Professional Voice Care

You’ve been blessed with a special voice. You’ve worked for years to build it, nurture it, and sell it to the world. It represents you and who you are. No one else has the same voice. You’ve trained it to communicate the most profound and sublime feelings even in the absence of words. You have built this instrument, no one knows it better than you do, and you are its guardian. Directors, conductors, managers, and agents will all ask you to use your voice to its full potential (and rightly so), but it’s up to you to know where the line is between full use and abuse. So here is a quick guide to help you take care of your voice, and decide the limits of your instrument.

Collision Force (It’s not just for crash dummies)

Everything affects your voice. It’s the gateway to your lungs, it’s at the entrance to your esophagus, and it’s at the crossroads of everything. Damage to the tissues of the voice can come from infection, irritation, or illness. But aside from wrapping yourself in bubble wrap, there’s really only one area over which you have direct control – phonotrauma. This neologism refers to the damage the vocal folds incur from the very act of vibrating, or ‘phonating.’ To make sound your vocal folds need to regularly stop the airflow emerging from your trachea – on the order of 55-1,400 times each second. By doing this they must swing apart and together. When they swing inward to stop the airflow, they make contact at speeds anywhere from that at which you stroll to that at which Olympians run the 100 meters. When they collide, that’s ‘contact force.’

If you recall your high school physics class, Force = Mass x Acceleration. While the mass of your vocal folds is fairly constant, it can change depending on which register or ‘voice’ you are using. Chest voice gets its unique, heavier timbre from the fact that the vibrating part of the vocal folds is - well- heavier. Acceleration of the vocal folds is affected by the frequency of vibration (pitch) and the amplitude of vibration (how widely they vibrate which is loudness). The higher the pitch you sing, the more frequently the vocal folds collide. The louder you sing the greater the distance they travel per vibration. So if you want to maximize the collision force of the vocal folds, sing loud, high, and in chest voice.

Other Factors That Can Confound Collision Force

Duration: Timing is important. The longer you subject the vocal folds to a heavy load, the more cumulative trauma they sustain. That’s why your voice is grainy after a full day in the recording studio, or after a day of full-voice rehearsals. You can lessen this cumulative affect by taking breaks before damage starts to occur. This is highly dependent on how you’re using the voice. You’ll know when your voice needs a break – just don’t run it into the ground before taking a break, because at that point you’ve caused phonotrauma, and the vocal folds will swell after 15 minutes, starting the recovery/scarring process.

Tissue condition: The vibratory part of the vocal fold is the mucosal covering, and is only 20 cells thick. It’s meant to be very elastic yet able to take the impact of the other vocal fold against it. If the mucosa is stiff from damage (scarring, surgical recovery) it takes more effort to make it vibrate. This means more airflow across the vocal folds, which means more collision force. Also, because the mucosa is not vibrating easily, the entire vocal fold making collision, which increases the mass, which means more collision force. If your vocal folds are swollen (allergies, a cold, damage, etc) this means there is more mass in vibration. You usually know they are swollen because your voice becomes lower and huskier – like when you have a cold. Don’t ‘push’ your voice when you know the vocal folds are swollen – this is the time when most performers can pop a capillary and have a vocal hemorrhage. So if your voice is deeper and huskier than usual, warm it up well, don’t push it, and respect its fragile condition.

Medications: Certain medications have effects on the voice, and this varies quite a bit from person to person. Obviously antihistamines like Benadryl or Sudafed can dry out your system, and that includes the voice. The result would be that the mucosa is not as elastic. Soft voicing, especially at higher pitches, will be the first indication of this. Another class of medications that can affect the voice is diuretics (blood thinners). This includes not only the prescription blood thinners like Coumadin and Heparin, but also aspirin (salicylic acid), and large quantities of gingko, garlic, or ginger. Blood thinners can increase the likelihood of a hemorrhage if you’re singing on swollen cords. Advair and other inhaled corticosteroids can cause fungal infections (thrush) in the throat and mouth, but this can be avoided if you drink some water to clear the medication from your mouth and throat after each use.

Dehydration: Keeping the vocal folds moist increases elasticity – a good thing. There are two ways to do this. Internal, systemic hydration by drinking water or non-caffeinated beverages will get to the inner tissues of the vocal folds. This helps remove cellular waste, and other inter-cellular debris that results from phonotrauma. To keep the outer surface – mucosa- moist requires ambient humidity. You can feel the difference in your voice quality when you’re in New Orleans versus Phoenix. Steaming is the only way to get water in contact with the vocal folds. Nothing you drink will touch your cords – so don’t worry about that milk you just drank ‘coating’ your cords.

Fatigue: You can actually hear what happens to voices at the end of a work day. They sound tired. This has more to do with systemic energy level and the effect that decreased breath flow has on phonation. However, sleep is the time when the body recovers from the injuries of the day, and when new learning is encoded in the brain, especially coordinated activities. When we’re fatigued, we also tend to compensate in ways that are not always healthy for the voice.

