Online Health Chat with Claudio Milstein, PhD, CCC-SLP

April 7, 2011


Cleveland_Clinic_Host: The National Institute on Deafness and Other Communication Disorders estimates that more than 7.5 million people of all ages in the United States alone have some form of voice disorder that may impact communication. However, many people are not aware of the signs, symptoms, or potential significance of these conditions. People mistakenly think only professional singers and performers have voice concerns; but it is more common in teachers, lawyers, broadcasters, preachers, coaches, etc., who use their voices every day.

Each year on April 16, voice professionals worldwide join together to recognize World Voice Day. The celebration of World Voice Day encourages all men and women, young and old, to assess their vocal health and take action to improve or maintain good voice habits.

For more than 20 years, Dr. Claudio Milstein has been involved in the clinical management of voice patients, and is frequently invited as a lecturer at national and international meetings. Dr. Milstein has authored numerous publications primarily related to the human voice and its disorders.

Dr. Milstein has been a Staff Member of the Head & Neck Institute at Cleveland Clinic since 2001 and holds an Affiliate Scholar appointment at Oberlin College Conservatory of Music. He is a Speech Scientist with clinical interests in laryngology and voice disorders. Born in Buenos Aires, he completed his studies at the Medical School of the University of Buenos Aires, Argentina. In the U.S., he obtained his PhD in Speech Sciences from the University of Arizona, and trained at the Massachusetts Eye and Ear Infirmary of Harvard Medical School and the Massachusetts Institute of Technology.

Dr. Milstein’s primary interests involve diagnosis and treatment of adults and children with laryngeal-vocal-fold voice pathology, aerodigestive-tract disorders, treatment of early glottic carcinoma, functional voice disorders, and vocal-cord dysfunction.

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Claudio Milstein. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.

TrudyJane911: What is a voice disorder? And how is it diagnosed?

Dr__Claudio_Milstein: A voice disorder is any condition that changes the sound of the voice, resulting in hoarseness, breathiness, raspiness, and weak or fatigued voices. This may be a result of a variety of problems specifically in the larynx or vocal cords, or a systemic problem that affects the voice. The most common problems include voice overuse or abuse, irritation, allergies, acid reflux, benign growths, malignant growths typically associated with smoking, or neurological problems that affect the larynx, resulting in noticeable changes in the quality of someone’s voice.

jolly: What would be your top five tips on taking care of your voice?

Dr__Claudio_Milstein: I am glad you asked. You can also download our top 10 list at

  1. If you smoke, quit.
  2. Avoid “second hand” (passive) smoke.
  3. Drink plenty of water.
  4. Try not to strain your voice by yelling/screaming, singing too loud or out of your range, or talking too much.
  5. Seek professional help if your voice is injured or hoarse.

TeacherOfTheYear: I teach middle school and I find I am often unable to talk by the time my day ends. What can I do to make my voice last longer?

Dr__Claudio_Milstein: It is interesting that you bring this up. Teachers are the most at-risk profession for voice problems. Hoarseness is the #1 cause for teachers to miss work. I feel vocal training and voice care should be part of any teacher training curriculum. I urge you to have your voice checked by a specialist to avoid making the problem worse and, potentially, having to stop teaching altogether. The sooner you address the problem, the better. Voice therapy may be the way to go to make your voice last longer.

The Aging Voice

MINUTERVIS: Does the voice become lower as the singer ages, and what is the age when it happens? How can you prevent it or minimize the aging of the voice?

Dr__Claudio_Milstein: Individuals will exhibit signs of vocal aging at different times. Some people will show signs early, others at an older age, and some may never show signs of aging of the voice. Singing and exercising the voice can help maintain a youthful voice later in life.

LP1961: Is it necessary to accept "frogs" in your voice and lowering of the voice as a natural process of aging? Lots of throat clearing will get rid of the "frog" or gravel-like voice.

Dr__Claudio_Milstein: Frogs in the voice and lowering of pitch are not necessarily a direct result of the natural aging process. Frogs may be caused by allergies, sinus issues, or reflux. If they become bothersome, they should be evaluated by a professional.

