No more hiding: Videostroboscopy of my imperfect vocal folds

A few weeks ago, one of the voice-specialty speech-language pathologists (SLP) I currently work with wanted to see my vocal folds. The professor in my voice disorders class, who is also an SLP, had taken videostroboscopies of the students in class so that we got practice seeing them and seeing what a rigid videostroboscope feels like. So, this other SLP pulled up my file from class in spring of 2014.

Prior to this video being taken, I was enjoying thinking of my voice as functional and healthy. Seeing the paresis in action again, however, brought back the emotional memory of the first time I saw it. All the "how can I sing opera without an intact voice?" came flooding back into my head. Thus, I put the video away in a file on my computer and never looked at it past that spring semester in 2014. Until that SLP wanted to see it.

A few caveats: I wasn't tolerating the rigid scope very well (the one that goes in the mouth). I have a pretty hyper gag-reflex and I was certain I would gag the whole time, so the video is choppy and the SLP taking it never quite got a full shot of my vocal folds. I just want to say that the SLP who took this video is an amazing voice therapist and very skilled with the stroboscope. The fact that she never got a good look was entirely due to my hyper-reactivity. I just never managed to calm myself down! (The one at the ENT's office back in 2009 went through my nose.) The second caveat is that I wasn't singing regularly much at all at this point in time and I had a round of reflux that week so my vocal folds are a little swollen, but you can see the paresis still there.

When the other SLP wanted to see the video a few weeks ago, I realized that I had been avoiding it because I'm much happier thinking about my voice as healthy and functional for me. I've been practicing again and taking voice lessons again and my voice felt great! Why would I want to see it still being an issue? Then I realized that avoiding the video is silly. If I want to stick to my own philosophy of a balanced voice being the whole goal of technique, then I should learn to accept my whole voice--flaws and all. It still is functional for me right now. I am still able to express myself musically through my singing, so I should not be afraid of looking at my full voice for what it is at this moment.

With all that said, here's a little guide to interpreting this video. The front of the throat is at the bottom of the video and the back of the throat is at the top. You can see the epiglottis in full view at the bottom and you can see the root of the tongue where it meets the epiglottis there in most of the video as well. The opening to the esophagus is at the top of the video and is closed whenever you are not swallowing. (The muscle that closes the esophagus functions such that it's tonically closed during it's resting-state.) The right side of the screen is the left side of my larynx and vice versa. The vocal folds are the white strips of tissue you'll see in the middle of the screen--the posterior portion of the vocal folds are first visible around 00:20. There is a bit of redness there as well thanks to the reflux I was dealing with around that time. (I was having an issue getting my PPI prescription renewed with my doctor's office.)  The arytenoids are visible near the top of the video. These are the guys you want to keep your eyes on to see the paresis in action. The posterior glottic gap (i.e., the place where my vocal folds don't completely meet during phonation) extends further for me due to the paresis. This is where I "leak air" when I'm singing.

At 0:31:  You might need to stop and start the video in short bursts from here, but this is where you can see the left arytenoid doesn't go as far to midline as the right.  If you stop and start a few times, you can see the right arytenoid adduct smoothly and quickly. The speed with which the right arytenoid adducts makes it pretty clear the left arytenoid isn't traveling as far. It stops moving before the right arytenoid does.

At 0:48:  You can see the left arytenoid "crap out" (very technical term right there). It stayed in an adducted position, or as close as it gets to midline during adduction, so what you can briefly see is my right arytenoid adducting to meet it.

If you think you're seeing any bumps on my vocal folds that look like nodules or polyps, it's actually mucus. This is determined during stroboscopy by the very scientific method of having the patient clear their throat and swallow. If the bump moves off or moves to a different location, it's mucus.

So, those are my vocal folds as they are now (minus the swelling and redness from reflux). Yes, I can still sing with these folds and my voice doesn't fatigue during the day as long as I don't strain when I speak. Essentially, the biggest "enemy" to my being able to sing is tension, since it's still easy to want to "fight" with my voice, particularly on long phrases. But, I think if I stop hiding from my vocal flaws and learn to accept them, I'll start to sing better just by feeling more free to express myself flaws and all!

