Vocal Problems and What to Do About Them

“The flame that burns twice as bright burns half as long.”
Lao Tzu

Some singers believe that hoarseness is just part of the life of a professional singer.  You can expect to be vocally tired after a long performance, but ongoing hoarseness might be a sign of vocal issues.

A singer who experiences hoarseness for longer than two weeks, or any of the other indications of vocal trauma listed below, should schedule a visit to an ENT or otolaryngologist to be scoped- (undergo stroboscopy, preferably rigid stroboscopy) before continuing with lessons or singing engagements.

The most common result of vocal trauma is vocal fold lesions. Vocal fold lesions are noncancerous (benign), abnormal growths within or along the covering of the vocal fold. 

Lesions are thought to arise following overuse or traumatic use of the voice, including speaking at an improper pitch, speaking excessively, screaming or yelling, or using the voice excessively while sick, or singing with poor vocal technique.

Swelling of the vocal folds due to illness, fatigue, or poor vocal technique prevents midline vocal fold closure.

Manifestations of trauma such as nodules, polyps, and hemorrhages are the result of extended vocal abuse and make midline closure impossible.

Most vocal disorders such as cysts, nodules, polyps, and hemorrhages happen because of repeated trauma to the vocal folds.

Less often, but still a possibility, are issues presenting after a single event, such as screaming at an outdoor football game or singing for an evening when the vocal folds are compromised and swollen.

Singing too loudly, too long, or with too much air pressure will result in edema, or swelling of the folds, which then leads to further trauma if not addressed by vocal rest, rehabilitation, and better vocal technique.

Most disorders, once manifested, tend to reoccur unless vocal habits are radically changed. Singers need to attack the problem on several fronts; vocal rest, retraining the voice with better vocal technique, speech therapy, and if all else fails, surgery.

Surgery should be viewed as the last option; in some cases, surgery can damage the fold.  During surgery, part of the vocal fold tissue may be scraped away along with the growth; this will affect the quality of the voice. It might even destroy the ability to sing.

So it makes sense to avoid the problem in the first place.A change in voice quality and persistent hoarseness lasting more than two weeks are often the first warning signs of a vocal fold lesion.

Other symptoms can include:

• Vocal fatigue
• Unreliable voice
• Delayed voice initiation
• Low, gravelly voice
• Low pitch
• Voice breaks
• Airy or breathy voice
• Inability to sing high, soft notes
• Increased effort to speak or sing
• Hoarse and rough voice quality
• Frequent throat clearing
• Extra force needed to produce tone

The most common non-cancerous lesions of the vocal folds include: vocal fold nodules, polyps, and cysts.

The best preventive steps are:

• Develop and maintain good vocal technique. Singers should be taking a weekly voice lesson with a teacher who understands the concepts of mix and balanced registration and should vocalize daily to ensure good vocal function.
• Use caution regarding overuse of the voice. Do not shout or sing in loud or outdoor environments, limit the use of the voice in daily speaking or singing, don’t push or force the voice, and do not sing or speak at all if there is any evidence of vocal fold swelling.
• Hoarseness or breathiness that lasts for more than two weeks may signal a voice disorder and should be followed up with an otolaryngologist or ENT.

NODULES

Nodules are benign (noncancerous) growths that are caused by vocal abuse.

Nodules typically occur in people who use their voice in an intense manner over an extended period. They are a natural response to increased trauma, similar to calluses on the hands.

Vocal abuse can be defined as strenuous practices such as yelling, over-singing, talking in loud environments, pulling the lower register too high, singing too hard or with too much air, and forcing the voice, all symptomatic of excessive air pressure.

Over time, repeated abuse of the vocal folds results in soft, swollen spots on each vocal fold. These spots eventually develop into harder, callous-like growths. The nodules become larger and stiffer as the vocal abuse continues.

Also known as nodes, nodules form just below the epithelial surface of the vocal folds.

Nodules begin as swelling and progress to a hardened, callous-like growth of tissue, appearing on one or both vocal folds. Nodules appear in the area of the folds where contact between the folds is most forceful.

They are often present on both folds, facing each other, at the midpoint of the vocal fold, creating a thickened epithelium and a thickened superficial lamina propria.

