HEALTHWATCH
Be voice wise
DR. RAVI K VISWANATHAN
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Use your voice well. Do not abuse it.
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YOUR voice identifies you. Yet, how often do we take care of this wonderful organ of speech, the larynx? The larynx, commonly called the voice box, produces voice. It consists of a framework of cartilages. The thyroid and epiglottis connected by ligaments, membranes and lined on the inner aspect by respiratory mucosa and muscles. The movement of air in and out of the lungs and trachea causes vibrations of the vocal cords and produces speech. The larynx helps in breathing. It protects the lower respiratory tract by its sphincter action and prevents anything going down into the lungs by its strong cough reflex.
First complaint
A hoarse voice is the first complaint when there is a problem in the voice box. Roughness of voice results from variation of periodicity and intensity of consecutive sound waves. For production of normal voice the vocal cord should be: able to approximate properly with each other; have a proper size and stiffness; and an ability to vibrate regularly in response to the air column.
Any condition that interferes with these functions causes hoarseness. When the vocal cords get congested and inflamed the voice becomes hoarse. It alters the identity of the individual. Professional voice patients are a diverse group. Anyone who depends on speaking or singing for employment like salesmen, receptionists, telephone operators, lawyers, teachers, politicians, public speakers and most physicians should be considered professional voice users because they place varying demands on their voices.
Common problems
Gastroesophageal reflux is a problem often manifest by symptoms of heartburn, belching or an acidic taste on waking. Patients can have significant reflux with no abdominal and chest complaints, in what is called extra oesophageal reflux. The symptoms are often frequent throat clearing, mild change of voice, cough, a sensation of phlegm, or a foreign body sensation in the throat, vocal fatigue, or decreased singing range.
Singers and other vocal professionals with extra oesophageal reflux often have hoarseness in the morning and require a longer vocal warm up. Conservative management directed at diet and general lifestyle is initiated. Following these measures may be difficult for performers with a demanding travel schedule. Drugs to reduce acidity are effective in these cases.
The key to good laryngeal hygiene is adequate hydration. Poor hydration causes a decrease in mucus viscosity resulting in less efficient vocal fold vibrations. Singers should drink increased amounts of water At least eight glasses (64 ounces) of water a day appear to be needed, and should be increased if the voice user is travelling by air, is ill, or has a demanding or excessive performance schedule.
The use of caffeine is discouraged because of its diuretic effect. Dairy products also appear to increase the viscosity of secretions and hinder the healthy smooth vibratory function of vocal folds. The use of tobacco also contributes to poor laryngeal hygiene.
Vocal abuse is the gradual wearing down of the voice by over rehearsing; spending too long in the studio; singing too loud; singing outside the capable range; shouting or excessive talking in areas with loud background noise like restaurants and airports. Chronic misuse can eventually lead to organic vocal fold changes, which appear as vocal nodules and will disrupt the normal laryngeal vibratory pattern causing dysphonia. Elimination of the inappropriate vocal behaviour lessens the dysphonia.
In muscular tension dysphonia, the singer attempts to maintain a normal voice while the vocal fold or pharynx is swollen and develops inappropriate vocal behaviours. Patients often complain of hoarseness, vocal fatigue, loss of range and neck or ear discomfort.
Management would involve vocal training, warming up before singing and singing classical musical styles to decrease muscular tension. Retraining the patient to improve speaking and singing efficiency is necessary.
Common problem
Acute laryngitis (inflammation of the laryngeal mucosa) is common in adults and can be devastating to the professional voice patient. Inflammation of the vocal folds leads to irritation and oedema leading to dysphonia. To compensate, singers may exert more to maintain their normal voice. Singers may correctly compensate by decreasing their volume, increasing the amplification and other measures.
In very mild cases, conservative management includes increase in fluid intake and humidify the room. If cough is significant, cough syrups and suppressants may help. The singer should speak little, if at all, before the performance and warm up in normal fashion. He or she should speak in a normal, unforced voice without whispering. Vocalists with severe laryngitis should be advised not to perform.
Vocal fold varices is a dilated tortuous or elongated vessel stemming from the microcirculation of the vocal fold. It occurs mainly in the female vocalist and suggests that hormones are a major factor. The patient's symptoms correlate with menstrual cycle. It can be managed by improvement of vocal hygiene, increased water intake and avoidance of caffeine.
Management includes maintaining adequate hydration and avoidance of irritants like tobacco and caffeine, inhaled and topical corticosteroids, antihistamines, decongestants, aspirin, topical analgesics and mentholated preparation. Systemic corticosteroids can be given.
A speech language pathologist teaches singers to avoid cervical strain, learn proper breathing patterns, improve posture and develop a soft glottal attack when speaking. The goal is to improve laryngeal efficiency and thereby limit laryngeal trauma during singing and speaking.
Surgery is only performed when it is apparent that the patient cannot perform at the required level to maintain an acceptable performance schedule.
Voice is an extremely sensitive indicator of emotional status and general health. Therefore when evaluating voice disorder, the entire physical and psychological status should be considered. Altered function in nearly any part of the body can result in vocal changes.
Virilisation of voice in women is extremely rare. The main cause is tumour of the ovaries or the adrenal glands that produces testosterone. The critical period of change begins at menopause. If the woman is a singer, she can take precautions that the chest register does not take control of her voice.
Endocrine dysfunction like decreased thyroid function can cause a muffling of the voice, decreased range and vocal fatigue. Hormonal changes in women, before and during menstruation, can cause voice changes.
Diseases that affect the lungs, posture and hydration can affect voice. Asthma, emphysema or chronic bronchitis, which reduce pulmonary function, will decrease the power supply to the voice. Musculoskeletal injuries will alter posture and lead to vocal dysfunction. Drugs that decrease body secretion alter voice. In female singers oral contraceptives and hormonal drugs will affect the voice.
The singer's body is a vocal instrument and the larynx represents the most important portion of this instrument. Education and behaviour modification can enable singer to maximise their gift. The maintenance of good vocal hygiene and regular reminders of abusive speaking and singing behaviours are part of this process.
The writer is the Director, AVM Medical ENT Research Foundation, Chennai.
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