Edit to add:  Also, when I start to glide up the pitch, I start to shift my epilaryngeal area in the manner referred to as "covering" in the pedagogical literature. This is all great and good in the singing world, but it obscures the view of the vocal folds when using rigid stroboscopy. I should have tried for a more "choral sound" during my glide to maintain the laryngeal position. But, gliding is a check for the superior laryngeal nerve (that handles the action of the cricothyroid), and as you can hear, mine is pretty well-intact. Just the recurrent nerve (the one that handles the muscles of adduction and abduction) is a little impaired.

New blog, new topics

Hello all!  Once again, I let this blog lag quite a bit.  Sorry for my absence.

I've been wanting to get back into blogging a great deal, but I've been stuck as to which direction to go in.  I wanted to share the things I've learned about the most effective ways people learn complex motor tasks, like riding a bike or, well, singing, but I also wanted to open up a place where voice teachers, singers, and voice scientists could comment and discuss the best ways to go about that.  So, I recently decided to make a new blog for that purpose.  This blog is going to be more narrowly focused than this one, and I'm hoping it will develop into a great place for any pedagogical questions or issues that arise for any of you.  I'm also hoping it can be a resource for new teachers to ask experienced teachers for advice if you're dealing with a tricky voice for the first time.

The current plan is to keep this blog going, but to keep the focus of this blog my own personal and academic journey.  The new blog will be where I discuss the scientific evidence from physiological and behavioral studies that I think is often missed in pedagogy coursework.  As such, I'm starting off this new one as if folks already have some basic, general knowledge of how the voice works physiologically.  I hope you'll check out this new blog and feel free to begin the discussion there on any questions or issues you're currently having, either with your own voice/singing training or as a voice teacher, any questions you have about what science can offer vocal pedagogy.

I hope to "see" you there!  http://balancedvoice.com

You have a vocal injury? How did you do it?

Singing world: We have a serious problem, and it must stop.

This problem is so pervasive that it still exists in the clinical world too:  The idea that someone might "cause" their vocal injury, and in doing so, that they (or their private voice teacher) are somehow guilty of some horrendous wrong-doing.  (Side-note:  This mentally does not exist in any clinician that I would ever recommend to someone.  It still exists in some, but not all.)  (Okay, side-side-note:  I was just a guilty as everyone in this mentality prior to entering speech-language pathology, but I have turned 180 on these beliefs and I think everyone else should too.  Here is why.)

Let's start with this example:  The Olympic gold-medalist Lindsey Vonn.  If you clicked on the link, you'll read about how she wasn't able to complete in the 2014 Winter Olympics due to a knee injury.  

How many of you out there thought to yourself:  "Well, Lindsey Vonn is a terrible skier.  She just doesn't have good technique.  She doesn't even train with a good coach.  I heard she makes poor decisions in terms of what course to run, what competitions to sign up for, and when to stop.  She just doesn't have what it takes to really have a career as a skier."

Personally, I've never heard of anyone looking at a high-level athlete and scoffing at an injury they may sustain.  So why do we singers do that to each other?  Now replace "Lindsey Vonn" with "Maria Callas," "Natalie Dessay," or "Julie Andrews."  Do the above comments seem more justified all of the sudden?  If so, WHY?  Why are professional singers any different than high-level athletes?  Why would sustaining an injury of any kind make a singer (or their voice teacher) automatically deserving of scorn?

Here's the big secret that really shouldn't be a surprise:  No one intends to injure their voice!  It's an accident that's scary to deal with.  There is no reason people dealing with the emotional impact of those consequences should also carry the guilt of causing their injury.  It's not a necessarily a sign of poor singing technique and it also isn't necessarily a sign of bad voice teaching.  Often, the direct cause of an injury is very hard to determine.  (NOTE:  Cause is different than time of occurrence.  In some injuries, like a vocal hemorrhage, we can determine the time or day that the injury likely occurred.  However, the direct cause of the hemorrhage can still involve multiple variables.)

Did you ever:
-Go to an amusement park and lost your voice a little from screaming on the roller coasters?
-Sing a well-paying gig while sick because you had just enough voice to get through the gig?
-Go out to noisy restaurants/bars regularly with your friends/cast mates after singing for hours daily?
-Unknowingly sung (uncomfortably) with acid reflux for several months before getting looked at by your doctor?

