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Vocal folds, aka vocal cords, are two bands that come together and vibrate

to generate sound. Where are the vocal folds?

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Vocal folds are in your larynx, or the voice box. Please note, larynx, NOT

larinex, NOT larnex.

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Where is the larynx? Put your hand on your throat, then swallow. Do you

feel something moving up then down? That is your larynx.

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This is what your larynx looks like from the front. Trachea is like a folded

down straw tube.

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Your larynx has a very important role in your well being. Put a hand gently

on your throat and swallow. Do you notice your larynx moving up and

forward? This is done to protect your airway when you swallow food since

the esophagus (the food tube), is situated right behind your larynx.

Your larynx regulates airflow to and from your lungs, protect foreign objects

entering the airway, expels material by coughing/gagging, closes off the

airway to allow build up of positive pressure that’s necessary for heavy

lifting, pushing, etc. And, your vocal folds are inside the larynx.

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If you look at a view of larynx cut in half vertically, you can see 3 levels of

closure: epiglottis, ventricular/false and true vocal folds.

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Unlike other instruments, you cannot replace this one. Furthermore, your

entire body is the case for your instrument.

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Here I am phonating a male larynx. It sounded almost like this…. vvvvvvv

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If you and I, swapped our larynxes today, for the most part, I will still sound

like me, and you will still sound like you, because our unique voices are

shaped by the resonating structures in our faces. Isn’t that simply

amazing?

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Take a guess!

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Can you try to clap that fast in one second?

Listen to this, 400 times per second for soprano,

50-60 times per second for deep bass.

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Your vocal folds change in length from infancy to adulthood.

Shorter vocal folds produce higher pitches = hence, children’s voice is high

Longer and thicker vocal folds produce lower pitches.

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Advanced research in late 70’s (Hirano, 1977), early 80’s revealed the

following: the vocal folds are comprised of multiple layers that vary in

microscopic structure (histology) and mechanical properties, ultimately

affecting how they vibrate. The mechanical function of the vocal folds are

separated by Cover and Body.

The very top layer is the epithelium, you can think of it like a micro fine

seran wrap. It is fairly stiff and conforms to what is underneath but doesn’t

necessarily deform. Under the epithelium, there is the superior lamina

propia (SLP) divided into 3 sections. The superficial layer is gelatinous,

middle and deep layers make up the vocal ligament. Along with the

epithelium, the SLP account for most of the vocal fold vibration. The

vocalis muscles under the SLP usually doesn’t participate in vibration,

maybe in very low and loud phonation. Are you glazed over yet? Now

comes the fun stuff. If you are told by a laryngologist that you have vocal

fold swelling (edema), that means there are liquid gathering under the

epithelium. I want you to remember one thing: the SLP layer is not

replaceable. It does not regenerate. Have you heard of vocal cord

stripping? In this procedure, the surgeon takes off the SLP layer… Yikes!!!

Unfortunately, there are still some doctors performing this procedure for

vocal nodules. You need to have that vibratory upper layer to have a

normal voice. So if your doctor recommends this…. You know what to do

right? Run for your life!

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Another look at the vocal folds

These muscles control the vocal fold closure and opening

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The subglottic pressure (exhaled air from the lungs) open the vocal folds

from the bottom. The vocal folds are blown apart then suck right back in

due to the Bernoulli Effect (google this guys). The bottom part of the vocal

folds suck back in first. The vocal folds suck back in with harder impact

based on the loudness of the sound you make, which is related to

subglottic pressure, which is related to respiratory coordination with

phonation…. Ya, not simple.

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Here is a videostroboscopy of normal larynx and vocal fold vibration. Point

to left (which is actually on the right side of the viewer), right, epiglottis

(front side), false vocal folds, trachea and true vocal folds. Arytenoids bring

the vocal folds together. You cannot see the vocal folds vibrate with naked

eye. It simply moves too fast!

Stroboscopic light flashes light on the vocal folds with rate that is slower

than the actual vocal fold movement. Effectively, it tricks your eyes into

thinking that it’s seeing the movements in slow motion.

