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mise à jour du
16 octobre 2003
Auris. Nasus.Larynx
Bio-feedback and the yawning breath pattern in voice therapy: a clinical trial
Jia Hao Xu, Yoshimitsu IKEDA, Sohtaro KomIYAMA
Department of ORL, KyushuUniversity, Fukuoka, Japan
Bâillements, chants et relaxation le cas de Anna D


Proper control of respiration is necessary for optimal vocalization in singing devised by singers and voice teachers may be useful also in a clinical setting for treating patients with vocal problems. We have adopted the diaphragm breath support method developed by singing teachers. We call this method the "yawning breath pattern" (YBP) method, because patients seem to understand this term better than the original term in treating patients suffering from singer's nodules (N), recurrent laryngeal nerve paralysis (RNP), and incomplete glottal closure (IGQ associated with chronic laryngitis and sulcus vocalis. They were taught to correct their breathing by using this breath pattern.
When yawning, during the exhalation stage, the diaphragm and the lower part of the chest are kept in a sustained extended state. This situation may justly be regarded as an important part of breath technique not only in singing vocalization, but also in voice therapy practice.
In this report, we describe the details of this method in our clinical trial and its efficacy by evaluating the results for 91 patients who were treated with the YBP method. The evaluations included a voice test, a laryngoscopie examination, an evaluation of the patient's subjective improvement, and the patient's ability to master the YBP technique as evaluated by the therapist.
The results showed an extension of the patient's voice range, an increase of voice intensity, and a decrease in the air flow rate compared to pre-treatment. The laryngoscopie examination, the patients' subjective evaluation of their symptom showed the same improvement. This clinical attempt indicated that most patients can master this special breath technique when vocalizing and that their symptoms can be removed or improved distinctly after this therapy. It also tended to show a relationship between clinical efficacy and the patients' ability to practice this breath pattern as evaluated from the YBP curves. [...]
Discussion : Background of the clinical study jor YBP wice therapy. There have been many significant basic studies on the relation between hurnan voice and respiration using EMG. There have shown that respiration is one of the most important factors in good voice production.
Brodnitz (1971), Lin (1960), And Hixon, Goldman, and Mead (1973) observed the kinematics of the chest and abdominal wall, and emphasized that respiratory movement plays an important role in improving voice efficiency. Their significant experiments have demonstrated emphatically that a strong relationship exists between respiratory disorders and organic changes or dysfunctions of the vocal folds. Many reports from voice clinics have indicated similar results about this close correlationship between voice and respiration.
However, typically in voice work, the examination, and analysis of the respiratory mechanism has usually not been given sufficient attention. Clinical studies on the improvement of respiratory function in voice production is still insufficient in voice clinical work. There have been great advances in the field of phoniatrie surgery of late, but there are still not many adequate treatment for those dysphonic patients who are not suitable for phono-surgery. The necessity for the scientific examination and investigation on the respiratory mechanism in voice has not been recognized sufficiently. To fill this need, we developed a conservative method which employs a technique used to teach voice students, to aid and teach patients with voice problem and diseases to use their breath and voice correctiv. To develop an effective conservative treatment for voice dysfunctions, it is necessary and important to check and adjust the patients' breath pattern during respiration and vocalization.

The use of biofeedback to shape behavior and to classify the ability to practice the YBP method. This is an attempt to use instrumental bio-feedback to learn a special respiratory technique. The technique makes it casier for patients to learn to adjust their breath pattern effectively. The latter is normally very difficult work both for the learner and for the therapist without bio-feedback. Also it offers the therapist a technique for observing objectively the kinematics of the patient's rib cage, and for evaluating the patient's performance. According to their ability to practice the YBP, the shape of curves shown on the monitor can be classified into 3 types depending on the ability of the diaphragm and the other inhalation muscles to support or control the breath during phonation. This clinical experiment showed that most of the patients, after an average of about three months' outpatient treatment, improved from their original production curve ("d") to a better one. The results of voice examinations and the subjective improvement evaluations both significantly agree with the therapists' evaluation of the patients' ability to perform the YBP vocalization from the kinematic curves.

The relationship behveen the patients' ability to master the YBP and the results of voice examination. As shown in Figs. 3 and 5 (also Tables 3 and 5), the statistical results were divided into Group A (best), Group B (better), and Group C (normal). The results indicated that the better the patients' ability to master the YBP were the better the results of voice examination, Comparing Group A to Group I, B to II, and C to III, one notes a correspondence between the voice examination and YBP curve classification. This is especially true for patients with nodules. However, for cases of recurrent laryngeal nerve paralysis (RNP) and incomplete glottal closure (IGC), the results were somewhat incongruous. For those patients with IGC and RNP, it seems that an improvement of the symptom appeared before they were able to master the YBP technique perfectly.

The relationship between achieved YBP curves and subjective improvment. As shown in Figs. 3 and 5 (also Tables 3 and 5), each suitable data pair shows a a strong correlation. These results indicates that the patients' ability to master the yawning breath pattern is related to their subjective improvement. Therefore, the greater the effort which is made to master the YBP, the more improvement is seen in the respiratory curve, and the greater is the degree of subjective improvement felt by the patients.

The YBP method in voice therapy. At present, western opera singers are taught a method of vocalization using the YBP. This pattern is usually used only when yawning. As a technique for effect singing, it permits the maximum expression of the human voice. If dysphonia originates from attempting to phonation beyond the individual's ability, the YBP will be very useful for expanding their vocal ability. Eventhough there is no ultimately difference between patients' ability to master the YBP, a sustained effort on the part of the patients is needed in the first 2-3 weeks to master this technique. They have to practice the YBP as much as possible, at least 30 min every day. The clinical findings indicate that much practice causes a remarkable improvement in the symptoms. This YBP method requires no medication and no voice rest, and is shown to be an effective therapy in our clinics.

Directions for the future study of voice therapy. The YBP was used as the breath technique of Bel Canto. It is somewhat difficult to give a definition of this great singing technique, however it is a fact that this special breath technique which permits great expression in the human voice, has been proved, further, this technique is being utilized skillfully by present singers and their teachers. But in the field of phoniatries, the relationship between breath and voice phonophysiology has not been investigated sufficiently. Hence our laboratory has been interested in investigating aerodynarnics and the observation of breath patterns. For scientific effect of continuously maintaining the constrictive pulling state of the diaphragm and the low position of larynx when vocalizing by the YBP. By studying the basic relationship between breathing and voice, and the quantitative analysis between breath curve's change and breath pattern further, and the methods of voice therapy will progress and become much more effective.


  1. Details concerning the application of the YBP method as a clinical voice therapy are presented.
  2. Voice therapy applying the YBP method was used on 91 patients with dysphonia of vocal nodules, recurrent laryngeal nerve paralysis, and incomplete glottal closure. The clinical results shows that there was no difference in the patients' ability to master YBP respiration.
  3. The YBP method was effective in our clinical voice trial. About 1/3 of the patients roastered the YBP perfectly, and their symptoms improved satisfactorily.
  4. The results for the mastering of the YBP curve shows a correlationship between the results for laryngoscopy and voice evaluation, and the patients' improvement. The results indicated that it is necessary to check the breath pattern for dysphonia patients. Bio-feedback enables them to do this effectively.