I bet most of you have at least done one of the things on that list.  In some people, some of these behaviors can contribute to the developing of a voice disorder and in others, no disorder develops.  Truth is, even the best vocal scientists can't predict who will develop a voice disorder/injury and who won't.  Too many factors are at play.

Blame does nothing but inflict additional damage to someone dealing with a medical condition. Injuries are accidents that happen sometimes to good singers and that need to be dealt with in the best way possible.  That is all.  Vocal injuries for a singer are exactly like a knee injury for a pro skier.  Until we can travel back in time and prevent accidents from happening, guilt and blame does nothing but make it worse.  What is needed is a good plan to get the voice to a condition that, ideally, will meet the patient's vocal needs.  That is what a medical team (e.g., ENT & SLP) is for.

So perhaps the next time you hear someone say he/she is dealing with an injury, instead of saying "How did you do it?"  Say "Oh, I'm so sorry to hear that" and maybe offer condolences and wish them a speedy recovery.

We keep calling ourselves "vocal athletes."  It's time we start treating each other as such, especially when an injury occurs.

The power of kindness

I keep a regular yoga practice.  I mainly practice at home, since it's free to do there, but I also attend yoga classes regularly at a good studio.  I tend to do yoga about two to three times a week.  However, this past spring semester, I ended up only practicing once a week, at most.  So, I got decently out of shape from what I'm used to and I ended up hurting my left hamstring, somehow.  What sucked the most about this was that my left leg has always been more flexible than my right leg, while my right leg tends to be stronger, so I was usually able to do hand-to-foot pose and this one-legged arm balance with my left leg pretty easily, while I still struggled a little with the right.  However, this summer, while I've been trying to nurse my left hamstring back to health, my sides have reversed.  I'm still not able to do these poses, or others like them, with my left leg, but I've gotten them down with my right.

So just today, while I was practicing at home, I realized that I've been so careful with my left leg this past few months that I've actually let it become weak.  I've stopped trying to engage the muscles on that leg as much because of the injury.  Of course, this is not helping recovery at all, so today, I started forcing that leg to pull it's weight, and while my hamstring still isn't totally better, I actually got my full trikonasana on the left side back today and my hamstring feels better now than it has in a long time.  I'm sure the more I focus on working the muscles on my left leg, the better it will get, and I will be back to my normal yoga practice pretty soon.

This little experience with my hamstring really reminded me of my vocal recuperation, probably because I had a conversation with another singer dealing with their own voice disorder just this week.  See, the thing is, I was acting like my hamstring was still injured, even though it's been months since the actual injury.  My hamstring is quite likely healed up, it's just healed tighter than it was before.  Because of this tightness, I've been avoiding really using it in yoga, making modifications on the left side for any hamstring-intensive pose and just allowing my lunge on that side to kinda go out of form.  In essence, I was allowing my muscle to stay weak just because I was still acting like something was wrong with it well after it was healed up.  In an earlier post, I said I had a hard time learning to trust my voice after it was healed up, because I felt like my voice had betrayed me by being injured.  But I've talked to a few singers out there dealing with injury who have the added issue of still feeling like their voice is injured even after therapy is completed and they're given a full bill of vocal health by their team.  So they're still fighting with their voice and letting it do the wrong things because they still think it just doesn't "work right," even though it does.  It's a mind game, isn't it?

What these injuries really do to us is force insecurity upon us, so naturally, our reaction is to defeat the insecurity.  Attack it full on so that we can get past it as quickly as possible.  But when this tactic burns out, as it often does for many people out there, we start to retreat into the insecurity, allowing it to defeat us and beat us down until we give up.  This can lead to regret and perhaps even bitterness for so many of us, and maybe we find the fire to fight again and maybe we win, but what if we just changed our perspective of this insecurity?  What if, instead of fighting, we decide to accept this weakness that has been thrust upon us and still decide to be kind to ourselves?  And what if, by being kind to our whole new self, insecurity and weakness and all, we learn how to patiently and diligently work through our injury, not by forcing ourselves to be as we were before, but by moving toward being someone new and different because of this experience?  What if all we need to do is realize that healing doesn't typically mean going back to how things were before, but it can mean becoming better than we were before?

