Positive/ Negative Practice

This behavioral treatment is prescribed primarily for patients with nonorganic voice disorders. A patient with a nonorganic voice disorder has been diagnosed with aberrant voice production due to the abnormal use of a normal mechanism, often due to stress or some sort of secondary gain. She or he may have been ‘stuck’ with the abnormal voice for months to years, or may lurch between normal and abnormal voice production on an apparently involuntary basis. To help patients first “find” their normal voices, the clinician guides the patient through a variety of vocal elicitations such as: a yell, glissando, siren, or vocal fry. All of this may be with or without clinician digital manipulation of the laryngeal framework.

After preliminarily ‘settling in’ the patient’s reestablished normal voice, the clinician quickly asks the patient to alternate between the re-established normal voice and the old abnormal voice. First, the patient alternates upon clinician cue, again optionally with or without digital manipulation, and then the patient demonstrates the ability to switch between the two kinds of voice production at the sentence level, and then every few words, and then word-by-word. The positive and negative practice demonstrates mastery / control over the abnormal/ nonorganic voice production.

If possible, this process should occur with patient, clinician, and family/ friends in attendance. Other doctors, speech pathologists, pulmonologists, and allergists who may have previously attempted to help the patient using medical rather than behavioral treatments should also be made aware of the nature of the patient’s diagnosis, the purely behavioral approach to it, and the idea that behavioral intervention to resolve this problem completely should not normally exceed three visits to a speech pathologist, to avoid his or her becoming a co-dependent or source of secondary gain.

Listen to a few demonstrations below:

Mucosal Chatter

Mucosal chatter is an audible phenomenon of injured vocal cord vibration. It is commonly heard in the softly-sung upper voice of persons with nodules, polyps, etc.

Hoarseness or roughness are broad and nonspecific descriptors useful only for severe injuries. Small injuries that are nevertheless impairing the singing range may leave the speaking voice sounding normal. I suppose “hoarseness of singing range” could be used, but again, that would be an unsophisticated and basic description of vocal phenomenology. To hear more useful phenomena of injury, we elicit and thereby investigate the upper range of singing (even in nonsingers) because high, soft singing makes the phenomenology apparent.  This is why we have described “vocal cord swelling checks” and created a video to teach how to elicit them, and also how to evaluate and communicate the phenomenology that results. In particular, delays of phonatory onset (“onset delays”) above approximately C5 (523 Hz) may indicate mucosal injury even when speaking voice sounds normal. Also heard is air-wasting, where there is a “scratchiness” to the excess airflow. Segmental vibration is also a common audible phenomenon of a mucosal disorder can also be easily taught and recognized.

Vocal cord mucosal chatter adds an extremely rapid “shudder” on top of the pitch of the voice. I have used “chatter” rather than “shudder” because the latter suggests a lower frequency than the former. It could be called a very fine-grained diplophonia…but typical diplophonia, caused by independent vibrating segments, is a much grosser vocal phenomenon. While chatter is more subtle, once it is pointed out and taught briefly, most people can easily distinguish between onset delays, diplophonia, segmental vibration, the transient “squeaking” of a micro-segmental vibration, the crackling sound of mucus dancing on the vocal cords, and “chatter.”  Those who master recognition of these phenomena can easily communicate them to colleagues.

For our purposes, let me stress again that the above phenomena—and chatter in particular—do not happen in the normal larynx, where vocal cord margins match perfectly and the mucosa oscillates normally. When heard—even in the person with a normal speaking voice—the examiner can strongly suspect a mucosal abnormality even before examining the vocal cords. In fact, where these phenomena are heard and initial examination looks normal, it would be a good idea to “look harder.”

Patient examples:

Segmental Vibration

In the normal larynx, segmental vibration occurs when both chest and falsetto (head) registers are produced by vibration of the anterior 2/3 of the vocal cords. The posterior 1/3 is “inhabited” by the arytenoid cartilage and does not vibrate.

In certain pathological circumstances such as displayed in the photo sequences below, only a small part of the vocal cords vibrates.

This segmental vibratory phenomenon is typically seen in vocal cords that are damaged—such as by vocal nodules, polyps, cyst, scarring, etc. In such persons, upper voice is typically particularly impaired, until, as the person continues to try to ascend the scale, suddenly a crystal-clear “tin whistle” kind of voice emerges and may continue upwards to very high pitches.

