a figure of 100% jitter or shimmer (to indicate a
level worse than the most severe measurement). Change after
therapy was then compared to 100% jitter or shimmer before
therapy.
Journal of Voice, Vol. 18, No. 4, 2004
TABLE 1. Subject Ages
Treatment Group N Mean age (years) (SD) Range
Traditional 26 42.7 (17.0) 17–79
VLE 24 45.4 (21.1) 17–87
Total 50 44.0 (19.1) 17–87
treatment group and 24 to the TFL-assisted treatment
group. The ages of subjects are shown in Table 1.
The ratios of male to female subjects were 1:6 in
the traditional treatment group and 1:5 in the TFL-
assisted treatment group.
The effectiveness of voice therapy
The effectiveness of voice therapy was measured
by using the package of voice outcome measures
detailed above.
Perceptual rating of voice quality
The results of the perceptual rating of voice
quality (GRBAS) are shown in Tables 2 and 3.
Tables 2 and 3 present the results for all 5 of the
GRBAS parameters. The median value is quoted
due to the nonparametric nature of the results. The
p value was calculated with the Wilcoxon signed
rank test. The results show a statistically significant
improvement in these perceptual parameters (apart
from “roughness”) for subjects in both treatment
groups. It can be concluded that subjects in both
groups demonstrated a significant improvement in
a perceptual rating of their voice.
Patient questionnaire measurements
The VPQ was used to measure the impact of the
voice problem on each subject’s voice related quality
of life. This patient-completed questionnaire has 12
questions, each with 5 multiple-choice answers.
Table 4 presents the results before and after therapy
(VPQ) in each treatment group.
Subjects treated in both the traditional treatment
group and the TFL-assisted treatment group showed
statistically significant reductions in the total score
of the VPQ after voice therapy. Both types of
voice therapy proved to be effective in improving
voice-related quality of life in this study.
 HELEN J. RATTENBURY ET AL 527

TABLE 2. GRBAS Results Traditional Treatment Group

Parameter Pre-median (n ⫽ 25) Post-median (n ⫽ 26) Pre-range (n ⫽ 25) Post-range (n ⫽ 26) p value

Grade 2.0 0.0 0–3 0–3 ⬍0.01*

Roughness 1.0 1.0 0–2 0–2 0.24
Breathiness 2.0 1.0 0–3 0–2 ⬍0.01*
Aesthenia 1.0 0.0 0–3 0–2 ⬍0.01*
Strain 1.0 0.0 0–3 0–3 ⬍0.01*

*Result significant at 5% level. P values from Wilcoxon signed ranks test.

TABLE 3. GRBAS Results VLE Assisted Treatment Group

Parameter Pre-median (n ⫽ 23) Post-median (n ⫽ 24) Pre-range (n ⫽ 23) Post-range (n ⫽ 24) p value

Grade 3.0 1.0 0–3 0–3 ⬍0.01*

Roughness 1.0 1.0 0–3 0–2 0.86
Breathiness 2.0 1.0 0–3 0–3 0.01*
Aesthenia 2.0 0.0 0–3 0–3 ⬍0.01*
Strain 3.0 1.0 0–3 0–3 ⬍0.01*

*Result significant at 5% level. P values from Wilcoxon signed ranks test.

