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June 24, 2021 Thursday 11:23:18 AM IST

Be in Good Voice

Health Monitor

Voice is the medium through which one communicates to the outside world and how one expresses his ideas and emotions. Voice gives personality or identity to an individual. From the deep baritone voice of Amitabh Bachhan to the melodious voice of Shreya Ghoshal, we listen to a diverse range of voices every day.

How is it that each person has a unique voice? Do you know that in forensic science voice prints are used to identify the suspects in the same way finger prints are used? Mimicry artists astound us by mimicking the voices of our favourite artistes. How is sound produced in humans? How is it modified or modulated?  How diseases affect voice? How voice therapy and various surgeries helps in treating voice disorders?

Mechanism of Voice Production

The ability to produce voice starts with airflow from the lungs in the expiration process which is coordinated by the action of the diaphragm and abdominal and chest muscles. Sound is produced when this airflow vibrates the vocal folds (vocal chords) situated in the neck. This sound  is modified by resonators which includes the vocal tract, oropharynx  oral cavity and the sinuses and finally articulated . It involves 4 processes- Initiation, phonation, oro-nasal process and articulation.

Voice quality may be affected by diseases that affect any of the above areas- lungs and muscles, larynx or resonators. The pitch of the voice depends on the number of times the vocal cord vibrates in a second.  The range of pitch change can be trained and altering the resonators intentionally can also change the quality of at the voice which is what most the mimicry artists do to imitate other voices and this needs lot of observation and training .Similarly any disease affecting these cardinal areas which play a role in sound production can cause changes in the quality of voice and can help in detecting the pathology earlier.

Voice Clinic

Any change in voice persisting for more than two weeks should be examined by a doctor. Cancer of the vocal cord can be better treated with early detection.  Video laryngoscopy or videostroboscopy enables the ENT surgeon to see the vocal cords vibrating in slow motion enabling better diagnosis. Special voice software can be used to help regain voice with the support of speech therapists.

Speech therapy plays an integral part in voice restoration because different voice pathologies require specific techniques of voice therapy. Surgical interventions are required where conservative approaches don’t show results.

Speech therapy

Speech therapy is the assessment and treatment of communication problems and speech disorders. It is performed by speech-language pathologists (SLPs) or Speech Therapists to improve communication.  These include articulation therapy, language intervention activities, and others depending on the type of speech or language disorder. Speech therapy may be needed for speech disorders that develop in childhood or speech impairments in adults caused by diseases of vocal cords or after laryngeal surgeries or illness, such as stroke or brain injury.

Speech therapy helps with the following problems

•Speech- Unable to make the right sound, using the voice fully, and not straining. •Language and communication - problems in understanding language, expressing thoughts, or responding in a social situation.

Some professionals require a good quality voice to succeed. Occupational voice users include teachers, clergy, salespeople, telemarketers, receptionists and others. Professional voice users include singers, actors and broadcast personalities. They are more likely to suffer from voice disorders than others and hence the need to ensure vocal hygiene.

Vocal Hygiene

Vocal Hygiene is a daily regimen of good habits to maintain the health of your vocal folds. These include eliminating inappropriate vocal habits and situations that place unnecessary wear and tear on the voice and common sense behaviors which contribute to efficient voice production and overall vocal health. Our vocal folds are covered by a thin layer of mucous which is vital for  the correct vibration of the vocal folds. To function properly, the mucosal layer needs to stay moist.

Vocal Hygiene Tips

•Hydration- Be sure to drink plenty of healthy fluids every day. Water at room temperature is ideal- it will lubricate and protect your vocal fold tissues.

•Use voice that is most optimal for you. Using a pitch range level that is either inappropriately high or low can put excess stress on the vocal mechanism. Don't make strange noises with your voice and try not to imitate voices that are abrasive

•Avoid using a voice that is too loud. Yelling and screaming, or talking, laughing, or singing louder than required can be quite abrasive to the vocal fold tissues and can contribute to swelling and altered voice production.