This clip shows vocal folds vibration in 30 frames per second.

-VF, shiny and moist, straight edges.

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This is the real, super slow mode of vibration. 4000 frames per second.

Remember I said for female that vocal fold vibrates about 200 times per

second? So high speed slows it down 20 times more per second.

This is my favorite image of vocal folds because it shows that you can have

a complete vocal fold closure (they meet) without squeezing the vocal

process (the backside) or having too much false vocal fold tension! No

need to have that pushing or straining sensation in the throat!

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Here is a trivia…

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Dislocation of your vocal cord

Injury to the lining of your vocal cord =scarring

Granuloma formation

Partial or total paralysis of your vocal cord

The vocal fold on bottom right show granuloma from intubation.

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In this video, the left vocal fold is bowed due to intubation during surgery. It

may be caused by subluxation = incomplete or partial dislocation of the

arytenoid (joints) The right side (left on screen) is moving well but the left

one doesn’t move well at all due to paresis/weakness. The vocal folds are

not meeting together to produce a regular vibration needed for normal

voicing.

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Let’s get back to voice disorders, specifically, what causes them. Most

importantly how to prevent them.

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One way of causing voice disorders is based on how you use your voice:

Functional voicing behavior that contribute to the development and

maintenance of laryngeal pathologies (disorders/disease). These patterns

of voicing, DO NOT have to be abusive based on technique.

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Hysterectomy – would required “pure estrogen therapy” some estrogen

contain testosterone which would cause lowering of pitch, permanently.

Anabolic steroids has increased sharply the risk of permanent virilization

(lowering in pitch) of voice.

Lung cancer can cause idiopathic paralysis of the vocal folds.

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Let’s talk about “sinus” problems and “post nasal drip.”

Sinus drainage causes pharyngeal irritation. So we take medication to

control sinus and allergies. These medications are known to cause

dryness. Dry vocal folds do not vibrate well.

Now, post nasal drip does not usually touch the vocal folds. However the

pharyngeal irritation is a real sensation so you end up throat

clearing…which is an abusive act for your vocal folds. Just drink water

instead of throat clearing.

Hormonal imbalance: Not just sex hormones. Example: Hypothyroidism

can cause tickle, cough and swelling of the vocal folds.

Alcohol/drug abuse is likened to taking a stradivarius (violin) and smashing

it over and over again.

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If the eyes are the mirror of the human soul, then the voice is the

barometer of human emotion. It reflects our deepest feelings and

intentions, and permits us to glimpse at the state of our emotional lives. We

may be unaware of our emotional reactions to stress, but our voices are

constantly vigilant. They respond to the stresses and strains of life on a

minute-to-minute basis.

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Conversion disorder is a mental disorder causing a wide variety of sensory,

motor, or psychic disturbances. Conversion voice disorders, can result from

severe stress. An individual develops the voice disorder as an avoidance

reaction to counteract the trauma that they are having difficulty facing. The

disorder permits the individual to avoid awareness of emotional pain, and is

completely subconscious.

Identity Conflict: sexual, social. A woman who wants to sound authoritative

in a male dominated board meeting…

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Congenital means condition present at birth.

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You can get these from scarring after surgery as well. Remember how Dr.

Lott showed a video of separating the web? Successful voice outcome

really depends how thick the web is.

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Airway is really small causing breathing problems. Stenosis means

narrowing. This requires surgical intervention.

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Cyst is caused by a blocked fluid duct in the vocal folds. Fluids and puss

gather. This is an internal lesion. A lesion is any abnormality in the tissue

of an organism.

This lesion requires a microsurgery where the surgeon very carefully

makes an incision on the lateral aspect of the epithelium, takes out the cyst

and covers it over with the cut epithelium, saving the SLP (remember the

jelly?) layer from damage.

Many famous people have had this…Rachel Ray, and Flicka to name a

couple.

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The laryngeal cartilages are not well formed at birth. They are soft and

sponge and collapse into the airway on inhalation.

