Quality of your voice can be a sudden change or one that occurs gradually over time. If this change was sudden or has persisted for longer than 2 weeks, it might be a good idea to seek an ENT assessment. This can be via your GP (NHS route), or you may wish to seek private ENT opinion. If you are reliant on your voice for work there may be additional support you can receive from your place of work or financial support is available to performing artists and singers in crisis. Please speak with Carrie about your situation and she may be able to signpost you to further support which may be available to you. 

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Whether it’s anatomy or technique contributing to your voice change, Carrie is trained in vocal performance (singing and speech techniques) and has experience evaluating with observation, discussion, manual palpation, acoustic analysis and behavioural assessment to get you back to doing what you love.

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Voice Therapy through the Singer's Clinic can help you with the following potential diagnoses:

What is Muscle Tension Dysphonia?

Muscle Tension Dysphonia, or MTD, is a broad definition and encompasses a wide range of potential presentations. 

There are two types: Primary MTD occurs when no apparent structural reason for the tension. Secondary MTD is when muscle tension is compensating for a disturbance in the larynx such as a structural change, swelling or paresis. 

An accurate picture of an MTD results from a thorough case history, general observations, a detailed auditory-perceptual analysis, manual palpation, appropriate instrumental analysis and excellent laryngeal imaging. The treatment for MTD is behavioural voice therapy with goals based upon the information gathered from all of these assessment approaches. Endoscopic observations of vocal tract function and laryngeal gestures used during speech or singing can be extremely helpful in guiding individualised approaches to voice therapy, particularly for professional voice users. Which is why a trip to a specialist voice clinic is recommended prior to seeking voice therapy. 

Voice therapy teaches you to coordinate your vocal subsystems: breathing, phonation and resonation back to a baseline level or a level that manages your symptoms more effectively. You will learn how to reduce tension at the level of the vocal folds and reprogram your muscle memory for speech and/or singing. 
 

What are Vocal Cord Nodules?

Nodules are not the end of the world. They are the most common lesions on the vocal folds and they are unlikely to end your career! Nodules will require hard work to resolve, and they will likely cause worry and frustration along the way. Take heart that by just reading this, you're taking your first steps to being in the right hands to changing your habits, resolving your nodules and taking back control of your voice. 

Nodules can cause various symptoms including vocal roughness, breathiness, tension, reduced range, voice and body tiredness, and neck pain. Change to vocal quality occurs because the nodules touch when you bring your vocal folds together to make sound, and air escapes from above and below the nodules. Secondary muscle tension dysphonia can often occur alongside nodules, exacerbating symptoms. 

Vocal nodules develop as a result of repeated trauma to the vocal folds. Overuse, misuse and new use of the voice are often the culprits. Nodules can occur in children and adults and are a result of stressful vocal behaviours like excess talking, singing, shouting or screaming more than the larynx can handle (genetics and training play a role here). The vocal fold tissue forms callouses in response to repeated tissue overuse and small swellings develop at the site of the trauma. These are usually known as “soft nodules”. They occur on both vocal folds, are symmetric, and vary in size. They interfere with the closure and vibration of the vocal folds causing hoarseness. If soft nodules are ignored, persistent damage may begin to produce fibrous scar tissue. When this happens they are often referred to as “hard nodules”.

Soft nodules are usually treated successfully with voice therapy (acting much like physiotherapy for your voice) and good voice care. With a reduction in vocal habits that caused the issue in the first place, the callouses will lessen or disappear altogether. Hard nodules respond less well to voice therapy and usually require surgery.

What are Vocal Cord Polyps?

Polyps are growths on the vocal cords filled with fluid and they can change the way your voice sounds. It may be easiest to think of a nodule as a callous and a polyp as a blister. 

They can occur from long-term vocal abuse (like nodules), or from just one instance of vocal abuse - like yelling at a concert. Smoking, thyroid problems and reflux may also cause polyps. Polyps usually occur in adults and are rarely found in children. Polyps can cause various changes in the voice similar to nodules.

Some polyps may look like a swollen spot or bump, a blister, a thin long growth, or they may even look like a grape on a stalk! Surgical removal is usually the option for treatment, however a combination of voice therapy and surgery is best to improve the patient’s vocal habits and to decrease the chance of a recurrence. You may hear them occasionally called polypoid degeneration or Reinke's edema. 

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What is Vocal Fold Hemorrhage?

Traumatic injuries to the vocal fold blood vessels can cause vocal fold hemorrhage. The larynx may suffer external trauma from sports injuries, physical attacks or from seatbelt compression in car accidents. Vocally abusive behaviours like shouting, screaming, violent coughing or crying can cause capillary rupture in the vocal fold and blood can leak into the superficial layer of the lamina propria (a layer within the vocal fold). Your voice can change dramatically when the rupture occurs.

Treatment includes vocal rest and conserving the voice, but surgical treatments are sometimes recommended. Voice therapy is recommended to promote healing, and stop the trauma from occurring again. 

What are Vocal Fold Cysts?

