Swelling Checks to Detect Vibratory (Overuse) Injury to the Surface Tissue (Mucosa) of the Vocal Cords

Definition: Vocal tasks (swelling checks) that detect acute or chronic vocal fold mucosal injury reliably; Secondarily, they can also detect gaps between otherwise normal folds.
Purpose /rationale: To provide persons with a way to detect mucosal trouble for themselves. We are in effect “taking all of the clothes off the mucosa.”
Who they are for: Anyone who uses the voice extensively or vigorously—particularly vocal overdoers.*
What they are not for: Voice training or performance.
When they should be done: When first learning the tasks, they should be done often until the concept of one’s mucosal ceiling is understood (see below). Once both proficiency and ceiling are established, the tests require 20 seconds or less both morning and evening.

TEST I: “HAPPY BIRTHDAY”

  1. In your upper voice range, sing the first phrase of “Happy Birthday” as softly as you can, using a “boy soprano pianissimo.” Resist the temptation to “make it work” by getting louder!
  2. Repeat the phrase at progressively higher pitches.
  3. Verify carefully the pitch at which you falter (onset delays or air escape) or can’t go higher without getting louder. THIS IS YOUR MUCOSAL CEILING PITCH, FOR THIS TASK.
  4. If your mucosa is normal, the “soft voice” and “loud voice” ceilings should be about the same.
  5. If your mucosa is abnormal, the “loud” ceiling should be higher than the “soft.”

TEST II: STACCATO

  1. Sing again “boy soprano pianissimo” using the descending staccato figure so so so so so fa mi re do
    (5-5-5-5-5-4-3-2-1; e.g. G-G-G-G-G-F-E-D-C) Attack each note precisely in the middle of the continuum
    between an aspirated ho and a coupe de glotte. In other words, lightly, precisely, and with a little bounce.
  2. As for “Happy Birthday,” repeat at progressively higher pitches.
  3. Again carefully verify the pitch at which you experience onset delays or air escape or can’t go higher without getting louder. THIS IS YOUR MUCOSAL CEILING PITCH, FOR THIS TASK.

COMMON QUESTIONS

My mucosal ceiling is higher when I do the staccato exercise than it is when I do “Happy Birthday.” What does that mean?

Though needing verification via careful laryngeal examination, this phenomenon suggests that a small gap between the folds, rather than swelling, is the problem.

My mucosal ceiling is higher when I do the “Happy Birthday” exercise than it is when I do staccato. What does that mean?

Again needing verification, this phenomenon suggests a mucosal disturbance rather than a gap as the explanation.

I can figure out my mucosal ceiling easily enough, but how do I know if it is normal?

This can be answered best at the outset by individuals who can compare your performance with that of hundreds of others to whom they have applied these tests (e.g. laryngologist, speech pathologist, voice teacher). It is also helpful at the beginning to correlate your mucosal ceiling with high quality visualization of the vocal folds.

What if my ceiling isn’t normal as compared to others?

The swelling tests are nevertheless just as valuable! Here’s how: Suppose an individual’s initial mucosal ceiling is abnormal because of small vocal nodules, but the person is happy with the voice’s capabilities. Here, the swelling tests can be monitored to help the individual prevent additional mucosal injury, by not allowing the ceiling to descend any further. A different person whose initial ceiling is abnormal might be unhappy with
perceived limitations due to mucosal injury. Now, ongoing use of the swelling tests can confirm the benefits of medical, behavioral (voice therapy) or, eventually, surgical treatments, because the ceiling will rise with successful treatment. Furthermore, these tests can help to avoid recurrent injury.

What if I notice that my ceiling is abnormal (lower) as compared to my usual?

First, consider recent voice use for the possibility that it was “too much.” If so, and/or if the ceiling
remains lowered on subsequent trials of the tests later in the day, “back off” by reducing voice use
until the ceiling returns to your usual pitch, whether “normal” as compared to other persons or not.
Women: Some may find that the ceiling lowers routinely during pre-menstrual days, but returns to normal in a few days.

Do I need to cancel everything until the ceiling recovers?

This depends on the severity of the lowering of the ceiling. Generally, however, careful strategy concerning amount and manner of voice use during this time will allow the mucosa to recover while you continue to work or perform.

Are there common pitfalls in use of the swelling tests?

First and foremost, is the tendency to adjust how the voice is produced when the voice begins to falter. A singer will, for example, unconsciously get a bit louder or use a slight glottal attack to “make it work,” thereby reducing the sensitivity of the tasks. Another might be to perform them without a pitch reference at hand, so that the value of comparing with one’s known “ceiling” pitch is lost. A third might be to become a bit too obsessive and easily “spooked” with any ceiling change. And finally, comes the tendency to “lose the habit!”

* Vocal overdoer: Defined as an individual with both of the following:
  1. A high propensity to use the voice. Generally, “sixes and sevens” on a 7-point (maximum) intrinsic talkativeness scale.
  2. A high extrinsic opportunity or invitation to use voice, based on family, social, vocational, and avocational considerations.

Open Epidermoid Cyst

An open epidermoid cyst occurs when it spontaneously ruptures, but yet not empty all of its contents (keratin). The outline of the partially-emptied cyst may still be very evident, but it usually assumes an oval shape with the long axis oriented anteriorly and posteriorly. If the cyst empties nearly completely, the white oval is no longer seen, but the vocal cord may have a mottled appearance. If the cyst empties completely, a sulcus lined by epithelium remains.