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Failure of formation of the partition separating the pharyngotracheal canal

from the esophagus in embryonic life will result in open communication

between the airway and the esophageal lumen.

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These affect the way the vocal folds oscillate. Which means you will not

have a normal sounding voice.

Look these up online for detailed information. Of all these, vocal nodules

are the least severe and can be treated by voice therapy alone.

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These are voice disorders involving your brain. You can sing normally even

with Spasmodic Dysphonia, but not with laryngeal tremor.

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Aphonia means no voice. Whispering is considered no voice.

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Remember that the vocal folds appeared white, smooth, and straight in

earlier slides…

These look very angry, rough, and swollen.

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It is better to have nodules than any other laryngeal pathologies we are

going to see. Therapy helps to reduce the nodules.

Vast majority of the soprano singers have, and it is normal to have a slight

swelling in the mid-fold known as the “soprano pads” (term coined by Dr.

Joseph Stemple).

For this reason, it’s very important to have an image of your vocal folds at

baseline. Meaning, what your vocal folds look like you are singing well. We

call this a “wellness check.”

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Pendunculated (Tissue irruption or broken blood vessels pooching out on

the cover)

Sessile (BLISTER)

Polyps are fluid filled sac on the surface of the vocal folds. The cause can

be behavioral.

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Got smoke? The vocal folds gathered fluid in the COVER.

This is definitely not how you get your low notes!!!!

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This looks like a polyp doesn’t it?

Actually, a polyp looks more translucent.

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This can be congenital or caused by a ruptured cyst.

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Human Papilloma Virus:

Can get it from mother at birth, or it can be sexually transmitted. Dr. Lott

showed how these can be treated with KTP laser.

This is what Adele and Steven Tyler had.

Blood vessel breaks in vocal folds suddenly.

IT IS VERY IMPORTANT TO AVOID TAKING ASPIRIN and Ibuprofene

during heavy singing SINCE IT THINS THE BLOOD VESSELS.

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This is not a fresh hemorrhage…still very bad. Blood vessel can break in

vocal folds suddenly.

IT IS VERY IMPORTANT TO AVOID TAKING ASPIRIN and Ibuprofene

during heavy singing SINCE IT THINS THE BLOOD VESSELS.

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Presbylaryngis (aging voice) refers to age related structural changes of the

vocal folds. Some degree of vocal fold deconditioning and decreased

elasticity is part of the normal aging process. In fact, some degree of vocal

fold bowing is present in 72% of persons over 40 years of age. If the

atrophy and bowing becomes severe enough, significant dysphonia

(hoarseness), throat clearing, cough, and even aspiration (swallowing

difficulty) may result. As women get older the frequency (pitch) of their

voice gets lower (deeper). As men get older, the pitch of their voice gets

higher.

Gelatin in the vocal gets thicker and more viscous. This is the stiffening of

the system.

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Pre-cancerous white plaques on the vocal folds- you will sound hoarse

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This is a cancer of the vocal folds.

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Singers put more pressure on the stomach when singing, so we are more

susceptible to acid reflux.

Avoid eating close to singing time. I generally tell singers to eat a small

meal 2 hours before singing.

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A rock and roll singer’s raspy voice is his signature so quality may not be

what’s bothering him. Voice goal is different for each individual.

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What type of voice user are you?

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Vocal exercise physiology by Keith Saxon is a helpful book.

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Describe the component parts of voice production.

Then add artistry and alignment that affects optimal voice production for

vocal athletes.

Quite a complicating task don’t you think?

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Demonstrate low abdominal breathing technique to explain inspiratory and

expiratory volume. (I did not describe this for you during the lecture. Think

of a dry sponge being dunked into a pot of water. Do you have to make it

soak up water? No! It does that on it’s own. Now, take that sponge out, ring

the water out, hold the sponge tightly in your fist, then dunk your hand with

the sponge in the water pot. Will it soak up the water as easily as it did

without the hand holding it tight?) Now think of your body as that hand.

