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

April 25, 2013


You use it everyday. When you give a presentation at work. call your best friend or laugh at a joke. Or when you tell your children that you love them. Most people don’t give their voice a second thought until they notice a problem.

Yet, approximately 7.5 million people in the United States have trouble using their voices. Voice problems can occur in both the young and the elderly. Disorders of the voice affect how you sound, and can result in changes in quality, pitch and loudness. Voice problems can happen after an accident, a surgical procedure, a viral infection, benign or malignant growths in the throat, or even from yelling, talking too much or singing too loud.

Symptoms of a voice problem include:

  • hoarseness
  • whisper
  • roughness
  • pain or fatigue after talking or singing
  • loss of singing control, and increased effort or strain

The way a voice disorder is treated depends largely on how it was caused. Often, voice therapy with a certified speech-language pathologist can dramatically improve a person's voice. Voice therapy may include vocal and listening exercises, information on vocal hygiene (appropriate uses of voice), and education regarding proper voice technique.

It is important to know how to maintain a healthy voice, as well as what you can do to prevent or treat hoarseness or other voice and throat problems.

About the Speaker

Claudio Milstein, PhD, is a speech-language pathologist at the Cleveland Clinic’s Voice Center in the Head & Neck Institute. 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 and laryngeal cancer, functional voice disorders and vocal-cord dysfunction (including difficulty with vocal range, dysphonia, effortful talking and singing, hoarseness and immobile vocal folds). He also specializes in the care of the professional voice, laryngeal physiology, laryngopharyngeal reflux, vocal cord diseases, vocal cord paralysis, and voice and swallowing problems in general.

Born in Buenos Aires, Dr. Milstein completed his studies at the Medical School of the University of Buenos Aires, Argentina. He taught at this same University, and joined the faculty of the National Conservatory for Dramatic Arts, teaching voice courses for actors and singers, and developing an expertise in the care of the professional voice.

Dr. Milstein earned his doctoral degree in Speech Sciences from the University of Arizona, with further training at the Massachusetts Eye and Ear Infirmary of Harvard Medical School and the Massachusetts Institute of Technology.

He has been actively involved in the clinical management of voice patients for over 20 years, 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. He has been a Staff Member of the Head and Neck Institute at Cleveland Clinic since 2001 and holds an Affiliate Scholar appointment at Oberlin College Conservatory of Music.

Let’s Chat About Let’s Talk About Voice: Ask an Expert

Voice Basics and Terminology

why oh why: What is the correct terminology: vocal cord or vocal fold?

Claudio_Milstein,_PhD: Both terms are correct. Vocal cord is an older term and vocal fold is the one we currently use.

edf: How do I find a qualified speech language pathologist who has experience in voice?

Claudio_Milstein,_PhD: There are many ways to find one:

  1. Contact your local ENT (ear, nose and throat) doctor who will know the specialists in your area.
  2. Contact ASHA (American Speech-Language-Hearing Association) for a list of referrals. (Their website is
  3. Use the Internet to do a search. You can search for ‘voice center’ in your area and call them for specific referrals

too muchy: Are speech therapy and voice therapy the same?

Claudio_Milstein,_PhD: No. Speech therapy usually refers to the treatment of articulation disorders such as difficulty pronouncing certain speech sounds. Voice therapy treats problems with the sound and quality of the voice, or hoarseness caused by damage to the vocal folds, irritation, voice strain, etc.

critter3: When should I see a physician about my voice?

Claudio_Milstein,_PhD: We typically recommend consulting a physician about a voice problem if you have been hoarse for more than two weeks in the absence of the cold or flu.

Voice Condition with Associated Medical Diagnoses

Theo: My 71-year-old aunt has seen the physician for nodules on her thyroid. Her voice is always hoarse, and it has been for over a year. He wanted to do an endoscopy as well, but her stress test didn't allow her to. She is cleared for the endoscopy now, and will be making her appointment with the gastroenterologist. At what point should a nodule be biopsied? Wouldn't an ultrasound be more appropriate than an endoscope? Shouldn’t an ENT (ear, nose and throat) physician diagnosis her?