I suppose saying I'll get back to my normal yoga practice is a bit of a lie, because before this injury, my right side was more inflexible than it is now.  If my left side is restored to it's former, flexible state, my whole body will actually be more balanced than it was before this.  Just like how, even if my voice is only better because of being healed and the glories of vocal technique, I'm a better, more joyful singer because there was a time when singing was taken away from me.  So to all those out there recuperating from any injury:  May recovery make us all stronger, more balanced, and more joyful; may we be kind to ourselves and patient with our injury as we build our strength back up; and may we all realize that we will never be the same...and that can certainly be a good thing.

A voice teacher vs. medical professionals: An important distinction

Of course, there are those of us who either are working toward, or who already are, both a medical professional and a voice teacher/singer, but there are distinctive differences in these professions that need to be remembered.  I'm going to draw that line of distinction the way I see it.  Why?  Cause when the lines get blurred about who the true "vocal experts" are, the people who suffer the most are singers who are the most in need of guidance.

There is an epidemic in the voice-teacher community of folks who feel they have enough (cursory) scientific knowledge about the voice and vocal disorder stuff that they feel they can successfully assess and diagnose specific vocal problems in their students.  And you know what, maybe a few decades ago those voice teachers did know more than the medical community.  But now, this epidemic needs to be stopped.  Along with the many, many singers I've known whose voice teachers "diagnosed" vocal nodules, acid reflux, etc., I myself fell into this "assumers paradise" when critiquing other's voices that didn't sound "quite right."  Luckily, though, I was humbled out of it quite quickly with my therapy experiences and SLP classes without actually putting any of my assumptions onto my own students.  Whew!  But, although I survived without public humiliation in class or otherwise, I still felt ashamed of myself for being so presumptuous.

The truth is that the medical field has made huge advances in their knowledge of vocal and articulatory function, down to the neural organization of coordination for these functions, in the past two decades, and the advances are expected to just continue. Voice teachers and singers should know about the healthy function of the vocal system for the sake of monitoring their progress and protecting their voice from harm, but normal, healthy function is the point where medical professionals begin their understanding.  They must start from normal function, because their ultimate goals are to help treat and/or cure people suffering from disorders or injury.  And the level of detail needed to fully understand each and every disorder and effectively treat them is rather mind-boggling.

A very condensed look at the responsibilities of these folks is something like this (for the singer suspecting vocal difficulty):

An ENT is the guy with the medical license to actually diagnose an issue using advance technology in combination non-invasive assessment tools to determine the source of a problem.  They also can perform surgery and prescribe medication, so they have some ability to treat the issue they diagnosed with those steps.  They can give a general timeline of recovery for surgeries based on how invasive the procedure is and the patient's own medical history, age, etc.  In order the have the ability to legally diagnose and treat disorders requires a whole lot of knowledge to diagnose and training to treat.  But, if regaining vocal health requires more than just surgery and/or medical prescriptions, then the ENT needs to refer the patient to a therapist for further treatment.  This is where the SLP typically comes in (at least in relation to ENT offices.)

The SLP is the person with similar medical knowledge as the ENT in regards to the systems of communication and swallowing, but they are not able to diagnose legally at all.  This is because their assessment tools can show if something is wrong and can narrow down where in the body the issue is located, but they cannot say specifically what is wrong.  SLPs can assess the health of a person's linguistic and communicative system, from higher processing of language all the way down to specific anatomical functions, and they are trained to treat whatever problem might be present with therapies proven to be effective.  They have a professional license that they must maintain, like ENTs, in order to legally do these assessments and therapies.  This makes SLPs very good compliments to ENTs who are not trained to treat with non-invasive, therapeutic methods.

A voice teacher is someone who, ideally, takes an intricate knowledge of healthy vocal function and applies that knowledge to train a person's voice to do something beyond ordinary vocal function.  But, that singer's voice/communicative system only requires healthy function to train effectively.  No more, no less.  (Just as an Olympic gymnastic coach only needs a healthy body to train to do gynmastics.)  A voice teacher does not have the full medical knowledge to either diagnose nor scientifically assess the health of a person's system.  What a voice teacher can do is suspect an issue...much in the same way a mom or teacher can suspect a child has an illness based on a handful of symptoms they observe.

