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Let's Talk About Voice - Dr Benninger

Online Health Chat with Dr. Michael Benninger

April 15, 2010


Introduction

Cleveland_Clinic_Host: Does your voice sound hoarse or raspy? Does talking require increased effort? Do you have trouble hitting high notes while singing? If you are suffering from a change in your voice, take advantage of this rare opportunity to chat live with a doctor in a secure online setting. Cleveland Clinic voice specialist, Michael Benninger, MD, answers questions about voice preservation and rehabilitation.

Symptoms of a voice problem include such things as hoarseness, whisper, roughness, discomfort to talk or sing, loss of singing control and effort/strain. They are potentially serious and their cause cannot be determined simply by the way they sound. These disorders could be something relatively mundane or could be as serious as voice box cancer. Therefore, a person experiencing difficulty should be evaluated promptly by voice disorder specialists.

The Voice Center at Cleveland Clinic represents a dedicated center of excellence to uniquely serve the voice disordered population, with special focus on the professional voice user. It is staffed by recognized experts from Speech Language Pathology and Laryngology;

Verbal communication and the demands of the human voice have increased as society has evolved toward service oriented professions. Many professions require the voice to be professionally trained. As a result, ‘vocal arts medicine’ has emerged in an effort to develop the professional voice, prevent injury and protect quality while focusing on voice problems and pathology.

Michael Benninger, MD, a nationally recognized otolaryngologist specializing in voice disorders and care of the professional voice, has authored or edited five books, including his most recent, The Performer’s Voice. He has lectured extensively across the country and throughout the world. Dr. Benninger was recruited from Henry Ford Hospital in Detroit, MI and appointed Chairman of Cleveland Clinic’s Head & Neck Institute in 2008.

Dr. Benninger sees patients at Cleveland Clinic’s main campus and Solon Family Health Center.

To make an appointment with Dr. Benninger, or any of the other specialists at the Voice Center of the Head and Neck Institute at Cleveland Clinic, please call 216.444.6691 for main campus or 440.519.6950 for Solon or call toll-free at 800.223.2273, ext. 46691. You can also visit us online at clevelandclinic.org/voice.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Benninger. We are thrilled to have him here today for this chat. Let’s begin with the questions.


Voice Health: General Information

15 jumpup: What are some of the common problems that can affect your voice?

Speaker_-_Dr__Michael_Benninger:

  • Overuse of the voice
  • Lack of hydration
  • Smoking and other irritants
  • Improper use

Ohno: Are there any new treatments out or being studied in regards to voice health?

Speaker_-_Dr__Michael_Benninger: There are continuous new treatments that are being developed all the time with multiple multi-day conferences and journals (Journal of Voice for one) devoted to these new treatments. It would be difficult to address them here.

Pincer: What effect can medication have on your voice? Is there a certain type of medicine that has a greater effect? What about herbal medications?

Speaker_-_Dr__Michael_Benninger: Many medications have effect on voice. The most significant are diuretics and sedating allergy medications which can cause dryness. There are whole book chapters devoted to this topic. You can find a chapter on both prescription medications and alternative medications in my book, Benninger and Murry, The Singer’s Voice, published by Plural publishing.

Jack_o_brien: What is the most common cause for changes in the voice?

Speaker_-_Dr__Michael_Benninger: Overuse, misuse and age are all common causes for voice change.

EvieM: If someone damages their vocal chords, is it always permanent?

Speaker_-_Dr__Michael_Benninger: Rarely is it permanent. Most (even significant voice disorders) will recover with proper rest, diet, hydration and general voice care.

If recovering from a voice injury, voice therapy with an experienced speech-language (voice) pathologist is almost always helpful.

berta233: What is happening when I go to speak and nothing comes out?  I try again and it's fine. This has been happening more frequently of late. Should I be worried?

Speaker_-_Dr__Michael_Benninger: If your voice is normal between these events and you are a non-smoker, you should not be worried.  It may be related to appropriate voice use and adequate breath support. If you begin to speak before you take a deep breath, it is often difficult to initiate speech. This may also be related to reflux disease. To be sure, see an ENT physician.

seconds: How do you know when you have voice problems? What are the signs?