Vocal cord cysts can be present from birth, or appear with age. Cause of a vocal cord cyst can be genetic or behavioural. They are tricky in that they do not respond to traditional voice therapy alone. Usually, the patient will have to undergo surgical extraction. Most cysts are either white or clear and are usually found on only one side of the vocal cords. Sometimes, what’s called a “reactionary lesion” is formed on the opposing cord in the spot where it meets with the cyst during phonation. This opposing lesion can be smaller or the same size as the cyst. Videostroboscopy is key when this happens to rule out vocal nodules. Cysts cause the affected vocal cord to become stiff and not vibrate as well. The lack of vibration in one cord causes changes in the person’s vocal quality. Problems can range from mild voice changes, difficulty with singing range, diplophonia (two sounds coming out at once) and complete loss of voice.

Voice therapy can help you to improve vocal hygiene (voice care), coordinate vocal subsystems, and reduce vocal abuse and misuse. Voice Therapy is recommend before and after surgical removal of a cyst.

What is Vocal Fold Scarring?

Vocal fold scarring can occur following the presence of a lesion, changes to the tissue following surgery, and if the vocal fold tissue is continuously irritated from vocal abuse and misuse. Just like with scars you can see on your arms or legs, scar tissue is stiffer than regular tissue. When the vocal folds accumulate scar tissue, they become more stiff and are not as pliable. This reduction in pliability results in a reduced mucosal wave and voice quality changing. Those suffering from vocal fold scars typically lose vocal flexibility for pitch changes, fatigue easily, have a quieter sound, and sound rough or strained. 

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Why should I seek ENT opinion?

Vocal symptoms can be similar across many different vocal conditions so it is very important to seek diagnosis from ENT to ensure you end up on the right path to recovery. 

If cyst, sulcus, or scarring is suspected it would be wise to seek opinion from a voice specialist ENT surgeon (laryngologist), preferably one working in a multidisciplinary voice clinic. The laryngologist will need to examine your vocal folds with specialist equipment, such as stroboscopy or high speed photography, in order to identify any areas of vocal fold stiffness that might indicate the presence of a cyst, sulcus or scar. Without this special equipment these lesions may be difficult to identify. Even when good equipment is available, it still may not always be possible to determine exactly what is causing a stiff area until the vocal folds can be palpated and examined under a microscope during surgery. 

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What is Vocal Cord Paralysis?

Paralysis is a condition in which you can't control the movement of the muscles that control your voice. It happens when nerve impulses to your voice box are disrupted. This results in paralysis of the vocal cord muscles. It can occur in one or both vocal folds, resulting in a breathy or weak voice quality with pitch instability. The vocal fold can be paralysed in the midline position and sometimes cause breathing issues during heavy exercise, but most commonly the vocal fold is paralysed in the abducted position (open). Paralysis occurs from damage to either the superior laryngeal nerve (SLN) or the recurrent laryngeal nerve (RLN). Paralysis can happen after injury to the head, neck or chest; surgeries, such as thyroid or heart surgeries; viral infection, stroke, tumors, neurological conditions, or for no reason at all (Idiopathic vocal cord paralysis). 

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Paralysis can make it hard to speak and breathe. That's because your vocal cords do more than just produce sound. They also protect your airway by preventing food, drink and saliva from entering your windpipe (trachea) and causing you to choke. 

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Treatment depends upon the cause, the severity of symptoms, and the time from the onset of symptoms. Treatment may involve voice therapy, bulk injections, surgery or a combination of treatments. In some cases you may experience spontaneous recovery and get better without surgical treatment. For this reason your ENT consultant may decide to watch and wait. However, bulk injections are commonly done within the first 3 months of voice loss. Voice therapy can help keep you from using your voice improperly while the nerves heal, maximising efficiency of vocal function through exercises to improve breath control, prevent tension in other muscles around the paralysed vocal cord (or cords). and protect your airway during swallowing. Occasionally, voice therapy may be the only treatment you need if your vocal cords were paralysed in a location that doesn't require bulking or repositioning. 

SUPERIOR LARYNGEAL NERVE PARALYSIS

SLN damage is the most difficult to identify because the patient usually complains of vocal fatigue, being unable to sing, and difficulty increasing pitch or volume. SLN damage can create a gap between the vocal folds after they come together (where one overlaps the other) which results in the patient being unable to achieve maximum closure. The affected vocal fold is also unable to lengthen upon pitch raising. Voice therapy can benefit anyone suffering from SLN paralysis to give the patient the maximum ability of vocal use in the presence of the paralysis, but no medical treatment is successful in treating SLN damage.

RECURRENT LARYNGEAL NERVE PARALYSIS

RLN damage is easier to identify as most patients complain of diplophonia (two sounds at once), reduced volume and pitch, and breathiness. This paralysis can cause atrophy of the vocal fold(s) affected and impact the ability for the vocal folds to completely close (adduct). A combination approach of surgical treatment and behavioural voice therapy is most beneficial, as detailed above.  

PARESIS

Often times there is SLN and RLN paresis which can improve spontaneously in about 6-12 months. Again, behavioural voice therapy can maximise the your ability to utilise the best voice possible whilst reducing the risk of developing unhelpful patterns of vocal behaviour. 

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