Photos of open epidermoid cyst:






Indicator Lesions

Indicator lesions are visual findings of vibratory injury in a person who has no current voice complaints, and whose “swelling checks” are normal.

Background:

Individuals who fit the “vocal overdoer profile” may only notice vocal limitations caused by vibratory injury on an occasional and transient basis. These episodes may be brushed off as insignificant, because they are so brief, and recovery so complete. Even while asymptomatic, however, such individuals may have subtle visual findings of vibratory injury—“Indicator lesions.” Unless discovered during a screening examination for entry to music studies, the individual may be unaware of these findings. What if indicator lesions are found? Suggested responses:

1. Make sure the individual understands that these are indicator lesions and as such constitute a “yellow flag” suggesting at least occasional overuse of voice.

2. Define the “vocal overdoer syndrome” for the person as the combination of and interaction between an expressive, talkative, extroverted personality and a “vocally busy” life. Said another way, there may be both intrinsic, personality-based and extrinsic, vocal commitment based reasons that amount and forcefulness of voice may be excessive. A 7-point talkativeness scale can be used to estimate the intrinsic risk, where “1” represents Clint Eastwood, “4” the averagely talkative person, and “7” the life of the party. The extrinsic risk is addressed by making a list of vocal commitments such as for occupation, childcare, hobbies, social activities, religious practice, athletics/ sports, and rehearsal and performance.

3. Discuss the symptom complex of mucosal injury: a) loss/ impairment of high, pianissimo singing; b) day-to-day variability of vocal clarity and capability; c) a sense of increased effort to produce voice; d) reduced mucosal endurance, or becoming “tired” vocally from amount/ manner of voice use that does not seem to induce this in others; and e) phonatory onset delays—the slight hiss of air that precedes the beginning of the sound, especially if high and soft. Speaking voice hoarseness can be a fairly late and gross symptom of mucosal injury.

4. Talk about managing the amount, manner, and spacing of voice use to reduce unnecessary wear and tear on the vocal cord mucosa.

5. Teach vocal cord swelling checks as a means of detecting even subtle injury. Respond to what they tell you!

Singers are understandably distressed when they discover even the tiniest mucosal swelling such as indicator lesions. That is because for true singers, singing is not just what they do; the term “singer” also defines who they are. So injury threatens both activity and identity. Consequently, discuss indicator lesions with great care and sensitivity. Keep in mind that some doctors speak of “small vocal nodules that do not interfere with singing.” Small nodules that are but a tiny step above indicator lesions, especially when spicule-shaped rather than fusiform, always exact a penalty to the singing voice (see #3 above), but limitations can often be concealed by warming up, and singing more loudly. Singers often say “I have a big voice that doesn’t do pianissimo.” That is, pp becomes p; mp becomes p; mf becomes f; and so forth. Alternatively, the singer considers the missing pianissimo to be a technical fault.


Photos of Indicator Lesions:



Submucosal fibrosis

A disorder in which the attachment of the mucosa to the underlying vocal ligament appears to thicken and toughen, yet without creating any protrusion, such as one sees with nodules or polyps. The mucosa thereby becomes less flexible. Think of satin turning into canvas of a similar thickness.


Photos:





Glottic Sulcus Video

 

Glottic Sulcus: Laryngeal Videostroboscopy
Glottic sulcus is a degenerative lesion consisting of the empty “pocket” of what was formerly a cyst under the mucosa of the vocal fold. The lips of the sulcus may be seen faintly during laryngeal stroboscopy. Or, vibratory characteristics may suggest this lesion.

See also: glottic sulcus in the encyclopedia.

Glottic furrow

A disorder in which a furrow or groove is seen on the vocal cord, running parallel to, and at or just below, the cord’s free margin. This glottic furrow normally represents a defect in the underlying vocal ligament. Often, the deepest part of the furrow is lined with epithelium that is attached directly to thinned vocal ligament. Pseudobowing (due to mucosal and ligament abnormality more than atrophic muscle) is also a common feature.

Glottic furrow vs. glottic sulcus

A furrow is to be distinguished from a sulcus, which is more a defect within the mucosal layer only, and is thought to represent the empty sac of what was formerly a cyst. A furrow is typically shallow, and its lips are apart; a sulcus is usually deeper, and its lips are in contact and therefore harder to see. A furrow normally adheres to the vocal ligament, and the apex or deep surface of a sulcus often does as well. However, in the case of a sulcus, the vocal ligament itself is normal. Also, in the case of a furrow, the mucosal layer—often only an epithelial layer, in fact—will tend to adhere more broadly to the ligament, due to loss of the Reinke’s space layer of the mucosa.


Photos:










 

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:








Mucosal edema or swelling

Mucosal edema or swelling is the build-up of edema (tissue fluid) within the mucosa, the layer of tissue that lines the body’s interior. In the larynx, this build-up of edema usually occurs at the mid-point of the vocal cords, as the body’s response to vocal overuse, and it resembles a small, low-profile blister.

Vocal overuse triggers this build-up of edema because, with vocal overuse, the vocal cords undergo more vibratory stress and trauma than they are designed to handle. The body responds by gathering edema to form a protective cushion. However, this swelling distorts the vocal cord’s shape and can limit its flexibility, which can thereby impair the voice, making it sound acutely husky or hoarse.

From mucosal edema to nodules:

If the voice is rested even moderately, this edema fluid will disperse rapidly—within 12 to 24 hours if not severe—so that the swelling vanishes and the voice returns to normal. However, if the voice continues to be overused, then the body may build up more chronic swelling materials (no longer just edema), so that the vocal cords develop nodules.


Photos:





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 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.