Taking Care of Your Voice

On this page:

What is voice? What are some causes of voice problems? How do you know when your voice is not healthy? Tips to Prevent Voice Problems What research on voice is NIDCD supporting? Additional Resources PubMed Database Search Where can I get more information?

What is voice?
We rely on our voices to inform, persuade, and connect with other people. Your voice is as unique as your fingerprint. Many people you know use their voices all day long, day in and day out. Singers, teachers, doctors, lawyers, nurses, sales people, and public speakers are among those who make great demands on their voices. Unfortunately, these individuals are most prone to experiencing voice problems. It is believed that 7.5 million people have diseases or disorders of voice. Some of these disorders can be avoided by taking care of your voice.

What are some causes of voice problems?

Causes of vocal problems may include upper respiratory infections, inflammation caused by acid reflux, vocal misuse and abuse, vocal nodules or laryngeal papillomatosis (growths), laryngeal cancer, neuromuscular diseases (such as spasmodic dysphonia or vocal cord paralysis), and psychogenic conditions due to psychological trauma. Keep in mind that most voice problems are reversible and can be successfully treated when diagnosed early.

How do you know when your voice is not healthy?

Has your voice become hoarse or raspy? Have you lost your ability to hit some high notes when singing? Does your voice suddenly sound deeper? Does your throat often feel raw, achy, or strained? Has it become an effort to talk? Do you find yourself repeatedly clearing your throat?

If you answer "yes" to any of these questions, you may be experiencing a voice problem. You should consult a doctor. An otolaryngologist (oh-toelar-in-GAH-luh-jist) is the physician and surgeon who specializes in diseases or disorders of the ears, nose, and throat. He or she can determine the underlying cause of your voice problem. The professional who can help you with improving the use of your voice and avoiding vocal abuse is a speech-language pathologist.

Tips to Prevent Voice Problems

Limit your intake of drinks that include alcohol or caffeine. These act as diuretics (substances that increase urination) and cause the body to lose water. This loss of fluids dries out the voice. Alcohol also irritates the mucous membranes that line the throat. Drink plenty of water. Six to eight glasses a day is recommended. Don't smoke and avoid second-hand smoke. Cancer of the vocal folds is seen most often in individuals who smoke. Practice good breathing techniques when singing or talking. It is important to support your voice with deep breaths from the diaphragm, the wall that separates your chest and abdomen. Singers and speakers are often taught exercises that improve this breath control. Talking from the throat, without supporting breath, puts a great strain on the voice. Avoid eating spicy foods. Spicy foods can cause stomach acid to move into the throat or esophagus (reflux). Use a humidifier in your home. This is especially important in winter or in dry climates. Thirty percent humidity is recommended. Try not to overuse your voice. Avoid speaking or singing when your voice is hoarse. Wash your hands often to prevent colds and flu. Include plenty of whole grains, fruits, and vegetables in your diet. These foods contain vitamins A, E, and C. They also help keep the mucus membranes that line the throat healthy. Do not cradle the phone when talking. Cradling the phone between the head and shoulder for extended periods of time can cause muscle tension in the neck. Exercise regularly. Exercise increases stamina and muscle tone. This helps provide good posture and breathing, which are necessary for proper speaking. Get enough rest. Physical fatigue has a negative effect on voice. Avoid talking in noisy places. Trying to talk above noise causes strain on the voice.

Avoid mouthwash or gargles that contain alcohol or irritating chemicals. If you still wish to use a mouthwash that contains alcohol, limit your use to oral rinsing. If gargling is necessary, use a salt water solution. Avoid using mouthwash to treat persistent bad breath. Halitosis (bad breath) may be the result of a problem that mouthwash can't cure, such as low grade infections in the nose, sinuses, tonsils, gums, or lungs, as well as from gastric reflux from the stomach. Consider using a microphone. In relatively static environments such as exhibit areas, classrooms, or exercise rooms, a lightweight microphone and an amplifier-speaker system can be of great help. Consider voice therapy. A speech-language pathologist who is experienced in treating voice problems can provide education on healthy use of the voice and instruction in proper voice techniques.

What research on voice is NIDCD supporting?

