Frequently Asked Questions About Voice Disorders
What are some indications that I may have a vocal problem?
Voice problems (dysphonia) are the symptoms of other physical and emotional issues. A person’s voice is highly reflective of their general health and emotional status, as well as the health of the actual tissues of the larynx itself. So while the voice is a sensitive indicator of many aspects of a person’s health, there are few physical indications of a voice problem other than the sound and function of the voice itself. A general rule of thumb is that if your voice has changed in its character, effort level, or function and not resolved for several weeks, it’s time to have a voice specialist help you determine what might be contributing to your dysphonia.
My voice is weak. Can something be done to make it stronger?
The voice is a complex phenomenon, with many various inputs. A weak voice can be the result of decreased pulmonary drive, incomplete closure of the vocal cords during vibration, or even depression or general fatigue. A complete voice evaluation by a laryngologist and voice therapist can help determine which of the many parts of your voice may be contributing to your weak voice, and what treatments (surgery, therapy, medications) could help rebalance the entire instrument. Voice problems rarely have only one cause, and most require joint approaches involving physical treatment and therapy.
Does heartburn and/or stomach acid affect my voice?
Heartburn is a symptom you get when acid from the stomach comes up into your esophagus (which it’s not supposed to do). It usually happens when you’re awake, and can be quite painful. If material from your stomach (of which hydrochloric acid is just one part) makes it up to your throat, this is called LayngoPharyngeal Reflux (larynx and throat), and this can irritate the tissues of the vocal folds and surrounding area. You do not have to feel heartburn or regurgitation to have reflux, and only 50% of those with reflux feel these symptoms. Results of this include a hoarse voice (worse when you awaken in the morning), and/or chronic dry coughing. Sometimes a deepening or increase in the hoarseness of your voice can be the only sign of this type of tissue damage. Repeated/long-term burning of these tissues can lead to pathologic tissue changes, and needs to be treated.
Does smoking affect my voice?
Do we really need to go over this? YES. Everything you inhale passes right across the vocal cords. The vocal cords, (whose easy vibration creates your voice), react to irritants like allergens, dry air, dust, chemical odors, reflux, etc. The burning end of a cigarette is 451 degrees Fahrenheit (remember Ray Bradbury?). By the time that air reaches 17-20 cm down your throat it has cooled-off some, but is still hot enough to irritate the delicate vocal folds. Not only that, but the tar and other irritants in the smoke cause swelling and other reactions on the cover of the cords. Repeated, long-term smoking of course causes tissue changes in the voice, also known as dysplasia or cancer. The first sign of glottic cancer (throat cancer) is a hoarse voice, not pain or coughing up blood. A study in the VA showed that when doctors referred their patients with hoarse voices that were not caused by upper respiratory infections (lasting more than 2 weeks) on to the Ear-Nose and Throat doctors for a look at the voice, the stage at which throat cancers were discovered dropped significantly compared to those who were not referred on, and survival rates increased.
What are singer's nodes?
Singer’s nodes or nodules are similar to calluses on the vocal cords. When you speak or sing (“phonate”) your vocal cords vibrate and hit each other between 100 – 1,000 times per second. This contact is called collision force and means just that. The way you use your voice can affect the amount of collision force. Generally, speaking /singing louder and higher in pitch creates more collision force. Just like your hands do when you first rake leaves each fall, the vocal cords react to this trauma by creating calluses, usually one on each vocal cord right opposite each other. Nodules make the voice drop in pitch. Singers especially will notice changes in the ‘feeling’ of their voice, especially on high, soft notes. Nodules by themselves are not dangerous, but they do affect the voice. People who have had them for a while begin to ‘push’ the voice, making it easy to fatigue as the day goes on. Treatments for nodules include voice therapy, and in more severe cases surgery. However, in all cases you must be taught how to change the way you use the voice, or they will simply re-form.
What is voice therapy?
Voice therapy is for your voice what physical therapy is for your limbs. A trained therapist (a speech pathologist with specialized training and experience) works with you to improve or regain your voice after injury. Just like physical therapy, we work with balancing muscle use, strengthening muscles, improving the coordination of the various parts of the voice, monitoring and control of the voice, and even help damaged tissues to heal properly or reverse some tissue damages. Voice therapists also work with laryngeal sensitivity to increase or decrease reactions to irritants you experience when speaking, swallowing, or breathing.