Some in the past have talked about flagelot, flute, bell, or whistle register.  We suspect that this was in the days before videostroboscopy and at least in some cases may have been segmental vibration.

The best way to determine if what sounds like a “tin whistle” upper voice extension is due to segmental vibration is by videostroboscopic examination during that kind of phonation. The other way is for the individual to produce their “tin whistle” kind of voice very softly and then try to crescendo. If full length vibration, smooth crescendo will be possible. If segmental, there will be a sudden “squawk” as the vocal cords try to go (unsuccessfully) from segmental to full-length vibration.


Photos:

Segmental Vibration Compared to Full-length

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Translucent polypoid swellings (1 of 4)

A younger man with chronic hoarseness due to large translucent polypoid swellings, not seen well at closed phase of full-length vibration at E3 (165 Hz).

Open phase, E3 (2 of 4)

Open phase of vibration at the same pitch showing that the full length of both cords swings laterally. Now the large polyp left vocal cord (right of photo) is easily seen.

Closed phase, E4 (3 of 4)

At E4 (330 Hz), vibration is damped (not allowed) except for the short anterior segment indicated by arrows.

Open phase, E4 (4 of 4)

At the same pitch, but open phase of vibration of that same short segment.

Whistle Register or Tin-whistle Segmental Vibration?

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Closed phase (1 of 4)

Closed phase of vibration at C4 (~ 262Hz) in a woman who is chronically hoarse and is a "vocal overdoer". Note the early contact at the bilateral swellings (right greater than left), and the MTD posturing (separation of vocal process "grey" zone posteriorly).

Open phase (2 of 4)

Open phase of vibration, shows that the entire length of the vocal cord margin participates in vibration at this pitch.

Segmental vibration (3 of 4)

Segmental vibration at F5 involves only the short anterior segment (brackets). The vocal cord swellings do not vibrate, nor does the posterior vocal cord. This is the closed phase of vibration.

Whistle register (4 of 4)

Open phase of that tiny anterior segment. This imparts a truly tiny "tin whistle" quality that cannot be maximized to a volume above beyond pianississimo. In some cases, singers who have not seen their vocal cords at this kind of high magnification under strobe light believe this to be a normal "whistle register".

Search not Only for Nodules, but Also for Segmental Vibration and Look at the Posterior Commissure for MTD

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Open phase (1 of 4)

In a young pop-style singer, the open phase of vibration under strobe light at C#5 (554 Hz). This magnified view is best to see the large fusiform nodules.

Closed phase (2 of 4)

Closed phase of vibration at the same pitch shows touch closure—that is, that the nodules barely come into contact.

Segmental vibration (3 of 4)

Even when patients are grossly impaired in the upper voice as is the case here, the clinician always requests an attempt to produce voice above G5 (784 Hz), in order to detect segmental vibration. Here, the pitch suddenly breaks to a tiny, crystal-clear D6 (1175 Hz) Only the anterior segment (arrows) vibrates.

Posterior commissure (4 of 4)

A more panoramic view that intentionally includes the posterior commissure to show that the vocal processes, covered by the more ‘grey’ mucosa (arrows), do not come into contact. This failure to close posteriorly is a primary visual finding of muscular tension dysphonia posturing abnormality.

Sulcus and Segmental Vibration

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Glottic sulci (1 of 4)

Closed phase of vibration, strobe light, at G3 (196 Hz) in a young high school teacher/ coach who is also extremely extroverted. Faint dotted lines guide the eye to see the lateral lip of her glottic sulci.

Open phase (2 of 4)

Open phase of vibration at the same pitch, showing full-length oscillation.

Closed phase (3 of 4)

Closed phase of vibration at E-flat 5 (622 Hz). Arrows indicate closure of the short oscillating segment.

Segmental vibration (4 of 4)

Open phase of vibration also at E-flat 5, Only the tiny segment opens significantly. As expected the patient’s voice has the typical segmental “tin whistle” quality.

Open Cyst and Sulcus; Normal and Segmental Vibration

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Margin swelling (1 of 6)

Breathing position of the vocal cords of a very hoarse actor. Note the margin swelling of both sides. The white material on the left vocal cord (right of photo) is keratin debris emerging from an open cyst. Find the sulcus of the right vocal cord (left of photo) which is more easily seen in the next photo.

Narrow band light (2 of 6)

Further magnified and under narrow band light. The right sulcus is within the dotted outline. Compare now with photo 1.

