Traditionally, singers and actors are the elite group of professional voice users. However, today, anybody whose voice is integral to earning a livelihood is considered a professional voice user. This opens up the arena to teachers, lawyers, physicians, radio jockeys, politicians, receptionists and salespeople. In today’s world, it is an undisputed fact that our voice is very important in our society and all patients should be treated keeping this in mind. Whilst we are treating or restoring a person’s voice, often we are effectively changing or restoring there complete persona. Two of my patients who immediately come to mind are a successful doctor with a vocal fold paralysis and another wanting a feminizing voice surgery. Following surgery the dramatic change in personality as each “came into there own” hammered in me the powerful and almost frightening role our voice plays in our personality. Respect this at all times at it will stand you in good stead.

As a voice professional is a vocal athlete, even slight disabilities in voice production may result in disturbing changes in the voice quality. Understanding and managing voice professionals thus becomes a challenging job where the voice specialist has to have a clear understanding of normal anatomy and physiology of voice and the pathophysiology of abnormal voice production. Not only is it important to use this information to be able to treat the voice professional so that current commitments can be met, it is paramount to preserve the voice in the long run. Over enthusiastic treatment in order to let the singer meet pressing singing commitments may damage the longevity of the voice and it is the duty of the treating physician to explain this gently but firmly to the professional voice user.

Successfully managing voice problems in professional voice users necessitates spending adequate time discussing there complaints, evaluating the speaking and singing voice and previous available recordings and their expected goals for recovery .This usually means spending double the time spent with a non professional voice user. This is not because of any change in importance in the latter group but because understanding the subtle voice changes in singers usually necessitates more time for the treating consultant. It is therefore important to schedule appointments with appropriate time slots to efficiently meet the demands of professional voice users.

Not all pathologies seen in a singer need treatment! A singer may have a characteristic voice loved by the audience with the presence of long standing vocal nodules and may come in with a sudden voice change due to a bleeding vessel. The acute problem needs to be addressed and often the nodules are in no way causing any vocal limitation for the singer. Often this tricky situation involves deciding which of the findings are contributing to the voice complaint. When I see multiple lesions in a professional voice user, I treat conservatively any lesions that could potentially be acute in onset first. Voice therapy is always an important component of the management of voice disorders. All non surgical treatment options should be exhausted before considering surgery in a professional voice user. This however is NOT the mantra to be followed if dysplasia or malignancy is suspected. Even the professional voice user group is a subset of the general population and may be inflicted with dystonia, tuberculosis or tumours. In fact, they would present at a very early stage being sensitive to subtle changes in voice. This should be kept in mind at all times and in our enthusiasm for treating them conservatively, bigger problems should not be overlooked.   

upcoming (part 2) on history taking in professional voice users

Bookmark It

Hide Sites

Humans have two vocal folds shaped like a “V” at the inlet of the breathing pipe that open and let air through to the lungs for us to breathe and close and vibrate allowing us to talk or phonate. When the movement of one vocal fold, or worse both, is affected, a large gap between the two allows air leak from the wind pipe resulting in a breathy or absent voice.

In Tanyas case the reason in all probability is a viral infection, more common in the monsoons. There is however no reason for alarm as paralysis of the vocal folds occurs in a very small percentage of individuals. Recovery usually does take place but may take from 6months to 18 months. Tanya has been advised a period of speech therapy, akin to physiotherapy, but for the voice muscles. If her voice does not come back with this therapy then a surgery called “thyroplasty” shall be performed where an implant is placed in the voice box to push the immobile vocal fold and close off the gap between the folds with an immediate return of the voice! The results of the surgery are very gratifying for both the patient and the surgeon as the entire surgery is done with the patient awake so as to “tailor make” the voice to the satisfaction of both.

It is essential to rule out cancer or tuberculosis, both of which are common in the Indian population, by doing a CT scan. Mangesh, a 7 year old boy who had a breathy voice since 6 months was detected with large tuberculous lymph nodes in the chest pressing on the nerve supplying the vocal fold. Following medical treatment for tuberculosis his voice is improving.

