The Re-education of the Voice

Article published in the journal Vie Médicale (no. 20-2), 2 May 1974, by Dr Alfred A. Tomatis.

Within the framework of the proposed theme, devoted to dysphonia, re-education holds a quite specific place. It aims to restore a normal voice to a subject formerly endowed with a phonation, if not excellent, at least correctly developed. Vocal reconstitution, carried out from often largely damaged or even mutilated organs, is practised according to different techniques whose essential principles are evoked in this article.

The author has chosen to split this account in two parts, each corresponding in fact to a school. The one, structured around a method which deserves, by its antiquity, the designation “traditional”; the other, which has seized the modern acquisitions offered by electronics and which is more particularly suggested by the cybernetic conceptions of language, in particular the audio-phonic regulation loops.

The methods “usually” employed will consist in palliating to the maximum the damage that may have been produced, in preventing it from recurring; or they will contribute to using to best advantage the elements that remain in place after medical or surgical mutilation. As regards the use of modern techniques, the re-educational aspect appears in its unitary principle. This viewpoint may doubtless lead to a too simplistic study of a procedure hastily labelled a “standard” method. Yet its unity is not only apparent: it is real, since it remains centred on the fact that it is a question of restoring above all the desire to communicate phonically and, on the basis of this desire, of structuring the audio-vocal monitoring circuits.

The different causes which entail dysphonia are grouped in this collection, and the order in which they are distributed indeed corresponds to that encountered in function of their frequency. But, whether functional or organic, these alterations entail identical vocal damage whose characteristics we shall now study.

To do this, it seems necessary to define what a good voice is so as to know the criteria from which proper re-education will be elaborated. The latter must indeed intervene in function of the different parameters inherent in an emission of quality and bearing on intensity, height and timbre.

In a voice, one distinguishes the fundamental sound and the harmonics. The fundamental sounds are produced by the laryngeal, buccal or labial constriction, while timbre bears witness to the reinforcement effect produced by the so-called “resonance” cavities: thorax, sub- and supra-laryngeal, pharyngeal, buccal, nasal, sinusoidal cavities, cranial vault, etc. On the mixture of these multiple resonances depends the “quality”, which is the specific and recognisable side of a voice.

For a voice to be “well placed”, the ratio of the harmonics to the fundamental sound (that is, to the first formant, to use a more physico-acoustic term) must be very positive. This characteristic, which we call H/F, in fact determines the output of the harmonic cavities in function of the laryngeal sound. What matters indeed is to be able to make sound without thereby making major efforts. Any emission which requires laryngeal fatigue is defective, and the H/F ratio inverts or modifies itself in such a way that the excited cavity becomes dominant. Let us cite for example the case of nasalised voices which excite above all the nasal cavities to the detriment of the others [fig. 1].

When there is dysphonia, there is alteration of the voice in its different parameters. Hoarseness is the major sign and follows the modification of timbre. One is then faced with a so-called “deepened” voice — an expression which suggests that the voice is not only altered, but that its emission seems to incline towards low sonorities; for the different harmonics are lowered, in the sense that the fundamental sounds have become considerably more prominent than the high harmonics, often non-existent or in any case strongly diminished.

Re-education will consist in restoring to the voice its characteristics bearing on the emission of the fundamental sound and on its reinforcement at the level of the resonance cavities. Numerous elements will have to be considered for the re-establishment of the spoken or sung act; the phonic function having to be decomposed into its various constituents: emission proper and its respiratory support.

The traditional methods will intervene solely on the laryngo-pharyngo-buccal apparatus at various points of support brought to light by recent phonetic research, while the new school will principally use audio-vocal counter-reactions, leaving a predominant place to the function of listening.

The traditional method

Therapeutic schema. It aims, by mechanical means bearing on the laryngo-bucco-pharyngeal apparatus, to restore to the vocal organ its synergistic possibilities, and relies on the classical principles of voice placement, which we shall study here in a very simplified manner.

There exists a generating source — the larynx — and a modifying ensemble, mobile in various parts. This distribution, which I willingly call “the phonetic fan”, is, in the case of a perfect emission, very open towards the front, as though the subject were given the possibility of pushing to the maximum the mobile anterior branch of the fan — the posterior branch lying at the level of the larynx. By contrast, in a poorly developed voice placement, there is a closing of the fan towards the posterior part, with projection of the emission towards the rear, entailing with it a posterior compression of the whole articulation [fig. 2].

Re-education will consist in opening the fan as far forward as possible, in order to carry the voice “into the mask” — to use a falsely consecrated formula — and to set in play the various resonance cavities which will engender the high harmonics and enrich the timbre. To this end, the re-educator must make the patient aware of several movements concerning respiration, posture, the place of the tongue and the buccal aperture.

Respiration

It is at the very foundation of the re-establishment of the phonic function and goes hand in hand with a harmonious distribution of the forces of air emission and of those of sound. There exists a kind of supple tension, close to a state of relaxation, which it is necessary to teach by insisting particularly on the just homogeneous distribution of the tensions of the different muscle groups, with the preservation of suppleness.