The calluses that form on the vocal folds prevent the folds from meeting at the midline, producing a gap and stiffening the mucosal tissue, causing irregular vibration and a raspy sound.

The quality of the voice may range from normal to breathy to very hoarse and strained.

Like other calluses, these lesions often diminish or disappear when overuse of the area is stopped.

The inability to sing high and soft notes is one of the hallmarks of nodules.

When the singer tries to sing high and soft, there is a delay in the onset of the sound, with an audible air escape, and then the sound starts abruptly.

Other indications include abnormal voice quality, limited pitch and volume, vocal fatigue, and discomfort when singing or speaking.

Treatment usually involves vocal rest, speech therapy, improved vocal technique, and retraining using therapeutic vocal techniques such as SOVT exercises. In advanced cases, surgery may be required.

Treatment is dependent upon the age and hardness of the nodules.  Soft or young nodules often resolve on their own with rest and therapy; surgery, is usually not necessary.

However, hard or old nodules generally require surgical removal.

Removal of the nodules may temporarily solve the problem, but nodules tend to return as soon as a singer begins to sing again with his or her original vocal habits.

New vocal habits must be acquired and maintained for life if the singer wishes to avoid further issues. Surgery is useless unless the singer has a committed attitude toward changing the habits that created the issue in the first place.

The best preventive steps are:

• Develop and maintain good vocal technique. Singers should be taking a weekly voice lesson with a teacher who understands the concepts of mix and balanced registration and should vocalize daily to ensure good vocal function.
• Use caution regarding overuse of the voice. Do not shout or sing in loud or outdoor environments, limit the use of the voice in daily speaking or singing, don’t push or force the voice, and do not sing or speak at all if there is any evidence of vocal fold swelling.
• Hoarseness or breathiness that lasts for more than two weeks may signal a voice disorder and should be followed up with an otolaryngologist or ENT.

POLYPS

Polyps are benign lesions of the larynx, located on the edge of the vocal folds, that prevent the vocal folds from meeting at the midline.

Polyps usually appear on only one vocal fold, as a swelling or bump, a stalk-like growth, or a blister-like lesion.

Most polyps are larger than nodules and may be called by other names, such as polypoid degeneration or Reinke’s edema.

The best way to think about the difference between nodules and polyps is to think of a nodule as a callous and a polyp as a blister.

Polyps can interfere with voice production and may produce a hoarse, breathy voice that tires easily.

Polyps may be caused by long-term vocal abuse but may also occur after a single, traumatic event to the vocal folds, such as yelling at a concert. Long-term cigarette smoking, hypothyroidism, and GERD (acid reflux) may also cause polyp formation.

Other contributors include allergies, tense muscles, oversinging, talking loudly, shouting, in loud environments and outdoors (avoid cheerleading if you want to sing!), and drinking caffeine and alcohol (dehydrates the tissues of the body).

One of the cofactors in the cause of these lesions may be laryngeal reflux disease.

Polyps, like nodules, may respond to treatment but tend to reappear if vocal habits are not changed and permanently maintained.

Surgery is an option if the polyps do not respond to rest and vocal therapy.

Treatment includes rest, speech therapy and Improvement of vocal technique and retraining for singers, including decreasing air pressure and extrinsic muscle engagement, singing at lower volumes, appropriate vocal fold adduction, and refraining from pushing the voice or singing with excessive volume.

The best preventive steps are:

• Develop and maintain good vocal technique. Singers should be taking a weekly voice lesson with a teacher who understands the concepts of mix and balanced registration and should vocalize daily to ensure good vocal function.
• Use caution regarding overuse of the voice. Do not shout or sing in loud or outdoor environments, limit the use of the voice in daily speaking or singing, don’t push or force the voice, and do not sing or speak at all if there is any evidence of vocal fold swelling.
• Hoarseness or breathiness that lasts for more than two weeks may signal a voice disorder and should be followed up with an otolaryngologist or ENT.

CYSTS

Cysts and polyps are sometimes confused.

A cyst is an air, fluid or semi-solid substance filled cavity that develops in soft tissues; a polyp is an abnormal growth of tissue, protruding from the mucous membrane.

