Maintaining Vocal HealthMaintaining Vocal Health

Lee A. Reussner, M.D.Director – Kansas Voice Center, Lawrence, Kansas

Assistant Professor – University of Kansas School of Medicine, Kansas City

Jennifer Cannady, CCC-SLPSpeech Pathologist, Kansas Voice Center

Who is at risk for voice problems?

You Are!Music teachers are over four times more likely than classroom teachers to develop voice disorders and greater than eight times more likely to have voice-related problems than the general public. J Voice. 2010 Jul 21

AnatomyLungs, thorax,

abdomen - power source

Larynx - oscillatorSupraglottic vocal

tract - resonator

Inspiration - ActiveDiaphragm

Primary muscle of inspiration:

Dome shaped Divides thorax from the

abdomen Descends and increases

volume of the thorax

Expiration: Passive

Gravity pulls down on the thorax. Volume decreases, pressure increases and results in air flow out.

ElasticityNo active muscular contraction necessaryNot typical for singing

Expiration: ActiveOccurs with singingPrimary muscles are of the abdominal

wallReposition the diaphragm‘Squeeze’ the thoraxBoth decrease volume and increase

pressure in thoraxProduces airflow through the larynx

Anatomy of the Larynx -Cartilages

Anatomy of Larynx - Muscles

Anatomy of Larynx - Motion

Respiration / Phonation

Anatomy of the Larynx - MotionAdductors of the Vocal Folds:

Anatomy of the Larynx - Motion

Abductor of Larynx:

Anatomy of Larynx - Histology

Functions of Larynx

Passage for RespirationPrevents AspirationPhonationAllows Stabilization of Thorax

Care for your instrument

Unlike any other instrument.

How to Maintain Vocal Health

Avoid voice misuse/overuseMaintain good physical health

Poor Vocal Behavior Can Cause:

FatigueNeck painHemorrhagePolypsNodules

Jennifer Jennifer CannadyCannady--ThezanThezan, MA , MA CCCCCC--SLPSLP

Kansas Voice Center Kansas Voice Center

Vocal Hygiene 101/102

Vocal Hygiene 101 Hydration, Irritants, Behaviors

Hydration: Vocal folds that are well lubricated vibrate with less phonatory effort and tend to be less susceptible to injury.

Your body weight/2 = ounces per day Hydrate with 2-3 minutes of direct steam to vocal

folds with personal steamer Excess caffeine, alcohol, some medications, dry

environments can dehydrateHumidifier where needed

Vocal Hygiene 101 continued..

IrritantsSmoking Acid Reflux Noxious fumes (strong cleaning agents,

mold)

Vocal Hygiene 101 continued…

probably fine to drink herbal teas, tea with honey, glycerin coated throat sprays, lozenges (avoid lozenges with menthol/mint), hard candy if they soothe your throat.

Milk products are probably fine as long as you don’t chug a glass of milk immediately before you sing.

Vocal Hygiene 101 continued..

Vocal BehaviorsExcessive talkingLoud talking Excessive coughing, throat clearingExcessive singing or improper singing

technique (singing without support, tension, over singing, singing out of range)

Vocal Hygiene 102current research

Voice Amplification Versus Vocal Hygiene Instruction for Teachers with Voice Disorders: a treatment outcomes study. Roy N, Weinrich B, Gray SD, Tanner K, Toledo SW, Dove H, Corbin-Lewis K, Stemple JC. Department of Communication Disorders, The University of Utah, Salt Lake City 84112-0252, USA. nelson.roy@health.utah.edu, J Speech Lang Hear Res. 2004 Apr;47(2):353-7; author reply 358-65. Teachers were divided into 3 groups: non-treatment, vocal hygiene changes, and vocal amplification use: results revealed that VA group reported more clarity of their speaking and singing voice, greater ease of voice production, and greater compliance with the treatment program.

Voice Amplification as a Means of Reducing Vocal Load for Elementary Music Teachers. Morrow SL, Connor NP. J Voice. 2010 Jul 21. [Epub ahead of

print]. Department of Music Education, Westminster Choir College of Rider University, Princeton, New Jersey. Placed a phonation monitor on music teachers and measured the vocal intensity levels for one week, then measured same teachers for a second week while wearing a personal amplification system. Results indicated reduced vocal intensity for those wearing amplification suggesting that this could be an effective intervention to decrease vocal load.

Vocal Hygiene 102 Amplifiers

AddVoxChattervoxSoniVoxThe Spokeman100% of teachers who have visited our

clinic through the years have no regrets for using an amplifier and many have said they wish they’d done it years before.

Vocal Hygiene 102 Resonant Voice Placement

Fact: Teachers need to have a strong voice. How do you achieve this without over load? Resonant voice placement = a technique where the

placement of the voice is in the mask area of the face, taking focus away from the throat. Can produce a more projected voice with less effort.