Is singing therapy different than singing lessons?
Yes. singing therapy is a type of voice therapy that targets repair of an injured singing voice. It is provided by a specially-trained voice therapist who has experience with the singing voice and the demands placed on it. The goal of singing therapy is the restoration of a healthy instrument (tissues and the control of those tissues). Singing lessons are music lessons for the instrument called the voice. As such they deal with making music with this most expressive of all instruments. A singing teacher is a specially-trained professional who understands not only the structure and use of the tissues involved, but helps a student learn how to ‘play’ those tissues and interpret pieces of music. A singing teacher’s knowledge must encompass technique (how to use the voice), languages and diction, musical styles, interpretation, and fostering the connection between the mind and the voice. Singing therapy and singing lessons are complimentary disciplines with different goals. Singing teachers and voice therapists are usually well-aware of the differences between these two disciplines, and go to great lengths to keep them separate, but complimentary. Often the singing teacher and the singing therapist will collaborate in the treatment of an injured singer or actor.
I have heard that drinking water is good for my voice. Is this true?
Drinking water is always a good idea. Your vocal cords open and close to regulate airflow in and out of your lungs. As such, they react to the relative humidity of the air you breathe. In very dry places your vocal cords can get drier and stiffer, making it harder to make them vibrate easily (think of dried leather). You can feel this effect of the air on your voice. However, drinking water does not ‘water’ or moisten the vocal cords. It never even touches them (if it does, you’ll know it!). Instead, drinking enough water keeps your whole body hydrated, including the vocal cords. However, you can also ‘water’ your cords by inhaling steam or water vapor through an open mouth. That’s one reason you might sound so good in the shower!
What can be done for a paralyzed vocal cord?
Paralyzed vocal cords can result from tumors, some surgeries, or viral infections when the nerve supplying the vocal cord is damaged. Usually a paralysis prevents one of the vocal cords from opening and closing, which are necessary for allowing air into the lungs and keeping material out of the lungs. A hoarse, breathy voice or choking on liquids are usually the only signs of a vocal paralysis. When the cause of a paralysis is not known, a temporary material can be injected into the vocal cord, moving it over to better close the airway. This will make swallowing safer, and voicing stronger. Voice therapy can also help in preventing you from pushing the voice and accruing bad habits that would be difficult to unlearn. The vocal cord’s movement is observed for 6-8 months, by which time it may regain its function. If however the cord is still not opening and closing by that time, a more permanent material is used to move the cords into a better position for achieving opening and closure.
Can drugs and medications cause problems in the larynx?
Because the voice reflects the general health of the individual, it is also very responsive to any medications that can change the working of a person’s body, both positively and negatively. For instance, some antihistamines that you might take for allergies will succeed in drying up your nasal secretions, but can also dry out the tissues of the larynx, making the voice more effortful. Another example might be blood thinners like heparin or coumadin that are very important for reducing blood clots. By the same mechanism they may also increase your chances of a vocal fold hemorrhage if the voice is over-used (phonotrauma). A good list of medications and how they can affect your voice can be found at the National Center for Voice and Speech website (ncvs.org).
Lately I’ve been coughing and clearing my throat whenever I smell certain things like smoke, dust, or perfumes. I never used to – what’s going on?
The lining of the larynx (mucosa) is extremely sensitive to things that should not be entering the lungs. Things like food, liquids, irritants, smoke, chemicals, and heavy odors can all cause a rapid response. These responses include coughing, gagging, sudden spasming of the vocal cords (laryngospasm), or throat clearing. We all have a level of ‘irritation’ below which we will NOT have these reflexive mechanisms. However, after particularly strong episodes of stimulation (excessive smoke inhalation, recurring reflux events, etc) the level of response or threshold can be lowered as a protective adaptation. This type of acquired laryngeal hypersensitivity usually results in excessive throat clearing, wheezing when inhaling, and even prolonged, non-productive coughing. Basically the reflex mechanism is over-reacting to small triggers that should not normally cause a response. We are finding that this hypersensitization can be progressive and escalate, especially if the initial trigger remains in place. Various treatments can include prescription cough suppressants, elimination of triggers (like reflux), and laryngeal desensitization therapy.
Eugen Grabscheid MD Voice Center
Department of Otolaryngology –
Head & Neck Surgery
5 East 98th Street
New York NY 10029