Cysts are fluid or gel filled sacs that occur within the delicate layered structure of the vocal fold, interrupting the mucosal wave responsible for sound production.

Cysts often occur near the midportion of the vocal fold. The cyst can be located near the surface of the vocal fold or deeper, near the ligament of the vocal fold.

The cyst causes a portion of the vocal fold mucosa to become stiff, preventing normal vibration and affecting voice quality and ease of production.

The size and location of cysts affect the degree of disruption of vocal cord vibration and subsequently the severity of hoarseness or other voice problem.

Indications of a cyst forming may include abnormal voice quality, vocal fatigue, discomfort or pain associated with increased talking, interference with breathing, and a sense of something irritating in the throat that needs to be cleared or coughed away.

The sound of the voice ranges from normal to breathy to extremely rough and hoarse and often worsens with increased voice use.

As with vocal fold polyps and nodules, the size and location of vocal fold cysts affect the degree of disruption of vocal fold vibration and phonation.

Cysts may be reduced by simply reducing vocal fold impact for a time. However, they often require surgical removal and are sometimes so deeply embedded that they are impossible to remove.

The best preventive steps are:

• Develop and maintain good vocal technique. Singers should be taking a weekly voice lesson with a teacher who understands the concepts of mix and balanced registration and should vocalize daily to ensure good vocal function.
• Use caution regarding overuse of the voice. Do not shout or sing in loud or outdoor environments, limit the use of the voice in daily speaking or singing, don’t push or force the voice, and do not sing or speak at all if there is any evidence of vocal fold swelling.
• Hoarseness or breathiness that lasts for more than two weeks may signal a voice disorder and should be followed up with an otolaryngologist or ENT.

HEMORRHAGE

Hemorrhage is the result of the rupture of a blood vessel on the vocal fold that creates bleeding into the mucosal covering of the fold. The accumulation of blood under the surface of the vocal fold makes the fold stiff, making the vocal fold vibration more difficult.

The amount of the bleed can vary greatly but often it is large enough to prevent vibration of the affected vocal fold. Sometimes the bleed becomes encapsulated into a cyst or polyp.

Hemorrhage is typically an acute (sudden) event, and the voice may suddenly cut out or become weak, breathy, or rough. Indications may include a sudden decrease in voice quality, a loss of pitch range, loss of volume, and loss of vocal control.

A person experiencing a hemorrhage may suddenly be unable to produce a sound. This resolves over time as the blood accumulation subsides. Small hemorrhages may cause only slight changes in voice quality, which could go unnoticed.

A hemorrhage occurs either when there is sudden high impact or a prolonged traumatic impact to the vocal folds and is more likely to occur when the blood vessels are already more susceptible to hemorrhage.

This may happen when aspirin products (an anticoagulant) or alcohol (a vasodilator) are used and is more common in women during the menstrual cycle.

English pop singer Adele has been diagnosed with vocal fold hemorrhages and has had to cancel performances as a result.

The best preventive steps are:

• Develop and maintain good vocal technique. Singers should be taking a weekly voice lesson with a teacher who understands the concepts of mix and balanced registration and should vocalize daily to ensure good vocal function.
• Use caution regarding overuse of the voice. Do not shout or sing in loud or outdoor environments, limit the use of the voice in daily speaking or singing, don’t push or force the voice, and do not sing or speak at all if there is any evidence of vocal fold swelling.
• Hoarseness or breathiness that lasts for more than two weeks may signal a voice disorder and should be followed up with an otolaryngologist or ENT.

GRANULOMA

A granuloma is a benign growth that typically occurs in the posterior (back) part of the larynx, either directly on the vocal fold or on one of the mucosal surfaces nearby.

A lesion that is not directly on the vocal fold may not interfere with voice quality, but it can be very irritating and painful. A large enough lesion may obstruct the airway.

The growth may prevent glottal closure, causing vibration to be weak or non-existent. This could cause a weak or breathy voice, frequent breaks in the voice, or the lesion may interfere with vibration, causing a rough, irregular sound.

The voice may fatigue easily and become worse with continued use.

A granuloma is one of the body’s ways of healing or protecting itself from an inflammatory or infectious process. It is believed to be related to an infectious process within the cartilage of the larynx.

