Laryngopedia

To educate about voice, swallowing, airway, coughing, and other head and neck disorders

Laryngopedia By Bastian Medical Media

Multimedia Encyclopedia


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Vallecula

Literally, the “little valley,” formed between the base of the tongue and the anterior face of the upright epiglottis.



Vallecular cyst

A vallecular cyst is a mucus-containing cyst in the vallecula. Such cysts are relatively common. Vallecular cysts are almost always asymptomatic and found during examination for another issue, such as a voice problem.


Photos of vallecular cyst:






Valsalva maneuver

The transient, somewhat forceful exhalation of air against an intentionally blocked airway. In a common variant of this maneuver, a person blocks the exhaled air by sealing the lips and plugging the nose, which forces air up the Eustachian tube and “pops the ears”; this variant is often performed when on a plane that is descending for landing. In a second variant, a person blocks the exhaled air by closing the vocal cords; this variant is often performed sub-consciously when a person lifts a heavy weight. This second variant of the Valsalva maneuver is also sometimes elicited by a physician during a cardiac or neurological evaluation.



Verrucous carcinoma

Verrucous carcinoma is a variant of squamous cell carcinoma (SCCA). In the head and neck, this uncommon subtype of SCCA is seen most often in the oral cavity or on the vocal cords. Visually, it tends to have an exophytic (outward-growing) and wartlike, irregular surface. This variant of SCCA is typically less aggressive than other squamous cell carcinomas. Local recurrence tends to be the issue more than distant metastasis. Surgery tends to be the most effective treatment, though of course every patient’s circumstance is individualized and considered in the light of three treatment options: surgery, radiation therapy, and chemotherapy.


Photos:




Vibrato

In the voice, a pulsating effect produced by small variations of pitch, typically occurring five or six times per second. The opposite of singing with vibrato is to sing with straight tone.




Videoendoscopic swallowing study (VESS)

A method of evaluating a person’s swallowing ability by means of a video-documented physical examination, looking from inside the throat. Also called the fiberoptic endoscopic evaluation of swallowing (FEES). The videoendoscopic swallowing study (VESS) is to be distinguished from the videofluoroscopic swallowing study (VFSS), which is an x-ray-based assessment.

How it works:

To perform a VESS, a clinician uses a fiberoptic or distal-chip nasolaryngoscope. The clinician begins by examining the structure and function of the patient’s palate, tongue, pharynx, and larynx, including sensation, if desired. Next, to assess the patient’s swallowing capabilities and limitations, the clinician positions the tip of the nasolaryngoscope just below the nasopharynx and, looking downward into the throat, asks the patient to swallow a series of colored substances with a range of consistencies (e.g., blue-stained water, blue-stained applesauce, and orange-colored crackers).

As the patient swallows these substances, the clinician watches to see if any significant traces remain in or reappear in the space above, around, or within the larynx, rather than disappearing into the entrance to the esophagus. If significant traces remain in view, or if any material spills into the opening of the larynx or down the trachea, the patient may have presbyphagia. If significant traces initially disappear but then re-emerge upward from the esophageal entrance, the patient may have cricopharyngeal dysfunction, with or without a Zenker’s diverticulum.

Benefits of the videoendoscopic swallowing study:

This method has particular value for patients who are bedfast and cannot travel to the radiology suite, or for patients whose swallowing function is rapidly evolving (improving, usually), such as those recovering from a mild stroke. For clinicians experienced with this technique, VESS can also often be used with new patients complaining of dysphagia during the initial consultation as a robust and—depending on patient history—potentially stand-alone method of diagnosis and management. Sometimes, the VESS findings, along with a patient history of solid food lodgment at the level of the cricoid cartilage or cricopharyngeus muscle, will indicate when VFSS should also be obtained to assess for possible cricopharyngeal dysfunction. Even in this latter circumstance, when VFSS is called upon to confirm a suspected diagnosis, VESS will have already oriented the examiner to the nature and severity of the problem. In most follow-up circumstances other than after cricopharyngeal myotomy, VESS is generally more efficient and inexpensive than VFSS.


Photos:




















Videos:

Videoendoscopic Swallowing Study (VESS)
This video features an example of a 100-year-old patient undergoing VESS.


Videoendoscopy

Videoendoscopy is the coupling of video-documenting technology to an endoscope, so that the examination of the larynxtrachea, or esophagus, as the case may be, is permanently recorded for later review and possible comparison with prior endoscopy examinations.