Claudio_Milstein,_PhD: There are several issues here. The thyroid nodule can be evaluated with an ultrasound, or a fine-needle aspiration for a biopsy. Her endocrinologist needs to decide when to do either of these procedures, if they are needed. If your aunt was sent for an endoscopy with a GI (gastrointestinal) doctor that means that they want to see if there is any esophageal or digestive problem, like acid reflux, which may be part of the problem. If there is a concern about her voice, it may be related to her thyroid, may be related to her GI problems, or may have a completely different cause. If she has been hoarse for one year, I strongly recommend a consult with an ENT with a specialty in voice.

writer53: My daughter, 21, a singer and performer, was accepted to a graduate program in musical theater in Wales that begins January 2014. After experiencing extreme sinus problems for several months this past fall, she was diagnosed in January with Granulomatosis with polyangiitis (GPA or Wegener's). This inflammatory autoimmune disease attacked her sinuses, throat, lungs and more. The white coating on her vocal cords and severe inflammation caused her to completely lose her voice for six weeks. She has been speaking for two months now, but her singing voice is still thin and weak. Her speaking voice tires easily and still sounds slightly hoarse. The ENT does not see any permanent damage to the vocal folds and he says they are moving well. Do you think my daughter can recover her professional singing voice within the next seven months in time to begin her graduate program in January? Does she need a speech pathologist or singing voice specialist to aid in her recovery?

Claudio_Milstein,_PhD: It is unfortunate that the disease is impacting your daughter’s ability to sing. As you know, this autoimmune disorder can affect different parts of the body, and can have various degrees of severity. The best option is to have a team of professionals working together, including a rheumatologist, an ENT with expertise in voice, and a speech pathologist or singing teacher with knowledge of this disorder. We get the best results when there is team work. I’m sorry I cannot answer your question of whether she will heal in time for her graduate program in January without evaluating her personally.

Tracy Z.: I have a severe post-decompression Chiari malformation 1, a rebuilt C Spine, geniculate neuralgia and POTS (postural orthostatic tachycardia syndrome). When I have a bad day from my Chiari, overtired or under stress, my voice changes and becomes very raspy. Is there a specific reason this happens? I also get complicated migraines several times a year and temporarily develop expressive aphasia. It is very scary, but after time my speech returns to normal. I have discussed this with several Neurologists and my Neurosurgeon and they don't seem alarmed. I am worried that at some point this could happen permanently. I have had Doppler studies, vascular CAT scans and MRIs, and my arteries are totally clear. Should I worry or just consider this part of the Chiari neurological rollercoaster?

Claudio_Milstein,_PhD: The voices changes may be related to your Chiari, spine issues or your neuralgia. You have to keep in mind that of stress and fatigue alone may cause hoarseness and weakening of the voice. Any of these factors may be playing a role—— therefore, it difficult to determine the exact etiology of the voice changes.

KareninBluffton: About six weeks ago I had a small case of laryngitis followed by a mild sore throat and cough. I think I caught this bug from friends who had been coughing near me. Now I find that while talking I tend to run out of breath or have to cough in order to continue talking. It is very bothersome to me although I no longer have coughing spells where I have to leave the room. Lozenges help, but I can't depend upon them forever. Will this go away on its own or is my multi-nodular goiter pushing against my windpipe causing this to happen? I have an enlarged thyroid and would like to avoid drastic measures.

Claudio_Milstein,_PhD: If the symptoms have been going on for over six weeks, it is time to see a physician. You can start with your pulmonary doctor or an ENT that can help determine the cause of your symptoms.

Judas: In 2010 I had a thyroidectomy due to a large goiter. Now I have Hashimoto thyroiditis, and I have been told that my voice had changed somewhat. A year later my husband had to get hearing aids and says it is hard to understand what I am saying due to the pitch in my voice. Is it possible for the voice to change from a procedure like I had? I'm not a loud person to begin with, let alone have a pitch that no one else can hear.

Claudio_Milstein,_PhD: Surgery for thyroid problems can indeed result in voice change, if the nerves that move the vocal cords were damaged. However, if your husband is the only one noticing your hoarseness, it seems more likely that this is related to his hearing loss. Ask your friends and family what they think about your voice, or check with your primary care physician.

Izzabelle: I was diagnosed with dermatomyositis and polymyositis in January 2012, which gave me interstitial lung disease. After this diagnosis I had no voice for nine months and for the last four months I have had a hoarse voice. I am on 3000 mg. of CellCept® (mycophenolic acid ) daily and just stopped prednisone. I have been scoped and nothing but white on my vocal cords showed up. Is anything else I can have done to get my regular voice back? I also had a video strobe in September 2012. My lungs are only functioning at 58 percent, which makes me very tired to use a lot of strength to speak.

