Your voice allows you to have a voice, Libby Smith, DO, FAOCO, Director of the Voice Center, said in The Eye & Ear Foundation’s February 21 webinar, “Protecting and Preserving Your Voice.” Dr. Smith is a board-certified otolaryngologist who specializes in the care of the professional voice and the treatment of voice disorders.
“Voice” has multiple definitions, all of which are important, Dr. Smith said. The word can refer to the musical sound produced by the vocal folds, resonated by the cavities of the head and throat. Or it can mean a wish, choice, or opinion openly or formally expressed. This can be a personal voice or a community voice.
“We want you out there being able to have your voice to have your voice,” said Dr. Smith.
A violinist stores their violin in a case to keep it nice and protected. Our larynx or voice box is not like that; it is in us. Wherever our body goes, so does our voice. Our environment – our body as well as the outside world – will definitely affect our voice.
Voice Production
We have to think to say something or make a sound, but then how do we make it happen? We power that voice with the air coming from our lungs followed by the air shooting through the vocal folds, Dr. Smith explained.
The sound that is created from the vocal folds vibrating together, with the air going through them, modified by our resonating cavity, makes everyone sound different. Most females have fairly similar vocal folds as long as they are of similar age, likewise for men. What makes Dr. Smith sound different than another female are the idiosyncrasies of the vocal folds themselves and the resonating cavity above.
The voice box is housed in the neck. Vocal folds will open and close. Air generated from the lungs shoots up through the windpipe through the closed vocal folds, which makes sound. The edges vibrate together to produce the sounds of speaking or singing, utilizing fine muscle control.
Lamina propria is the specialized covering of the vocal folds, with the most superficial portion being where most benign lesions occur. This very important layer is needed for vocal fold vibration but is also very sensitive to injury and very difficult to repair surgically.
When air from the windpipe (trachea) exceeds the vocal fold closure pressure, the vocal folds open and then snap back together. This equals one mucosal wave. In men, this happens in normal talking speech, ~100x/second. In women, it occurs ~200x/second. Singers, especially sopranos who can hit a high C, have this happen ~1,024x/second.
The amazing world of voice production requires coordination of the fine musculature of the larynx and proper lung support. The delicate nature of the edges of the vocal fold (superficial lamina propria) is the key to phonation. The rate at which it vibrates are what correlates to pitch.
Hoarseness
By 2050, 20 percent of the U.S. population will be Baby Boomers (born between 1944-1964). As we get older, our body changes. That includes voice changes – this is normal.
Presbyphonia is hoarseness due to age-related laryngeal (presbylaryngeus) and pulmonary changes. It can be gradual, with the voice having raspiness, inconsistency, vocal fatigue, decreased projection, strain, breathiness, and reduced range. Male voices tend to get higher in pitch, while female voices tend to become lower. This can have a functional impact on quality of life.
In the normal process of aging, decreased soft tissue bulk (skinny) leads to changes in the extracellular matrix composition and organization, as well as laryngeal muscle atrophy. Decreased tonicity (floppy) leads to neural changes associated with senescence.
Dr. Smith likened this to a guitar string that is too loose. You can still pluck it and it can make sound, but it may not be the robust sound you are looking for.
Aging Respiratory System
In an aging respiratory system, there is rib stiffening, which requires greater force to deform the chest wall; decreased elastic recoil, with a 25% decrease in respiratory muscle force; and decreased inspiratory/expiratory muscle strength.
Often when folks come in, the main thing they want is to make sure they do not have cancer, Dr. Smith said. About 39% of patients want this assurance. About 57% of patients want more from their voice, and the treatment is often voice therapy. In only 6% of patients is surgery actually indicated.
Voice therapy is the cornerstone of laryngology and involves working with speech-language pathology colleagues, who help balance the coordination of airflow, vocal fold vibration, and resonance.
Pulmonary Treatment
In terms of presbyphonia, can we do anything with the lungs? The first step is considering it as a power source. The more you use your voice and hopefully use it well, the better it is. You do not want to have disuse. Think about how to drive that system. Singing requires more; a lot of folks in choirs will keep their system in tip top shape. There are also devices that can be prescribed by physicians for strengthening those muscles in the rib cage to get the lungs to expand and close to get the air force.
Being active is always a positive. Whatever your energy level is, your voice can only match it, not exceed it. If you have a very low energy level, you only have so much to give, but if you are more energetic, the more voice you can have.
Voice misuse or overuse can occur, however, with yelling and lots of talking. Sometimes when the moment of activity overtakes us, this can lead to vocal misuse and potentially overuse. “A lot of our patients are teachers, pastors, physicians, people in vocally demanding jobs, Dr. Smith said. “Yelling creates more of a direct trauma to the vocal folds.” It is a delicate structure that can be injured.