Videofluoroscopic swallowing study (VFSS)

An x-ray-based method of evaluating a person’s swallowing ability. The videofluoroscopic swallowing study (VFSS) is also sometimes called the modified barium swallow, or the “cookie swallow.”

In a radiology suite under fluoroscopy (which creates moving rather than still x-ray images), the patient is asked to swallow barium in thin liquid and paste consistencies, and then in paste on a cookie or cracker. The barium bolus is followed radiographically through the mouth, throat, and into the esophagus. Both lateral and anteriorposterior views are recorded and, depending on the facility, a simple screening sequence of the subsequent movement down the esophagus is also recorded.


Photos:




Videos:

Barium Swallow (Barium Esophagram)
This video presents a clear visual example of a barium swallow, a test that involves having the patient swallow a barium solution while using x-rays to observe the flow of the barium, which can reveal swallowing deficiencies.
Cricopharyngeal Dysfunction: Before and After Cricopharyngeal Myotomy
This video shows x-rays of barium passing through the throat, first with a narrowed area caused by a non-relaxing upper esophageal sphincter (cricopharyngeus muscle), and then after laser division of this muscle. Preoperatively, food and pills were getting stuck at the level of the mid-neck, and the person was eating mostly soft foods. After the myotomy (division of the muscle), the patient could again swallow meat, pizza, pills, etc. without difficulty.


Viral laryngitis

Infection or inflammation of the vocal cord mucosa, caused by viral infection. The mucosa becomes pink or red, and the normally thin mucus blanket increases in volume and can become more viscous. If the mucosa becomes sufficiently inflamed and edematous, an individual can lose his or her voice transiently (for one to three days, typically). An analogy for these tissue and secretional changes in the larynx is viral “pink-eye.” For treatment, antibiotics are of no benefit; instead, as the patient waits for the infection to pass, supportive measures such as voice rest and hydration are suggested.



Vocal aberration

A vocal event or phenomenon that is unexpected and abnormal. It is “something the voice does that it shouldn’t.” These sorts of findings, in combination with vocal capabilities and vocal limitations, are listened for during the vocal capability battery.



Vocal capabilities

Vocal capabilities refer to the full extent of the voice’s abilities in terms of loudness, range, steadiness and control, rapid repetitive sound-making, high soft singing, and so forth. Understanding of any voice’s capabilities (and limitations) requires much elicitation by the examiner. Also required is an understanding of expected capabilities for sex and age, so that an individual’s capabilities can be compared with what is expected.



Vocal capability battery

The vocal capability battery is a variable set of vocal tasks that the clinician elicits from the patient in order to understand the individual’s vocal capabilities and vocal limitations. During the vocal capability battery, the clinician might assess average/anchor pitch, maximum range, ability to add loudness, sustained phonation (for stability), swelling checks of mucosal injury, maximum phonation time, and response to brief trial therapy.



Vocal commitments

Events or circumstances that permit, invite, or demand much voice use. A person’s vocal commitments could include his or her occupation, childcare, rehearsals and performances, hobbies or even volunteer activities to which a person is highly committed, sports, and so forth. Heavy vocal commitments and innative talkativeness are the two potential sources of vocal overuse and, unsurprisingly, are often seen together.



Vocal cord bruising

The rupture of one or more capillaries in the vocal cords, so that blood leaks into the tissue. This vocal cord bruising occurs as a result of excessively vigorous mucosal oscillation, usually during extensive or vigorous voice use, aggressive coughing, or even a very loud sneeze, and it can make the voice hoarse or otherwise limited.

If the ruptured capillary is extremely superficial, like the capillaries seen on the white of the eye, then a “thin suffusion” kind of bruise occurs, and there is no deformity of the vocal cord margin; within a few days, the voice recovers. If the vessel is a few cell layers deeper into the cord, then a small “puddle” of blood like a micro-hematoma may collect and create a kind of “blood blister.” Although a superficial bruise resolves quickly and doesn’t seem to cause permanent damage, the “blood blister” type can become a hemorrhagic polyp and require surgery; with state-of-the-art surgery, however, the voice can virtually always be restored to its original capabilities.


Photos:










Vocal cord dysfunction (VCD)

Vocal cord dysfunction (VCD). We refer to this disorder as nonorganic breathing disorder, laryngeal (see that entry for a fuller definition), which should be distinguished from nonorganic breathing disorder, tracheal.