Your sponge are your lungs! When you inhale, think of freedom in

inhalation to the maximum capacity. Your diaphragm descends as the lungs

expand in 3D motion. As a result the diaphragm pushes down on your

viscera, which makes your belly pooch out. That is normal!!! Due to the

lung’s natural recoil, it will begin to shrink as we exhale. I know this is too

simple of an explanation but we have to start somewhere. The abdomen,

diaphragm, and your ribcages are involved in controlled exhalation.

You can inhale up to 90% of your vital capacity for singing.

It’s 60% during conversational system.

This goes to show that the system that you use for singing is very different

from speaking.

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Check it out!!

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Postural alignment per Alexander technique. Kristen Linklater’s technique

for freedom in voicing is also conducive.

Pointing out the weigh bearing joints in the body: the stars placed on the

skeleton.

Buoyant cervical discs: feel tall, not squashed.

All these affect the ease of respiration. A small change means a great deal

for a vocal athlete.

Atlanto-Occipital Joint: Head position affecting laryngeal position and

flexibility of the suboccipital muscles affect vocal function.

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Lateral symmetry affecting rib cage expansion.

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Artistry can mean a few different things. In general it means skilled quality...

something that isn't just thrown together, but that has to be practiced and

perfected, but it can also mean quality or skill separately depending on the

context.

The more complete your artistic understanding and execution, the better

your vocal production will be.

I sure sing badly if I am sight reading a new song!! And my throat hurts

afterwards!

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Memorize this. Imprint it in your mind!

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Sleep: your instrument and its case needs rest.

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Surround yourself with supportive people. It’s worth having a handful of

loving and caring people around you rather than 50 critical and negative

people.

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They are all false.

The water you drink, needs to be processed by your body to reach the

larynx at the cellular level.

If water touched your vocal folds, you’d have a coughing fit and you will

sound very bad.

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If your body is dehydrated, your laryngeal membranes produce thick

mucus!! So drink up (water) me hearties yo ho!!!

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Research shows us that hydrated vocal folds vibrate easier and withstand

impact better.

Plants: According to a University of Agriculture in Norway study, indoor

plants can reduce fatigue, coughs, sore throats and other cold-related

illnesses by more than 30 percent, partially by increasing humidity levels

and decreasing dust. Plants also clean the air.

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Even though you may not be bothered by the noise, your brain is one step

ahead of you. It will compete with the noise.

Have you heard of the Lombard Effect? Google this.

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Loud speaking = harder impact on your delicate vocal folds.

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Do not underestimate the importance of “chilling out”

Soft tissue therapy targeting somatic (bodywork) dysfunction and resulting

pain and restricted motion. This is accomplished by relaxing contracted

muscles, increasing circulation and lymphatic drainage, and stimulating the

stretch reflex of muscles and overlying fascia.

Remember that your muscles and soft tissues are like a complex spider

web. Tight throat usually mean a lot more muscle tension elsewhere in your

body.

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Explain warm up. It’s not going into a practice room and immediately

belting out an aria. It should involve a systematic and slow warming up of

your vocal muscles. Cool down involves stretching of the vocal muscles to

release the lactic acid build up and to bring down the temperature.

Check out this video of Straw Phonation by Professor Ingo Titze. This is a

great voice warm up and cool down technique that rebalances the

laryngeal musculature: http://www.youtube.com/watch?v=asDg7T-WT-0

Opera singers often have misconception of “correct” speaking pitch and

technique. “Talk like you are singing” is really not a correct way of using

your speaking voice. Remember, classical singing take higher subglottal

pressure than speaking. So you end up using an unbalanced vocal

production for speaking which takes less subglottal pressure than singing.

We need to speak with resonant oral tone at modal/chest pitch.

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The voice therapist’s job is to help you bring back to your optimal function.

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Your voice teacher helps you to achieve technique and artistry.

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Voice Savy ENT is a laryngologist.

Not every ENT is trained in laryngology. So do your home work when

finding a good laryngologist. They must be an ENT with laryngology

fellowship training.

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