So what happens if you are a voice teacher and you suspect a student has a possible medical issue?  You can inquire about symptomology and try to narrow down the possibilities, which can be useful in getting the student to agree to see a doctor.  But all a voice teacher can really do is refer the student to an ENT, or an SLP, for a vocal assessment.  An SLP assessment is usually a cheaper option, but since they can't diagnose, if the screening turns up results that are outside of normal function, then they will have to refer to the ENT for full diagnostic tests.  If it turns out the student does have an issue that needs surgery and/or therapy, the student just needs to be in the hands of excellent medical professionals for a while.  Once treatment is over and further assessments have determined that the student has returned to perfectly normal health, vocal training for singing can resume with the voice teacher again with the understanding that training might have to start at "square one" at first if any old compensation exists from the injury or disorder.

But, what a voice teacher should not do is try to officially diagnose the issue, try to treat the issue, or distrust the medical professionals assessment of normal, healthy function.  And likewise, a singer should not seek a voice teacher for those issues.  What I see happening most often is voice teachers using technical issues during singing as evidence of a problem, which may or may not be true, but this is exactly why SLPs assess vocal health from speech and measurements taken during speech.  Healthy speech is some thing they have data on that they can use to compare/contrast someone's unhealthy function.  Tension during singing, however, has so many possible origins that only having that to go on can only lead to assumptions that may or may not be correct.  In contrast, when my voice teacher suspected my vocal injury, she wasn't only going on my technical issues during singing, she also noticed tension present when I was just speaking too...even speaking before singing at all at the beginning of a lesson.  This teacher also works very closely with SLPs and ENTs, so she knows a bit more of vocal assessment than the average voice teacher.

Now, are there medical professionals who get things wrong sometimes?  Of course there are!  ENTs misdiagnose, miss problems altogether, and SLPs can miss some abnormality on assessments if they're only thinking about communicating for daily speaking.  Also, the SLP field is a very, very broad field, so getting someone who doesn't specialize in voice might not do a whole lot of good.  This is why seeking out the best, most meticulous professionals that are available to you is vital for a professional voice user.  But if you're going to seek out the best, trust them too.  The prevailing attitude of "They might not really know what we singers require" is not only inaccurate, it is arrogant and insulting to the medical professionals who are trying to help us.  And the prevailing epidemic of voice teachers using their cursory knowledge to diagnose or treat anything is a bit like a teenager assuming they know everything and therefore don't need to listen to adults ever.  Both attitudes are damaging to what I believe should be the goal:  These three professions collaborating and working as a team, with responsibilities allocated to the right person at the right point in the singer's recovery, to ensure the singer's recovery is on the right track.

Laryngopharyngeal reflux is nobody’s friend

My last post discussed my own issue with LPR that I faced just last week, so I thought I’d write a little more on the topic since it is such a prevalent problem. 

Many, many singers, and just people in the general population, suffer from this condition.  As a singer, though, I know I was personally very quick to blame my “symptoms” on something else instead of facing up to the fact I have LPR.  The first thing that put me in denial was the fact that I never experienced heartburn (unless I ate greasy Chinese food…but who doesn’t get heartburn in that situation.)  The other more insidious issue is that I suffer from allergies.  I have always had allergies which were no small problem back on the east coast where I grew up.  I always attributed any excess mucus in the morning and/or irritated feeling in my throat to my allergies rather than reflux.  How did I climb out of this area of total denial?  My voice teacher took the time to ask thorough questions that led her to suspect reflux.  While I was still questioning her conclusion, I went through a few up and down vocal days that led me to think she was probably right.

Here’s a pretty generic list of the symptoms of LPR:

• Continual throat clearing
• Chronic throat irritation
• Chronic cough
• Hoarseness
• Excessive phlegm the throat
• Constant sensation of something in the throat
• Post nasal drainage
• Weak voice
• Cracking voice

Now, prior to the talk with my voice teacher, I had seen lists like this before.  I never connected it to reflux, however, because so many of the things on this list match up with the symptom list for allergies, asthma, or any number of other things.  So here’s what solidified the reflux issue for me:  I had very distinct “good” voice days and “bad” voice days.  In fact, singing would feel great for one day and then the very next day I would find myself thinking something like, “What’s going on with my voice today?  Yesterday was great and today feels like complete crap.  I just can’t seem to clear it up!”  Or I would have so much “junk” in there it would take me a couple of hours after waking up to feel like my throat had cleared enough to sing and warming up on those days took at least 30 minutes, which is much longer than it should take.  Also, singing itself would bring on more and more mucus to the point where I would be clearing my throat excessively either after a performance or during lessons.   Although this could have been caused by allergies, my allergies never struck that badly over the course of one day unless I had done some spring cleaning that caused me to inhale a lot of dust the day before.  And I did not have asthma at all.  So the fact that my “bad voice days” would come on so suddenly seemingly without cause and the mucus production was so excessive were a big red flag that something else beyond allergies was going on.