The National Institute on Deafness and Other Communication Disorders (NIDCD) supports and conducts research and research training on the normal and disordered processes of hearing, balance, smell, taste, voice, speech, and language. NIDCD also supports the development of assistive or augmentative devices that improve communication for individuals who have communication challenges. Within the research support for voice is a range of activity from the molecular mechanisms of disease processes, such as papilloma virus, to clinical research that identifies strategies for diagnosis, treatment, or cure of voice disorders. An active area of research is examining the dose of vibrational exposure that human vocal folds receive during phonation. At the cellular level, the effect of gene expression and protein production are being studied as a function of this vibrational dose. Results may lead to engineered vocal fold tissues that can withstand vibrational stress. Other studies of voice disorders focus on determining the nature, causes, diagnosis, and prevention of these disorders. These studies may lead to the development of treatments and interventions that will improve the quality of life for those who are already challenged by severe voice disorders. Substantial progress has been made in the development of augmentative communication devices to facilitate the expressive communication of persons with severe communication disabilities. An investigation of conversational performance by users of augmentative communicative devices is in progress. Other funded research evaluates whether a low-cost, laser-activated keyboard for accessing personal

computers is feasible. With access to personal computers, individuals with disabilities can immediately use software programs and speech synthesizers for augmentative communication. There is ongoing research on the mechanisms of laryngeal papillomatosis and of laryngeal cancer. Because teachers are among the individuals with a high incidence of vocal disorders, NIDCD is supporting the development of an educational web site for teachers to support healthy behaviors and protection of their voices.

Additional Resources
For additional information on conditions affecting voice, the following NIDCD Fact Sheets are also available:

Vocal Cord Paralysis Spasmodic Dysphonia Disorders of Vocal Abuse and Misuse Laryngeal Papillomatosis: Quick Facts (Internet only) Dysphagia

Here are several ways to contact us: Toll-free: (800) 241-1044 Toll-free TTY: (800) 241-1055 1 Communication Avenue Bethesda, MD 20892

PubMed Database Search

PubMed is a database developed by the National Library of Medicine in conjunction with publishers of biomedical literature as a search tool for accessing literature citations and linking to full-text journals at web sites of participating publishers. Search the database using "voice disorders" for medical journal articles.

Where can I get more information?

NIDCD maintains a directory of organizations that can answer questions and provide printed or electronic information on taking care of your voice. Please see the list of organizations at www.nidcd.nih.gov/directory.

Use the following keywords to help you search for organizations that are relevant to taking care of your voice:

Speech-language pathologists Papillomatosis Spasmodic dysphonia

Disorders of Vocal Abuse and Misuse

On this page:

What are vocal abuse and misuse? How is voice produced? Who may be at risk for a disorder of vocal abuse or misuse? What are some of the disorders of vocal abuse and misuse? How are disorders of vocal abuse and misuse diagnosed? How are disorders of vocal abuse and misuse treated? What research is being conducted on disorders of vocal abuse and misuse? Where can I get more information?

What are vocal abuse and misuse?

Vocal abuse is any behavior or occurrence that strains or injures the vocal folds (or vocal cords). This may include excessive talking, throat clearing, coughing, inhaling irritants, smoking, screaming, or yelling. Vocal misuse is improper voice usage such as speaking too loudly or at an abnormally high or low pitch. Frequent vocal abuse and misuse can damage the vocal folds and cause temporary or permanent changes in vocal function, voice quality, and possible loss of voice.

How is voice produced?

Voice is produced by vibration of the vocal folds. The vocal folds are two bands of smooth muscle tissue that lie opposite each other. They are located in the larynx or voice box. The larynx is positioned between the base of the tongue and the top of the trachea (windpipe), the passageway to the lungs.

When at rest, the vocal folds are open to allow an individual to breathe. To produce voice, the brain precisely coordinates a series of events. First, the folds come together in a firm but relaxed way. Once the folds are closed, air from the lungs passes through them, causing vibration and thus making sound. The sound from this vibration then travels through the throat, nose, and mouth (resonating cavities). The size and shape of these cavities, along with the size and shape of the vocal folds, help to determine voice quality. Variety within an individual voice is the result of lengthening or shortening, tensing or relaxing the vocal folds. Moving the cartilages, or soft, flexible bone-like tissues to which the folds are attached, makes these adjustments possible. For example, shortening and relaxing the vocal folds makes a deep voice; lengthening and tensing them produces a high-pitched voice.

Who may be at risk for a disorder of vocal abuse or misuse?

Disorders of vocal abuse and misuse are the most prevalent and preventable of the types of voice disorders. Anyone, from infants to the elderly, who uses his or her voice excessively may develop a disorder related to vocal abuse. Lawyers, teachers, clergy, cheerleaders, and professional voice users such as singers and actors often develop these types of voice disorders. Much of the chronic hoarseness experienced by children is caused by vocal abuse or misuse.

What are some of the disorders of vocal abuse and misuse?

The most common disorders resulting from vocal abuse and misuse are laryngitis, vocal nodules, vocal polyps, and contact ulcers. Health professionals who have training in voice and voice disorders often refer to these conditions as "hyperfunctional voice disorders."