Speaker_-_Dr__Michael_Benninger: There are many symptoms that would suggest a voice problem and most of them are not worrisome. The most common symptoms are hoarseness, breathiness, or voice fatigue.  If you have persistent hoarseness lasting for more than 2-3 weeks, an evaluation would be indicated.

brandy_099: My primary care doctor mentioned that I should get checked for vocal cord lesions. What are these and what effect do they have?

Speaker_-_Dr__Michael_Benninger: There are multiple vocal fold lesions. Fortunately most of these are benign, but there are also cancerous lesions. If your primary care doctor recommended an evaluation, I would strongly support that you identify a local ENT.

handymandy: How do you screen for vocal health problems? Does everyone need to be screened? If so, how often?

Speaker_-_Dr__Michael_Benninger: Not everyone needs to be screened for vocal health problems. Although voice problems occur at some time or another in most people, these largely resolve spontaneously in a short time with no long term effects. If you are a smoker or if you have had recurrent or persistent voice problems, a screening evaluation with an ENT is appropriate.

For general screening, we usually begin with a general validated voice assessment survey (you can look up the Voice Handicap Index - VHI) on-line, although it may be difficult to interpret without a physician.

As part of World Voice Day (April 16, 2010), for those of you who are local, we are doing voice screenings at the Cleveland Indians baseball game. As part of World Voice Day, many Institutions, including Cleveland Clinic, are hosting free screenings and other events.

remmy0: When a person’s natural speaking voice is very deep and raspy, is this normal or does it indicate some past problem that may not have been recognized as such?

Speaker_-_Dr__Michael_Benninger: In general, these are again related to how people technically use their voice. If it interferes with communication, either in your job or social life, I would have this evaluated by an ENT.

deedee: I am a teacher and talk a lot. Lately, at the end of the day, my throat is dry and scratchy. I try to drink throughout the day. What else can I do?

Speaker_-_Dr__Michael_Benninger: The profession with the most frequent voice problems is teaching. This is due to many reasons. Most teachers do not have any formal voice training.  They need to use their voices continually all day long, in uncontrolled or noisy environments.  Usually, teachers do not hydrate throughout the day.

I feel that all teachers should have some form of voice instruction and should practice appropriate vocal hygiene (you can visit our website at clevelandclinic.org/voice for voice hygiene tips). Teachers should also utilize amplification, where possible, in the classroom.

Thriller: I have noticed lately that as I do a lot of talking throughout the day, I get like phlegm buildup in the back of my throat that seems to sit right on my vocal cords. I have to clear my throat ‘hard’ in order to get it to clear. I know this is not good for my throat or voice.  What can I do to help alleviate this problem?

Speaker_-_Dr__Michael_Benninger: Try not to clear the throat as it can cause more irritation. You can try to clear the mucous with a couple of small sips of water and if it does not clear a gentle, breathy cough. The phlegm sticking is a sign of irritation which may mean that you are either using your voice too much or too loudly.

Hideaway: Someone told me that caffeine can have an effect on your voice. Any truth to this? I tend to drink a lot of coffee.

Speaker_-_Dr__Michael_Benninger: Caffeine can cause problems for the voice because of 2 issues. The first is that it dehydrates people as it acts as a diuretic. Try staying hydrated with other fluids. Caffeine can also cause increased stomach acid production and reflux which can irritate the voice. Overall, coffee is good for your health, so moderation is the best bet.

crazy8s: I quit smoking about a month ago, and my singing voice is not the same. Everyone asks how smoking affects the voice, but what are the effects of quitting?

Speaker_-_Dr__Michael_Benninger: Usually after stopping smoking there is a period of accommodation as the body needs to re-equilibrate. This is particularly true with the lungs as many people have a temporary increase in cough for a short while when they stop smoking. Smoking can cause swelling of the vocal folds and as that starts to go away, people may need to adjust their singing voice a bit. In the long run your lungs and your voice will be better, let alone all of the other important benefits of smoking cessation.


Aging and Your Voice

MnM: How does aging affect your voice?

Speaker_-_Dr__Michael_Benninger: Aging has multiple effects on the voice and just like any other aging phenomenon; it affects different people at different times and ages.