In general, with the aging process, female voices will drop in pitch and male voices will get higher. Voice therapy or singing may help maintain a youthful voice.

GrampaJoe: I feel anxious or frustrated because of changes in my voice as I get older. My grandkids play sports, and it's hard to cheer for them. I'm also having a hard time keeping up with my active family. Honestly, I'm not a grumpy old man at 66 years old. What can I do so my voice issues are less frustrating?

Dr__Claudio_Milstein: There are a number of things that can change in the body as we age, and changes in voice are not uncommon. The most common age-related voice changes are caused by a decrease in muscle tone of the vocal folds. They can get thin and weak, and that results in weak voices (old-people’s voice). But, there could be other causes to the problem you describe. I recommend you get evaluated by a voice specialist. There are many things we can do -- from voice therapy to surgery -- to improve voice quality when this happens. Think of it as “cosmetic surgery” for your voice. Improving the sound of your voice can make you feel and sound younger, and not a grumpy-old man, as you say.

Vocal Cord Dysfunction (VCD)

VCD1109: Can orthodontic braces cause vocal cord dysfunction?

Dr__Claudio_Milstein: In general orthodontic braces should not affect the vocal cords.

VCD1109: What is the best course of action for a full recovery from VCD?

Dr__Claudio_Milstein: Successful treatment always depends on a combination of medical treatment of the underlying cause together with respiratory and laryngeal-control therapy by a speech language pathologist with expertise in VCD.

VCD1109: If a person who developed VCD has a mild gastroesophageal reflux (silent) appear in an upper GI series test (barium swallow), would you believe the GERD to be the main contributing factor in the VCD?

Dr__Claudio_Milstein: GERD is frequently associated with VCD, and good reflux control is important in the treatment of VCD.

VCD1109: What should the course of action be for a person diagnosed with VCD who displays atypical intermittent wheezing symptoms instead of voice interruption?

Dr__Claudio_Milstein: I recommend a full evaluation by a team -- including ENT, pulmonary, and SLP (speech language pathologist). At the Cleveland Clinic, we have a multi-specialty team with expertise in this condition.

AnnamarieSV: I have been experiencing atypical wheezing/fluttering sensations in the center sternum area coupled with inspiratory squeak upon inhale since 11/2009.Occasional chest tightness emerges as well. During a nasal scope (while symptomatic), Ii was diagnosed with vocal cord dysfunction. My questions are: 1. Can orthodontic braces cause vocal cord dysfunction? 2. What should my course of action be to eradicate this issue? 3. I have been seeing a speech pathologist and abiding by proper breathing techniques. Typically, how long before conditions improve? 4.Do symptoms typically become worse overtime or continue in the way they initially present themselves? 5.What are my chances of full recovery? How long will it take?

Dr__Claudio_Milstein: VCD is a condition in which the vocal folds “misbehave,” creating a narrowing of the airway, resulting in episodes of shortness of breath. It is important to find out whether there are medical conditions that are causing it, such as asthma, irritation in the throat, etc. Once these conditions are treated, respiratory and laryngeal-control therapy is very effective for alleviation of symptoms. This therapy is done by a speech language pathologist with expertise in this disorder. The chances for full recovery are high, and most patients reach a level where they can control symptoms very well, and prevent shortness of breath. As to how long it takes, it varies, depending on many factors. If you do not improve after several sessions of therapy, you may need to get re-evaluated to determine whether there is something else going on.

VCD1109: How often is GERD the main contributing factor in VCD?

Dr__Claudio_Milstein: GERD is frequently a contributing factor in VCD.

connie: Does chewing tobacco pose a risk for VCD and related cancer?

Dr__Claudio_Milstein: Chewing tobacco poses a risk for oral cancer, including lips, mouth, tongue, and back of the throat.

For more information, you can check the Cleveland Clinic treatment guide on

VCD1109: Can anxiety and stress cause VCD?

