Puberphonia (also known as mutational falsetto, functional falsetto, incomplete mutation, adolescent falsetto, or pubescent falsetto) is a functional voice disorder that is characterized by the habitual use of a high-pitched voice after puberty, hence why many refer to the disorder as resulting in a 'falsetto' voice. The voice may also be heard as breathy, rough, and lacking in power. The onset of puberphonia usually occurs in adolescence, between the ages of 11 and 15 years, at the same time as changes related to puberty are occurring. This disorder usually occurs in the absence of other communication disorders.
There is a higher male prevalence of puberphonia, as the voice disorder is characterized by a high pitch that would be inappropriate for the age and sex of the patient. Typically, individuals with puberphonia do not present with underlying anatomical abnormalities. Instead, the disorder is usually psychogenic in nature, meaning resulting from psychological or emotional factors, and stems from inappropriate use of the voice mechanism. The habitual use of a high pitch while speaking is associated with tense muscles surrounding the vocal folds. Assessment and treatment of puberphonia is usually conducted by a speech-language pathologist (S-LP) or an otolaryngologist (ENT). Puberphonia is not a disorder that is likely to go away on its own. Without treatment, the changes in the patient's voice can become permanent. Treatment can involve direct voice therapy, indirect voice therapy, or audiovisual feedback.
Signs and symptoms
During puberty, changes in the larynx typically result in a decrease in pitch in both males and females. On average, the male voice deepens by one octave while the female voice lowers by a few semitones. The fundamental frequency (pitch) of an adult female typically falls between 165 and 255 Hz and an adult male between 85 and 180 Hz. Anatomical changes during puberty include enlargement of the larynx for both sexes. However, the larynx descends and grows significantly larger in males which often results in a visible laryngeal prominence on the neck (Adam's apple). Additionally, male vocal folds become longer and thicker and resonant cavities become larger. These changes contribute to a deepening of the voice characteristic of pubescent males.
Puberphonia is characterized by the failure to transition into the lower pitched voice of adulthood. In conjunction with an atypically high pitch, common symptoms include a weak, breathy, or hoarse voice, as well as a low vocal intensity, pitch breaks, and shallow breathing.
Causes
There are a number of proposed causes for the development of puberphonia. The aetiology of puberphonia can be both organic (biological) or psychogenic (psychological) in nature. In males, however, organic causes are rare and psychogenic causes are more common.
Puberphonia is described as having three main variants, related to the level of anatomical change. The most common presentation of the condition is characterized by a normal adult larynx and an increased pitch due to the vocal folds adopting the falsetto position. A second variant can occur when the laryngeal development is prolonged during puberty. Lastly, puberphonia can occur due to an incomplete transformation of the larynx into the adult form.
Psychogenic causes
Emotional stress
Delayed development of secondary sex characteristics
Resistance to pubertal changes
Self-consciousness resulting from an early breaking of the voice
Self-consciousness resulting from emerging adulthood
Organic causes
Laryngeal muscle tension which then causes laryngeal elevation
Muscle incoordination
Congenital anomalies of the larynx
Vocal fold asymmetries
Unilateral vocal fold paralysis
Non-fusion of the thyroid laminae. When this is the case, it is important that hypogonadism is ruled out, as this may be the cause.
Assessment
To determine whether a patient presents with puberphonia, a complete voice assessment including medical and diagnostic evaluations is recommended. These assessments are performed by otorhinolaryngologists and speech-language pathologists.