Laryngitis is an inflammation or swelling of the vocal folds. It may be caused by excessive use of the voice, by bacterial or viral infections, or by irritants such as inhaled chemicals or the backup of stomach acid into the throat (gastroesophageal reflux). The voice of someone with laryngitis will often sound raspy, breathy, and hoarse. Vocal nodules, which are small, benign (noncancerous) growths on the vocal cords, are among the most common voice disorders directly related to vocal abuse. This condition is often called "singer's nodes" because it is a frequent problem among professional singers. Vocal nodules are callous-like growths that usually form in pairs, one on each vocal fold. They form at the area that receives the most pressure when the folds come together to vibrate. The nodules develop from damage caused by repeated pressure on the same area much like a callous forms on areas of a person's feet that are irritated by tight shoes. The voice of a person who has vocal nodules usually sounds hoarse, low-pitched, and slightly breathy. Vocal polyp. A vocal polyp, also called Reinke's edema or polypoid degeneration, is a benign growth that is similar to a vocal nodule but is softer, more like a blister than a callous. It most often forms on only one vocal cord. A vocal polyp is often associated with long-term cigarette smoking but may also be linked to hypothyroidism (decreased activity of the thyroid gland which is involved in the growth and development of children and energy control in adults), gastroesophageal reflux, or chronic vocal misuse. People who

develop a vocal polyp usually have a low-pitched, hoarse, breathy voice, similar to the voices of people who have vocal nodules. Contact ulcers are a less common disorder of vocal abuse. They are experienced by people who use too much force when bringing the vocal folds together for speech. This excessive force causes ulcerated sores or a wearing away of tissue on or near the cartilages of the larynx that move to bring the vocal folds together. These ulcers are also found in people who have gastroesophageal reflux. People with this type of voice disorder often complain of their voice tiring easily and may feel pain in the throat, especially while talking.

How are disorders of vocal abuse and misuse diagnosed?

Anyone who experiences vocal change or hoarseness for more than 2 weeks should be examined by a physician, preferably an otolaryngologist (a physician/surgeon who specializes in diseases of the ears, nose, throat, and head and neck). While hoarseness is a common symptom of vocal abuse or misuse, it is also one of the first signs of cancer of the larynx. A physician's visit is especially important for people who smoke cigarettes, because smoking is closely associated with laryngeal cancer. The otolaryngologist will examine the individual's vocal folds and determine if a medical condition is causing the voice problem. As part of the voice examination, the otolaryngologist will often look directly at the vocal folds. This may be done by inserting a tiny mirror into the mouth to the back of the throat (laryngoscopy). The otolaryngologist may also examine the vocal folds by passing a small camera and light through the mouth or nose and into the throat (fiberoptic laryngoscopy). This method is often preferred because it allows viewing of vocal cord movement during speech. Following an examination, the otolaryngologist may refer the individual to a speech-language pathologist, a health professional trained to evaluate and treat people who have voice, speech, language, or swallowing disorders that affect their ability to communicate. The speech-language pathologist will evaluate the pitch, loudness, and quality of the person's voice, and will also assess vocal techniques such as breathing and style of voicing. A voice recording is often made, and trial therapy techniques may be used to test their effectiveness at improving the voice.

How are disorders of vocal abuse and misuse treated?

Most disorders of vocal abuse and misuse are reversible. The best treatment is to identify and eliminate the vocal behavior that created the

voice disorder. In many cases, a brief period of voice therapy is helpful so that the individual can learn good vocal techniques such as proper breath support for speech or eliminating forceful voicing. In some instances, eliminating the abuse or misuse and voice therapy are not enough. In these cases, medication to block the production of stomach acid may be helpful. In some cases, an operation may be necessary to remove growths from the vocal folds. Since most disorders of vocal abuse and misuse easily recur following surgery if the vocal misuse continues, another period of voice therapy by a speech-language pathologist after surgery may help prevent recurrence of the problem. Children with disorders of vocal abuse and misuse are often the most difficult to treat because it is not easy for them to change their vocal behaviors. Fortunately, most children outgrow these disorders by the time they are teenagers. For these reasons, many surgeons do not operate on children who have disorders of vocal abuse or misuse. A period of voice therapy, however, may help the child to learn proper voice behaviors.

What research is being conducted on disorders of vocal abuse and misuse?

Scientists are examining a multitude of issues related to vocal abuse and misuse. They are conducting in-depth studies of the tissues of the vocal folds to determine how various types of stress affect these delicate tissues. Scientists are especially interested in determining why vocal behaviors in some individuals lead to vocal nodules while similar behaviors in other individuals may lead to mild laryngitis, vocal polyps, or little or no voice change. They are also examining the tissue changes necessary for the development of laryngeal growths such as nodules and polyps, as well as laryngeal cancer, and how various treatments reverse those tissue changes. Speech-language pathologists are studying the effectiveness of behavioral techniques including use of machines to help people relearn proper vocal techniques such as good breath support or efficient use of the larynx. Studies that will improve the treatment of hyperfunctional voice disorders in children are also in progress. Of special interest is the longterm impact of various treatments, especially medical and surgical treatments.