In general, women particularly notice more dramatic changes in their early senior years. For example, very few women performers continue to perform into their late 60's and early 70's. This is less so with men and likely because of more dramatic hormonal changes in women.

Here are a few of the age-related changes:

  • Less mucous production
  • Mild bowing or laxity of the vocal folds (which can affect the very upper range)
  • Changes in sensation
  • Decreased neurologic responsiveness
  • Decreased lung capacity and breath support

Fortunately, with healthy living, voice moderation and, if necessary, voice instruction, most people can have a strong and healthy voice for their entire lives.

AK2: What can cause a voice to deepen as an adult? My son is in his 30’s and his voice seems to be getting deeper. He does not think this is an issue. Could this be the sign of a serious problem?

Speaker_-_Dr__Michael_Benninger: We rarely see men having a deepening voice as an adult. This may be just technically how he uses his voice. If he is a smoker, he may get some deepening in his voice. Please see the response to the other questions on smoker's voice. If the voice is clear and he has no pain or discomfort and he is a non-smoker, it is likely nothing to worry about.

gemstone: My nephew’s voice did not seem to get a whole lot deeper with puberty. His higher pitched voice embarrasses him, although his parents do not see it as a problem. Is this a problem and is there anything he can do about it, either now or in the future?  He is 18.

Speaker_-_Dr__Michael_Benninger: It is probably not a problem and it may just be related to the technique of how he uses his voice. If it is clearly not appropriate for his sex and age, he should have a medical evaluation to be sure that there are not any hormonal abnormalities and an ENT evaluation to make sure that the vocal folds are normal. Pitch modification can be accomplished through a speech/language pathologist.

bonkers: I noticed that my mom’s voice has changed over the years. It is now lower pitched and it is difficult to hear her sometimes when the room is noisy. Is this anything to sorry about? What can be done about age-related voice changes?

Speaker_-_Dr__Michael_Benninger: Please see question related to age above for response.

patacake: What’s up with kids who have not reached puberty but have a deep voice?

Speaker_-_Dr__Michael_Benninger: Hormonal changes begin before puberty. Some early adolescents have changes in voice before the visible signs of puberty.


Singing and Your Voice

constant: I have seen singers sing certain songs with a raspy voice, and afterwards are clearing their throats and coughing. Are they hurting themselves by doing this?

Speaker_-_Dr__Michael_Benninger: They may or may not be. Probably they are, but remember, different singers rely on different characteristics of their voice as their personal signature. For example, you would not want to hear a very clear Rod Stewart.

However, throat clearing should be avoided if at all possible as it may cause chronic inflammation. Instead, taking small sips of water and, if necessary, a gentle breathy cough, should clear any mucous from the vocal folds.

vested: How great an effect is proper breathing on the voice, as pertains to a singer?

Speaker_-_Dr__Michael_Benninger: The difference between a good singer and a great singer is probably more related to breath support and posture than it is to the voice box. Many of the greatest operatic singers have had very large lung capacity and most singing teachers spend a good portion of their work with a new student on breath support and posture. In other words, it is critical.

marko: How can gastric reflux affect a singer?

Speaker_-_Dr__Michael_Benninger: We mentioned reflux in another questions, but this is particularly important to performers. A small amount of swelling or irritation caused by reflux may have a dramatic effect on their performance. In addition, the lifestyle of performers is conducive to reflux with late evening performances and then eating or drinking after the performance, just prior to lying down.

figs: If I sing when I am sick (respiratory), am I putting my voice at risk, not just now, but in the future?

Speaker_-_Dr__Michael_Benninger: It really depends on how ill you are. If you have a fever, already have some mild hoarseness or have had a significant cough, you should probably not sing unless you have been evaluated and cleared by an ENT physician. If you have a very mild respiratory tract infection, sing with great caution and stop if your voice is changing.

leanonme: What exactly is laryngitis and what are its effects to a singer?

Speaker_-_Dr__Michael_Benninger: Laryngitis is a global term that just means inflammation of the larynx. We can see inflammatory changes of the vocal folds, even if there is not a significant change in voice. In general, however, most people refer to laryngitis when there has been an acute change in voice, usually related to a respiratory tract infection. Please see prior question/answer.

mamie: My daughter (16) wants to be a singer. What can I tell her now about taking care of her voice?

