Performance Voice and Professional Voice

At UC Health’s Voice and Swallowing Center, we understand how important your voice is to your life and your career. Our laryngologists (throat specialists) and speech-language pathologists have the training and experience to address both urgent and chronic problems with your voice.

We are the preferred physicians for singers at Cincinnati Opera and the College Conservatory of Music, because we offer the most current and comprehensive approaches to voice problems in the Tri-state area. In fact, our reputation draws people from across the Midwest to seek our expertise.

Whether you are an opera singer, choir member, actor, rock performer or musical theater professional, we can help you with performance voice problems. We also can help you if your profession – such as teaching, coaching, law or preaching – puts great demands on your voice.

 

Why Choose UC Health for Voice Problems?

  • Physician Expertise. We have two laryngologists, whose fellowship training and research put them in an elite group of about 200 laryngologists across the country who specialize in throat disorders. They interact frequently with this group to both share and learn about the latest advances in treatment strategies.
  • Team Approach. Our physicians and speech-language pathologists work alongside each other, giving you the benefit of two perspectives on your condition. They create a customized treatment plan for you and coordinate your care.
  • Study of the voice is a relatively new field, and our team is pursuing answers both in the lab and through clinical trials. A recent $2.5 million grant by the National Institutes of Health will help further our understanding of the mechanisms underlying voice production and improve treatments for vocal cord paralysis, laryngeal reconstruction, and laryngeal vocal injury seen in performers and professional voice users.
  • Advanced Techniques. Surgeries using precise microscopic and laser techniques for benign vocal fold growths and vocal fold scarring help spare healthy tissue and improve on previous techniques to produce better voice quality. For unilateral paralysis (paralysis of just one vocal cord), UC Health offers arytenoid adduction and reinnervation surgeries not available anywhere else in the Tri-state region in addition to more standard treatments. .
  • Comprehensive, Holistic Care. Problems with voice, swallowing and breathing all may occur in your throat. We look at how these issues affect each other and work with you to optimize all three. We also closely work with professionals in other specialties involved in voice problems, including pulmonology, gastroenterology, neurology, psychology and psychiatry, and integrative medicine.

 

How the Voice Works

Three systems work together to produce your voice:

  • Airflow from the lungs passes through the vocal folds (also called vocal cords).
  • Vocal folds vibrate to produce sound.
  • Structures above the folds (such as the tongue, nose and throat) shape the sound into intelligible words.

The larynx — voice box — consists of three cartilages, including the thyroid cartilage, which forms the Adam’s apple. The vocal cords are inside the thyroid cartilage. Muscles attached to the cords move them apart when we breathe and together when we talk or swallow.

When we talk, the cords come together and air from the lungs passes through the cords to cause a vibration. The vibration alters airflow as it exits the vibrating folds and produces sound. The cords open and close about 100 to 200 times a second. The loudness of the voice is determined by how quickly the vocal folds close to cut off airflow.

While the basic mechanisms of vocal fold vibration and voice production are known, the finer details are not fully understood. In our lab at UC Health, we are conducting in-depth studies to help interpret and treat voice disorders. Our advanced understanding of voice structures and functions enable us to find and treat your condition precisely, returning you to complete function sooner.

 

Diagnosis

There are dozens of conditions that can affect the voice. So, it’s important to make an accurate diagnosis. Following a thorough history and physical exam, we may use one or more of the following tests to determine the cause of your voice problem and create a personalized treatment plan for you:

  • Flexible laryngoscopy — Inspecting the voice box via a scope that passes through your nose.
  • Rigid laryngoscopy — Inspecting the voice box via a scope that passes inside your mouth at the back part of your tongue.
  • Videostroboscopy — A magnified, slow-motion assessment of the vocal folds and their vibration using a special strobe light source. This examination uses either the flexible laryngoscope (passed through the nose), or the rigid laryngoscope (placed at the back of the tongue).
  • Acoustic analysis — A recorded analysis of the range and quality of your voice. We may record your voice during your initial evaluation.
  • Aerodynamic evaluation — An assessment of air pressures and air flow rates during various voice tasks. Absent or excessive air pressure or airflow usually results in improper use of the voice.

 

Conditions

At UC Health, we treat all voice problems, from the most common to the rarest. We often help people who have not found help elsewhere. We address both the form (structure and anatomy) and function (how they work) of the vocal cords.

Conditions we treat include:

 

Benign Vocal Cord Growths

The more you use your voice each day and the louder your volume, the more you are prone to develop lesions — growths — on your vocal cords that create symptoms such as a breathy voice, gravelly voice or voice fatigue.

We treat all types of vocal cord growths, some occurring from trauma (overuse) and others that don’t have a known cause.

Conditions such as laryngopharyngeal reflux, infection and allergies often affect the voice. These conditions frequently are treated with medicine and/or dietary and lifestyle modifications.

We offer speech therapy to help you optimize lung support and recommend ways to reduce strain on your vocal cords and improve the quality of sound. Voice therapy by itself is useful for many conditions. The benefit of many surgical procedures also may be enhanced by post-operative voice therapy.

