7 Effective Phonotraumatic Vocal Hyperfunction Treatments

Phonotraumatic vocal hyperfunction, also known as phonotrauma, is a chronic misuse of the voice that can cause nodules and other vocal cord lesions.

In this article, you’ll learn 7 effective phonotraumatic vocal hyperfunction treatments to use in your voice therapy practice!

But First, What is Vocal Hyperfunction?

Vocal hyperfunction is a pathologically tense voice. Specifically, it’s excessive or imbalanced perilaryngeal musculoskeletal (voice box) activity during phonation (Hillman et al., 2020). Vocal hyperfunction is common in voice disorders.

There are two types of vocal hyperfunction:

1. Nonphonotruamatic vocal hyperfunction (aka muscle tension dysphonia), which is laryngeal tension without a structural issue.
2. Phonotraumatic vocal hyperfunction, which leads to vocal fold lesions, such as nodules or polyps.

This article focuses on phonotraumatic vocal hyperfunction.

What Is Phonotraumatic Vocal Hyperfunction?

Phonotraumatic vocal hyperfunction or “phonotrauma” is trauma to the vocal folds believed to be caused by excessive use or misuse of the voice. This trauma may lead to vocal fold lesions.

Behaviors that cause phonotrauma include yelling, excessive throat-clearing, speaking too loudly, talking too much, and screaming (Naqvi & Gupta, 2023). 

Phonotrauma can be acute or chronic. Over time, chronic phonotrauma can cause vocal cord lesions, including:

• Vocal fold nodules
• Vocal fold polyps
• Scarring of the vocal cords
• Vocal fold cysts
• Vocal fold grooves/sulcus
• Varices and ectasias of the vocal cords (Akst, n.d.)

Phonotruama is a type of “functional voice disorder,” which is when the disorder is caused by the inefficient use of the voice–and not due to a structural problem. Functional voice disorders are fairly common, with around 20 million cases in the U.S. (Naqvi & Gupta, 2023).

Who Experiences Phonotrauma?

Both adults and children can develop phonotrauma. However, adult females, especially singers and teachers, make up a greater population of voice disorders caused by phonotraumatic behaviors (Nudelman et al., 2022; Van Stan et al., 2021).

How Do You Identify Phonotraumatic Vocal Hyperfunction?

The only way to view your patient’s laryngeal anatomy is through laryngeal imaging, such as videostroboscopy.

Laryngeal imaging can identify the extent of the phonotrauma, the type of vocal fold lesion(s), and what treatments may be best. Refer your patient to an otolaryngologist or SLP who specializes in voice and can perform laryngeal imaging.

Another tool to measure phonotrauma is the Daily Phonotrauma Index (DPI). Primarily used by researchers, the DPI utilizes neck-surface acceleration magnitude (NSAM) to measure the frequency of phonotrauma. There’s strong evidence that DPI can detect even mild cases of phonotrauma incidences (Van Stan et al., 2021)

Before starting voice treatment for a patient with phonotrauma, complete a thorough voice assessment. Read our step-by-step guide to voice assessment for adult speech therapy.

Speech Therapy For Phonotrauma?

The goal of therapy for phonotruama is to improve the patient’s pain/discomfort, vocal fatigue, vocal effort, and/or vocal quality (Nudelman et al., 2022).

Voice therapy has been shown to improve Daily Phonotrauma Index scores and quality of life in people with phonotrauma. However, chronic vocal fold lesions may not resolve with voice therapy alone and may also require medical treatment (injections, phonosurgery; Van Stan et al., 2021).

Consult with your patient’s multidisciplinary team, including their otolaryngologist and physician, to decide on the best course of treatment. Provide resources for mental health support and counseling as needed (Lloyd, n.d.).

Next, let’s dive into 7 treatment options for phonotrauma!

1. Voice Rest For Phonotrauma

Depending on the type and severity of the patient’s phonotrauma and vocal fold pathology (they have vocal fold nodules, polyps, edema, scarring, hemorrhage, etc.), you may recommend voice rest. Voice rest is also often recommended after phonosurgery.

Voice rest is using the voice less. It often includes talking/singing less, avoiding talking if there’s background noise, and avoiding harsh whispering.

That being said, it’s also important to balance voice rest with learning new, healthy vocal behaviors through voice therapy.

2. Vocal Hygiene For Phonotrauma

Studies show that non-medical voice treatment that includes vocal hygiene can successfully treat vocal fold nodules (Mansuri, 2018)

Good vocal hygiene is a set of behaviors that optimize vocal health and voice production. This means avoiding behaviors that irritate or damage the voice and adding behaviors that support a healthy voice.