Claudio_Milstein,_PhD: I am not sure if you are referring to white plaque (coating) on the vocal folds or if you mean nice, white tissue. Keep in mind that a decrease in lung function will decrease your breath support, and this is what gives the voice its power.

myadvocate: I am a 67-year-old male. Over the last year, my voice has become raspier. I can no longer sing in tune, and it feels like my voice is coming from way down in my throat. Cleveland Clinic has diagnosed me with small fiber neuropathy. I have seen three ENT (ear, nose and throat) doctors. I had an esophageal pH test and sinus CT scan. Both were negative. Should I stop trying to figure it out?

Claudio_Milstein,_PhD: My recommendation is to see an ENT that specializes in voice to figure out what is causing your voice change.

asong4u: Can certain medications that I take for hypertension cause throat dryness?

Claudio_Milstein,_PhD: This is a perfect question to follow up with your physician.

dcsstudent: I have reflux and sinus issues for which I am being treated at National Jewish Health®. Because I cough (a lot) most days I think I am wearing my poor throat out. Also my vocal cords don't close completely. My ENT (ear, nose and throat) physician has considered a collagen injection to close my vocal cords, but says it will change my voice. I am a singer. I saw a speech therapist until my insurance ran out last year. Do you have any suggestions that might help me to keep singing while we try to solve my coughing?

Claudio_Milstein,_PhD: Chronic cough can be a very tricky problem to treat as it may have many different causes. Certainly reflux and sinus problems as you have mentioned can cause the cough, but other things like asthma, allergies, laryngeal irritation or neuropathies can be part of the problem also. If your vocal folds are not closing completely, I wonder if you have nodules, a vocal fold paresis, or bowing of your vocal folds. Therefore, it is difficult to give you recommendations online. A collagen injection may help the vocal folds close better, but in most cases this is only a temporary solution. National Jewish Hospital® is a wonderful facility, and I am sure that they have the resources to help you with your singing voice.

jklingenspeil: I had head and neck radiation 15 years ago for squamous cell carcinoma, which was successful. However, over the last two to three years I have been experiencing random coughing fits—sometimes with a sensation to vomit (but I don't). I had esophageal dilation 18 months ago, which improved my inhalation after coughing. I understand scar tissue from radiation can begin to grow years later. I also have a very frequent sore throat. I am taking tramadol, omeprazole and Neurontin® (gabapentin). My voice also comes and goes.

Claudio_Milstein,_PhD: I recommend you see a lung doctor to start looking for the cause of your cough as it may or may not be related to your history of cancer 15 years ago.

asong4u: What damage can the acid reflux do to the vocal folds?

Claudio_Milstein,_PhD: Small traces of acids from the stomach on the vocal folds may create irritation, swelling or redness. In more severe cases it can form lesions on the vocal folds. If you know you have a problem with acid reflux, you want to have it evaluated and keep it under control.

cabby: Is vocal cord dysfunction a type of asthma?

Claudio_Milstein,_PhD: No these are different disorders, although vocal cord dysfunction is frequently misdiagnosed for asthma. In asthma, there is a narrowing or inflammation of the small airway passages that move air in and out of the lungs. In vocal cord dysfunction, there is an obstruction of the airway caused by an inappropriate closure of the vocal folds which are sitting right on top of the trachea. So, these are two very different conditions with very different treatment modalities, although many patients can have both at the same time.

Effect of Aging on Voice

BTroyer: I sing in some local choral groups and used to have a nice vibrato and tonal quality to my voice, but now I have more of a warbling or slow vibrato. My voice also cracks or tires easily. Can you suggest some possible causes for this?

Claudio_Milstein,_PhD: A change in vibrato into a warble may be a sign of aging, as vocal fatigue or instability in the singing voice. If this concerns you, you may want to consult a voice specialist to evaluate the cause of your voice change.

cschulzie: Please address the effect of aging on our vocal cords, particularly what effect is expected vs. beyond the ordinary changes. I'm developing a very wobbly and weak characteristic to my voice, with occasional squeaks (rather than a true voice) coming through sometimes. A quick scope in an ENT (ear, nose and throat) doctor's office revealed nothing. Would voice therapy possibly be of benefit?