Athletes have coaches to help with strained muscles, provide instruction, increase performance. Music teachers are vocal athletes, using their vocal fold muscles daily! If you need a little extra help, therapy can be beneficial.

Examples

Video ExamplesPre/Post Voice Therapy

Severe muscle tension

Post Therapy

Moderate muscle tension

Post Therapy

Vocal Hygiene 102 Recovery Time

Challenges of trying not to miss work, having a substitute, preparing for concerts, being control freaks will push music teachers to the limits, not allowing for vocal fold tissue recovery time. Be your own advocate and allow for recovery time. Otherwise you reach…

The Tipping Point: The moment that your voice goes from being relatively functional to not being able to complete your job responsibilities or enjoy your profession.

Physicial Condition - Exercise

How Important?

Obesity

20% over recommended weightBMI > 30Increased risk of :

AsthmaRefluxDiabetesSleep apneaHypertensionCancer

Verdolini K, J Voice V8 1994.

Water and the Singer

Nearly universally recommendedHow much? Body wt. (lbs) /2 equals

amount of water to be taken in daily in fluid ounces.

Studies point toward lower phonatory effort and some therapeutic benefit in patients with nodules.

How to Prevent Illness(particularly the common cold)

1. Wash hands2. Don’t touch face3. Drink fluids4. Aerobic exercise5. Don’t smoke6. Avoid excess alcohol7. Sleep and rest8. Eat a balanced diet with fruits and

vegetables

How to Prevent Illness(particularly the common cold)

What Doesn’t Work1. Antibiotics2. Zinc3. Vitamin C4. Echinacea

Quackwatch.com

How to Treat a Cold

WaterSaline spraySalt water garglesConsider decongestantHumidityChicken soup!

Smoking and the VoiceCauses chronic

swellingMucous collects on

vocal folds Increases cancer risk

American Pharmaceutical Association, 1996

Medication Use in the U. S.

46% use prescription medications on a regular basis

84% use over-the-counter medications at least once a year

Antihistamines

Used to treat allergiesBenadryl, Clarinex, Zyrtec, Allegra, etc.

Older antihistamines cause significant thickening of secretions due to their anticholinergic effect. Newer medications still can cause difficulties, but to a lesser degree.

Diuretics

“Water pills” Used for hypertension, CHF, etc.

Lasix, Dyazide, Lozol, Spironolactone etc.

All are drying to some degree. Spironolactone may cause deepening of the voice in females.

See PDR for each medication

Antihypertensives

Used to treat hypertensionMany medications

ACE inhibitors can cause cough. Most newer antihypertensive medications have little effect on the voice.

See PDR for each medication National Center for Voice and

Speech AMA-Drug evaluations

Mucolytics

Expectorant used to “loosen mucous.”Guaifenesin contained in a large number

of brand named compounds. (Mucinex)

Use for voice based primarily on tradition. Often seems to be effective. No good studies on voice.

See PDR for each medication DelGaudio JM, Arch OtoHNS, June 2002 Multiple other

sources

InhalantsMultiple types used for asthma, COPD,

etc.AtroventAlbuterol, Serevent, etc. Azmacort, Flovent, etc. (steroids)All oral inhalers can cause hoarseness and dry mouth –should gargle after use. Steroids carry higher incidence of hoarseness and may cause candida infection. Nasal sprays are safe for the voice.

Koufman JA, ENT J Sept 2002 Multiple other sources

Dr. Stasney

“Reflux Medications”

Used for ulcers, gastritis, reflux.Nexium, Prevacid, Prilosec, Protonix,

Aciphex, Zantac, Pepsid, etc.

Often help to prevent laryngeal reflux and damage from acid exposure.

See PDR for each medication Abitbol J, J Voice, Vol13 1999

PDR health

HormonesMultiple uses including: birth control, post

menopausal replacement, thyroid replacement.

Multiple types are available.

Thyroid replacement hormone has no significant direct vocal effect, though hypothyroidism can cause hoarseness. Estrogens, progesterone, and androgens can significantly effect the voice. BCPs generally safe. Hormone replacement therapy is generally beneficial to the voice after menopause, but benefits of use must be weighed against other medical risks.

See PDR for each medication

Analgesics

Used for pain, inflammation, antiplatelet effect etc.

Aspirin, ibuprofen, acetaminophen, etc.Aspirin may predispose to vocal hemorrhage. Ibuprofen less likely to cause this effect. Acetaminophen does not cause bleeding. No well controlled studies.

What is Likely the Single Worst Thing You Can do to Your Voice?

Smoking!!

Additional Sources of Information on Care of the Voice

Voicefoundation.orgKansasvoicecenter.comVoiceproblem.org