Open phase, strobe light (3 of 6)

Under strobe light, open phase of vibration at A3 (220 Hz). The full length of the cords participate in vibration.

Closed phase, same pitch (4 of 6)

At the same pitch, the closed phase again includes the full length of the cords.

Segmental vibration (5 of 6)

At the much higher pitch of C5 (523 Hz) a “tin whistle” quality is heard and only the anterior segment (at arrows) is opening for vibration. The posterior opening is static and not oscillating, as seen in the next photo.

Closed phase (6 of 6)

The closed phase of vibration involves only the tiny anterior segment of the vocal cords, at the arrows. The posterior segment is not vibrating and is unchanged.

Tiny Vibrating Segment Gives Tiny Tin Whistle Voice

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Prephonatory instant (1 of 6)

This young woman has been hoarse for many years. This preparatory posture shows marked separation of the cords posteriorly, suggesting MTD as well.

Phonation (2 of 6)

Now producing voice, with vibratory blur of the entire length of the cords on both sides.

Gaps due to nodules (3 of 6)

Under strobe light at a lower pitch of A4 (440 Hz), closed phase of vibration. Large gaps anterior and posterior to the polypoid nodule(s) explain breathy quality and short phonation time.

Open phase (4 of 6)

Open phase of vibration also at A4 (440 Hz) shows that the full length of the vocal cords are vibrating. Compare with the following two photos.

"Tin whistle" sound (5 of 6)

Now at A5 (880 Hz), the patient can only make an extremely tiny (tin whistle) quality. The only segment vibrating is within the circle (here, closed phase). The posterior segment does not vibrate.

"Tin whistle" at open vibration (6 of 6)

Still at A5 (880 Hz), the open phase of vibration, again of *only* the tiny anterior segment.

False Cord Phonation

False cord phonation is making voice by vibrating the false vocal cords. This kind of phonation is unlike normal phonation or voice-making, which uses the true vocal cords.

This produces a much deeper, rougher voice quality than normal phonation. It is purposefully used in certain kinds of vocal performance, such as Tibetan chant or heavy metal screaming. It can also occasionally serve as an alternate voice for a person whose true cords are unable to vibrate—due, for example, to their surgical removal or to scarring. It can also be produced concurrently with true cord phonation to produce a “Louis Armstrong” effect.


Photos:

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False cord phonation due to flaccid true cords (1 of 5): before false cords begin to vibrate

An elderly man, quiet by nature who uses the voice little, complains of weak, gravelly voice quality. This view of phonation, standard light, shows a slightly wider dark line of phonatory blurring. Also, the false vocal cords are overly approximated, but not yet participating in vibration (for that, see images 4 and 5).

False cord phonation due to flaccid true cords (2 of 5): before false cords begin to vibrate

Strobe light reveals an unusually wide amplitude of vibration, denoting flaccidity of the true vocal cords.

False cord phonation due to flaccid true cords (3 of 5): before false cords begin to vibrate

Maximum closed phase shows the telltale residual opening at the anterior commissure (from this perspective, the lowermost end of the true cords), also a potent indicator of flaccidity.

False cord phonation due to flaccid true cords (4 of 5): after false cords begin to vibrate

When asked to produce louder voice, the false cords begin to participate in vibration, and a rough, gravelly superimposed “ godfather” quality arrives. Notice that the true cords are in at least partial open phase of vibration.

False cord phonation due to flaccid true cords (4 of 5): after false cords begin to vibrate

When asked to produce louder voice, the false cords begin to participate in vibration, and a rough, gravelly superimposed “ godfather” quality arrives. Notice that the true cords are in at least partial open phase of vibration.

True and False Cord Voice

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Thin and weak voice (1 of 4)

This man has a thin and weak voice, often with a superimposed gravelly, rough quality. In this view, false cords, marked with dotted lines, obscure the true cords and their vibration is indicated by blurred margins.

True cords during closed phase (2 of 4)

At much closer range under strobe light, the true cords are approximated during the closed phase of vibration. The false cords should remain lateralized throughout voice production (but don’t).

Flase cords during open phase (3 of 4)

From same viewing position, but during open phase of vibration, showing very “wide” amplitude of vibration caused by flaccidity. The false cords are beginning to come together.

False cords during phonation (4 of 4)

Withdrawing the scope slightly, one can now see the false cords have completed their vibratory closure, explaining the superimposed rough quality. The arrow points to where true cords are, hidden in darkness below the false cords.