Photos:





Vocal cord paralysis, bilateral

A neurological disorder in which the nerve supply to both vocal cords is absent. This may be as the result of injury through external trauma, thyroid surgery, or blunt or penetrating trauma to the neck. Sometimes vocal cord immobility due to scarring—from an endotracheal tube, for instance—is mistaken for vocal cord paralysis, though the distinction is usually easy to determine, provided that an appropriately intense and directed workup is done. In particular, this workup must include topical anesthesia to the larynx so as to enable an extremely close visualization of the posterior commissure and subglottis, which may uncover evidence of scarring.

See also: intubation injury, stenosis, vocal cord synechia, and vocal cord paralysis, unilateral.


Photos:





Vocal cord paralysis, unilateral

Neurogenic inability of one vocal cord to move. Unilateral vocal cord paralysis is associated with weak voice of a degree that can vary between individuals. Symptoms may include one or more of the following: weak, air-wasting dysphonia; inability to be heard in noisy locations; a tendency of the voice to be somewhat stronger in the morning but to “fade” with use; and a tendency to cough when drinking thin liquids.

See also: vocal cord paralysis, bilateral.


Photos:






 






Vocal cord paresis

The partial loss of voluntary motion for one or more of the muscles that move the vocal cords. Paresis is to be distinguished from paralysis, which refers to a complete loss of motion. Sometimes, however, the terms “paralysis” or “paralyzed” are used less precisely to encompass any kind of loss of motion, partial or complete. But we prefer the term “paresis” whenever it applies, and below we suggest a way to use this term when describing more complicated cases of vocal cords with reduced or no mobility.

Paresis or paralysis of a muscle or muscle group is caused by damage to its nerve supply. In other words, the underlying cause of a paretic or paralyzed muscle’s immobility is not a disorder of that muscle per se, but a disorder of the nerve supplying that muscle. Perhaps for this reason, it is common to speak of paralysis according to the nerve involved, rather than the muscle or muscles; in the world of laryngology, for example, we speak of “paralysis of the recurrent nerve.” However, it seems more logical to describe paralysis or paresis according to what is actually immobilized: the muscles. For example: if in a given case only the posterior cricoarytenoid (PCA) muscle is immobilized, then instead of calling that “paralysis of the recurrent nerve,” we would call it “PCA-only vocal cord paresis.”

In that example, though, some might wonder if it would be better for us to say “paralysis” instead of “paresis.” In other words, should we describe the nature of the immobility of the PCA muscle alone (so that, if the PCA is totally immobile, we would say “PCA-only vocal cord paralysis”) or that of the vocal cord’s entire set of muscles (which as a group is only partially immobile, so we would stick with “PCA-only vocal cord paresis”)? We think that, in general, it is more helpful to do the latter. To illustrate, here is an imaginary conversation: “Is this vocal cord paralyzed or paretic?” “Paretic.” “Which kind of paresis is it?” “PCA-only.”

It is surprisingly easy to diagnose the different variants of vocal cord paresis with a straightforward visual examination. Click on a particular variant to learn more:


Photos of TA + LCA vocal cord paresis:









Photos of TA-only vocal cord paresis:



Photos of LCA-only vocal cord paresis:


Photos of PCA-only vocal cord paresis:



Photos of IA-only vocal cord paresis:





Videos:

Injection Medialization for Vocal Cord Paresis
See an example of one variant of vocal cord paresis and how it limits the voice. Then watch a medialization procedure in which voice gel is injected into the vocal cord affected by paresis, and hear how the voice thereafter improves.


Vocal cord scissoring

Mismatching of the levels of the vocal cords. Vocal cord scissoring may in some cases be asymptomatic, but more often it introduces a rough quality to the voice, because the desired mirror-image bilateral symmetry of oscillation will be lost.


Photos:






Vocal cord synechia

Vocal cord synechia is a strand of scar tissue that tethers the vocal cords to each other. It can prevent the vocal cords from opening fully for breathing.

A synechia can also form in other parts of the body. (Note the subglottic synechia shown below.)


Photos:











Videos:

Vocal Cord Synechia
This video provides a clear example — using laryngeal videostroboscopy — of a vocal cord synechia.


Vocal fry

The name given to a quality of sound produced at low pitch (generally below 70 Hz, or around E2 or F2 in musical notation). Vocal fry is produced in what some call pulse register, as compared with chest and falsetto registers. Once defined with the help of audible examples, most individuals can readily identify this quality of voice. It may be heard in poorly produced voices; in other cases, it is used intentionally as a training technique, particularly for air-wasting dysphonia that has a functional cause.