Emotion: Emotion is what we communicate with our voices. We have spent many years learning how to convey emotions through our voices in a purposeful way. Because the voice does reflect our emotions so easily, it can also be affected by strong emotions, either beneficially or adversely. The balance of emotions and how they affect your voice is highly individual, and you will learn how to use emotions when performing.

Muscle tension: We work hard to get rid of detrimental muscle activity in our voices. Usually this tension is the result of unconscious compensation. We unconsciously try to ‘make’ the voice work. The result is usually muscles working against each other – we tend to fire all at once. Unlearning these tension patterns can be difficult, and may involve deconstructing or revamping your vocal technique. It’s always best to avoid learning tension behaviors before they become a habit. Just be aware when you’re working harder than you should be to make the voice perform.

Technical changes: It is a pedagogical principle among voice teachers that it takes a year to integrate a new technical concept into a voice from the time it is first presented. This combined with the fact that the tissues of the voice change from decade to decade means that we are in a constant state of adaptation regarding our voice ‘techniques.’ Our complex motor patterns have been hard-wired into our brainstems after much practice (and sleep), and we remember what a phrase feels like. That’s why performers have such difficulty coming back to a role or piece that they initially learned long ago with a previous ‘technique.’ The technique and the tissues are now different, and the old motor patterns don’t work right. This disconnect can lead to unconscious tension. (see above). That’s why you need to re-learn pieces or monologues, even though you know them.

Factors That Can Lessen the Effects of Collision Force

Common sense: Basically you know when you’re hurting your voice. It’s not pain that you’ll feel. It may be discomfort, but it’s usually the way the voice sounds, behaves, or simply feels. Factors that can lessen the chances of phonotrauma are the common sense ones: adequate hydration, rest, and pacing. Pacing is important. You need to know when it would be prudent to ‘mark’ and how to do so. ‘Holding back’ your voice is not marking – you are usually changing your technique and energy level when you do this – robbing your voice of breath support, and your colleagues of acting support. Proper marking involves the same emotional energy as full voice rehearsing, just at a quieter dynamic level, or down an octave where necessary. More frequent short breaks (under 10 minutes.) will also help lessen the vocal load.

Warm ups: A baseball pitcher would never think of starting to pitch without a warm-up in the bullpen. Complex motor activities like this require not only preparing the tissues for exertion, but also necessitate fine-tuning the connections between the brain and the tissues. A warm up usually takes 10-20 minutes, but a general rule of thumb is that we need five additional minutes with each decade. A warm up starts easy, and should take you through the entire range of motion that the muscles will use. You want to get them moving fully, and that means large vibrations. If you keep your mouth more closed (hums, lip and tongue trills, and closed vowels) the vocal folds can still vibrate widely but they will not collide with as much force. You also need to re-establish your control over all parameters such as loudness, tone color, vowel placement, articulation, and focus. Moving the voice through each of these parameters at various pitches and various vowels is a great way to remind your brain how to control that aspect of the voice. For instance, a messa di voce is one of the best exercises for balancing breath flow and tonal focus as you move from soft to loud and back to soft phonations.

Warm downs: If warm-ups are important, warm downs are critical, especially after heavy voice use. It usually takes 20 minutes of full voicing for the tissues to increase in temperature (3 degrees Fahrenheit!), increase circulation, and desensitize. This is why you warm-up before you start performing. After this the vibration of the tissues keeps the accumulation of fluid, and harmful components that are the product of tissue activity from building up. As soon as 10 minutes after stopping however, the tissues start to shift into repair mode. A cascade of tissue changes starts that begin with swelling as fluids accumulate. There are dead cells, lactic acid, and other chemical and hormonal components that cause the vocal folds to swell. The purpose of the swelling is to immobilize the damaged tissues to prevent further harm. The swelling usually peaks 8-12 hours after damage, which is why your voice may be worse the next morning. But the swelling also launches chemicals that start the process of scarring. So – if you can prevent the swelling from starting, you can stop the progression towards scarring. Some good early studies have shown us that doing 10 minutes of warm-down exercises within 15 minutes of stopping can significantly stop the initial swelling of the vocal cords.

Intermissions: Because of this rapid change in voice after stopping, many performers find intermissions or long off-stage breaks to be difficult. They find that their voice is rougher for the first few minutes when they start using it again after their break. Some performers have in their contracts that intermissions must be either shorter than 15 minutes so that the voice does not fully ‘cool-down’, or else 30 minutes so that they can warm it up again. Doing gentle lip trills during a break can help keep the voice from cooling off.

Self Triage

Scenario one: So you wake up in that stuffy motel in Schenectady with an afternoon performance to do. There was a party after the opening show by the presenters last night that really went to long after the show. You notice your voice this morning is rough. You warm up in the shower and you lack the ability to easily float into head voice. Before you call the road manager you should try a few things. First, warm up the voice fully – give it the best chance of working well. Second, try singing Happy Birthday in a light, high voice. If it’s effortful, tight, or breaks apart, it’s likely that your vocal cords are swollen. Do you feel sick? Are you having allergies? If so, these may be the primary cause of the swelling. If you feel fine but the high, soft singing is tight, it is likely from last night’s heavy voice use (a performance, and then a long meet-and-greet party). If you’re sick, the cords will likely stay swollen until you’re feeling better. If it’s mild overuse, you may be able to resolve much of the swelling over the course of the day with lots of gentle lip trills, resonant humming, and water.

