Online Health Chat with Dr. Claudio Milstein

April 26, 2012


Caring for your voice is a lifelong process, which requires vigilance to protect a very personal part of yourself from becoming seriously injured, regardless if you are a professional singer, teacher or speaker. Aging can sometimes affect the vocal folds. If you scream or talk loudly, you increase your risk for voice problems. If you have ever had surgery on or near your vocal cords, if you are a smoker, or have had throat cancer, your risk for developing scar tissue and future voice problems increases as well.

Although most voice disorders are not life threatening, maintaining overall good health through healthy habits is critical and if you do have a voice disorder, there are a variety of treatment options from medical treatment, surgical to functional voice therapy.

For over 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. Get answers to the most frequently asked questions about voice concerns and bring your own questions to the web chat. This is your time to ask!

Dr. Milstein has been a Staff Member of the Head and Neck Institute at the 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., Dr. Milstein 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. His 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.

To make an appointment with Dr. Claudio Milstein or any of the other specialists in our Head & Neck Institute at Cleveland Clinic, please call 216.445.8255 or call toll-free at 800.223.2273, ext. 58255. You can also visit us online at

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic voice specialist, Dr. Claudio Milstein. We are thrilled to have Dr. Milstein join us today for this chat. Let’s begin with some of your questions.

Voice Weakness/Hoarseness

pluto: Does using oxygen at night and inhalers cause hoarseness?

Dr__Claudio_Milstein: Oxygen at night may dry your throat. There are some inhalers [like fluticasone propionate and salmeterol inhalation powder (Advair®)] that can potentially cause irritation of the throat, hoarseness, or even thrush (a type of yeast infection).

C: Though too young (I think!)-–I am in my early 50s--to be developing a weak and warbling voice, I find that I have developed one. A quick look by an ears, nose, and throat doctor (an ENT) using a scope mirror revealed nothing concerning. Is this unusually early to have an "old person's voice," and is there anything I can do to reduce the warbling/wavy voice?

Dr__Claudio_Milstein: Voices do not usually show signs of age at age 50. I would guess that there may be something else going on. My recommendation would be to consult with a voice specialist to determine the nature of your voice problem.

whisper: I have not been able to yell or have full vocal range for some time. ENTs and scopes have not found any evidence of acid reflux or other issues with the vocal cords. What vocal exercises can be done to strengthen the cords so that they fully extend/collapse when they should in order to extend the strength of the voice?

Dr__Claudio_Milstein: It is difficult to prescribe voice exercises for you without knowing the specifics of your voice problem. My recommendation is to see a speech pathologist with expertise in voice problems to give you a specific exercise program that will work for you.

myadvocate: I am 66. During my career, I did infrequent presentations without problems. Progressively, I was unable to speak at length, with the time falling now to about 20 minutes. My mouth gets dry; my throat clogs up; and my voice becomes deeper. The ENT sees nothing on visual and CT scans other than some thick mucus on my vocal chords. Stressed talk shortens the time and increases the severity. Do you have any ideas for me? Thanks.

Dr__Claudio_Milstein: With issues like this, a specialist in voice disorders may be better able to help you than a general ENT physician. I would recommend making an appointment at a specialized voice center, where a team composed of a laryngologist and a speech pathologist with an expertise in voice will be able to detect more subtle voice problems, such as yours.

Whisper: What can be done to strengthen a left vocal cord which is slightly bowed and may not always meet together with the other side and provide a strong pitch? When they don't meet, my voice gets airy or has no sound at all.

Dr__Claudio_Milstein: There are several voice exercises that can be used to strengthen a weak vocal fold. Voice therapy with a speech pathologist with an expertise in voice disorders will give you an individualized exercise routine that will help you with this.

Singing-related issues

CHERJU12: I am 68 years old and am a first soprano. I am a retired teacher and now sing in two choirs. Either during or after singing, I am developing a cough and an irritation. What can I do to preserve my voice?

Dr__Claudio_Milstein: You should probably find out the cause of your cough and irritation. It could be allergy, reflux, asthma or many other sources. I recommend that you get evaluated. Getting rid of the cough will help preserve your voice.

BTroyer: I enjoy singing but have had problems with dryness after singing a short time...say, 10 to 15 minutes. Are there any steps to take to eliminate this problem? Thank you!

Dr__Claudio_Milstein: Keeping good hydration is very important to keep the vocal folds well-lubricated and well-sounding. You can increase hydration by drinking more water or making sure that the air quality is not too dry in your home/environment. Using a humidifier may help. There may be other health reasons for increased dryness. You may want to check with your doctor.

suscanter: What are the best vocal exercises to increase vocal range? I'm just turning 50 and have noticed that (with regard to singing) my voice has more difficulty in the high range. Thank you!

Dr__Claudio_Milstein: Sometimes, as we age, we may experience changes in voice quality that may be a result of hormonal changes, overall aging of our bodies, or perhaps other health issues. I recommend that you work with a singing teacher who will give you precise instruction on how to work on your vocal range without strain or effort.

robtoby: I am a singer. It usually takes me a LONG time to get my voice warmed up before a performance. Do you have any suggestions on this front? Also, I drink a LOT of water daily. Is there anything else that I can do to keep my voice in 'good shape'? Thanks!

Dr__Claudio_Milstein: This may depend on what kind of vocal warm-up exercises you are doing. For a list of very good warm-up exercises specific for singers, you can check the National Center for Voice and Speech website at There you will find very good warm-up exercises recommended by Dr. Ingo Titza, who has done a lot of research in voice and voice disorders.

sheilag7: I have been diagnosed with a vocal polyp on my right vocal cord. Do you have any suggestions to help prevent them from recurring? I am scheduled to have surgery this summer, but I do perform and teach voice lessons at this time.