Vocal fry dysphonia

An abnormal production of voice during speaking, generating vocal fry (“pulse register”) phonation with only the true vocal cords. The voice quality from vocal fry phonation tends to be rough, very low-pitched, “gritty,” and monotonal. A typical pitch at which vocal fry occurs is around E2 (~82 Hz) or lower, and airflow required for vocal fry is minimal. An individual with vocal fry dysphonia cannot maintain vocal fry (that is, will move to more normal voice production) if asked to project the voice, or to raise pitch even a few semi-tones.

The only disorder occasionally confused with vocal fry dysphonia is false vocal cord phonation. Vocal fry dysphonia (when functional rather than the result of a disorder such as Parkinson’s disease) is most often seen in individuals from the “underdoer” end of the vocal “overdoer-underdoer” spectrum.

For those who desire treatment, speech/voice therapy is the course to take. The individual must first develop the ability to identify normal and abnormal pitch and quality, and then adopt a higher pitch and a bit more vocal vitality, with strategies such as imagining that they are “reading to children.”



Vocal hygiene

Vocal hygiene, loosely defined, means the constellation of both good and bad habits that affect the voice, positively and negatively. At our practice, the wrap-up discussion at the conclusion of the initial diagnostic process as well as the initial therapy session with a speech pathologist contain a concise summary of vocal hygiene, with special emphases relevant to the individual. Examples of vocal hygiene tips include instructions on hydration, smoking cessation, spaced – rather than massed – voice use, and so forth.



Vocal instability

This characteristic might manifest most clearly during sustained phonation as a glitch, catch, wavering, tremor, in-and-out vocal fry, or other such finding. In each case, the patient would be unable, partially able, or only intermittently able to produce a steady and predictable voice.




Vocal limitations

Vocal limitations are expected capabilities that the individual has lost. Via elicitation, the examiner seeks to answer the question: “What can’t this voice do that it should be able to do?” In other words, vocal limitations are the set of incapacities of an individual voice, as compared with what would be expected, if that voice were entirely normal for age and sex.

Vocal limitations may not be understood by clinicians who: (1) do not have a complete understanding of normal capabilities, often derived from thorough knowledge of singing voice capabilities; (2) can’t or don’t elicit a complete vocal capability battery, with necessary modeling of various vocal tasks, particularly at the extremes of vocal capability.



Vocal loudness scale

A scale from 1 to 7 that we use to describe the loudness of a person’s typical speaking voice as compared with one’s experience of the rest of the human race. For example, someone whose vocal loudness seems to be unexceptional and does not draw any attention to itself—average, in other words—might be considered a “4.” The person who speaks so softly that everyone who encounters him or her has to strain to understand might be a “1.” The person whose voice is (often unconsciously) so loud that one needs to step back or hold the telephone away from the ear might be considered a “7.” See also: disorder of vocal loudness perception.



Vocal nodules

Small chronic swellings, one on the edge of each vocal cord. These swellings, or nodules (nodes), are vibratory injuries caused by vocal overuse. The most obvious symptom of medium-to-large nodules tends to be hoarseness. The top symptoms for nodules of any size may include: 1) difficulty with high, soft singing; 2) day-to-day variability of vocal capability and clarity; 3) a sense of increased effort to produce voice, especially for singing; 4) reduced endurance, so that the voice becomes husky or “tired” after less voice use than formerly; and 5) phonatory onset delays, when there is a slight hiss of air before the voice “pops in.”

How nodules happen:

When you overuse your voice, your body tries to cushion the vocal cords by pooling together edema (fluid) beneath the vocal cord mucosa (the surface layer of the cords); this pooled edema is like a small, low-profile blister on your finger. If after a few days you stop overusing your voice, the edema disperses readily, within a few days, and this “blister” on the vocal cords vanishes. If, however, the amount or manner of voice use remains excessive for many weeks or months, then more chronic swelling materials (no longer just edema fluid) are laid down by the body, and the vocal cords develop true nodules.

Why nodes affect the voice:

In either case (acute swellings or chronic nodules), this injury to the mucosa can impair the voice in two ways: it reduces the vibratory flexibility of the mucosa, and it interferes with the accurate match of the cords when they come together to produce voice. This impairment causes the voice to be hoarse or, more subtly, to suffer from onset delays, difficulty with high notes, and other similar problems.