Speaker_-_Dr__Michael_Benninger: Please see prior answers. She should clearly obtain voice and singing lessons from an experienced voice teacher (if you do not know one, contact the National Association of Teachers of Singing and they can give you a local recommendation).

Remember, you only have one voice box and taking into consideration all of the voice use, both speaking and singing, will help make sure that her voice is healthy and strong.

nitad: Will drinking water through a “long” singing performance help with keeping the voice healthy? My daughter’s singing group does not allow this, as I am sure most don’t because of how it would look. But anyway, would it help?

Speaker_-_Dr__Michael_Benninger: Yes it would help. I suppose it would have a lot to do with how long a singing performance it is. If they cannot hydrate during the performance, make sure that she hydrates appropriately throughout the day, but not too much that she feels she has to go during the performance. A good rule of thumb is to 'pee pale' - in other words, when the urine is clear in an individual with normal kidneys, drinking more does not tend to improve hydration.

luckyaces: Are there potential dangerous effects to singers who have smoke on stage as they perform? I see many shows/concerts and there can be smoke everywhere. How do these people keep from coughing and be able to sing? Is it training? My son is in a local band and they have considered using smoke machines in their act. I am trying to talk him out of it.

Speaker_-_Dr__Michael_Benninger: It really depends on the smoke machine. The water-based smoke machines cause little to no problem, but they should be very careful with the oil-based smoke. Adequate ventilation when smoke machines are used is very important. There have been some studies related to stage smoke that you can probably search for on the Internet.

kiss: Can excessive talking, singing, yelling (like some of the singers today do) permanently damage the vocal chords?

Speaker_-_Dr__Michael_Benninger: We discussed this in a previous question. Rarely do these things cause permanent damage.

happyfeet3: A friend of mine (also a singer) has told me that she uses a Neti pot everyday to help keep her sinuses clear. Is this safe and does it really do any good?

Speaker_-_Dr__Michael_Benninger: A Neti pot with salt water, or any type of salt water nasal rinses are good for nasal health, particularly in people who have chronic sinus disease or allergies. There is no real down side as long as you do not swallow the salt water.


Disease and Voice Health

xoxo: I had a pretty bad cold where my voice got raspy. The cold went away about a month ago, but I still have a raspy voice at times. How can I help my voice get back to normal?

Speaker_-_Dr__Michael_Benninger: Following an upper respiratory tract infection, particularly if you had a significant cough, you may have caused some bruising of the vocal folds. The simplest measures are voice rest (minimizing excessive speaking, volume or intonation - what we call library voice), hydration, avoidance of irritants (such as smoke or secondary smoke), and general health recovery from your illness.

If your hoarseness persists for another couple of weeks despite the conservative measures, you may have developed a small benign nodule or polyp and an evaluation with an ENT physician would be indicated.

Nifty: I find when I am speaking with someone in a noisy room, afterward my voice gets somewhat hoarse and feels strained. Also, most mornings I feel a need to constantly clear my throat when I begin to talk, like a catch in my throat where an occasional word sounds like a whisper. When I swallow, it feels like there is something down in my throat, but can't seem to cough anything up.

Sipping moderately hot coffee seems to help my speaking voice. I was examined several years ago by an ENT and nothing serious was found in my voice box.  I was told it was probably sinuses acting up. I don't sneeze or cough a lot, like most allergy symptoms would cause. I also have been singing in a chorus many years, and over time my voice box has probably been strained, possibly due to improper warm-ups. Also told to avoid dairy products prior to singing. I would appreciate any advice on these issues? Thank you so much.

Speaker_-_Dr__Michael_Benninger: There is probably more than one thing going on here. The morning symptoms are very consistent with Gastropharyngeal Reflux, which is acid coming up into the back of the throat. This also would account for the foreign body or lump sensation in the throat. You should see your doctor about treatment for reflux disease.