•Avoid excess talking.

•Do NOT whisper. Whispering has a drying effect on the mucosa of the vocal folds. It also forces the airstream during expiration and in turn can increase muscular tension and effort somewhere in the vocal mechanism.

•Cut down and eventually eliminate excessive coughing, habitual throat clearing, or hard sneezing.

•Avoid spicy foods which results in GERD/Laryngopharyngeal reflux

•Get enough voice rest -When fatigued, the natural voice is lower in intensity and sometimes in pitch and tone, contributing to forced voice in order to be heard.

•No Smoking

•Avoid excess alcoholic consumption as it causes  drying of mucosal linings of tissues. Also, alcohol makes the stomach produce more acid than usual, which can lead to acid reflux. Alcohol further increases this risk of acid backflow because it also relaxes the lower esophageal sphincter (LES), allowing liquid to pass through more easily.

•Avoid mouth wash which contains over 25% alcohol as it can be drying to delicate tissues.

A vocal warm-up is an exercise that prepares the voice for singing, acting, or other use. Whether recording in the studio or performing live, vocal warm-up exercises are essential for achieving the best performance (.tongue trills, lip trills, tongue exercises).

Role of Surgery

•Phonomicrosurgery-Surgical techniques that are performed with a microscope for viewing (microsurgical techniques) and are used to remove vocal fold lesions or abnormalities that hamper vocal fold vibration - for vocal cord cyst /polyps.

•Laryngeal framework surgery- Surgical manipulation of voice box framework that improves vocal fold closure, which is important for vocal fold vibration during speaking and singing.(Thyroplasty - for vocal cord paralysis /puberphonia(abnormal high pitch in males  /Androphonia(abnormal low pitch in females )

•Injection augmentation- Surgical injection of fat or other substance to add bulk to vocal folds for better vocal fold closure

Vocal Cord Cancer

Vocal cord cancer is also referred to as laryngeal cancer. It comprises 59% of all throat cancers. 90% of vocal cord cancers occur due to excessive smoking. Vocal cord cancer is often detected early because even small lesions (which are cancerous) may cause hoarseness in voice and prompt patients to seek medical advice.

The treatment for vocal cord cancer depends on the location, stage, and grade of cancer in the larynx. The treatment options in the early stages are endoscopic laser surgery and radiation therapy. Endoscopic laser surgery is performed as an outpatient operation through the mouth and without external incisions. It is a focused treatment that targets only the affected areas of the vocal cord (s) and has no effect on the non-diseased regions to maximally preserve voice quality. It is a one-day treatment and is less invasive with excellent cure rate.

Radiation therapy is a good option when the cancer is too small and surgery isn’t needed. Open surgery ( Laryngectomy)- has to be done in advanced stage of cancer and is more extensive. It is done where minimally invasive surgeries don’t work.


In Laryngectomy, our voice box (larynx) is removed to treat cancer. Laryngectomy results in permanent loss of voice which is very debilitating and requires alternative measures or voice production.  In Esophageal Speech, the patient learns how to swallow air, and hold it in the upper food pipe(esophagus). Then he slowly ejects the air from food pipe, and speaks 6–10 words which are even though rough, are loud and understandable. Second method is Artificial Larynx which is useful when patients fail to learn esophageal speech. It is a battery operated, and portable device. This device is kept pressed to neck and it produces a sound which is further modulated into speech by the tongue, lips, teeth and palate. Now  the gold standard method is tracheoesophageal prosthesis (TEP) insertion,  where air is allowed to pass from wind pipe to food pipe though TEP and this air is  modulated  into speech by the tongue, lips, teeth and palate and then forcefully ejected through mouth.

Written by:

Dr. Rajesh Raju George - Senior Consultant & HOD,  Dr. Shalini Kurian – Consultant, Dr. Naveen George Kodiyan – Consultant (Dept of ENT, Rajagiri Hospital).