I will admit that the prevalence of reflux for me was MUCH more obvious after I was treated for my paresis, but this up and down pattern was there even before the paresis diagnosis.  The biggest trigger for there being something wrong was the presence of excessive mucus in my throat that got much worse on the days where my voice was burned.  Now, excessive mucus alone is not a diagnostic factor of anything, but vocally speaking, excessive mucus is just a sign that the tissue of the larynx is irritated.  And if you experience excessive mucus during or after singing, it is either a sign that singing on that irritation increased the level of irritation or that the act of excessive voice use is bringing about irritation.  (The later is more common in cases where there is an asymmetry on the vocal folds, usually due to excess pressure being called upon in an attempt to “clarify” the sound.)  So I had a double-whammy of mucosal production on those days when I had some burning from my reflux that made singing on those days a nearly impossible task. 

I did go on Nexium for a while which worked very well, but due to financial constraints I was unable to continue on that.  Since then, I have elevated the head of my bed at least five inches, I don’t eat anything four hours before bed, I monitor my dinners very carefully for anything that might cause reflux, and I take an OTC proton pump inhibitor for a couple of weeks before a singing gig to ensure I don’t have reflux prior to the event.  (Obviously, getting the stomach flu a week before a singing gig didn’t let me stick to this lovely schedule of PPIs I have invented for myself.)

The main take-home message for anyone out there who suspects they, or their student, might be suffering from LPR:  Go to the doctor.  They are the only ones who can really diagnosis this issue and treat it effectively if it is too severe to be controlled by OTC medication.  But truly, anytime there is any sign of excess irritation in the larynx via mucosal production that cannot be explained, a trip to the doctor is warranted, especially if the issue seems to be chronic.

Acid Reflux: The clingy, possessive boyfriend who won’t go away

Here’s a little something from what’s going on currently in my singing life.  Acid reflux.  Still a giant pain in my butt sometimes…like this week.  Two weeks ago, I was singing great.  Then, I got the stomach flu.  Lovely.  Even lovelier was that I had two concerts this week to sing which I hadn’t gotten enough practice time thanks to midterms, so I was stuck listening to the pieces on youtube over and over while lip singing through them since my voice was toast from the stomach acid.  I was finally better on Saturday, as in finally able to eat solid food again, but my LPR had kicked up thanks to this little stomach bug and has fried my voice.  Just lovely. 

Since starting my SLP undergraduate courses this year, I haven’t really had a lot of time to devote to practicing or singing, and I rarely get to perform much at all.  (It seems that when you emerge yourself into a non-music field, fitting music in becomes a bit of a difficulty.  Who knew?  I didn’t.  I had never NOT been emerged in music before. )   Anyway, it just would figure that my dirty little friend would pop up this week.  But, I thought to myself, I should write something about it.  And so I shall!

First, let’s start with a bit of science…since it’s what I love so well.  Notice I called my reflux LPR up there and not GERD.  GERD is the common medical term for gastroesophagial reflux disease.  GERD tends to come with the traditional heartburn and such we all associate with acid reflux.  But some of us have laryngopharyngeal reflux (LPR), which is usually silent, meaning it doesn’t have any of the heartburn-like symptoms of GERD.  Ever wondered why it can be so silent like that?  How does stomach acid manage to burn our vocal folds without us noticing?  Wouldn’t we at least taste it in our mouth or have bad breath or something?  Well, the answer lies with our anatomy, of course.  Check it out:

The opening to the esophagus is located posterior, or behind, the opening to our larynx.  This is a rather unfortunate position for the singer who has LPR.  It means the acid doesn’t have to go too far up to “splash” over into our larynx.  It doesn’t have to get to the tongue or the soft palate, and the epiglottis isn’t much help either.  (The job of the epiglottis is to help close off the larynx during swallowing, not to protect it when stomach contents come up due to esophageal sphincter malfunctions.)  We all think of LPR as something that happens over night, but in truth, if it’s bad enough, it could spill over even during the day.