Here’s how to do vocal hygiene treatment:

1. Find the cause. First, help your patient identify the key behavior(s) causing their voice disorder.
   • It may be related to job, lifestyle, illness, climate, etc.
2. Educate. Use visual aids and videos to demonstrate how this behavior affects their vocal anatomy and physiology.
3. Find triggers. Next, help them identify any personal triggers for the damaging behavior.
   • For example, the end of the day, when tired, when stressed, in certain postures (twisting at the chalkboard), allergy season, winter, etc.
4. Improve self-awareness. First, help patients identify when the damaging behavior is happening in your session. Then, help them carry over this self-awareness into daily life.
5. Add healthy behaviors. Introduce healthy behaviors to replace or modify the damaging ones.
   • Practice in a variety of speaking settings to encourage carryover (waiting room, cafeteria).

Download our free vocal hygiene checklist!

3. Refer For Medical Procedures or Medication 

If a patient’s lesions are too invasive, such as scarring, nodules, or polyps, they may benefit from a medical procedure (i.e., steroid injections, laser treatment) or surgery (Lloyd, n.d.). In some cases, medications can help.

Refer the patient to their physician and/or otolaryngologist to learn more about these options.

4. Voice Therapy For Phonotrauma

Voice therapy, including voice exercises, is highly effective in treating phonotrauma. You may provide voice therapy before and/or after a medical procedure or surgery for phonotraumatic lesions.

Below, we’ll describe well-regarded 3 voice therapy treatments for phonotrauma: SOVT, resonant voice therapy, and flow phonation.

Read Voice Therapy Exercises for more exercises and treatment ideas.

5. Semi-Occluded Vocal Tract Exercises For Phonotrauma

Semi-occluded vocal tract (SOVT) exercises aim to take pressure off the vocal folds and offload it onto the lips. Patients practice this by doing exercises with occluded (partially closed) lips.

Joseph Stemple recommends imagining a reverse megaphone with an open throat and a small, rounded mouth (Stemple, n.d.). Have patients focus on an easy, forward focus while feeling the vibrations at the front of their mouth.

Some SOVT exercises include:

• Humming
• Buzzing
• Straw phonation. Put a straw in your mouth. Close your lips gently around the straw and puff air into the cheeks, making an /u/ or ‘ooo’ sound, feeling the vibration in the face.
• Straw singing. Sing through a straw with your lips at the edge of the straw. 
• Straw bubbles. Use the straw to blow bubbles in a cup of water. Continue by blowing bubbles while making an “oo” or voicing sound.

6. Resonant Voice Therapy For Phonotrauma

Resonant voice therapy can improve vocal quality in patients with phonotraumatic vocal hyperfunction (Lloyd, n.d.).

It helps these patients learn to speak with a resonant voice (feeling vibrations at the front of the face with easy phonation). The goal of this therapy is to produce a strong, clear voice with the least amount of vocal effort.

You can learn a full resonant voice therapy protocol by taking course by Verdolini Abbott’s (Lessac-Madsen’s Resonant Voice Therapy) or Joseph Stemple’s (Resonant Voice Therapy).

Some common resonant voice therapy exercises are:

• Chanting
• Humming exercise
• Lip trills
• Forward/oral focus
• Nasal consonant exercises with /m, n, ng/

Read our step-by-step guide to resonant voice therapy.

7. Flow Phonation For Phonotrauma

Flow phonation is a treatment for patients who hold back their airflow (breath-hold) while they speak. It helps them improve airflow while decreasing muscle tension at the throat and can be helpful for patients with vocal nodules.

Throughout this treatment, the patient focuses on feeling forward airflow without throat tightness. Flow phonation was adapted from stretch and flow phonation by Jackie Gartner-Schmidt.

Here are the general steps of flow phonation (Gartner-Schmidt, n.d.):

1. Release airflow without voicing on a sigh on /u/ (rounded lips).
   • Hold a tissue in front of the lips for feedback.
2. Next, move on to articulated airflow. As the patient releases voiceless airflow, they will slowly move their articulators.
3. Add voicing to airflow. Release a sigh on /u/, then add in the voice. Move from voiceless fricatives to voiced fricatives. For example, /s/ to /z/. 
4. Add articulation to this voicing and airflow. 
5. Practice discriminating between breathy voice, flow voice, and pressed phonation. Feel and hear the difference between each.
6. Next, practice articulatory precision with words, phrases, and sentences.