Occasionally patients may develop vocal fold weakness following thyroid, heart, spine or food pipe surgery.

One of the commonest causes of a voice change however is acute infection i.e. Laryngitis which settles with voice rest and medicines. Vocal nodules, also known as teachers, singers or screamers nodules are seen more commonly in professional voice users and people who abuse their voice.

It is advisable to visit an ENT specialist for a voice change persisting for over 3-4 weeks.

Not all cases of an immobile vocal fold however are due to infection, tumour or surgery.

The most recent patient I had the occasion of performing Thyroplasty surgery on had come to me with a complete loss of voice following an accidental fall on his bedpost injuring his neck. A CT Scan showed a fracture with fixation of one of the vocal folds. Since he was a call center employee, he lost his job promptly and was desperate for his “voice”. Happily for this patient, following his surgery, he is today with a job and a voice to go with it!

Dr Nupur Kapoor Nerurkar
M.S. (ENT)
Laryngologist and Voice Surgeon
Bombay Hospital and Medical Research Center

Bookmark It

Hide Sites

A type 1 thyroplasty surgery medializes the paralyzed vocal fold using Silastic, titanium or Gore-Tex giving excellent postoperative voice.

Microflap endoscopic surgery is performed for excision of polyps, nodules and cysts.

Early laryngeal malignancies can be tackled with CO2 laser endoscopic excision obviating the need for tracheostomy and decreasing morbidity to a large extent.

Gone are the days when a patient had to “just live with problem”. A better understanding of the anatomy of the vocal folds, physiology of phonation and improved instrumentation has resulted in optimizing the treatment of vocal fold disorders.

Bookmark It

Hide Sites

Stroboscopy is an important diagnostic tool in the armamentariery early laryngeal lesions such as early glottic cancer. Stroboscopy also allows differentiation between various laryngeal lesions.

Laryngeal EMG is performed by introducing a Teflon coated needle into the specific laryngeal muscle to check its response to phonation or breathing. This helps in diagnosing vocal fold paralysis and its prognosis. Laryngeal EMG is primarily used in the injection of Botulinum Toxin into the larynx in cases of spasmodic dysphonia. The toxin weakens the spasms of the voice but needs to be re-injected every 6 months.

Bookmark It

Hide Sites

Our voice is like our signature – unique and characteristic to each individual.

What are the causes of voice disorders?

Bookmark It

Hide Sites

A voice clinic has facilities to see the vocal folds on the monitor using a rigid telescope and showing this image to the patient helps in patient compliance towards the treatment.

A large percentage of voice disorders in tertiary hospitals are due to unilateral vocal fold paralysis. This can be attributed to a large number of referrals, cancer surgery for the thyroid, food pipe or trachea, Cardiovascular Thoracic surgery, Trauma, congenital paralysis and Strokes. Tuberculosis remains an important cause of vocal fold paralysis. A vocal fold paralysis is labeled idiopathic only when a CTscan of the base skull to upper mediastinum is unremarkable.

Vocal fold polyps, nodules and cysts are formed as a result of vocal abuse (talking too much) and vocal misuse (talking with a wrong technique).One wrong technique of talking is using the false vocal folds to talk rather than the true vocal folds. This is called ventricular phonation.

With age, like muscles everywhere in our body, the vocalis muscle also atrophies resulting in bowed vocal folds with a gap between them.Hypothyroidism, laryngopharyngeal reflux and smoking (especially in women) may cause vocal fold oedema referred to as Reinkes oedema.

Due to the widespread use of chewing and inhaled tobacco in India, laryngeal cancer remains an important cause of dysphonia.Human Papilloma Virus can cause multiple papillomas in the larynx that often is a cause of dysphonia in children.

Spasmodic dysphonia is a laryngeal dystonia and the patient has a voice with spasms that often is mistaken to be psychogenic. A neurologist’s examination is vital to rule out causes such as Parkinsonism, myasthenia, ALS etc

An absence of the sub-epithelial layer of the vocal fold creates a gutter called sulcus vocalis.