True and False Cord ‘Godfather’ Voice

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Bowing (1 of 4)

The true cords are together posteriorly but with major bowing seen at the pre-phonatory instant, to explain the husky, weak quality of voice.

Closed phase (2 of 4)

As a result of the need to compress together the weak true cords, false cords also overcompress. This is closed phase of true cords; false cords have not yet reached midline as they are vibrating more slowly than the true cords.

False cord phonation (3 of 4)

Now the false cords have come into contact but below them the true cords have begun their open phase of vibration. We hear the husky, weak true voice with the superimposed rough, gravelly false cord phonation.

True and False cords in open phase (4 of 4)

The true cords are at maximum open phase with enormous lateral excursions typical of flaccid cords. False cords are also at open phase, but as shown in photos 2 and 3, they are vibrating at a lower frequency and out of phase with the true cords.

True and False Cords Vibrate Mostly in Tandem (in phase)

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True cords vibrate (1 of 4)

At relatively high pitch, only the true cords vibrate. This is closed phase, under strobe light.

Open phase of vibration (2 of 4)

Open phase, same pitch.

True and false cords, closed phase (3 of 4)

At low pitch, where false cord phonation is facilitated. Both true and false cords are in closed phase of vibration (though the true cords are obscured by the false cords).

True and false cords, open phase (4 of 4)

Both true and false cords are simultaneously in open phase of vibration.

Another Voice Without Vocal Cords

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Hemilaryngectomy (1 of 4)

After removal of the anterior larynx (hemilaryngectomy) for cancer that recurred after radiation therapy. Though not well seen here, the vocal cords are surgically absent. The black dot seen is for orientation to the next photo. A = arytenoid; E = epiglottis.

Within the larynx (2 of 4)

A view within the larynx. Note again that vocal cords are surgically absent, with only the arytenoid cartilages remaining at the level of the cords. The black dot, on the left arytenoid cartilage, orients to the prior photo. The dot is on the right vocal process.

"Wolfman Jack" voice (3 of 4)

The patient is about to produce his rough, “Wolfman Jack” voice but the arytenoid mounds have not yet started to vibrate.

Arytenoid vibration (4 of 4)

Aggressive voice use brings arytenoid mounds into vibration (notice blurring). With time and practice, this kind of supraglottic voice can serve moderately well, but it is always difficult to be heard in competition with background noise.

Audio:

True cord phonation

False cord phonation

True and false cord phonation

Vocal Instability

Vocal Instability is a characteristic that 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.


Teflon

A synthetic material, polytetrafluoroethylene, most popularly associated with non-stick cooking pans. Until 25 or so years ago, it was common to treat paralyzed vocal cords by injecting a paste of Teflon particles deep within the cords. It was an effective treatment for its time, but it occasionally caused granuloma formation and required late debulking.

Today, injected materials such as hyaluronic acid gel or hydroxyapatite particles suspended in hyaluronic acid are typically used instead for temporary or somewhat permanent rehabilitation. For permanent rehabilitation of permanent paralysis, surgically implanted silastic wedges are used most often, though other materials are also used optionally.


Photos:

Teflon Bulge, before and after Removal

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Teflon bulge (1 of 4)

Abducted, breathing position, standard light. The left vocal cord (right of image) was injected with Teflon paste decades ago, before contemporary materials and techniques were available. Note the bulge in the ventricle, and also at the free margin of the cord (arrows).

Teflon bulge (2 of 4)

Phonatory view, strobe light. Notice how the right vocal cord (left of image) must “wrap around” the convex left vocal cord.

Teflon bulge: after removal (3 of 4)

A few weeks after microsurgical “excavation” of part of the Teflon. Straighter free margin, and reduced bulge within the ventricle.

Teflon bulge: after removal (4 of 4)

Phonation, strobe light. In spite of blurring, can see that the match of the cords is improved, and this correlates with the patient’s much improved voice.

Posterior Commissure Synechiae

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Tethered vocal cords (1 of 5)

This man has right vocal cord paralysis and a history decades ago of Teflon injection into the right vocal cord, resulting in posterior commissure synechiae. He is short of breath, partly due to the tissue band and partly because it tethers the vocal cords closer together than they would otherwise need to be as seen in photo 4 after the band is removed. See also photo 5.

Before laser removal (3 of 5)

The thulium laser fiber (F) is touching the synechiae, with laser energy about to be delivered.