Electroglottograph (EGG) measurements
Percentage jitter and percentage shimmer were
calculated with the Laryngograph from samples of
a sustained vowel /a:/ and a sentence of the Rainbow
Passage (RP). Table 5 shows the median values of
jitter and shimmer before and after voice therapy in
both treatment groups. The table also includes the
statistical significance of any change in mea-
surements before to after therapy.
As can be seen from Table 5, all perturbation
measures showed a significant reduction after ther-
apy in both treatment groups apart from % shim-
mer (RP) in the traditional treatment group. It would
appear that the electroglottographic measurements
support the perceptual and patient ratings to suggest
that voice therapy in both of the treatment groups is
effective. However, the range measurements indicate
that these results should be treated with caution, and
the relevance of these results requires further con-
sideration and discussion.
The efficiency of voice therapy
The time take to complete voice therapy for all
subjects was documented in 5-minute units. The
median total time taken in each treatment group was
calculated and is presented, with the range of times, in
Table 6.
The median time taken to complete therapy in the
TFL-assisted treatment group was 120 minutes (2
hours) less than the median time taken in the tradi-
tional treatment group. The significance of this dif-
ference was calculated by using the nonparametric
test for 2 unrelated samples, the Mann Whitney U test.
TFL-assisted voice therapy significantly reduced
treatment time (p ⬍ 0.01) when compared with tra-
ditional voice therapy.
The time taken to complete voice therapy was
subdivided into time spent on indirect and direct
therapy techniques. The median time spent on these
activities was calculated for each treatment group.
The results are shown in Table 7.
The time spent on indirect treatment techniques
was significantly less in the TFL-assisted treatment
group compared with the traditional treatment group
(p ⬍ 0.01). Time spent on direct treatment tech-
niques in the TFL-assisted treatment group was less
than in the traditional treatment group, but the differ-
ence was not significant at the 5% level (p ⫽ 0.06).
As can be seen, the reduction in the total time taken
to complete voice therapy in the TFL-assisted treat-
ment group (the improvement in efficiency) was
mainly due to the reduction in time spent on indirect
therapy techniques.

Journal of Voice, Vol. 18, No. 4, 2004

528 TRANSNASAL FLEXIBLE LARYNGOSCOPY

TABLE 4. VPQ Results

Treatment Group n Pre-mean Pre-SD Post-mean Post-SD p value

Traditional 25 35.0 (10.6) 17.7 (4.6) ⬍0.01*

VLE-assisted 24 33.8 (8.6) 20.1 (6.5) ⬍0.01*
Total 49 34.4 (9.5) 18.8 (5.6) ⬍0.01*

*Result significant at 5% level. P values from paired samples t-test.

TABLE 5. EGG Results (v ⫽ vowel and RP ⫽ Rainbow Passage)

Median % (range)
Treatment Group Parameter Pre Post p value

Traditional % Jitter (V) 55.2 (0.1–100.0) 6.8 (0.2–80.7) ⬍0.01*

% Jitter (RP) 58.6 (3.9–100.0) 24.7 (3.5–86.4) 0.01*
% Shimmer (V) 23.8 (0.0–100.0) 0.9 (0.0–47.4) ⬍0.01*
% Shimmer (RP) 22.5 (10.3–77.5) 24.2 (6.9–78.4) 0.29
VLE assisted %Jitter (V) 84.1 (0.2–100.0) 31.2 (0.0–100.0) ⬍0.01*
% Jitter (RP) 67.6 (9.7–100.0) 19.9 (5.8–78.6) ⬍0.01*
% Shimmer (V) 45.8 (0.1–100.0) 2.7 (0.0–100.0) ⬍0.01*
% Shimmer (RP) 47.4 (8.8–100.0) 15.0 (4.1–56.3) ⬍0.01*

*Result significant at 5% level. P values from Wilcoxon signed rank test.

DISCUSSION offer no benefit to traditional voice therapy in terms

This study was the first randomized controlled
trial to evaluate the effectiveness and efficiency of
TFL-assisted voice therapy compared with a ‘tradi-
tional’ voice therapy approach.
The study hypotheses
The first null hypothesis was that there would
be no statistically significant change in voice outcome
measures after voice therapy in either treatment
group, and that voice therapy with or without TFL
would not be effective. Perceptual auditory ratings
of voice quality (with the GRBAS scale) and the
patient’s voice-related quality of life measurements
(with the VPQ) both showed significant improve-
ment after therapy for subjects in both treatment
groups. EGG measurement (with Laryngograph) of
% jitter and % shimmer also improved significantly
posttreatment in 3 of the 4 voice sample conditions.
Therefore, the first null hypothesis was rejected.
The second null hypothesis was that there would
be no statistically significant difference in the time
taken to complete voice therapy with either tradi-
tional treatment approaches or TFL-assisted voice
therapy, and that TFL-assisted voice therapy would
of efficiency. The results showed that the median
time taken to complete therapy in the TFL-assisted
treatment group was significantly less than in the
traditional treatment group. The TFL-assisted voice
therapy program was more efficient than traditional
treatment in this study. Furthermore, there was a
statistically significant difference in the time spent on
indirect voice therapy between the treatment groups,
but not with regard to time spent on direct voice
therapy. Therefore, the second null hypothesis was
also rejected.
Therapeutic issues
This study assessed the clinical value of TFL
in voice therapy by using the 3 main therapeutic
applications of the procedure (prognostic indicators,
patient information, and visual laryngeal biofeed-
back). However, further research is needed into the
individual benefits of each of these applications. It is
not possible from this study to ascertain which of
the therapeutic applications of TFL most benefited
any subject. Not all subjects in the TFL-assisted
treatment group received all 3 therapeutic applica-
tions in equal amounts due to variations in patient