The fatigue that occurs with speaking or singing may be technical and I would recommend seeing either a speech therapist or taking a few singing lessons.

mojosingforme: I have similar problems to Nifty, with frequent need to clear my throat and the occasional voice ‘catching.’ I was examined by an ENT specialist and he suspected reflux, but even after taking Omeprazole for a month, the symptoms did not improve at all. The symptoms improve a bit when I gargle daily with a warm salt water/hydrogen peroxide mixture, but the throat-clearing is severe enough at times to make my throat very sore. It gets worse after I eat.

Speaker_-_Dr__Michael_Benninger: People with significant throat and larynx irritation from reflux disease often require more aggressive treatment than mild gastroesophageal reflux (GERD). This may mean a twice daily proton pump inhibitor, like Omeprazole. Plus, a night time H2 blocker, like Zantac® or Pepcid®.  In addition, it may take 2-3 months to have a noticeable response. If you are on once daily Omeprazole, try taking it 1/2 hour before the largest meal of the day and don't forget dietary and lifestyle measures.

reikigirl: How does hyperthyroidism and/or removal of the thyroid affect long term voice health?

Speaker_-_Dr__Michael_Benninger: Hypothyroidism can result in some fluid accumulation in the vocal folds with an associated reduction of pitch. If your thyroid hormones are in good control, there should be no long term affects on voice health.

mojosingforme: Speaking of thyroid, I have Hashimoto's Disease. Can that affect the vocal chords?

Speaker_-_Dr__Michael_Benninger: Yes, if your thyroid hormones are poorly controlled and not within a normal range. In addition, surgery for thyroid disease has some potential risks for injury to the vocal nerve.

jr999: My mother has some vocal cord paralysis due to a stroke. Honestly, what are her chances of recovering full use of her vocal cords? What does this depend on?

Speaker_-_Dr__Michael_Benninger: If her only problem is voice, and not also speech, in our hands we can get nearly everyone back to a normal voice. However, this would likely require surgery. If you would like her to have an evaluation, we would be glad to evaluate her. You can contact our offices at 216.444.6691. If you are not in this area, you can go to the Voice Foundation website for a list of local ENT doctors that specialize in voice.

reikigirl: Are there any known issues with MS and vocal health? Or, would it be based on the type and presentation of symptoms? Thanks! This is great by the way!

Speaker_-_Dr__Michael_Benninger: Many patients with MS experience changes of voice, particularly if the disease progresses. Usually this is voice fatigue and weakness of the voice.

Singanddance: What are the risk factors associated with laryngeal cancer? My dad was just diagnosed. I am worried about myself and my brothers, who both smoke.

Speaker_-_Dr__Michael_Benninger:  Almost all patients who develop laryngeal cancer are smokers and this is by far the most important. If they smoke they are at risk for laryngeal cancer. There are other very uncommon risk factors, such as long term reflux and human papilloma viral infections.


Smoking and Your Voice

solly: When someone refers to “smoker’s voice,” what exactly does this mean? If this is caused by damage, is it permanent?

Speaker_-_Dr__Michael_Benninger: Smokers voice typically refers to gradual reduction of the pitch of the voice, particularly in women where the voice can become masculinized. These effects are often permanent because of changes in the structure of the vocal fold. The most important thing that people can do to protect their voices is to never smoke or to stop smoking.

CMe: How are singers who smoke and drink all the time able to maintain their voices for so long?

Speaker_-_Dr__Michael_Benninger: There are very few singers that smoke and drink all the time who can maintain their voices for a long time.

Most singers do not smoke and very few, now, use significant alcohol. I had one very famous rock singer who would frequently have a Jack Daniels bottle with him on stage. He actually had it filled with water. Many singers have lost their careers because of excessive alcohol, tobacco and drug use.


More Information

Cleveland_Clinic_Host: I'm sorry to say that our time with Michael Benninger, MD is now over. Thank you again Dr. Benninger for taking the time to answer our questions about voice health.

Speaker_-_Dr__Michael_Benninger: Thank you for your attention. We will try to answer all unanswered questions within the next couple of days. Please see the transcripts for these responses. Feel free to visit our website for more information on voice health at clevelandclinic.org/voice. Also, do not forget that tomorrow is World Voice Day. For information about events in your area, please check your local health institution's web sites. Again, you can go to clevelandclinic.org/voice for Cleveland Clinic events.