The most common benign growths are mid-membranous lesions, which grow in the middle of the vocal cord, where vibrations occur most strongly. Growths include nodules, polyps and cysts. 

  • Nodule — A callus or lump on the vocal cord that creates a gap as the vocal cords come together. As air escapes through the gap, the voice becomes breathy. Your voice will wear out more easily and lose volume, causing you to strain to make yourself heard. Voice therapy usually reduces or eliminates the nodules, and surgery for this condition is uncommon.
  • Polyp — Growth that usually occurs on one of the vocal cords and can cause voice problems similar to the nodule. Depending on the location and type of polyp, surgery may be warranted, with post-operative voice therapy for optimal voice restoration.
  • Cyst
  • Vocal process granuloma — Also called a contact ulcer, a lesion at the back of the vocal cord, caused by laryngopharyngeal reflux (backup of stomach acid into the throat area). It often follows irritation from an endotracheal tube (ET) used during surgery in the throat. However, granulomas can occur without an ET tube. Treatment options include rest, medication, voice therapy, in-office laser or surgery, in rare cases. Treatment of the underlying reflux is essential. Surgery can be used to remove large lesions, but the granulomas will recur if the underlying reflux is not treated.

 

Other Benign Lesions

Vocal fold hemorrhage — Rupture of a blood vessel on the surface of the vocal cord that causes sudden loss of voice following yelling, shouting or other strenuous vocal tasks. These lesions can completely resolve or they can form cysts, polyps or scars. Treatment may include regular exams, voice therapy, medicines and surgery.

Vocal fold scar and sulcus — Irregularities in the tissue just below the outer layer of the vocal cord that disrupt the vibrations and creation of normal sound. As a result, you may experience hoarseness and breathiness and need increased effort to speak. These are difficult conditions to treat, although we have had some success with voice therapy and/or specialized surgical procedures.

Vocal fold bowing — Tissue loss (atrophy) of the vocal fold can produce a bowed shape instead of the normal flat surface. This results in a gap between the folds and produces a breathy, soft voice. This is similar to what happens in unilateral paresis/paralysis (see below). Atrophy can occur in certain neurological conditions (e.g., Parkinson’s and paralysis) but can also occur as a normal function of aging. First-line treatment is voice therapy. Less often, surgery is used to bulk up the fold and restore the flat surface.

Reinke’s polyp — Enlargement of the upper layer of the vocal cord with gelatinous material, almost always caused by smoking. Treatment is to stop smoking. Surgery may be required in severe cases if the polyp is blocking the airway or if there is a concern that the polyp is a malignant cancer.

 

Movement Disorders that Affect the Voice

Unilateral paralysis/paresis (weakness of the vocal cord) — When we breathe, our vocal cords move apart. When we talk or swallow, the cords move together. If there is a gap between the cords, air escapes and the voice sounds breathy. One cause of a gap is paralysis or weakness of one vocal cord due to viral infection, surgical complication or tumor growth. The size of the gap depends on the degree and severity of the paralysis. Hoarseness is a common symptom.

Bilateral vocal fold immobility — Paralysis of both of the nerves to the vocal fold muscles or scar tissue between the folds that prevents them from moving. Either condition usually results in the folds sticking together. Since the folds normally move apart when we breathe, both conditions affect breathing. If your vocal cords are not moving apart, we can perform surgery to create a balance between ability to speak and breathe.

Paradoxical vocal fold movement disorder — Vocal cords function abnormally, closing as you breathe instead of opening up. This makes it harder to get air into or out of your lungs. The condition often is confused with asthma. You may need a test to examine the movement of air in and out of your lungs. Speech therapy techniques can teach you to control your vocal cords and relax your throat muscles. 

Spasmodic dysphonia — Muscles that cause vocal cord movement experience sudden involuntary movements called spasms that interfere with the ability of the folds to vibrate and produce voice. Voice breaks occur and can become worse over time. Once thought to have a psychological cause, this condition now is recognized as a neurological problem, treatable with Botox injections to weaken the vocal cord muscles and stop the spasms. Although voice therapy cannot help this disorder, therapy is often used to treat other voice problems (such as muscle tension dysphonia) that occur as compensation for spasmodic dysphonia.

 

Malignant Vocal Cord Growths

Leukoplakia — Precancerous, white growths on the vocal cords are called leukoplakia and should be removed to reduce the risk of cancer. These can be treated with the KTP laser in select patients.

Laryngeal cancer  Very treatable cancer if diagnosed in its early stages. We use advanced techniques such as robotic-assisted and laser surgery to remove the cancer.

 

Other Conditions

Muscle tension dysphonia (MTD) — A voice disorder associated with voice fatigue, strained voice, and throat or neck discomfort. It results from over-activity of certain muscles that squeeze more than normal. Muscles may try to compensate for vocal cord weakness, scarring, lesions (e.g., cysts, polyps, nodules), or poor breath support. More often, MTD is associated with improper voicing technique, resulting from an unconscious attempt by the brain to “push out” a better voice. The best treatment option is voice therapy, including laryngeal massage, reorganizing breathing patterns while speaking to improve airflow, and vocal exercises to improve re‐balance and relaxation of the voice box.    