Journal of Voice, Vol. 18, No. 4, 2004

 HELEN J. RATTENBURY ET AL
TABLE 6. Median Total Treatment Time (minutes)
Treatment
Group n Median Range
Traditional 26 182.5 mins (3 hrs 3 mins) 50–380 mins
VLE assisted 24 62.5 mins (1 hr 3 mins) 20–290 mins
Total 50 97.2 mins (1 hr 38 mins) 20–380 mins
tolerance to the scope. There was no measure of the
degree of facilitation used in the present study.
Some subjects were motivated by regular visual
feedback and actively requested additional TFL ex-
aminations to enable them to verify their own
proprioceptive and auditory feedback. Other subjects
were less enthusiastic and were given the minimum
of 2 TFL examinations only (n ⫽ 5/24). These sub-
jects were unable to benefit from TFL as a regular
visual laryngeal biofeedback tool. They were, how-
ever, able to view the video recording of their own
pretreatment TFL examination and compare this to
video recordings of more appropriate laryngeal
physiology. These subjects also benefited from the
use of TFL as a prognostic indicator during their
initial TFL examinations.
The list of prognostic indicators used in this study
was not exhaustive. Trials of other vocal facilitation
techniques are also likely to result in changed phona-
tory physiology. Most direct vocal rehabilitation exer-
cises have been developed based upon the effect of
the technique on the sound of the voice.31 However,
several authors1,13 have stated that the voice patient
may (temporarily) improve voice quality without im-
proving the pathophysiological phonatory pattern.
TFL-assisted prognostic trails enable the clinician to
determine the most likely route for effective treat-
ment, when both the phonatory physiological pattern
and the auditory output are improved. In certain cir-
cumstances auditory vocal improvement can be at
the expense of good phonatory habits, and this ap-
proach to phonation should be discouraged wher-
ever possible.
Methodological issues
The benefits of a randomized controlled trial
design have been well documented.32–34 It was par-
ticularly valuable in this study when 2 treatment
529
techniques were prospectively compared. Random-
ization allows assignment of the same range of se-
verity of problems to each group. The treating and
examining voice therapist was the same for all 50
subjects regardless of their treatment groups. This
ensured that clinician variables were controlled as
much as possible. However, this also meant that the
treating clinician was not blind to the treatment
group of each subject. It is also acknowledged
that it is unlikely that another clinician would be
able to deliver treatment in exactly the same way.
The relative impact of individual clinician variables
(for example, clinical judgment, wisdom, and skill
level) can be studied by using the same design with
a number of different clinicians.
This study measured treatment effectiveness by
using a number of voice outcome measures (percep-
tual auditory rating of voice quality, patient question-
naire measurement, EGG measurement). A similar
degree of change across different measurements
provides convincing evidence of treatment effec-
tiveness. The GRBAS scale15 for the perceptual au-
ditory rating of voice quality may now be superceded
by the more extensive CAPE-V Scale,35 which uses
a visual analogue format. This might have provided
even more sensitive perceptual ratings. In addition
to these outcome measures, we also systematically
documented physiological changes observed at the
TFL examination. However, this required the devel-
opment of a novel documentation tool, adapted from
previously published formats.36–38 Because this pro-
cedure has not undergone rigorous intra- and in-
terrater reliability analysis, we did not include this
data. However, it would appear that this model
of documenting phonatory behaviour during the
therapy process has further important benefits.
Further implications of the study
It is the clinician’s responsibility to ensure that
all treatment is as maximally effective and efficient as
possible. This study illustrates the effectiveness of
2 approaches to voice therapy for 50 subjects with
muscle tension dysphonia. These results further cor-
roborate with other recent voice therapy effective-
ness studies.16,29,39–41 However, analysis of voice
therapy time efficiency has not been widely reported
in the literature. Improved voice therapy efficiency
Journal of Voice, Vol. 18, No. 4, 2004
530 TRANSNASAL FLEXIBLE LARYNGOSCOPY
TABLE 7. Indirect and Direct Treatment Times
Treatment Group n Median (range)
Traditional 26
VLE assisted 24
Total 50
has several clinical implications. For the voice pa-
tient, this means that his or her voice problem and its
associated impact on quality of life can be resolved
in less time. This has obvious advantages, including
the prevention of long-term habituation of compen-
satory behaviors and maintaining patient motivation
during the therapy process. Efficient voice therapy
can also have financial advantages for service
providers.
One other implication of this study is that voice
pathologists require access to TFL to be able to
provide the full range of therapeutic applications.
This level of access might not be possible for some
departments, and collaborative arrangements might
need to be made with other centers. Financial bids
to service providers might be required. Karnell1 and
Hirano and Bless11 provide a summary of the clinical
and financial benefits of TFL to present as part of a
financial bid for more equipment. Additional scien-
tific evidence of the clinical and therapeutic benefits
of the voice pathologists’ use of TFL will further
enhance the case.
Acknowledgment: This study was supported by the
Northern and Yorkshire NHS Executive. UK grant
number RCTC69.
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APPENDIX 1—INDIRECT VOICE THERAPY TECHNIQUES