Immediately after laser (4 of 5)

This is just after the thulium laser division of the band using topical anesthesia only, with patient sitting in a chair.

One month post-op (5 of 5)

A month later, no residue of the synechiae is seen, and the vocal cords can spring farther apart than in photo 1.

Audio with photos:

Interview:

The patient describes original problem with Teflon granuloma/ overinjection, and the improvement after debulking Teflon.

Teflon Bulge, before and after Treatment

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Teflon bulge (1 of 5)

Abducted (breathing) position. 25 years ago, this woman had left vocal cord paralysis and was injected with Teflon paste. Unfortunately, this bulge of Teflon is below the cord’s margin, rather than within its center, which is disrupting the person’s voice (see next photo and caption). Space for breathing is diminished but adequate.

Teflon bulge (2 of 5)

Phonation, open phase of vibration, with strobe light. Voice quality is poor, because the Teflon bulge interferes with vocal cord vibration by deflecting the pulmonary air stream, stretching and stiffening the tissue, and putting the vocal cords out of symmetry with each other. Treatment will involve removing part of the Teflon bulge.

Teflon bulge (3 of 5)

Phonation, closed phase of vibration.

Teflon bulge: after treatment (4 of 5)

A few months after debulking of the Teflon. The contour of the undersurface of the left cord (right of image) is still abnormal, but much less so. Compare with photo 1.

Teflon bulge: after treatment (5 of 5)

Strobe light, open phase of vibration, showing how the airstream delivered to the cords is now much less obstructed. Compare with photo 2.

Flaccidity of the Vocal Cords

Vocal cord flaccidity correlates to some degree with atrophy of the muscle comprising them. Bowing also accompanies flaccidity most of the time. It is possible to have bowed/slender vocal cords that are not particularly flaccid—they still vibrate with good firmness and resilience. Similarly, vocal cords that appear to have good bulk (and are not atrophied) can nevertheless have a flaccid vibratory pattern. Photos below show the visual findings of flaccidity as distinct from bowing and atrophy. Voice manifestations of flaccid vocal cords are similar to bowing in cases such as:

  • Loss of “edge”
  • Reduced ability to be heard in noisy places
  • Reduced vocal endurance (The voice becomes fuzzier or raspier and more air-wasting as the day progresses and the atrophied muscles tire).

Vocal Cord Flaccidity at Two Pitches

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Vocal Cords (1 of 5)

This woman in her sixties is experiencing loss of vocal strength. Her voice becomes raspier as the day progresses. Under standard light during voicing at her average pitch for speech, F3 (175 Hz), vibrating cords have blurred margins. Notice that the gap at the anterior vocal cords is wider (arrow) than between the rest of the cords. This anterior gap is a typical finding of flaccidity.

Wide anterior gap (2 of 5)

Still at her habitual pitch for speech, F3 (175 Hz), the closed phase is not closed at all! And again, the gap is wider anteriorly. This incomplete closure explains her air wasting, fuzzy voice quality.

Vocal Cords (3 of 5)

Still at her habitual pitch for speech, F3 (175 Hz), the closed phase is not closed at all! And again, the gap is wider anteriorly. This incomplete closure explains her air wasting, fuzzy voice quality.

Telltale small gap (4 of 5)

Higher pitch lengthens the vocal cords (stretches them longitudinally, making them less flaccid: think “rubber band”) Yet under strobe light at C4 (252 Hz), that telltale small gap is still seen anteriorly during closed phase of vibration.

Vocal Cords (5 of 5)

At the same pitch, the vocal folds fly less far laterally, but definitely farther than would normally be seen at moderate loudness at this pitch.

Flaccid Vocal Cords

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Flaccid vocal cords (1 of 4)

Pre-phonatory instant, standard light.

Flaccid vocal cords (2 of 4)

Vibratory blur with standard light. Note relatively wide "gray" zone of blur.

Flaccid and bowing (3 of 4)

Dramatic lateral excursions due not only to bowing, but also flaccidity.

Flaccid vocal cords (4 of 4)

Eventual recoil towards midline, but cords never come into full contact before they are again thrown to their maximum lateral vibratory excursion, as in photo 3.
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Flaccid vocal cords (1 of 3)

Open phase of vibration showing large amplitude in middle voice.

Flaccid vocal cords (2 of 3)

Maximum closed phase, but with persistent open area anteriorly (at arrow) If this area of exaggerated flaccidity oscillates independently, a rough quality is added to the voice.