Granulomas can occur in a number of ways, but most are related to some acute or chronic injury, such as trauma from intubation during surgery, an extended bout of coughing or other vocal trauma, chronic acid reflux GERD/LPRD, mild chronic trauma such as frequent throat-clearing, and poor vocal technique while singing.

Vocal fold trauma or impact will usually make the granuloma worse.

Loud or excessive talking, throat-clearing, coughing, grunting, and effortful vocal production can all cause the granuloma to grow larger.

Singer John Mayer has been diagnosed with granuloma and has recently undergone a second surgery.Surgery is often prescribed for granuloma.

However, recurrence of the granuloma is common, even after surgery. Here are some non-surgical treatments:

Anti-reflux medications are usually prescribed to eliminate burning from acid reflux. Dietary and lifestyle changes may alleviate GERD/LPRD.

A short course of steroids is prescribed to reduce the inflammation and, hopefully, the size of the granuloma.

Antibiotics are given to alleviate infection.

Speech therapy can identify sources of high vocal fold impact and teach techniques to reduce impact while talking.

Rehabilitation of the singing voice with speech therapy and vocal technique that minimizes excessive air pressure.

The best preventive steps are:

• Develop and maintain good vocal technique. Singers should be taking a weekly voice lesson with a teacher who understands the concepts of mix and balanced registration and should vocalize daily to ensure good vocal function.
• Use caution regarding overuse of the voice. Do not shout or sing in loud or outdoor environments, limit the use of the voice in daily speaking or singing, don’t push or force the voice, and do not sing or speak at all if there is any evidence of vocal fold swelling.
• Hoarseness or breathiness that lasts for more than two weeks may signal a voice disorder and should be followed up with an otolaryngologist or ENT.

DYSPHONIA

In general, the most common vocal complaint from adults is vocal strain (hyperkinetic dysphonia) from overuse of the vocal muscles while singing or speaking.

The voice tires quickly and lacks volume; talking against background noise becomes an effort. Symptoms of voice weakness and an aching throat improve with rest, but return as soon as the singer or speaker speaks or sings again.

Dysphonia is due to poor voice production and occurs often in tense individuals who speak or sing for a living.

Teachers, preachers, salesman, politicians, and telephone workers are all at increased risk.

Dysphonia caused by muscle strain can happen to singers (and speakers) who do not use correct breath management and appoggio; they tend to squeeze the extrinsic muscles surrounding the vocal tract as a result of poor breath support.

Working in a dry, hot, or polluted environment increases the problem.

MUSCLE TENSION DYSPHONIA

Muscle tension dysphonia occurs when excessive laryngeal muscle tension squeezes the vocal folds and surrounding muscles into a fist configuration, preventing air from moving through the vocal folds to enable normal vibration.

Indications include throat tightness, muscle aches in the neck while talking or singing, rough, hoarse voice that gets worse with continued use, throat or neck pain when talking, excessive use of the false vocal folds and surrounding supraglottic musculature, and persistent straining and pressing of the voice.

Nodules may also be present on the true vocal folds. The voice is reduced to a “squeaky” sound.

MTD occurs when the external laryngeal muscles are either too tight or are over-used in the speaking or singing voice.

When this happens, the vocal folds do not function properly.

Medications can also contribute to dysphonia: Inhaled steroids, testosterone, decongestants, antihistamines, anticoagulants, and some antipsychotics can be problematic.

These conditions respond to speech therapy with a qualified speech-language pathologist. Surgery is not indicated if the patient responds to speech therapy and if new habits of speaking are maintained.

Correct speaking and singing habits with relaxation of the laryngeal musculature with massage. Refraining from the medications listed above that may contribute to the issue.

ACID REFLUX

Acid reflux is a condition in which stomach acids rise into the esophagus because the valve that separates the stomach contents from the esophagus is faulty.

The stomach produces strong acids and enzymes (gastric juices) which are used in food digestion.

The inner lining of the stomach has several mechanisms to protect itself from the effect of the gastric juices, but the lining of the esophagus does not. The valve that stops the gastric juices from going up the esophagus is called the lower esophageal sphincter. The esophageal sphincter lies at the junction where the stomach and the esophagus join.