People do not think of voicing as an activity, as it is something we do. But it expends energy. Imagine you were asked to go on a walk for 10 hours straight without stopping. You will be pretty tired. The same goes for voice; you need to give yourself vocal breaks.
Vocal Danger Zones
Vocal danger zones are loud environments like parties, concerts, or loud restaurants. What can we do to mitigate vocal misuse? We end up yelling automatically and may not even realize we are doing it over the background noise. This is called the Lombard Effect.
Dr. Smith suggested using earplugs – even just one. You will hear yourself better and less compelled to yell. It will help to protect your hearing and your voice.
Muscle tension dysphonia is one of the common things seen in the Voice Center, Dr. Smith said. It basically means inappropriate use of the muscles when making sound. People will complain their voice is raspy and they get tired while talking. It can be an effort to talk because there is so much tension in the system. The voice can be inconsistent; sometimes it sounds normal, and the next second, it sounds horrible again. People work really hard to make sound and eventually the voice just cuts out.
Another thing that can happen from overuse and misuse is developing benign bumps of the vocal folds, which greatly impact the ability to create good voice. People with this may start avoiding social situations and activities that bring them joy. These non-cancerous bumps impair the mucosal wave that occurs through the vocal fold as well as the glottic closure. Treatment is often voice therapy.
A very small percentage of patients end up needing voice surgery. This is because the Voice Center SLPs are specially trained in voice, which is not the norm in the community. As a result, the majority of people do well without needing surgery. But when surgery is necessary, everything is done underneath a microscope and with very small instruments to remove the lesions.
Preserve & Protect
“How do we make all that never have to happen?” Dr. Smith asked.
Vocal wellness is key. This means:
- No smoking
- Exercise
- Hydration
- Diet
- Sleep
- Relax/stress reduction
- Smart vocal choices
Aerobic activity that involves “oomph,” conditioning, and exercise is also helpful. This may be difficult for people with lung disease or who smoke. We all know smoking is bad and we fear cancer, which can happen. But there are non-cancer changes to the vocals that can also occur, like Reinke’s Edema. This is when the superior layer of the lamina propria (remember, it is the layer involved with mucosal wave) becomes abundantly huge. It will change the way the folds vibrate and drop the pitch tremendously. Usually, women come in complaining because they are mistaken for male on the phone.
If you are 40+ weeks old and have been hoarse for 2-4 weeks, you need to have your larynx examined. The ENT will look at your vocal cords to make sure there is no cancer and figure out why you are hoarse.
Hydration is another important factor in preserving and protecting your voice. Lubrication offers mucosal protection. Caffeine, lack of water, or medications (antihistamines, antidepressants) can lead to dehydration. Dry air, especially when using a CPAP, means you need to rehydrate.
Food is another factor. You are what you eat, Dr. Smith said. If you eat foods that provide you with good energy, then you will feel better. There are a lot of natural foods that are hydrating. Also think about foods that can cause reflux. A lot of times if people have it, they have heartburn and indigestion, but they can also have hoarseness or feel like something is stuck in their throat, called globus. This results in frequent throat clearing and excessive phlegm production. Risks for reflux are caffeine, spicy and fatty foods, along with tomato-based foods. There tends to be more reflux with CPAP use and obesity.
“We should eat healthy, balanced meals,” Dr. Smith said. Everyone has their own version, so whatever works best for you. Avoid things we know have reflux and things you might be sensitive to. Avoid large meals before bedtime and wait several hours before laying down. “Think about how you can change your behavior, what you eat, when you eat, how much you eat, all to mitigate the effects of reflux,” she added.
Wellness is important: sleep, relaxation/meditation, and mental health will help your voice. If you are tired, your voice will be tired. If you are stressed, your voice will be stressed. A night of restorative sleep is really important. Some people are more hardwired that their voice quality and mental health status are directly linked. Your voice quality will track with your mental health state.
“We take a very holistic approach to the whole person and understanding what’s driving their voice issue so we can focus on where we can help out,” Dr. Smith said. “We acknowledge that we are not mental health providers, but sometimes just having that open dialogue with someone really helps them realize the source of the problem or issues with the voice. It might not be the voice box, but something else going on in their life. We will help guide them through that.”
Ultimately, it is about making smart vocal choices, and knowing that hoarseness is never normal, especially repeated episodes.
Dr. Smith pointed out that World Voice Day is April 16, a worldwide day in recognition of voice and vocal wellness. “I challenge everyone, not just today, but maybe even especially on April 16, to think about how you will use your voice, what’s important to you about it, what can be better, how do you want to be heard?” she said. “And realize that everyone has a voice and we’re always here to help.”