Dr__Claudio_Milstein: Yes. At times, anxiety and stress can exacerbate symptoms of VCD.

Illness and Your Voice

bruce: I have had a paralyzed left vocal cord since infancy (nerve ending was severed during heart surgery). Are there any treatment options other than surgery to restore my full voice?

Dr__Claudio_Milstein: Voice therapy is always a good start for voice improvement. If that does not give you the desired results, a vocal cord injection or an implant may be needed.

connie: Can allergies affect voice function? I seem to have problems with my voice when I am around strong scents -- perfumes, cleaning products, etc.

Dr__Claudio_Milstein: Odor sensitivity can be caused by irritation of the larynx or the upper airway. This can cause a change in voice quality. I suggest that you get an evaluation.

PS: I sleep on my side, tossing back and forth all night because the “bottom" side gets clogged up, so I can't breathe through it. The only thing that helps is the 24-hour nose drops, which open it up just fine, but can only be used two or three days. I have tried everything else, including the Neti pot. Another issue - maybe related: during the day I have frequent need to very aggressively (and loudly) clear my throat because of the congestion I feel there.

Dr__Claudio_Milstein: It sounds like you may have allergies, sinus problems, lung problems, or reflux. You should definitely consult with an ENT doctor.

LP1961: Could the accumulation of phlegm possibly be a sign of diminished heart/lung capacity?

Dr__Claudio_Milstein: Not necessarily, but heart/lung problems can potentially decrease the ability to manage secretions well.

connie: Are there other symptoms related to voice disorders? Can you feel polyps or do you have pain sometimes?

Dr__Claudio_Milstein: In general, you cannot feel polyps in the vocal cords, but they can make your voice very hoarse. Typically, most vocal fold lesions do not cause pain.

connie: I usually am hoarse when I wake up and have periods of laryngitis at least a couple of times per year. Usually it happens after a cold, but not always. I also have asthma.

Dr__Claudio_Milstein: A few periods of laryngitis per year are not uncommon. Asthma does not necessarily affect voice. Allergies though, can make you hoarse.

Jennifer27: After a bout of laryngitis last year I never regained my full voice. Should I consider vocal manipulation?

Dr__Claudio_Milstein: The only way to determine the appropriate treatment is to be evaluated by a voice specialist. If voice manipulation is appropriate, it would be recommended at that time.

nystrom: Can intubation affect your voice? I had a difficult time recovering from surgery.

Dr__Claudio_Milstein: Yes. Intubation can affect the voice in different ways. You can get trauma to the vocal fold mucosa, lesions on the back of the voice box as a reaction to damage from the tube, or even nerve trauma resulting in a vocal cord paresis or paralysis caused by the tube. It is a good idea to discuss the risks of intubation with your anesthesiologist prior to surgery.

Tobacco's Effects

JulieK: Does smoking change your voice? If I stop smoking will my voice be restored?

Dr__Claudio_Milstein: Smoking can affect the voice in different ways. Swelling of the vocal folds from chronic smoking is common. This will cause the voice pitch to drop. A common complaint of women who smoke and develop this condition is that they sound like a man. Also, smoking can cause damage to the vocal folds, like pre-malignant and malignant lesions. The first step in the treatment of any of these, is to quit smoking. Some of these problems are reversible and can get much better if you quit. If you think you have changes in voice quality because of smoking, I urge you to have your larynx checked by an ENT doctor.

pp00689: I am an acting student. I used to smoke occasionally, now I smoke more often because I find it helps with my accents. Is it true that smoking makes your voice deeper?

Dr__Claudio_Milstein: Smoking does not necessarily make the voice deeper. Smoking will not improve your acting abilities, or make your voice any better. If you are an acting student, please take care of your body and your voice by NOT smoking.

claudiaj007: I realize now that I ruined my singing voice because I smoked for years. Will I get it back when I stop smoking? I perform locally with a wedding band and I'm hoping my range will return as soon as I kick the habit.