Posture

It also plays a very important role in the field of re-education. For there to be a maximum bringing into resonance of the sub- and supra-jacent cavities, it is necessary to obtain from the person being re-educated a correct position of head and body. The spinal column must be straightened, avoiding the lumbar hollow and the curve at the cervical level. Which will require of the patient that he learn to replace his pelvis, to open his thorax, to situate his clavicles on a horizontal plane, to draw his shoulder blades back.

The position of the tongue

Respiration being acquired, posture being established, the phonic exercise begins. It consists in teaching the patient to recognise the elementary sensations of phonation, to reveal to him how the tongue is placed, how it positions itself in the mouth during defective phonation and how it must function in a good emission. To this end, the re-educator must make sensible the linguo-palatal point of support of the phoneme [g] — pronounced as in the word “key” [fig. 3]. A transverse barrier is installed, which divides the curve of the tongue into two parts: the one anterior, buccal; the other posterior, pharyngeal. This barrier can be moved at will. If it withdraws, the voice is altered; by contrast, as it advances, the timbre lights up and the associated vowel takes on an ever brighter brilliance, corresponding to the opening of “the phonetic fan”.

The buccal aperture

In another stage, in addition to the first three, the notions of aperture of the mouth are taught, as well as the awareness of the movements proper to the lips. The type buccal aperture, achieved in function of the vowel, is all the better felt as the boundary of the [g] has been integrated and as it installs itself automatically in the anterior part of the mouth. From then on, the patient is considerably helped by the fact that his vowel action henceforth places itself in function of this barrier and that the vowels situate themselves in front of it.

The table of the opening of the mouth, observed in a mirror by the patient himself, is then useful for allowing re-education to advance faster. Each vowel having its own resonance cavity, it is necessary to observe the corresponding buccal aperture. The patient must learn to regulate his phonation in function of this aperture and to consider that each vowel is engaged with the [g]. The posterior part of the barrier of the [g] is thus freed by adding the retroaction of the vowel upon the supra-laryngeal resonance. There is then ignition of the anterior cavity and not interference of the latter upon the resonance proper to the vowel; the vowel translating the sound emitted by a cavity whose physico-acoustic characteristics are those corresponding to the volume inherent in this vowel.

Such are the main data the re-educator of phonation must know, to transmit to the patient entrusted to him. It goes without saying that he must himself possess a phonatory system of good quality, express himself with a well-placed voice, have a hearing capable of analysing the imperfections of the subject to be re-educated. He must also have perfectly integrated the proprioceptive sensations he is called to teach in the course of the working sessions, which requires of him a very advanced vocal education.

The audio-vocal method

Onto the modes of traditional re-education, centred essentially on the different stages of phonation — larynx, tongue, lungs, etc. — there has been grafted for some twenty years now a modern technique which has allowed the introduction of a more global approach to phonation: the setting in action of the auditory circuits. Indeed, the audio-vocal counter-reactions have completely reformed all previously acquired conceptions, by the demonstration of the regulation circuits which direct underneath all the cybernetic monitorings of the laryngeal mechanics.

In this approach to the reconstitution of the voice from the new data of auditory physiology, the listening factor plays a primordial role as a stimulating and regulating element of the spoken function. The essential share that the ear holds in the domain of phonation has been too long forgotten. It is yet an element of the first importance which intervenes permanently in all the processes of monitoring voice and language.

The human ear thus becomes the receptor of a cybernetic circuit allowing the engagement of the audio-vocal counter-reactions that are at the foundation of the modern techniques of voice re-education. It is known that upon the auditory apparatus depends balance, but also posture and notably verticality, a determining factor in the elaboration of the phonatory act. On it also depends the greater part of cortical recharge thanks to the stimulations it gathers in the part of the high frequencies, the richest in cells of Corti. The energy thus transmitted ensures the activity of the laryngeal apparatus, whose neuronal reign is bound up with that of the auditory apparatus.

To amplify the possibilities of listening, to increase cortical recharge, to widen the ear’s faculties of analysis up to the highest frequencies, to structure the audio-vocal monitoring circuits: such are the objectives pursued by the techniques recently developed in the field of voice re-education. By intervening on the ear and through counter-reaction, results are obtained on phonation which regularises itself in its various parameters and, in particular, on the plane of timbre.

The dysphonic submitted to these techniques recovers a clear, modulated voice, rich in high harmonics. His respiration normalises and thus allows the larynx to play its role of sound emitter within the limits of air pressure necessary for the vibration of the cords. His phonation projects forward, owing to a better integration of high frequencies.