Treatment:

Nodules will often dissipate, with the help of rest and perhaps speech/voice therapy, over a period of weeks or months. Sometimes, the swellings are so stubborn that surgery is required.


Audio with photos:

Vocal nodules’ effect on the voice, BEFORE surgical removal (see this patient’s photos just below):

Same patient, seven weeks AFTER surgical removal of the vocal nodules:


Photos:























Videos:

Nodules and Other Vocal Cord Injuries: How They Occur and Can Be Treated
This video explains how nodules and other vocal cord injuries occur: by excessive vibration of the vocal cords, which happens with vocal overuse. Having laid that foundational understanding, the video goes on to explore the roles of treatment options like voice therapy and vocal cord microsurgery.


Vocal overdoer syndrome

Vocal overdoer syndrome is a term coined by Dr. Anat Keidar and Dr. Bastian1 to designate an individual whose amount and manner of voice use can be considered excessive and to thereby put the person at risk of mucosal injury. Typically, the vocal overdoer syndrome comprises two parts: 1) innate talkativeness; 2) a life circumstance (occupation, performance, family, hobby, social) that permits, invites, or demands much voice use.


Photos:


Videos:

Nodules and Other Vocal Cord Injuries: How They Occur and Can Be Treated
This video explains how nodules and other vocal cord injuries occur: by excessive vibration of the vocal cords, which happens with vocal overuse. Having laid that foundational understanding, the video goes on to explore the roles of treatment options like voice therapy and vocal cord microsurgery.

  1. Bastian RW. The vocal overdoer syndrome: a useful concept from the voice clinic. Journal of Singing. 2002; 58(5): 411-13. 



Vocal phenomenology

Description of the phenomena that are observed in an individual’s voice production. Of most interest is the vocal phenomenology elicited at the extremes of an individual’s expected vocal capabilities. Many diagnoses are associated with highly specific, even diagnostic, vocal phenomenology, provided one knows how to elicit and is singing voice qualified.



Vocal polyp

A large swelling on the vocal cord that typically occurs unilaterally—that is, without a similar swelling on the opposite cord. The term vocal polyp is somewhat imprecise, but vocal polyps can be distinguished from a similar kind of swelling, vocal nodules, in at least two ways: 1) polyps tend to be larger than nodules; 2) polyps occur unilaterally or are markedly larger than an injury of the opposite vocal cord, whereas nodules occur in pairs and are usually similar in size. Both vocal polyps and nodules are caused at least in part by vibratory trauma, due to vocal overuse that is acute (with polyps) or chronic.

A vocal polyp disrupts the voice’s clarity and other capabilities by interfering with accurate approximation of the vocal cords during phonation. A polyp may also add mass to the vocal cord, thereby dropping the pitch range available to the voice. Polyps may be referred to as hemorrhagic, pedunculated, and so forth.


Photos of vocal polyp:
















Audio :

Patient comments about the improvement of voice after surgical removal of a vocal cord polyp.

Audio with photos:

Voice quality, with a vocal polyp, BEFORE surgery (see this patient’s photos just below):

Same patient, AFTER surgery:



Vocal process

A projection of the anterior arytenoid cartilage, to which is attached the membranous vocal cord.


Photos:






Vocal self-rapport

The ability to relate to one’s voice and to hear and experience it insightfully. Vocal self-rapport includes being self-aware of pitch, effort level, quality, loudness, etc. Accomplished singers may have exquisite vocal self-rapport, being able to match pitch and be aware of vowel color, larynx position in the neck, and other kinesthetic feedback. At the other end of the spectrum, a small percentage of individuals have remarkably limited vocal self-rapport. Such individuals may not be able to match pitch. In addition, they may not even perceive the difference between an upward and downward vocal siren.

For a clinician, assessing the vocal capabilities of a patient without vocal self-rapport can be difficult, because such a patient may not be able to respond correctly to elicited vocal tasks which could otherwise reveal vocal limitations or aberrations. Furthermore, it can be difficult for a speech/voice therapist to shape or modify inappropriate voice production because, though the patient’s hearing may be normal, he or she may yet struggle to “hear” with any insight. That is, the patient can struggle to understand what is being asked of them during speech therapy, or to identify whether or not changes he or she makes to voice production are on target.



Vocal task

A vocal task is a specific voice production, typically modeled by the clinician, with a request that the patient imitate that task. Examples: swelling checks, sustained phonation, and other components of the vocal capability battery.