Dr__Claudio_Milstein: We recommend a course of voice therapy before and after a surgery to remove a vocal polyp. Sometimes, voice therapy alone may help the polyp go away, and allow the patient to avoid surgery. Voice therapy is also going to help you optimize your voice so you can do your daily activities in a more efficient manner.

robtoby: I've heard that raw apples are good for a singer's throat. Is this true? Are there any other fruits/foods/beverages you recommend?

Dr__Claudio_Milstein: Raw apples may be good for your health, but we have no indication that they are good specifically for a singer's voice. If you have problems with acid reflux, we may recommend staying away from citrus or acidic, spicy, greasy, and fried foods, as this may have an impact on your voice. As a rule of thumb, eating a healthy diet will help maintain a healthy voice.

CHERJU12: Who should I contact for an evaluation as to why I cough or experience irritation after I sing?

Dr__Claudio_Milstein: An allergist, a pulmonary doctor, or an ENT may be good place to start.

SkeletonKey: I've recently retired (age 61). On my "bucket list” is a goal to take singing lessons. I have a monotone voice when singing and realize that I cannot carry a tune (even in a bushel basket!). However, I've heard that voice/singing lessons can help even the most awful singers improve somewhat. Are there any dangers to my voice involved in starting singing lessons so late in life?

Dr__Claudio_Milstein: It is never too late to start singing. I would encourage you to start taking singing lessons. If you do this with a trained singing teacher, you will avoid voice problems. Embrace and enjoy your new hobby.

Specific voice disorders and treatments

happydak: If a person with spasmodic dysphonia is treated with speech therapy and then Botox injections without success, what other options are available?

Dr__Claudio_Milstein: Individual cases should be discussed with your voice doctors.

helenma: Is a glucocorticoid needed to treat chronic laryngitis?

Dr__Claudio_Milstein: No.

lmorgan: My voice sounds, and feels, hoarse from a tracheostomy tube that was inserted during a stroke that I had back in 2003. Is there any way to return it to normal?

Dr__Claudio_Milstein: This requires an individual evaluation to determine the extent of the damage.

happydak: I have the "mixed" type of spasmodic dysphonia. Botox has not helped, and speech therapy does not seem to help. I also take fluoxetine (Prozac®) for depression. Is there any possibility the Prozac is causing this problem? Does stress make it worse? The more stressed I am, the worse my voice becomes. Sometimes I'm almost mute. What is the best treatment?

Dr__Claudio_Milstein: The mixed type of spasmodic dysphonia can be the most difficult one to treat. We have no indication that Prozac causes spasmodic dysphonia. Stress does have an effect on the voice; it is a very common complaint of people with spasmodic dysphonia that their voices get worse when stressed or anxious. You may want to get another opinion or consultation.

jones043: Is paralysis of the vocal cords always permanent?

Dr__Claudio_Milstein: Paralysis may be temporary, depending on the extent of nerve damage. As a rule of thumb, if the paralysis does not get better one year after onset it will likely be permanent.

Voiceover: I have adductor spasmodic dysphonia and receive Botox injections. Are there any other treatments?

Dr__Claudio_Milstein: There are a couple of new surgery procedures that seem to be promising, although very few places are doing these surgeries right now. It is our hope that if the long-term effects of these surgeries are good, more places around the country will start offering this treatment modality.

Voiceover: With adductor dysphonia, will speech therapy help extend the time between Botox treatments? What other advice can you give to extend the time between Botox treatments?

Dr__Claudio_Milstein: In some cases, voice therapy is beneficial in maximizing voice efficacy in between Botox treatments. Speech pathologists with expertise in voice may be able to help.

Ken45140: What would be the best (most chance for achieving good voice) surgical approach with a paralyzed right vocal cord and a bowed and atrophied left vocal cord?

Dr__Claudio_Milstein: This type of problem can be helped with a bilateral medialization thyroplasty. However, there is a lot of variability, and each individual case needs to be considered independently. This is a general answer, as it is difficult to give advice with patient-specific information; each individual case may require variations in treatment.

General questions

love_me: Which is the correct term, vocal cord or vocal fold, or are they even the same thing?

Dr__Claudio_Milstein: Both terms are correct. Vocal cord is an older term, and vocal fold is a newer, more anatomically correct term. They both refer to the same thing.

oh_yeah: I have to clear my throat a lot. Does this cause damage to the voice? What causes a person to have to keep clearing their throat, and can it be helped?

Dr__Claudio_Milstein: If you clear your throat in a very harsh manner, many times during the day, this could cause irritation to your vocal folds. There are many possible causes for frequent throat clearing; some are medical. It could even be a bad habit. Advice on how to make this better will depend on the specific cause of the problem.

happydak: What are the criteria that make an ENT doctor a "voice specialist”?

Dr__Claudio_Milstein: In order to become a voice specialist, an ENT you must have an additional year, or more, of specialized training to become a laryngologist, which is a specialist on problems of the larynx and voice.


Cleveland_Clinic_Host: Dr. Milstein is heading off to see patients. Thank you Dr. Milstein for stepping in at the last minute to fill in for Dr. Bryson.

Dr__Claudio_Milstein: Thanks everyone.

More Information

To make an appointment with Claudio Milstein, MD or any of the other specialists in our Head & Neck Institute at Cleveland Clinic, please call 216.444.8500 or call toll-free at 800.223.2273, ext. 48500. You can also visit us online at 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

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2012 The Cleveland Clinic Foundation. All rights reserved.