When the lower esophageal sphincter becomes weakened, gastric juices can seep upward into the esophagus.

Many people have acid reflux problems occasionally; in the majority of cases, this is harmless.

If the problem becomes persistent and goes untreated, heartburn can develop into GERD, Gastroesophageal Reflux Disease, a condition in which the stomach contents (food or liquid) leak backward from the stomach into the esophagus (the tube from the mouth to the stomach).

This action can irritate the esophagus, causing heartburn and other symptoms. In chronic and severe cases the esophagus can become scarred, leading to difficulty swallowing. In severe cases, the risk of developing cancer of the esophagus increases significantly.

Indications are:

• Asthma; gastric juices seep upwards into the throat, mouth and air passages of the lungs, making breathing difficult
• Chest pain
• Dental erosion due to acidic substances on the teeth
• Dysphagia – difficulty swallowing
• Heartburn – a burning feeling rising from the stomach or lower chest towards the neck
• Hoarseness
• Regurgitation – bringing food back up into the mouth. Reflux of acid into the larynx can have detrimental effects on the voice; when acid bathes the vocal folds and larynx, the tissues become red and inflamed, and singing becomes difficult. Individuals with acid reflux may have hoarseness and a persistent cough that can lead to vocal fold lesions. As the vocal folds begin to swell from acidic irritation their normal vibration is disrupted.
• Excessive throat clearing

Even small amounts of exposure to acid may be related to significant laryngeal damage.

This disruption in the vibratory behavior of the vocal folds will often produce a change in the singing or speaking voice. When a singer or speaker encounters an undesirable vocal sound the first impulse is to compensate, resulting in potentially abusive vocal behaviors.

This can exacerbate the original symptoms through excessive muscular tension and can eventually lead to the development of vocal fold pathologies.

Acid reflux may be caused by several factors including a hiatus hernia (malfunction of the stomach valve), obesity (being overweight), and poor eating habits, including night eating, overeating, and consuming food or drinks that promote stomach acid production, such as spicy, fatty, or fried foods, acidic foods (tomato sauce, orange juice), soda, coffee, tea, chocolate, mints, and alcohol.

Using tobacco products in any form promotes stomach acid production.

Lifestyle changes sometimes help prevent symptoms of gastroesophageal reflux disease, or GERD.

Because fatty foods, mints, chocolates, alcohol, nicotine, and caffeinated beverages such as coffee or colas relax the lower esophageal sphincter, sufferers may be able to reduce the amount of acid reflux they experience by avoiding these foods.

Carbonated drinks, citrus fruits and juices, spicy foods, and tomato sauce may irritate the lining of the esophagus and make the effects of GERD more severe. Cutting out these foods helps some people who have GERD.

Sufferers may help reduce reflux by quitting smoking, wearing loose clothing, eating smaller meals, not lying down for at least three hours after eating, and losing weight if overweight.

Some people can prevent symptoms at night by raising the head of their bed with 6-inch blocks or by sleeping on a special wedge-shaped pillow that elevates the upper part of the body.

Sleeping on the left side may also lessen symptoms.

Some medications, such as birth control pills and drugs for osteoporosis may cause reflux as a side effect. If drugs seem to be causing heartburn, talk with a doctor about alternative medications.

PRESBYLARYNGIS

Presbylaryngis is caused by deterioration and thinning of the muscles and tissues due to aging. The vocal folds have less bulk and therefore do not meet in the midline. As a result, the singer has a hoarse, weak, or breathy voice. This condition can be corrected by injection of fat or other material into both vocal folds to achieve better closure.

Daily vocalization can prevent many of the conditions associated with aging and preserve a youthful sounding voice well into the advanced years.

As a voice teacher, you should not take the risk of continuing to teach a student with ongoing (longer than two weeks) issues such as hoarseness and the inability to sing high and softly. The student may blame you for vocal problems resulting from their poor habits, and this will damage your reputation irretrievably. Insist they get a clean bill of health from a qualified otolaryngologist, and have them bring a picture of their pristine vocal folds to you.

A final note: singers who undergo surgery should insist on SMALL sized tubes for intubation.  Let the docs know you are a singer- intubation can cause vocal fold trauma such as granuloma!

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