Flaccid vocal cords (3 of 3)

Between open and closed phase, showing vibratory contact is aberrant.

Vocal Cord Bowing

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Vocal cord bowing (1 of 4)

Open phase vibration, strobe light. Notice the large amplitude of vibration. The wide lateral excursions suggest flaccidity, especially when this is seen in middle voice.

Cause of a gravely voice (2 of 4)

Partially closed phase, strobe light. Notice that the anterior cords are more flaccid, with delayed return to midline contact. When this is seen, that anterior segment may vibrate independently and cause a rough, gravelly voice quality. The capillary ectasia, left vocal cord is an incidental finding an not related to the patient’s rough voice quality.

Vocal cords do not close completely (3 of 4)

Coming to closed phase, but with persistent anterior open segment.

Vocal cord bowing (4 of 4)

Closed phase of vibration, strobe light.

Flaccidity Without Bowing

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Flaccidity without bowing (1 of 4)

The patient exhibits typical symptoms of bowing/atrophy/flaccidity, but in this case there is little bowing or atrophy—primarily flaccidity is seen. In this view, the abducted vocal cords appear full, with no exaggeration of the ventricles. (The apparent asymmetry between the vocal cords is due to the viewing angle; both cords are the the same.)

Flaccidity without bowing (2 of 4)

Now seen under the strobe light, the amplitude of vibration of the vocal cords is excessive. These flaccid vocal cords lack the firmness to "recoil" back to the mid-line, until maximal separation of the cords is reached.

Flaccidity without bowing (3 of 4)

As the patient is reaching the closed phase of the vibratory cycle, the anterior cords are arriving late to closure, a typical finding with flaccid vocal cords.

Flaccidity without bowing (4 of 4)

Now at the maximum closed phase of vibration, a pinhole of incomplete closure is seen. In this case, there is no independent oscillatory vibration of the anterior segment of the vocal cord.

False Cord Phonation

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False cord phonation due to flaccid true cords (1 of 5): before false cords begin to vibrate

An elderly man, quiet by nature who uses the voice little, complains of weak, gravelly voice quality. This view of phonation, standard light, shows a slightly wider dark line of phonatory blurring. Also, the false vocal cords are overly approximated, but not yet participating in vibration (for that, see images 4 and 5).

False cord phonation due to flaccid true cords (2 of 5): before false cords begin to vibrate

Strobe light reveals an unusually wide amplitude of vibration, denoting flaccidity of the true vocal cords.

False cord phonation due to flaccid true cords (3 of 5): before false cords begin to vibrate

Maximum closed phase shows the telltale residual opening at the anterior commissure (from this perspective, the lowermost end of the true cords), also a potent indicator of flaccidity.

False cord phonation due to flaccid true cords (4 of 5): after false cords begin to vibrate

When asked to produce louder voice, the false cords begin to participate in vibration, and a rough, gravelly superimposed “ godfather” quality arrives. Notice that the true cords are in at least partial open phase of vibration.

False cord phonation due to flaccid true cords (4 of 5): after false cords begin to vibrate

When asked to produce louder voice, the false cords begin to participate in vibration, and a rough, gravelly superimposed “ godfather” quality arrives. Notice that the true cords are in at least partial open phase of vibration.

Flaccidity

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Flaccidity (1 of 5)

Under strobe light, the vocal cords begin opening at the area of flaccidity anteriorly. The patient has a husky and gravelly voice quality (view here rotated 90 degrees counterclockwise).

Flaccidity (2 of 5)

Vibratory separation continues and is still greatest anteriorly.

Flaccidity (3 of 5)

Open phase of vibration now complete. Distance of lateral excursions is large, indicating the flaccidity of cords.

Flaccidity (4 of 5)

The cords are returning to closed vibratory position, but anterior cords close late due to flaccidity. Sometimes this anterior segment vibrates independently and this causes a rough voice quality.

Flaccidity (5 of 5)

At maximum closed phase, there is still a tiny incomplete closure anteriorly.

Voice Building:

Voice Building (shorter version):

Vocal Cord Bowing

Vocal cord bowing is a descriptive term to specify that the vocal cords are not matching in a straight line, with only a thin dark line between them at the moment of pre-phonation. Instead, the cords become gently concave or bowed outwards. At the moment of pre-phonation, there is a wider, oval slit between the cords.