Patient education (Prater RJ, Swift RW. Manual of voice therapy. Boston, Mass: College-Hill Press; 1984)
Counselling (Prater RJ, Swift RW. Manual of voice therapy. Boston, Mass: College-Hill Press; 1984)
Auditory training (Johnson TS. VARP–voice abuse reduction program. New York, NY: Taylor & Francis; 1985)
Vocal rest program (Fawcus M. Voice disorders and their management. London: Croom Helm; 1986)
Reassurance (Martin S. Working with dysphonics. Oxon, England: Winslow Press; 1987)
General relaxation (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood Cliffs, NJ: Prentice
Hall; 1988)
Elimination of abuse-misuse (Stemple JC. Clinical voice pathology. New York, NY: Macmillan; 1984)
Voice diary (Fawcus M. Voice disorders and their management. London: Croom Helm; 1986)
Vocal hygiene program (Aronson AE. Clinical voice disorders. 2nd ed. New York: Thieme Publications; 1985)
A 10-step outline for voice abuse (Aronson AE. Clinical voice disorders. 2nd ed. New York: Thieme Publications; 1985)
Avoidance of irritants (Martin S. Working with dysphonics. Oxon, England: Winslow Press; 1987)
Environmental awareness (Fawcus M. Voice disorders and their management. London: Croom Helm; 1986)
Voice conservation advice (Martin S. Working with dysphonics. Oxon, England: Winslow Press; 1987)
Hierarchy analysis (Wilson DK. Voice problems in children. 3rd ed. Baltimore: Williams & Wilkins; 1987)

Journal of Voice, Vol. 18, No. 4, 2004

532 TRANSNASAL FLEXIBLE LARYNGOSCOPY

APPENDIX 2
Specific laryngeal relaxation (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood Cliffs,
NJ: Prentice Hall; 1988)
Yawn-sigh method (Wilson DK. Voice problems in children. 3rd ed. Baltimore: Williams & Wilkins; 1987)
Chewing technique (Wilson DK. Voice problems in children. 3rd ed. Baltimore: Williams & Wilkins; 1987)
Altering tongue position (Wilson DK. Voice problems in children. 3rd ed. Baltimore: Williams & Wilkins; 1987)
Diaphragmatic breathing (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood Cliffs, NJ:
Prentice Hall; 1988)
Coordination of breathing with phonation (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood
Cliffs, NJ: Prentice Hall; 1988)
Establishing and maintaining appropriate laryngeal tone (Wilson DK. Voice problems in children. 3rd ed.
Baltimore: Williams & Wilkins; 1987)
Pitch variation and control (Wilson DK. Voice problems in children. 3rd ed. Baltimore: Williams & Wilkins; 1987)
Reduction of vocal loudness (Fawcus M. Voice disorders and their management. London: Croom Helm; 1986)
Elimination of glottal attack (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood Cliffs,
NJ: Prentice Hall; 1988)

