Vocal overdoers and Benign mucosal disorders

This information is for patients with problems affecting the surface covering of the vocal folds. In my experience mucosal disorders almost uniformly appear in vocal overdoers.

The common names for mucosal disorders includes vocal nodules, vocal polyps, vocal cysts and other injuries commonly thought to happen when yelling or singing too aggressively. If the following seems not to apply to you, yet you have been told you have vocal hyperfunction or plicae ventricularis. Please read about vocal underdoers.

• Causes of a mucosal disorder
• Symptoms of a mucosal disorder
• Why did I get a mucosal disorder?
• Do I talk a lot?
• Tests to detect swelling
• How often should I check for swelling?
• A management program
• Benefits of managing swelling

Causes

1. Overusage
   • This is probably the most common factor causing injury to the surface covering of the vocal folds. On a self rating scale of talkativeness, almost everyone with a benign mucosal injury rates themselves as a 5, 6 or 7 which means they enjoy talking. However, if you are a 5, 6 or 7 you are also likely a vocal overdoer. (This usually causes an swelling on both vocal cords in the form of either nodules or polyps)
   • It is possible not to be a chronic vocal overdoer and yet injure the surface lining with one poorly timed vocal misuse such as a loud scream at sports game. (This usually causes a polyp on one vocal cord)
2. Cyst formation
   • A mucous gland may become plugged and form a cyst by trapping a pocket of material under the surface of the vocal fold. If present from birth this would be a congenital cyst. If this ruptures, an infolding of the surface may result called a sulcus.

Symptoms

• Variability
  • The patient with a mucosal disorder will complain of daily variability in the use of their voice.
• Huskiness
• Fatigue
  • This may be vocal fatigue. If severe enough this may be a combined vocal and general fatigue.
• Pitch range limitations
  • Singers may note a loss of the upper end of their range, but only if they perform soft singing. Singers may note onset delays and a breathy quality in their mid to upper range.
  • At times the loss is on a single note somewhere in the middle of the range and it is usually quite predictible and repeatable on the note which it occurs on.
  • Singers often attribute each symptom as it comes along to technique problems, thus delaying, for some time, their presentation to the laryngologist. Commonly, a singer will just sing louder and overcome the problems caused by swelling with an increase in volume.

Physiology 101

The vocal folds are two folds of tissue narrowing the windpipe that can open widely for breathing and close for speaking and singing. These folds are covered with a tissue that is similar to the moist lining on the inside of the lip. When you speak the vocal folds move together in order to vibrate, but it is actually the lining that does most of the vibrating. The actual vocal ligament itself moves much less. This lining is designed to vibrate many times per day, but it does have limits. At some point, with extensive use, the vocal fold lining suffers much the same way that the skin of you hands suffers if you have to dig ditches all day with a shovel. The lining swells and may thicken with continued use. Like skin, if you rest your vocal folds, the acute swelling may resolve. More chronic swelling may not completely resolve.

Self Rating talkativeness scale

• Use a seven point scale from 1 to 7
  • Rate your innate degree of talkativeness
  • This is your ongoing tendency to talk, given the opportunity to talk
  • Do not include the amount of talking required of you at work in this estimation
  1. quiet untalkative person
  4. averagely talkative person
  7. extremely talkative person
• Where do you fall on this rating scale of innate talkativeness?
• If you have a mucosal disorder, most likely you are a 6 or a 7.
• Do not confuse being a 6 or a 7 with anything bad. This is a wonderful personality. You may typically find yourself the life of the party, the social engine.
• 6’s and 7’s make wonderful actors and singers since your personality is one that will engage the audience.
• However, being a 6 or 7 is a vocally expensive personality.

Swelling tests

• soft singing
  • Sing the first phrase of a well known tune such as Happy birthday.
  • Use the softest voice possible (boy soprano pianissimo).
  • Sing it at progressively higher pitches.
  • At some pitch you will begin to experience delays in the onset of your voice or you will be unable to produce a soft tone. Your voice will sound like air is passing through the voice box without causing a tone.
  • This pitch is your vocal ceiling caused by swelling. You will know it is caused by swelling because with a loud voice you will be able to overcome this pitch ceiling and sing to a higher pitch ceiling.
  • If you have no swelling, your soft and loud ceilings will be approximately the same (this is true whether or not you are a singer).
  • There are exceptions. This test basically detects a gap in the vocal folds and any disorder that causes a gap may cause these onset delays. Once you have been diagnosed with a swelling then this test can reliably be used to monitor the degree of swelling.
• Staccato test
  • Sing the following phrase using a ho sound and a staccato length tone.
  • So So So So So Fa Mi Re Do.
  • As for the soft singing test, sing at progressively higher pitches.
  • Monitor the pitch at which only air comes out rather than a tone.

Daily testing

If you are a 6 or 7 and have been diagnosed with vocal swellings, it is extremely unlikely that you will be able to change your personality and I, for one, would not wish to change your personality. However, you can learn to monitor your vocal overdoerness with daily performance of the swelling tests. After a few days of performing the swelling tests you will find a baseline pitch that you can reach. A lowering of the baseline means that your swellings have increased. You should take an introspective look at yesterdays vocal usage and I suspect you will discover that it was an overcommitted day. Now is your opportunity to rest and see the swelling tests recover.

A management program

1. Swelling tests.
   • Perform the swelling tests every day of your life. Since you cannot put a telescope down your voice box every day to look at the swellings, this is the only way for you to monitor them.
2. Speech therapy.
   • To benefit the most, visit a speech pathologist (voice therapist) to review your speaking and/or singing techniques. They can review breath use, support and other technical issues.
3. Vocal hygiene.
   • Consume water frequently to remain well hydrated. Treat any acid reflux if present.
4. Manage your voice use.
   • Most vocal overdoers have a difficult time remaining quiet. In some instances vocal overdoers can consciously cut back their voice use to a 4 (an average talker). This may seem to you like you are being almost totally silent. You may need to ask those around you how you are doing. For example, at the end of dinner, you may ask your family how they perceive your speaking on the 1-7 scale above and see if they agree with your own perception. However, most vocal overdoers seem to be all or none talkers and they find it easiest to schedule time when they will be totally silent during the day and other times when they will speak freely. You might have to skip a party on a day with many work related talking commitments. Thus, you remain a 6 or a 7 when interacting with others but you schedule talking times to reduce the overall amount of daily talking.

• A video on vocal nodules in vocal overdoers.

Benefits

1. Many vocal overdoers can manage their tendency for vocal fold swelling and keep the swelling down to a satisfactory and functional level.
2. However, if you are dissatisfied with the functioning of your voice, there usually are other options, including surgically removing the swellings that may benefit your voice.

Medical Diagnostic Information

Information for physicians, medical students, residents and other voice professionals using symptom complexes and the three part model for voice disorder diagnosis.