Bowing can be physiologic, asymptomatic, and a genetic “given.” In this physiologic type, the bowing will be subtle to mild and there will be good vibratory pattern. When moderate or severe, bowing may more likely be the result of aging, vocal disuse, Parkinson’s disease, or other conditions. Moderate and severe bowing correlate with a degree of vocal cord atrophy and the vibratory pattern can be more flaccid. The voice tends to have a soft-edged quality, a little higher in pitch than normal, and can fade with use. Voice building is the primary treatment, but very occasionally severe bowing is treated with bilateral vocal cord implants.


Photos:

Vocal Cord Bowing

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Wide lateral excursions (1 of 4)

Open phase vibration, strobe light. Notice the large amplitude of vibration. The wide lateral excursions suggest flaccidity, especially when this is seen in middle voice.

Anterior cords are more flaccid (2 of 4)

Partially closed phase. Notice that the anterior cords (arrows) are more flaccid, with delayed return to midline contact. When this is seen, that anterior segment may vibrate independently and cause a rough, gravelly voice quality. The capillary ectasia, left vocal cord (right of image), is an incidental finding and not related to the patient’s rough voice quality.

Vocal cord bowing (3 of 4)

Coming to closed phase, but with the persistent anterior open segment.

Vocal cord bowing (4 of 4)

Closed phase of vibration.

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Glottic gap (1 of 3)

Vocal cords at the prephonatory instant under standard light. Note the highly bowed glottic gap.

Vibratory blur (2 of 3)

After vibration begins. Note the very wide “vibratory blur,” consistent with bowing under standard light.

Wide lateral excursion (3 of 3)

Open phase of vibration under strobe light, showing unusually wide lateral excursions of the cords resulting from their flaccidity.

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Vocal cord bowing (1 of 2)

Vocal cord bowing, at the prephonatory instant.

Vocal cord bowing (2 of 2)

Immediately after phonation, showing better closure, but only due to vibratory blur.

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Vocal cord bowing (1 of 4)

Bowing of vocal cords as seen under continuous light, at prephonatory instant, just before vibratory blur.

Vocal cord bowing (2 of 4)

Under strobe illumination, at maximum open phase (greatest lateral excursion).

Cords do not close (3 of 4)

Maximum "closed" phase of vibration, which is not fully closed; greatest medial vibratory excursion does not bring the cords into full contact.

Vocal cords only come in near contact (4 of 4)

Due to vocal weakness, when effort is increased the false cords come into near contact, and can even add a rough second sound to the voice.

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Oval gap during prephonatory instant (1 of 4)

Prephonatory instant shows an oval gap between the cords, rather than a thin line.

Vocal cord bowing (2 of 4)

Bowing, as seen in abducted, breathing position.

Anterior flaccidity (3 of 4)

Strobe light, maximum closed phase, with poor closure especially anteriorly. The greater flaccidity anteriorly may cause an independent vibratory segment and chaotic vibration with rough, gravelly quality.

Vocal cord bowing (4 of 4)

Strobe light, maximum open phase of vibration.

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Vocal cord bowing (1 of 5)

Bowed vocal cords, abducted breathing position.

Musculomembranous are bowing (2 of 5)

As the cords begin to adduct, medial turning of vocal processes accentuates the bowing of the musculomembranous (anterior 2/3) of the vocal cords.

Elliptical gap (3 of 5)

The prephonatory instant under continuous illumination, showing bowed free margins and an elliptical gap rather than the straight-line match of more normal vocal cords.

Vocal cord bowing (4 of 5)

Under strobe illumination, open phase of vibration.

Vocal cord bowing (5 of 5)

Under strobe illumination, closed phase of vibration. The closure here isn't complete because the cords' return to midline is flaccid.

Bowing of vocal cords and effect of pitch

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Weak voice (1 of 8)

This patient has a weak, air-wasting, and gravelly voice. In this distant view, prephonatory instant at a low pitch, D3 (147 Hz), severe bowing can be seen.

Phonatory view (2 of 8)

Also at D3 (147 Hz), but while producing voice. Note that the vibratory blur occurs only in the posterior membranous vocal cord.

"Closed" phase (4 of 8)

At D3 again, now closed phase, which is not closed except posteriorly, explaining the lack of vibratory blur anteriorly in photo 2. Some vibratory cycles are chaotic, too, explaining the gravelly, rough quality of the voice.