Establishing optimal pitch (Wilson DK. Voice problems in children. 3rd ed. Baltimore: Williams & Wilkins; 1987)

Voice ‘placing’ (Wilson DK. Voice problems in children. 3rd ed. Baltimore: Williams & Wilkins; 1987)

Developing optimal resonance (Johnson TS. VARP–voice abuse reduction program. New York: Taylor & Francis;
1985)

Specific laryngeal deconstriction techniques (Estill J. Compulsory figures of voice: a user’s guide to voice quality.
Santa Rosa, CA: Estill Voice Training Systems; 1997)

APPENDIX 3—PROGNOSTIC PROBES

(BASED UPON MORRISON AND RAMMAGE CLASSIFICATIONS)
Isometric closure pattern
Humming / mhuh huh (Harris T, Harris S. The voice clinic handbook. London: Whurr Publishers; 1998)
Yawn-Sigh (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood Cliffs, NJ: Prentice Hall; 1988)
Sob / “soft whimper” (Estill J. Compulsory figures of voice: a user’s guide to voice quality. Santa Rosa, CA: Estill
Voice Training Systems; 1997)
Glottal onset (Estill J. Compulsory figures of voice: a user’s guide to voice quality. Santa Rosa, CA: Estill Voice
Training Systems; 1997)
Glottal fry / creak (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood Cliffs, NJ: Prentice
Hall; 1988)

Glottic contraction
Yawn-Sigh (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood Cliffs, NJ: Prentice Hall; 1988)
 HELEN J. RATTENBURY ET AL 533

Glottal fry / creak (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood Cliffs, NJ: Prentice
Hall; 1988)
Humming / mhuh huh (Harris T, Harris S. The voice clinic handbook. London: Whurr Publishers; 1998)
“Breath before tone” onset (Estill J. Compulsory figures of voice: a user’s guide to voice quality. Santa Rosa, CA:
Estill Voice Training Systems; 1997)
Gentle onset and chanting (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood Cliffs, NJ:
Prentice Hall; 1988)

Supra-glottic (lateral) contraction

Yawn-Sigh (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood Cliffs, NJ: Prentice Hall; 1988)
“Breath before tone” onset (Estill J. Compulsory figures of voice: a user’s guide to voice quality. Santa Rosa, CA:
Estill Voice Training Systems; 1997)
Inspiration / expiration phonation (Harris T, Harris S. The voice clinic handbook. London: Whurr Publishers; 1998)
Laughing aloud and silent (Estill J. Compulsory figures of voice: a user’s guide to voice quality. Santa Rosa, CA:
Estill Voice Training Systems; 1997)
Glottal fry / creak (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood Cliffs, NJ: Prentice
Hall; 1988)

Anterior–posterior contraction

Changing pitch (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewoods Cliffs, NJ: Prentice
Hall; 1988)
Sirening on a trill / glissandos (Harris T, Harris S. The voice clinic handbook. London: Whurr Publishers; 1998)
Yawn / Sigh (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewoods Cliffs, NJ: Prentice Hall; 1988)
Sob or “soft whimper” (Estill J. Compulsory figures of voice: a user’s guide to voice quality. Santa Rosa, CA: Estill
Voice Training Systems; 1997)
“Breath before tone” onset (Estill J. Compulsory figures of voice: a user’s guide to voice quality. Santa Rosa, CA:
Estill Voice Training Systems; 1997)

Total incomplete adduction

Glottal onset (Estill J. Compulsory figures of voice: a user’s guide to voice quality. Santa Rosa, CA: Estill Voice
Training Systems; 1997)
Phonation from a cough (Andrews M. Manual of voice treatment: pediatrics through geriatrics. San Diego and London:
Singular Publishing Group; 1999)
Half swallow, boom (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewoods Cliffs, NJ: Prentice
Hall; 1988)
Phonation from reflex laryngeal closure (Andrews M. Manual of voice treatment: pediatrics through geriatrics. San
Diego and London: Singular Publishing Group; 1999)
Glottal fry / creak (Boone D, McFarlane SC. The voice and voice therapy. 4th ed. Englewood Cliffs, NJ: Prentice
Hall; 1988)

Journal of Voice, Vol. 18, No. 4, 2004