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.
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.”
In the normal larynx, 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.
Segmental vibration compared to full-length: Series of 4 photos
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?: Series of 4 photos
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: Series of 4 photos
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: Series of 4 photos
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.
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.
Closed phase (3 of 4)
Closed phase of vibration at E-flat 5 (622 Hz). Arrows indicate closure of the short oscillating segment.
Open cyst and sulcus; normal and segmental vibration: Series of 6 photos
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: Series of 6 photos
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.
A popping onset refers to the sudden start of the voice after a little hiss of air, but once the voice begins, it is very clear. It doesn’t sound like laryngitis, or scratchy like one would hear after a nodule popping onset.
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.
True and False Cord Voice
True and False Cord ‘Godfather’ Voice
True and False Cords Vibrate Mostly in Tandem (in phase)
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.
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.
Teflon bulge, before and after removal: Series of 4 photos
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: Series of 5 photos
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.
At closer range (2 of 5)
At closer range.
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:
The patient describes original problem with Teflon granuloma/ overinjection, and the improvement after debulking Teflon.
Teflon bulge, before and after treatment: Series of 5 photos
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.
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).
This 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.
Vocal Cord Bowing
Bowing of vocal cords and effect of pitch
Four views of vocal cord bowing in the same person
Red herring capillary ectasia and mucosal injuries
Glottic furrow—not just bowing and not glottic sulcus
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.