B3, open phase (5 of 8)

At B3 (247 Hz), open phase of vibration, the anteroposterior stretch required to produce higher pitch, also somewhat reduces the tissue flaccidity. Vibratory amplitude (lateral excursion) is diminished as well.

D3, open phase (3 of 8)

Under strobe light, open phase of vibration at D3 (147 Hz), note that the amplitude of vibration is enormous, as the air stream easily throws flaccid vocal cords very far laterally.

B3, closed phase (6 of 8)

At B3 again, closed phase of vibration is not really closed, yet is more successful than at the lower pitch in photos 3 and 4. Reduced closure anteriorly is typical for flaccid vocal cords.

Bb4, open phase (7 of 8)

Open phase of vibration at B-flat 4 (466 Hz). Added antero-posterior stretch subtly reduces vibratory amplitude further, especially anteriorly.

Bb4, closed phase (8 of 8)

Closed phase at same pitch as photo 7, is not closed, but the excess lateral amplitude anteriorly is no longer seen.

Four views of vocal cord bowing in the same person

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Bowed vocal cords (1 of 8)

An older man has a foggy voice, worsening with use. At medium range in partial abduction, note the bowed vocal cord margins.

Prephonatory view (2 of 8)

At a greater distance but at the prephonatory instant, there is a large oval gap between the cords.

Open phase (3 of 8)

Now under strobe light, at C3 (131 Hz). The lateral excursions of the cords are huge due to the flaccidity of the cords. Compare with photos 5 and 7.

Gravel voice (4 of 8)

At the same pitch, the closed phase of vibration is not fully closed, and the anterior segment that remains open is often unstable and flutters or vibrates as an independent segment, causing ‘gravel.’

Reduced flaccidity (5 of 8)

The vocal cords must lengthen to produce this higher pitch of F#3 (185 Hz). Lengthening also reduces flaccidity, explaining reduced amplitude (lateral travel) of vibration. Compare with photo 3 and 7.

Closed phase (6 of 8)

The closed phase of vibration, also at F#3, is completely closed, and the voice is more stable at this pitch. Compare with photo 4 and 8.

Falsetto, open phase (7 of 8)

Now at B-flat 5 (932 Hz), the cords are stretched and thinned. Amplitude is quite large, because falsetto tends to de-activate tension within the thyroarytenoid muscles. Compare with photos 3 and 5.

Falsetto, closed phase (8 of 8)

Closed phase of vibration at the same pitch in falsetto is not closed at all for the same reasons described in the caption for photo 7. Compare with photos 4 and 6.

Red herring capillary ectasia and mucosal injuries

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Ectatic capillary (1 of 4)

This young performer has a sense of a weakened voice and loss of vocal stamina. Here, we see an ectatic capillary of the left vocal cord (right of photo). Is the problem intermittent vocal hemorrhage from this vulnerable capillary? Is there increased susceptibility to edema due to this margin capillary?

Ectatic capillary, narrow band light (2 of 4)

Under narrow band light, the capillary is even more evident. The additional network of prominent capillaries prompt the same questions as in caption 1.

Margin swelling (3 of 4)

Under strobe light at B-flat 4 (494 Hz), we see subtle margin swelling (arrows), here of only “indicator lesion” magnitude.

Bowing, atrophy, and flaccidity (4 of 4)

The large amplitude of the open phase of vibration at the same pitch, along with the lack of closure in photo 3, reveals the actual problem to be bowing, atrophy, and flaccidity. These findings fit with the “bowing” symptom complex: loss of edge to voice quality and the tendency of voice quality and strength to “fade” as the day progresses.

Glottic furrow—not just bowing and not glottic sulcus

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Bowing vocal cords with furrows (1 of 4)

This middle-aged man's voice has become increasingly husky and weak across many years. In retrospect, it was never a "strong" voice. The cords are bowed, and the furrows seen here (arrows) become more visible in subsequent photos.

Closed phase (2 of 4)

Under strobe light at B-flat 2 (117 Hz), this is the "closed" phase of vibration, perhaps better defined in this instance as the "most closed" phase.

Open phase (3 of 4)

The open phase at the same pitch, shows a linear groove just below the margin of each cord. Some might call these glottic sulci, but "furrow" would be the better definition, as seen in the next photo.

Lower pitch reveals furrow (4 of 4)

At lower pitch, the amplitude of vibration is larger and the right cord (left of photo) reveals more clearly that the the linear depression is a wide furrow, not a slit-like sulcus.

Voice Building:

Voice Building (shorter version):

 

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):