So that stomach virus of mine last week really kicked my reflux up in a bad, bad way.  My voice felt gravely, sounded slightly hoarse, and my mean speaking pitch was lower than usual.  And singing in head voice was a nearly impossible task.  I didn’t sing all week, but my voice wasn’t completely healed up by the concert, either.  See, another issue with having your vocal tissue burned by stomach acid is a pretty big decrease in your threshold of vocal fatigue.   So the rehearsal the night before the concert was fatiguing.  Singing the first concert was fatiguing, and singing the rehearsal and second concert were fatiguing as well.  I proceeded to rest my voice each night, and it did feel better the next morning every time.  However, once I started to sing, I could tell it just wasn’t right yet.  I had simply not given it enough time to heal up well enough to function optimally.

I did manage to make it through the concert, and it did go pretty well…although I wasn’t able to get enough “chiaro” in my sound thanks to my vocal condition.  So here’s the take-home for fellow LPR suffers, or anyone who suspects they might have LPR, your voice is going to take a few days before it’s really, truly healed…depending on severity of the burn.  Think about when you accidently burn your finger on a pot on the stove.  It might be a small, red spot that will take a couple of days to heal up, or if your reflexes didn’t kick in right away, it might be a blister that will take several days to heal.  Laryngeal tissue simply is not composed in such a way as to withstand stomach acid, so a burn there will take at least a couple of days to heal up.  Constant burning of the vocal folds can cause some pretty serious damage, though, so do try to treat your reflux if you have it so it gets under control. 

And if you have to sing on a concert in spite of  those burns, just be wise with your technique, forgive your voice for not being able to function optimally, and move on…(instead of getting all frustrated and complainy-under-the-breath for your condition…like I did.  Sorry to my colleagues from that day.)  

Voice Science Talk: Paresis

           

So, some of you may be asking:  What the heck is paresis anyway?  Here’s the definition straight from my text book, Anatomy and Physiology for Speech, Language, and Hearing by Seikel, King, and Drumright:  “Paralysis refers to loss of voluntary muscle motor function, whereas paresis refers to weakness.”  In other words, paralysis is the complete loss of motor function and paresis is a partial loss of motor function, or partial disruption in the nerve signal.  So, why would loss of nerve function be a big deal in vocal function?  To begin answering that question, let’s review some basic anatomy and physiology.

The voice functions through the combined effort of laryngeal muscles and aerodynamics, which is called the myoelasticaerodynamic theory of vocal fold vibration.  In this theory, the intrinstic musculature of the larynx helps to close, or adduct, the vocal folds, through the adductor muscles at the onset, or beginning, of vocal sound, aerodynamic properties of subglottic air pressure and the Bernoulli effect (http://en.wikipedia.org/wiki/Bernoulli_effect if you want to get your physics on), keep the vocal folds in motion during voice use, and the muscular action takes place again at the end of voicing to separate the vocal folds past their usual resting position so that the air stream for inhale is more open (especially important for a singer).  (I’m not going to go too far into the aerodynamic principles here, but I might in future posts, so keep checking back in for that info.)  I will focus on the musculature since this is where the effects of paresis take place.  

The main adductors of the voice are the lateral cricoarytenoid and the transverse and oblique interaryntenoids.  The thyroarytenoid has two parts:  the internal, or vocalise portion, which is the “vocalise muscle” located under the lamina propria, and the external portion, or muscularis.  This muscle does assist with adduction, but it is primarily used to regulate vocal fold tension.  (Note to add here:  The vocalise muscle is covered in four layers of tissue:  the first is the epithelial tissue which is extremely thin and is the outer most layer, and the next three layers make up the lamina propria, which is loose connective tissue.  The complex movement of the lamina propria during vibration is what makes up much of the complex sound wave produced at the vocal fold level during vibration.  I'll be getting into this more in future posts, but wanted to introduce it here.)   The main abductor, or opener, of the voice is the posterior cricoarytenoid.  This is the muscle that keeps your vocal folds out of the air way if you’re breathing very heavy (so after a good workout, thank your cricoarytenoid for opening up the passage way for those large breaths you were taking).  The other main muscle involved in vocalizing is the cricothyroid.  This is the muscle responsible for elongating the vocal folds, which results in changing the pitch of the voice.  (*For an excellent example of this muscle in action, as well as the adductors and abductors, see this video:  http://www.youtube.com/watch?v=ajbcJiYhFKY)