Scenario two: You’re in a production of Arsenic and Old Lace. You have a scream in the last act. You’ve been under the weather the past two days, and your voice is a little hoarse, but you go ahead and give it a good scream for the show. Something didn’t feel quite right, and as the scene progresses your voice gets rougher and more effortful. By the curtain calls your voice sounds funny. This is likely a vocal fold hemorrhage. Like a bruise, a capillary has been broken from one cord slamming against the other, and it has bled under the surface of the cord. The result is a fairly quick (usually within an hour) deterioration of the voice to a noticeably rough sound. Plan on not using your voice for the next two weeks, and get to a good voice medical practice to help speed up the re-absorption of the bruise and prevent possible scarring.

Scenario three: Big audition. You’ve been working with a new voice teacher and re-vamping you technique. You feel healthy, but the voice is tight and breathy, not focused and clear. The importance of this audition doesn’t help you relax and find your voice easily. You drink your warm liquids, try to relax your neck, and think about breathing. Now try this: Clasp your hand tightly over your wide open mouth, take a deep breathe, and yell “AHHH.” As you sustain this muffled AH relax your throat and neck, feel the air pressure against your hand. Make sure the mouth is tightly covered. The AH should last for 30 seconds as there is so little air escaping. Do this three times in a row. Now try using your voice again. If the voice has focused, relaxed, and sounds rich, then you’ve just correct muscle tension. It won’t last for more than a minute, but re-acquaint yourself with how relaxed and crisp it feels, and see if you can make it that way by yourself.

We’re here for you

Many voice professionals can help you with your instrument and they often wear several hats. Just make sure that you are seeking the right help from the right person:

Voice teacher: This is a person who helps you build a vocal technique. They may or may not coach you on repertoire, play the piano, or know about voice pathologies.

Vocal coach: This is someone who helps you with interpreting repertoire, monologues. They may work with you on accents, pronunciation, pacing, tempi, and for singers, they accompany you. They may or may not know about vocal technique, but almost never know about voice pathologies.

Laryngologist: This is an Ear, Nose & Throat doctor who specializes in the voice. They should evaluate your voice with a stroboscopy. The laryngologist will help you understand what is happening with your voice, and will recommend treatment options that can include medications, voice therapy, or surgery. A phonosurgeon is a laryngologist who specializes in surgery with the aim of improving the voice quality.

Vocologist: This is a speech pathologist that specializes in the voice. They usually work collaboratively with a laryngologist to take care of your voice. Voice therapy can help you to unlearn muscle tension patterns, increase the elasticity of the cords, and help heal the cords properly after surgery.

Things to Avoid

Again – common sense should guide you. After performance meet-and-greets with the local promoter are part of what they expect, but that does not mean you need to ‘make yourself heard,’ especially if the ‘background’ music is cranked up. The same goes for any restaurant or bar. 96 dB music is not uncommon, especially in Manhattan venues. Besides killing hair cells in your ears, this kind of noise can cause real harm to your voice if you try and shout over it. Other difficult situations includes screaming at games, smoking (need we say it?), hard voice use and going right to sleep without warming down. But perhaps the most dangerous thing to do is singing or speaking full-voice on swollen cords.

Reflux that rises to the level of the larynx happens at night, and can damage the tissues. This irritation causes you to clear your throat because you feel as if there is something there. Signs of nighttime reflux include waking before dawn with an irritating cough, and hoarse voice or a bad taste in your mouth in the morning. While the reflux itself can damage the vocal folds, the throat clearing and coughing likely cause more harm.

Hormones clarified – When your vocal folds are swollen, either from allergies, illness, or phonotrauma, a short dose of corticosteroids (Prednisone, Medrol Pack) can bring down the swelling in a hurry. You don’t need to worry about these kinds of corticosteroids, especially in short-term doses. Just be sure to taper off of these as per instructions. Androgenic steroids (those that cause male traits) are a different story. Androgens like testosterone and progesterone can cause such side effects as hirsutism (hair growth where you don’t want it), loss of hair where you do want it, and even permanent enlargement of a woman’s vocal folds. It’s basically what happens to 12 year old boys at puberty. Androgenic compounds such as these are powerful medications and are used to treat endometriosis, skin conditions, acne, and hormone therapy at menopause. Some birth control pills also have androgenic components to them – so ask your OBGYN.

Insecurity exists in the absence of knowledge. We hope that by learning about your voice you can feel secure in taking control of it and taking responsibility for it, expanding its communicative power, and using it for years to move people’s minds and hearts. If you need any help, please feel free to call us at the Eugen Grabscheid Voice Center.


Contact Us

Eugen Grabscheid MD Voice Center
Department of Otolaryngology – 
Head & Neck Associates
5 East 98th Street
New York NY 10029
Tel: 212-241-9425