Claudio_Milstein,_PhD: This is a perfect segue from the previous question! As we age, there are changes to all the tissues in the body, including the respiratory system, larynx and vocal folds. In general the tissue becomes stiffer, less pliable and drier. We can also experience a decrease in muscle tone. Everyone ages differently, but singing or exercising the voice can help keep it sounding younger for a longer period of time. Voice therapy can help you regain voice health.

Treatment for Spasmodic Dysphonia and Essential Tremor

zgmac: Please discuss the latest treatments for spasmodic dysphonia and essential tremor's effect on the vocal cords.

Claudio_Milstein,_PhD: Unfortunately, there have not been many advances in the treatment of spasmodic dysphonia or essential tremor lately. The tremor is treated with a trial of an antitremor medication. If this fails, then a treatment with Botox® (botulinum toxin) injections can be recommended. Botox® is also the treatment of choice for people with spasmodic dysphonia. There are some new surgeries that are being tried, which have shown benefit for some patients. Check out the website from the National Spasmodic Dysphonia Association to keep up to date with treatment options for these voice disorders. The tremor would be treated with the guidance of a neurologist.

Voice Therapy

efdjld: I was extremely hoarse for about eight weeks. I was finally able to see an ENT (ear, nose and throat) doctor. After he examined me with a scope, he indicated that the hoarseness was caused by reflux and allergies. I am going to undergo allergy testing next week and regarding the reflux, he wanted me to raise the head of my bed six inches and be sure to wait four to five hours after my last daily meal before going to bed. These measures have helped quite a bit. However, if I talk quite a bit or talk louder than normal, I begin to get somewhat hoarse again. Are you able to suggest some basic voice exercises for me or do you think voice therapy would be beneficial?

Claudio_Milstein,_PhD: It appears that your ENT has seen evidence of irritation of your vocal folds suggestive of allergies and acid reflux. The fact that you are getting hoarse after talking for long may be related to the irritation or you may have developed maladaptive voicing techniques. Depending on the cause of the hoarseness, voice therapy may be beneficial.

Care of the Voice

rosalie: What do I need to do to best protect and care for my singing voice? I am a 57-year-old female and have noticed a stronger voice since I passed into menopause about a year ago.

Claudio_Milstein,_PhD: There are many ways to protect and care for the singing voice:

  1. Talk to a good singing teacher.
  2. See a speech language pathologist with expertise in the singing voice. (A few sessions of singing voice therapy may be helpful.)
  3. There are many excellent books on the care of the singing voice. (Doing an internet search and looking for other readers’ recommendations may help you find the best book for you.)


Moderator: I'm sorry to say that our time with Cleveland Clinic expert Claudio Milstein is now over. Thank you, Dr. Milstein, for taking your time to answer our questions today about voice health.

Claudio_Milstein,_PhD: I would like to thank everyone for your participation in this web chat and for posting great questions.

For Appointments

If you would like to make an appointment with Dr. Milstein or any of our other specialist in the Voice Center of the Head & Neck Institute, please call 216.445.TALK or 800.223.2273, ext 58255 or request an appointment online by visiting

For More Information

On Cleveland Clinic

Cleveland Clinic’s Voice Center in the Head and Neck Institute is a dedicated center of excellence to uniquely serve the voice disordered population, with special focus on the professional voice user. It offers a team approach to evaluating and treating problems related to the human voice and the physical structures that produce it. These structures include the mouth, nose, throat, and voice box.

Ear, nose and throat specialists, speech pathologists and voice teachers provide primary services, in conjunction with several other medical disciplines to treat disorders such as voice box or larynx cancer. Related problems may require the assistance of experts from neurology, gastroenterology, endocrinology, allergy, pulmonary medicine and clinical psychology/psychiatry.

The Voice Center staff perform a physical exam and specialized tests to determine the nature and extent of the problem. A special slow motion video picture of the voice box often provides the explanation of the problem.

Most voice problems are managed successfully without surgery, through behavioral change and medical care. If surgery is necessary, specialized techniques that reduce tissue harm and promote faster healing are available through our trained surgeons.

The Voice Center includes recognized experts from Speech Language Pathology and Laryngology who uniquely focus on the professional voice user. If your voice is your profession, we invite you to learn more about our services by downloading our free brochure below. For an immediate expert voice consultation call: 216.445.TALK or 800.223.2273, ext. 58255.

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Reviewed: 05/13