Bookmark It

Hide Sites

The question that comes to mind – Why would we want to create muscle weakness?
Well, many reasons really. Lets start with one of the most popular – prevention of wrinkles! Facial muscles where wrinkles are developing are injected with botulinum so as to cause a localized weakness of that area which then cannot wrinkle and appears smooth (and at times expressionless!)

When I was doing my Laryngology training in America I was amazed to see hoards of very pretty and wrinkle free 20 something girls line up for a shot of left-over botulinum. On my very naïve inquiry I was told that the injection was being taken to prevent the future possibility of a wrinkle!So anyway, the toxin was “left-over” from being used for a debilitating voice disorder called as “spasmodic dysphonia”. In this uncommon voice disorder the patients vocal muscles contract too much giving rise to a strained voice. The toxin is injected into the straining vocal muscle under EMG control so as to weaken and relax it. Interestingly the voice in this disorder tends to get better while singing, whispering or after a few drinks! One of my patients came to me 2 months after his first injection of botulinum saying he had a problem. Since his voice was sounding good I wondered what it was.Well, as it turns out his friends were aware of the fact that his voice improved with alcohol and now they were ribbing him about being constantly under the influence of alcohol!

Botulinum has helped in the rehabilitation of children and adults suffering from dystonia’s in which large muscle groups become rigid such as cerebral palsy and cervical dystonia. Hemi facial spasms, blepharospasm , migraine, severe underarm sweating and strabismus are other indications for its use.

Side effects can include pain at the injection site, flu-like symptoms, headache,upset stomach,allergic reactions. You should not use Botox if you are pregnant or breast feeding.

Botulinum is expensive, not currently made indigenously, not covered by insurance companies, and so for many the treatment can prove to be prohibitively expensive. Matters do not improve on telling the patient that every 6 months or so a repeat shot is needed.

One way out to reduce costs is pooling of resources by doctors and clubbing together patients who need the toxin. Basically working as a TEAM –Together Everyone Achieves More!

Bookmark It

Hide Sites

Certain professions, such as teachers, singers, politicians, lawyers, radio jockeys, stage artists and call centre employees use there voice for prolonged periods with no breaks. These professional voice users are vocal athletes and just as sportsman can sprain a tendon, get a muscle cramp or develop corns and calluses on there hands and feet, they too can develop swellings or calluses on there vocal cords (vocal nodules). Infact, vocal nodules are referred to as singers or teachers nodules as they commonly affect this group. Take away the vocal abuse (overuse) and give relaxation exercises to these individuals and one can expect a good return of normal voice. A speech therapist ( akin to a physiotherapist) gives these exercises.

However, not all causes of persistent voice change resolve with voice rest and speech therapy. Polyps and cysts of the vocal fold usually need to be surgically excised. This is done endoscopically with no external scar. What appears to be a polyp may at times be a tumour. Therefore all tissue excised by surgery is sent for histopathology study.

In India, the use of tobacco is unfortunately high. This is responsible for a high percentage of head and neck cancer. Early cancer of the vocal cords can be treated by endoscopic laser surgery or radiation therapy. When this cancer spreads outside of the voice box, external surgery and/or radiation therapy is warranted. Preventive action by creating awareness of the effects of tobacco use cannot be overemphasized. Early diagnosis is of paramount important with cancer. Today, we have highly specialized yet non-invasive techniques of detecting early cancer. Stroboscopy is one such helpful test that allows the doctor to see the vocal fold vibrations in slow motion.

Some of the golden rules in maintaining a good voice are

1. Adequate hydration of the voice box. Drink 7-8 glasses of water a day. You know that you are getting enough water if your urine is pale yellow in color.
2. Avoid caffeine , cola drinks,junk (packet) food and tobacco use in any form.
3. Avoid screaming or whispering
4. Do not talk continuously as far as possible. If taking a lecture, create breaks by interactive sessions or show video clips. Sip water in between the talk.
5. Constant clearing of throat is to be avoided.
6. Refrain from very spicy and oily food.
7. Do not sleep straight after dinner to prevent acid reflux at night

Most importantly,Visit a Voice specialist if voice change persists over 2 weeks.

Bookmark It

Hide Sites