All this can only be explained insofar as one restores to the ear the importance to which it is entitled in the domain of psycho-sensory monitorings. The auditory nerve holds an essential place on the bodily plane, since it innervates all the anterior horns of the spinal cord. By this fact, every muscle of the body is concerned by the setting in action of the auditory apparatus, and in particular the muscles of the face whose ontogenetic origins are closely linked to those of the muscles of the middle ear. Let us also note that the tympanum is innervated, in its external part, by the pneumogastric nerve, which holds under its sway the innervation of the larynx in its sensory and motor parts, as well as that of the pharynx, lungs, heart and viscera. It is thus understood that, when the tympanum tenses itself in a certain way, it can influence the neuronal reigns dependent on the X^th pair.

It is difficult, within the limits allotted, to expand further on the influence of the ear in the psycho-sensory domain. Let us only say that the techniques of audio-vocal re-education are destined to bring to the auditory apparatus the stimulations that should permit the tonification of the being and the structuring of the monitoring circuits of the spoken and sung voice by fortifying right laterality. They are conducted with the help of electronic mountings capable of triggering audio-vocal conditionings, causing the ear to pass successively from a state of muscular release — and thereby of non-listening — to a posture of listening and of perfect analysis over the whole range of frequencies, thanks to a system of filters allowing the modulation of information. The latter is distributed either by a high-fidelity tape recorder, or by the subject himself who speaks into a microphone; the latter returns the sound to him, modified by the apparatus, in a headset he wears on his head. The two earphones are adjusted in such a way that, little by little, the right earphone becomes dominant, in order to make the right ear the directing ear. It is known indeed that the latter has the power to monitor all the parameters of voice and language. For cases of dysphonia, it regulates timbre, normalising at the same time the height and intensity of phonation.

We have seen that the ear is a factor of balance and verticality, and that it intervenes directly in the domain of posture. One conceives that it may, in another measure, intervene upon pharyngo-buccal kinetics, thanks to the intimate relations it presents on the ontogenetic plane with the muscles of the face and those innervated by the IX^th pair. Moreover, the auricular branch of the X^th pair explains in large part the influence of the ear upon the larynx and the respiratory function which, as we have seen, are very much concerned in the problem of phonation.

The results acquired by these modern techniques are incomparably superior and much more rapid than those obtained by classical means. They call upon a physiological, even a psycho-physiological, reconstruction, recreating in reality, beyond the impulse circuits, the desire for communication. Thanks to the energy transmitted by the charging sounds — high frequencies — and to the self-monitoring progressively put in place, the phonatory apparatus resumes its normal functions. The interest of these new techniques comes from the fact that they require the use of an apparatus of easy handling which does not constantly require the re-educator’s intervention, while allowing a rapid self-monitoring by the patient.

Conclusion

In this article intended to propose means for helping the dysphonic, we have tried to bring out the great principles enabling the therapist to intervene effectively. To be sure, this can only be an overview of the techniques of vocal re-education, and the field of action in which the generality of dysphonias is inscribed must necessarily be stylised. An aside however demands to be included: that having to do, on the one hand, with recurrential disorders with paralysis and, on the other, with the dysphonias consequent upon large surgical ablations with exeresis of the phonatory apparatus. For these two well-determined categories, special techniques must be envisaged. It is useful to specify, however, that the methods employed in a classical way encounter, in these cases, considerable difficulties in restoring to the subject a timbred voice, while, through audio-phonic counter-reaction, much more satisfactory results are obtained — even when it is a question of the education of an oesophageal voice.

It is evident that the different methods we have just evoked may readily come together. The audio-vocal re-educational undertaking does not in any way dispense the re-educator from insisting on the processes of respiration, posture, vowelisation, etc. It is in sum a question of two complementary techniques and not, as one is often inclined to believe, of two schools at odds. All means are to be put to work to help the dysphonic recover his voice.

It is known, at present, that the loss of phonation strongly affects the deep layers of the being in his various structures — psychic, mental, physical —, to the point of disturbing the whole of his personality. And one knows the somato-psychic counter-reactions that such a consequence may trigger. This is why it is indispensable to find the solutions to satisfy the imperious need man feels to communicate with his environment, a need itself organised on the basis of a process which leads the Being towards Listening.

Bibliography

• Cours international de Phonologie et de Phoniatrie. — La Voix, 1953, Maloine, Paris.

• Tarneaud J. — Traité pratique de Phonologie et de Phoniatrie, 1961, Maloine, Paris.

• Tomatis A. A. — Relations entre l’Audition et la Phonation, 1954, G.A.L.F.

• Tomatis A. A. — L’Oreille et le Langage, 1963, Éditions du Seuil, Microcosme Collection.

• Tomatis A. A. — Vers l’Écoute Humaine, 1974, ESF, Sciences de l’Éducation Collection.

— Pr Alfred A. Tomatis, journal Vie Médicale*, no. 20-2, 2 May 1974, pp. 2588-2591.*

Illustrated pages from the original document

Pages of the PDF facsimile containing figures, diagrams or audiograms. Depending on the original layout, certain pages may appear in landscape orientation.

Page 5 of the facsimile