Vocal tremor

Vocal tremor: A regular, wavering quality of voice, analogous to a singer’s vibrato but occurring, to an individual’s distress, during speaking, not just during singing. May occur as a sole abnormality in essential voice tremor, or in combination with spasmodic dysphonia.


Teaching demonstration (mimicked):

Patient example dystonic tremor: Note accompanying squeezedowns and difference in two registers



Vocal underdoer syndrome

Vocal underdoer syndrome is a term coined by Dr. Anat Keidar and Dr. Robert Bastian to designate an individual whose amount and manner of voice use can be considered inadequate to keep the mechanism in good condition. Typically, the vocal underdoer syndrome comprises two parts: innate introversion/taciturnity and a life circumstance that permits, invites, or demands very little voice use.


Voice Building:

Voice Building (shorter version):



Vocal “vincibility” syndrome

Vocal “vincibility” syndrome is to believe mistakenly that one’s voice is inadequate to the demands of life. Typically, an individual with this syndrome becomes progressively averse to voice use. The term “vocal ‘vincibility’ syndrome” is not found in textbooks, but is coined here to describe this kind of self-sabotaging belief system.

A classic case of this disorder was a man who taught chemistry at the college level in the 1960s and felt vocally tired at the end of lectures. Though introverted and only moderately sociable by nature, and though lectures did not occupy more than two hours of any workday, he was advised to rest his voice. The problem only became worse, however, and he was advised to take even more stringent voice rest, despite the fact that this was not helping and that, from the start, the amount of voice use in a week for this man was quite modest. Eventually this man was forced by the stress he was experiencing and also by his progressive aversion to voice use to take a job as a research chemist, where the requirement to talk was minimal. When first evaluated at the age of about 65, this man had become semi-reclusive. His wife said that within 20 minutes of the start of any social gathering, he would find her in a mild panic and insist that they leave because his voice was failing him.

Treatment for this disorder is a “vocal boot camp” approach under the supervision of a voice-qualified speech pathologist. When the patient described above did his speech therapy sessions, the physician was also on hand, so as to allay the patient’s anxiety and to examine his larynx after each session. The patient’s belief system about his voice was reconfigured only as it was proven to him that, even after “marathon” sessions of strenuous voice use, his voice was not being harmed and his vocal cords remained unbruised and quite normal-looking. Once this patient’s “vocal vincibility” subsided, he experienced a remarkable “rebirth” as a person, without further social vocal limitations.



Vocologist

A vocologist is an individual who by a specific course of study is able to habilitate (develop or make capable) the voice. In the medical realm, this term is sometimes applied to speech pathologists with some sort of voice performance training, or else to singing teachers or voice coaches who have taken courses in anatomy, voice disorders, speech pathology, and so forth, leading to a vocology certificate, but who do not necessarily have a speech-language pathology degree.



Voice building

Voice building is the process of adding strength to the voice by using a variety of tasks that tax its strength capabilities. The idea is that over time the larynx will rise to the challenge and adapt to increased demands, much as might happen to the arms as a result of a weight-lifting regimen. Sometimes the voice building regimen is very simple and “do-it-yourself”; other times it is more sophisticated and requires the assistance of a speech pathologist who is singing voice qualified.


Voice Building:

Voice Building (shorter version):



Voice evaluation

Voice evaluation can refer to the second part of the integrative diagnostic model as performed by the laryngologist, or to an initial assessment of the vocal capabilities and vocal limitations as carried out by the speech pathologist. Should be distinguished from other things that are sometimes confused with laryngeal examination and also from “objective” measures.



Voice fatigue syndrome

Voice fatigue syndrome is a clinical scenario that, when seen, almost always accompanies the vocal underdoer syndrome. Typically such individuals report that, with any significant amount of voice use, the voice seems effortful and tight; they may also complain of paralaryngeal discomfort. Most often seen in vocal underdoers whose job requirements for voice use have increased due to a promotion to a management level.



Voice production

Voice production refers to the act of making voice, and the details of the use of breathing (power supply), larynx (sound source), and resonators (mouth and throat) to create a specific voice quality. Using different strategies of voice production, the same person may bring forth various voices: one may be clear and normal-sounding; another may be harsh and unpleasant; a third may be air-wasting, or breathy.



Voice therapy

Voice therapy, as delivered by a speech pathologist, is a comprehensive process that includes teaching the patient concerning the diagnosis; review of occupational and other life demands and problems posed by a voice deficit; and establishing and implementing a comprehensive plan for remediation. A significant component of voice therapy may include work on voice production.



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