Here are some visuals of these muscles to help you out:

The biggest thing to know about the voice is this:  It is a system which works on symmetry.  If the symmetry of the voice is off, due to any reason, it results in vocal dysfunction, muscular compensation, and possible damage to the vocal fold itself.  It simply is not an effective system if both sides of the voice are not working correctly.

Why is this important to understand?  Well, the larynx is innervated by two branches of the vagus nerve:  http://en.wikipedia.org/wiki/Vagus (if you're curious about it.)  One branch, the superior laryngeal branch, innervates the cricothyroid muscle and the recurrent nerve branch innervates all the other intrinsic musculature:  the adductors, abductor, and thyroarytenoid muscle itself.  Due to this, paralysis or paresis of either of these nerve sets can have different symptoms.  

If paresis is affecting the superior nerve branch, it will mainly affect the range of the voice.  Singers who experience this might experience unexpected voice breaks and/or a shortened vocal range from what is normal.  There can also be breathiness present in the voice as well due to asymmetrical vocal fold motion.  If paresis is in the recurrent nerve branch, the symptoms can vary depending on which muscle is affected, but some symptoms can include:  breathy voice quality, horse voice quality (which is breathiness + harshness), vocal fatigue and reduced volume, (or loss of vocal power).  Paresis in the recurrent nerve does not usually affect vocal range.  Although singers who recover can gain a few notes on their range, the difference is not as dramatic as with recovery from superior nerve paresis.  The symptoms that brought me in were tongue tension, breathiness, and vocal fatigue.  My asymmetry was bad enough for the left side of my tongue root to be pulled downward as the left fold went over towards the right.  If you look at the picture above that shows the root of the tongue directly anterior and superior (in front of and above) the epiglottis, you can begin to see just how much the paresis impacted my laryngeal function after nine or ten years of muscular compensation.  

Here's what to take away from this:  Nerves are the communicators that transmit the impulse from the brain down to the muscles (as well as carries signals from muscles to the brain...to let it know how everything's doing, basically.)  If that communication system is damaged, it results in a loss of muscular function, mainly causing muscle atrophy if it goes untreated for a while.  (This is why my right vocal fold was notably thinner and smaller than my left vocal fold when I saw it on the video, which also strengthens the case for my injury being rather long-standing prior to diagnosis.)  What can cause this?  Well, these nerves can be affected by a virus from a respiratory infection, which is most likely my cause, although the superior nerve branch is more commonly affected by viruses.  (That was why it was unusual for the ENT to see paresis in the recurrent nerve in voice performers like me.)  Basically, in this scenario, the virus gets down to the nerve in the tissue and irritates or obstructs part of the nerve, and the nerve then remains that way after the virus has been killed off by the immune system.  Other more serious causes can be tumor of the thyroid or neck, blunt trauma to the neck area or thyroid, intubation during surgery or emergencies, and aortic aneurysms, which could affect the left recurrent branch.  Full paralysis of these nerves is an issue if you are having thyroid or heart surgery if the nerves get severed during surgery.

My ENT sent me for a CAT scan of my neck and upper chest cavity to rule out any of these more serious reasons for recurrent nerve paresis.  He also did some basic facial muscle tests to rule out Bells’ Palsy and other neurodegenerative conditions.  (Quite frankly, given all the possible issues that could have been wrong with me, I am rather grateful it was only a simple virus that had long passed out my system that caused the trouble.  Facing voice therapy is much, much simpler than facing chemo, surgery, or an untreatable, neurodegenerative condition.)

I hope this was not too much information packed into a small entry.  If you have any questions, please post below and I’ll be happy to answer them if I know the answer.  If I don’t know the answer, I’d be happy to search and find the correct one for you as well! 

Up next:  Heading Out to Voice Therapy

(All images are public domain and can be found on wikipedia if you wish for a larger view.)