More Voice Resources

See the Voice & Resonance Pack for patient handouts and treatments!

References

1. Akst, Lee. (n.d.). Phonotrauma. Retrieved February, 2025, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/phonotrauma
2. American Speech-Language-Hearing Association. (n.d.). Voice Disorders. (Practice Portal). Retrieved February, 2025, from www.asha.org/Practice-Portal/Clinical-Topics/Voice-Disorders/.
3. Brewer, C., Aparo, M. (2021) The Adult Speech Therapy Starter Pack. Harmony Road Design Publishing.
4. Cleveland Clinic. (n.d.). Laryngoscopy. Retrieved February, 2025, from https://my.clevelandclinic.org/health/diagnostics/22803-laryngoscopy
5. Gartner-Schmidt, J. (n.d.). Flow Phonation. [Online Course]. Medbridge. https://www.medbridge.com/educate/courses/flow-phonation-jackie-gartner-schmidt
6. Gray, H., Coman, L., Walton, C., Thorning, S., Cardell, E., & Weir, K. A. (2024). A Comparison of Voice and Psychotherapeutic Treatments for Adults With Functional Voice Disorders: A Systematic Review. Journal of voice : official journal of the Voice Foundation, 38(2), 542.e9–542.e27. https://doi.org/10.1016/j.jvoice.2021.09.018
7. Hillman, R. E., Stepp, C. E., Van Stan, J. H., Zañartu, M., & Mehta, D. D. (2020). An Updated Theoretical Framework for Vocal Hyperfunction. American journal of speech-language pathology, 29(4), 2254–2260. https://doi.org/10.1044/2020_AJSLP-20-00104
8. Lloyd, A. T. (n.d.). Voice disorders: Differential diagnosis and treatment. Medbridge. https://www.medbridge.com/educate/courses/voice-disorders-differential-diagnosis-and-treatment-adam-lloyd 
9. Mansuri, B., Tohidast, S. A., Soltaninejad, N., Kamali, M., Ghelichi, L., & Azimi, H. (2018). Nonmedical Treatments of Vocal Fold Nodules: A Systematic Review. Journal of voice : official journal of the Voice Foundation, 32(5), 609–620. https://doi.org/10.1016/j.jvoice.2017.08.023
10. Naqvi Y, Gupta V. Functional Voice Disorders. [Updated 2023 Apr 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK563182/
11. Nudelman, C. J., Ortiz, A. J., Fox, A. B., Mehta, D. D., Hillman, R. E., & Van Stan, J. H. (2022). Daily Phonotrauma Index: An Objective Indicator of Large Differences in Self-Reported Vocal Status in the Daily Life of Females With Phonotraumatic Vocal Hyperfunction. American journal of speech-language pathology, 31(3), 1412–1423. https://doi.org/10.1044/2022_AJSLP-21-00285
12. Stemple, J. A. (n.d.) Resonant Voice Therapy: Generalizing the Balanced Voice. Medbridge. https://www.medbridge.com/course-catalog/details/resonant-voice-therapy-generalizing-the-balanced-voice-joseph-stemple-speech-langauge-pathology/
13. Toles, L. E., Roy, N., Sogg, S., Marks, K. L., Ortiz, A. J., Fox, A. B., Mehta, D. D., & Hillman, R. E. (2021). Relationships Among Personality, Daily Speaking Voice Use, and Phonotrauma in Adult Female Singers. Journal of speech, language, and hearing research : JSLHR, 64(12), 4580–4598. https://doi.org/10.1044/2021_JSLHR-21-00274
14. Van Stan, J. H., Burns, J., Hron, T., Zeitels, S., Panuganti, B. A., Purnell, P. R., Mehta, D. D., Hillman, R. E., & Ghasemzadeh, H. (2023). Detecting Mild Phonotrauma in Daily Life. The Laryngoscope, 133(11), 3094–3099. https://doi.org/10.1002/lary.30750
15. Van Stan, J. H., Ortiz, A. J., Marks, K. L., Toles, L. E., Mehta, D. D., Burns, J. A., Hron, T., Stadelman-Cohen, T., Krusemark, C., Muise, J., Fox, A. B., Nudelman, C., Zeitels, S., & Hillman, R. E. (2021). Changes in the Daily Phonotrauma Index Following the Use of Voice Therapy as the Sole Treatment for Phonotraumatic Vocal Hyperfunction in Females. Journal of speech, language, and hearing research : JSLHR, 64(9), 3446–3455. https://doi.org/10.1044/2021_JSLHR-21-00082