Dr__Claudio_Milstein: Smoking can certainly damage your voice and decrease your range if you are a singer. It is difficult to say whether your range will return as soon as you kick the habit, but the best you can do for your singing is to stop smoking soon, and get your voice and larynx checked by a specialist to make sure you don't have damage from smoke.

damon88: I quit smoking five years ago, but I still suffer from smoker’s cough. Are there voice exercises I can do to get rid of it?

Dr__Claudio_Milstein: You may have lung damage from years of smoking, or perhaps your cough is caused by other factors, such as vocal fold damage, allergies, asthma, reflux, etc. If you haven't done so, please see a pulmonary doctor or an ENT doctor to evaluate the cough. In general, voice exercises will not improve your cough.

curiousgeorge: Does chewing tobacco affect your voice as much as cigarettes?

Dr__Claudio_Milstein: Chewing tobacco has less of an impact on your vocal folds or your voice than cigarettes, but it increases your risk of getting mouth, lips, or tongue cancer.

Volume and Sound

atlaw97: I work in my law office most days but when I have to be in court I find that my voice isn't as strong as it is in the office. Since I have to project my voice in court is there something I can do in advance to prepare?

Dr__Claudio_Milstein: It is not clear to me whether you are talking about the acoustic properties of the room or if your voice really behaves differently in those different environments. If it is not room acoustics, it may be that the increased stress and anxiety of being in court may be affecting your voice. Or you may have to learn how to use your voice in a more efficient manner. Voice therapy or voice classes for actors can help.

qoute16297: It feels like I have to strain my voice in order to sound the way I think I should. Am I doing damage to my vocal cords? Or is it just the way I hear myself in my head?

Dr__Claudio_Milstein: It is difficult to say without an evaluation, but in general, straining the voice may be the result of a problem in the larynx or vocal cords. You may want to have this checked by a voice specialist.

GreenDragon009: I noticed when I was younger that I have trouble talking loudly or being heard in noisy situations. I thought I would outgrow this in my adult life. Is there anything I can do to improve my voice sound?

Dr__Claudio_Milstein: It may be just the way you use your voice, or there may be an actual problem that prevents you from getting louder. If it’s just how you use your voice, voice therapy, taking singing lessons, or voice lessons for acting can help you learn how to support your voice better and become louder without straining your vocal folds.

LisaLewis: I've been a singer for more than 20 years, and my voice sounds higher in pitch recently. Does this mean I'm losing notes at the top of my range? Is there any way to correct this?

Dr__Claudio_Milstein: Some voice changes may be related to aging, hormonal changes, irritation, or changes in singing technique. It is important to identify the cause of the problem first.

fh0086: I'm a college student and I have to repeat myself to be understood in normal conversation and often people don't understand what I say in class. Does this mean I have a voice disorder? I signed up for a public speaking class but it didn't help.

Dr__Claudio_Milstein: If this is really bothering you, you can consult with a voice specialist, who can determine whether there is a problem and suggest treatment options for you. Again, if there is no medical problem, voice therapy, singing lessons, or voice training for actors can help.

WKRP: I am a morning news anchor. I often have trouble with my voice first thing in the morning. Any suggestions on what I can do to kick start my voice?

Dr__Claudio_Milstein: Good hydration and vocal warm-ups can help. However, make sure that you do not have allergies, asthma, reflux, or any other condition that may be affecting your voice.

peteg: How much damage can you do by forcing your voice, singing/yelling too loudly, or making your voice gravely?

Dr__Claudio_Milstein: Those abusive voice behaviors can result in vocal fold trauma, and potentially cause benign vocal fold lesions or vocal fold hemorrhages. It is always recommended to take good care of your voice by avoiding yelling/screaming, talking too loud, or forcing your voice. If you do, voice rest after these behaviors is a good idea.

Your Throat

SN: I've been feeling a lump in my throat for about a year now. I always thought it was a ball of extra phlegm or something sticking there, now I'm not so sure. Is there a medicine I can take or do I need to see my doctor?

