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.
The term ‘vocal cord chatter’ describes the audible phenomenon one hears when the voice starts and stops in rapid alternation because the mucosa is at the edge of its ability to vibrate at a given pitch, loudness, and subglottal air pressure. So, it “catches” the airstream and vibrates for a fraction of a second, then stops, then restarts, then stops, etc. The best understanding is gained through audio and video examples.
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.
In addition, however, a phonatory gap occasionally occurs in patients who have none of the above conditions. In this type of case, the patient will struggle with onset delays, but delays that “pop” followed by relatively clear voice rather than the scratchier or hoarser-sounding onset delays associated with vocal cord mucosal swelling. Also, if asked to perform our vocal cord swelling checks, such a patient will tend to struggle more with the “Happy birthday” task than the descending staccato task (the opposite is true for patients with mucosal swelling).
Phonatory gap: Series of 4 photos
Phonatory gap (1 of 4)
At the prephonatory instant, D4 (~294 Hz), standard light. Notice how separated the vocal cords are.
Phonatory gap (2 of 4)
Phonation, a moment later, with vibratory blur. The cords remain separated. The question is whether this gap is due to: 1) a posturing problem, such as muscular tension dysphonia (MTD); 2) flaccidity-induced bowing; 3) some other cause.
Phonatory gap (3 of 4)
The most “closed” phase of vibration, as seen under strobe light, at the relatively low pitch of F4 (~349 Hz); again, the cords are not actually closed. This is not the picture of MTD, however; with MTD, there would be a greater gap between the vocal processes of the arytenoid cartilages (at arrows).
Phonatory gap (4 of 4)
Open phase of vibration, at the same pitch as photo 3. The lateral amplitude of each cord's vibration is equal, and relatively small (midline shown by a dotted line), which would not be seen with vocal cord flaccidity. Hence, neither MTD nor flaccidity is the explanation for this patient's gap. Also, this patient's voice manifests "popping" onset delays that are similar to other phonatory gap patients who have neither MTD nor flaccidity.
The same vocal cords shown short and fat vs. tall and thin: Series of 4 photos
Closed phase at a high pitch (1 of 4)
A mezzo soprano is singing at A5 (880 Hz). This is the “closed” (or rather “more closed,” since a slight gap remains) phase of vibration as seen under strobe light.
Open phase at a high pitch (2 of 4)
Here the voice is at the same pitch, but at the open phase of vibration. The amplitude of vibration (distance moved from the midline) is small.
Closed phase at a low pitch (3 of 4)
Now singing 2 octaves lower at A3 (220 Hz). This is the closed phase of vibration. The vocal cords are short and “fat.” In contrast to stringed instruments and the piano where high pitches are made with short and thin strings, the voice produces high pitches with long and thin. For an analogy, twang a rubber band stretched to different lengths and hear the change in pitch.
Open phase at a low pitch (4 of 4)
Still at A3, but now during the open phase of vibration. The amplitude (distance moved from the midline) is also typically greater for low pitches, at similar loudness level.
A benign bony growth on the medial surface (tongue side) of the mandible or jaw bone. Also known as mandibular torus. Mandibular tori are usually seen on both the left and right sides (bilaterally). They often require no treatment unless they interfere with denture fitting.
In laryngology, mandibular tori come to attention because, when large, they can make it difficult or impossible for the clinician to gain a view of the vocal folds during microlaryngoscopy. That difficulty arises because during a microlaryngoscopy, the floor of the mouth is normally compressed by the laryngoscope to allow the scope to angle anteriorly at the viewing end, but mandibular tori, being composed of bone, do not compress.
Torus mandibularis: Series of 2 photos
Torus mandibularis (1 of 2)
View inside the mouth, focused on the floor of the mouth, with tongue retracted. The “mounds” seen in the foreground are unusually large tori, which are touching anteriorly.
Torus mandibularis (2 of 2)
Looking more directly downward onto the tori, with the tongue now pointing upward at the roof of the mouth.
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.
Pulling of the posterior pharyngeal wall to one side, as sometimes seen when a patient performs the “pharyngeal squeeze.” This finding accompanies paresis or paralysis of the constrictor muscles of one side of the pharynx. In these cases, elicitation of the pharyngeal squeeze will reveal that the pharyngeal wall pulls to the normal (non-paralyzed) side. On the normal side, one will typically see bulging of normally functioning muscle to fill one pyriform sinus; meanwhile, the other pyriform sinus will appear capacious and almost dilated. The midline pharyngeal raphe, which joins the pharyngeal constrictor muscles, moves far to the normal side. A person with these findings normally experiences considerable swallowing difficulty, with pooling of saliva or ingested materials, particularly in the pyriform sinus on the paretic or paralyzed side.
Pharyngeal paralysis, seen with pharynx contraction: Series of 2 photos
Pharyngeal paralysis (1 of 2)
View of the laryngopharynx. This patient has pharyngeal paralysis on one side, which is already slightly evident because the posterior pharyngeal wall's midline (dotted line) is deviating here slightly to one side, even at rest.
Pharyngeal paralysis, more obvious with pharynx contraction (2 of 2)
The pharynx is contracted, and the posterior pharyngeal wall (midline again at dotted line) now deviates dramatically toward the non-paralyzed side of the pharynx. This pharynx contraction was elicited via extremely high-pitched voicing.
A phenomenon in which, when the palate is lifted, the midline deviates to the normal side and the weak side droops. Palate deviation is seen in individuals who have paresis or paralysis of a hemi-palate due to Vagus nerve injury or dysfunction. It can be observed from either the oral cavity or nasopharynx view; subtle cases sometimes seem easier to see from the nasopharynx view.
Photos of palate deviation:
Palate deviation showing hemi-palate paralysis: Series of 1 photo
Palate paralysis (1 of 1)
View of the upper surface of the palate from within the nasopharynx. Due to this patient's hemi-palate paralysis, the palate deviates to one side, such that its midline (darker dotted line) no longer matches the nasopharynx's midline (lighter dotted line).