Laryngopharyngeal reflux – The term reflux usually refers to the flow of stomach acid and other substances back into the esophagus (heartburn) and even into the larynx or the pharynx. With laryngopharyngeal reflux (LPR), the acid damages the lining of the larynx or pharynx. Common symptoms include: hoarseness, a “lump” in the throat, trouble swallowing, too much throat mucus, throat clearing, cough and sore throat. LPR generally doesn’t cause heartburn. Determining the exact cause of the inflammation requires a history and physical exam; sometimes other tests are also required. Treatment includes dietary and lifestyle changes and, sometimes, medicines.

 

Treatment

The voice team at UC Health excels at both conservative and surgical options for voice conditions.

 

Voice Therapy

Our certified speech-language pathologists specialize in voice disorders. They train your voice with vocal exercises to improve or achieve the most optimal voice quality. They also help provide relief from vocal symptoms that may be bothersome (vocal fatigue, “lump in the throat,” tightness with voicing, etc.).

Voice therapy is sometimes the first line of treatment for benign vocal fold lesions, and most always the treatment for muscle tension dysphonia. The voice therapy program is tailored to each person’s unique needs and personal goals.

Depending on your voice disorder and its severity, your therapy program will typically last four to eight weeks. Generally, you will perform exercises that retrain coordination of respiration (breathing), phonation (voicing), and articulation (resonance). For most people, all three of these are disorganized, and we give you tasks to reorganize your system.

The program may also include tasks that are designed to eliminate harmful vocal behavior, shape healthy vocal behavior and assist in vocal fold healing after surgery or injury.

 

Surgery

 Microscopic Laryngeal Surgery

Sometimes, surgery to remove a growth is your best option to restore your voice. This procedure is performed in the operating room through the mouth. Our laryngologists use a microflap surgical procedure in which we remove the growth while preserving the thin layer (0.1 mm) of tissue (mucosa) covering the vocal cord. The surgeons also minimize cutting of healthier tissue.

The meticulous skill required to perform this delicate procedure results in faster healing time for you — two weeks rather than six to eight weeks with conventional surgery that does not preserve the mucosa. UC Health performs more of this complex surgery than anyone else in the region.

 

Suspension Microlaryngoscopy

At UC Health, we perform two variations of this endoscopic procedure to remove abnormal tissue:

  • With microflap excision — Surgery using an operating microscope and fine microlaryngeal instruments to remove abnormal tissue. The mucosa is lifted off the benign growth. The growth is removed and the mucosa is placed back in the normal position.
  • With laser excision — Surgery using an operating microscope with either the CO2 or KTP laser (see below) to ablate abnormal tissue.

We perform more of these complex procedures than anyone else in the region.

 

Angiolytic KTP Laser

If you have problems with growths that keep returning (for example, laryngeal papilloma or white, precancerous leukoplakia lesions on the vocal cords), we can treat the lesions in our office with an angiolytic KTP laser, an advanced option not found anywhere else in the Tri-state region. The laser is fitted into a flexible laryngoscope, which is a lighted scope that goes through your nose into your throat.

Because our physicians treat the lesion right in the office, you can leave and return to work or other activities immediately following your treatment. These growths have a tendency to return, so the in-office laser procedure has the benefit of minimizing the disruption to your normal routine and sparing you the need for hospital procedures and general anesthesia.

 

Medialization Laryngoplasty

For vocal folds that do not come together completely, the physician injects material to provide support to a vocal fold to plump or augment the fold and reduce the gap between vocal folds.

 

Surgery for Vocal Fold Gaps and Unilateral Paralysis

Surgical procedures to correct gaps caused by unilateral vocal cord paralysis or other conditions include:

  • Injection Laryngoplasty — An operation on your voice box with a temporary injectable, such as hyaluronic acid and other materials.
  • Thyroplasty — An operation on your voice box to make your voice stronger. Our surgeon inserts an implant next to your vocal cord to push the vocal cord towards the midline to improve your voice. The implant is made of silicon or Goretex. This operation is performed from the outside of your neck. You will have a small horizontal scar over your neck.
  • Arytenoid adduction — An operation to close the gap between your vocal cords with both an implant and repositioning of the paralyzed vocal cord cartilage (arytenoid adduction) to the middle. UC Health is the only hospital in the Tri-state area to perform this surgery.
  • Laryngeal reinnervation — Surgery that creates a new, functioning nerve supply to the paralyzed vocal cord. UC Health is the only hospital in the Tri-state area to perform this surgery.

 

Laryngeal Reconstruction.

A number of conditions, such as previous operations on the larynx, trauma and cancer can cause permanent damage to the vocal folds, cartilages or other laryngeal structures. This damage may result in missing or scarred tissue. We use several techniques to replace damaged laryngeal tissue with different types of tissue, including rib cartilage, fascia from the temporalis muscle (chewing muscle), fat, and lining from the cheek, skin, and muscles in the neck.

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