Dr__Claudio_Milstein: I recommend that you see an ENT doctor that can evaluate the problem and recommend appropriate treatment.

JB3: What foods have a “phlegm” effect on your voice? I know milk is supposed to.

Dr__Claudio_Milstein: Milk products and chocolate can create a temporary increase of phlegm in the back of the throat. For example, if you are a singer, actor, or public speaker, we recommend not consuming milk products or chocolate a couple of hours prior to performing.

JB3: Is gargling salt water good or bad for the voice/vocal chords? How about mouth washes?

Dr__Claudio_Milstein: Gargling with salt water is neither good, nor bad. However, if you feel that gargling with salt water is soothing for your voice, by all means, do it.

zzxm55: I am prone to several cold and flu bugs each year. Even when I'm not sick, my throat feels sore or achy. Is this something I need to look into?

Dr__Claudio_Milstein: Yes. If you have frequent sore throats, you should look into it. Talk to your doctor or see a voice specialist.

General Questions

MINUTERVIS: Would you recommend Alexander technique to deal with voice problems?

Dr__Claudio_Milstein: Alexander technique can be very effective to help improve voice in some cases, particularly when the voice problem is caused by poor posture or other body muscle problems. Many speech language pathologists who treat voice patients incorporate elements of Alexander technique in voice therapy.

connie: Is weight related to voice disorders?

Dr__Claudio_Milstein: Weight in and of itself does not necessarily result in a voice problem, but obesity can lead to hypertension, diabetes, and other serious health problems.

OperaDiva77: After work I sometimes sing karaoke with my friends. I often struggle with my voice the next day. I don't want to give up my karaoke habit but how can I help my voice get through it?

Dr__Claudio_Milstein: When singing karaoke, you are possibly straining your voice and singing out of your range. A good way to improve that is to take singing lessons and learn how to sing with no effort.

DoctorRX: I'm a pediatrician and I find by mid-morning I'm extremely thirsty. I drink a bit throughout the day, but because I'm constantly talking to patients I find myself hoarse before the day is over. Should I drink more water? And will drinking hot liquids hurt or help?

Dr__Claudio_Milstein: Maintaining good hydration is usually good for vocal health. The temperature of the beverage does not really matter. However, if you become hoarse toward the end of the day frequently, I suggest that you be evaluated by a voice specialist.

connie: You suggest voice therapy. Where can you find voice therapists? Also, you mention singing. Does that include casual singing, like singing in church choirs?

Dr__Claudio_Milstein: You can check the web sites of the Voice Foundation, American Speech-Language-Hearing Association, or contacting your local ENT doctor to get a referral for a voice therapist.

Any singing that is performed without strain or effort is good, whether you sing in a choir, the car, or in the shower.

Jennifer27: I read your article on NPR last year regarding vocal manipulation. What makes a patient a candidate for that treatment?

Dr__Claudio_Milstein: Vocal manipulation is designed to treat specific voice problems such as vocal hyperfunction, muscle tension dysphonia, or functional dysphonia.

Cleveland_Clinic_Host: To download our free guide to voice treatment, please visit:

JB3: What activities/exercises are good/not good for singers? I have read that running is bad, because of the way you breathe, and swimming is a better activity. I want to keep in shape but don’t want to do anything to hurt my voice either.

Dr__Claudio_Milstein: There is absolutely no contraindication for running in order to have a good singing voice. There are some exercises that may have an impact on voice such as weight lifting, if you tend to grunt when lifting or making the 'Monica Seles' sound when striking the tennis ball. But lots of singers run to keep fit, and it does not affect their voices in a negative way.


Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Milstein is now over. Thank you again Dr. Milstein for taking the time to answer our questions about Voice Health.

Dr__Claudio_Milstein: Thank you very much. Don't forget about World Voice Day coming up on April 16, a day to promote good vocal habits, and voice health. Check with your ENT department at local hospitals or universities to see if there are any voice-related activities around you. Be safe, and take care of your voices.

More Information

  • To make an appointment with Dr. Milstein or any of the 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.
  • A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit