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

April 11, 2014


Your voice is used every day to talk, sing, and yell, reaching others to communicate, advise, motivate and connect. Approximately 7.5 million people in the United States have trouble using their voices. Yet, your voice does not receive much attention until you experience a problem. Assessment of your vocal health is important, and is recognized by World Voice Day on April 16.

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, or a viral infection. Voice disorders may be due to benign or malignant growths in the throat. Other voice conditions can result from yelling, talking too much, singing too loud, smoking or regurgitation of stomach acids in the throat.

Voice disorders have the following symptoms:

  • hoarse or raspy voice
  • an inability to hit high notes when singing when previously you could
  • a suddenly deeper voice
  • raw, achy, or strained throat
  • difficulty speaking
  • repetitive coughing

How a voice disorder is treated depends largely on its cause. Treatment options can include medications, sometimes surgery, and voice therapy. Voice therapy with a speech-language pathologist who specializes in voice problems, can dramatically improve a person's voice. Just like physical therapy can help when we experience limbs, back or muscle problems, voice therapy can help when you have injured your voice, or experience any type of hoarseness.

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, CCC-SLP, is a speech scientist and Director of Cleveland Clinic’s Voice Center in the Head & Neck Institute. He also has an affiliate scholar appointment at Oberlin College Conservatory of Music. Dr. Milstein’s clinical interests include laryngology and voice disorders.

He has been actively involved in the clinical management of voice patients for over 20 years. 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. 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 general voice and swallowing problems.

Dr. Milstein completed his studies at the Medical School of the University of Buenos Aires, Argentina, where he later taught. Dr. Milstein 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 obtained his doctorate in speech sciences from the University of Arizona, in Tucson, Ariz., and trained at the Massachusetts Eye and Ear Infirmary of Harvard Medical School, and the Massachusetts Institute of Technology.

Let’s Chat About Let’s Talk About Your Throat: Ask an Expert

Moderator: Let's get started with our questions...


Addie: I have been coughing for three years with no apparent reason. Now my voice is becoming affected. Is there any help for this problem?

Claudio_F._Milstein,_PhD,_CCC-SLP_: Cough is the most common cause for patients to see a doctor worldwide. Once the most common causes of cough have been ruled out, if the cough persists, it can be quite challenging to treat. In your area, try to find a multidisciplinary team with expertise in the treatment of chronic refractory cough. These teams typically include a pulmonary and allergy specialist, an ENT (ear, nose and throat) specialist and a speech language pathologist.


tjc456: Whenever I raise the volume my voice (e.g., in an argument), my throat becomes sore and I become hoarse afterwards for a few days. I am in my 50s, and this had never happened before the last few years. Whispering seems about as bothersome then as talking. Do you have any suggestions for someone in my situation?

Claudio_F._Milstein,_PhD,_CCC-SLP_: Hoarseness after yelling could be caused by irritation of the larynx and vocal folds, a small growth on the vocal folds, or weakening of the vocal folds due to aging—among other causes. A voice specialist will be able to determine the cause of your hoarseness and recommend the most appropriate treatment.

musicteacher: I teach music in an elementary school and am worried about the consistently hoarse voices of some of my students. Both the speaking and the singing sounds they produce are affected. Occasionally I have suggested parents seek medical advice. The doctor that I recommended said the child was fine. I don't believe a raspy, low and monotonic vocal sound is appropriate for anyone and don't want to see young children consigned to a life of sounding this way. What can I do to help them?

Claudio_F._Milstein,_PhD,_CCC-SLP_: I understand your concern. There are many possible causes for a child to have a hoarse voice, and finding out what is causing the hoarseness is the first step towards improving it. Often pediatricians or pediatric general ENTs (ear, nose and throat doctors) will examine the throat and look for irritation, lesions or growths. If they don’t see any of those, they may say that everything is fine. A pediatric laryngologist or voice specialist will not only look at the health of the vocal folds, but will try to determine the cause of the hoarseness and recommend an appropriate treatment. Try to get familiarized with voice experts in your area, and next time you have a student with hoarseness, you can suggest the parents take the child to see him or her.

music: My young students experience vocal hoarseness. What can I do to help them?

Claudio_F._Milstein,_PhD,_CCC-SLP_: There are many resources online about maintaining vocal health, and vocal hygiene. A common cause of hoarseness in children is talking too loud, yelling frequently, or singing loud with poor singing technique. Basic education regarding voice care, avoiding overuse, maintaining good hydration, and avoidance of bad vocal behavior can help your students prevent voice problems and hoarseness. You will be able to keep them sounding healthy for years to come.

music: Do you think that vocal hoarseness in children may be reflective of how their parents speak? If so, is there any chance of overcoming the behaviors that caused the hoarseness?

Claudio_F._Milstein,_PhD,_CCC-SLP_: Yes, sometimes children can mimic poor vocal habits displayed by the people they interact with the most. Indeed it is possible to teach children good vocal behaviors, awareness of vocal habits that may harm their voices, and learn how to prevent voice problems in the future. A school speech language pathologist may be a good resource to inquire about vocal health.

Stress and the Voice

tjc456: Is personal stress, which I have been having quite a lot of lately, a factor in voice problems? Also this year I developed Raynaud syndrome wherein the temperature regulation of my toes has gone, so they are either hot or cold. I read that this problem may be stress-induced.

Claudio_F._Milstein,_PhD,_CCC-SLP_: Yes, stress can be a factor that affects our voices. It typically manifests as tightness of the muscles of the upper back, shoulders, neck and throat, which can make us sound pressed or tight. Finding ways to relieve your stress in combination with an individual course of voice therapy can be very helpful.

Swallowing Difficulties

gatorfrog: I have some swallowing issues with my throat and went through five weeks of electrical stimulation which helped quite a bit. However, my swallowing issues are already coming back five months later. I really don't want to do the therapy again. Will it continue to come back the rest of my life? I am 56 years old.

Claudio_F._Milstein,_PhD,_CCC-SLP_: It is difficult for me to answer your question without having additional information about what kind of swallowing problem you have. We typically do not endorse electrical stimulation for swallowing problems at Cleveland Clinic. I recommend that if your swallowing problems are back, consult with your doctor to figure out why, rather than going for a second round of therapy.

Vocal Fold Paralysis

Marie1: I was diagnosed a few years back with the side of my voice box being paralyzed shut. I began with speech therapy due to a swallowing problem, and they sent me to an ENT (ear, nose and throat doctor) who found this. He said surgery doesn't usually last, so there really is nothing I can do. My MRI or CT did not show anything. I asked if the other side could also shut also, but the doctor said he had never seen that. What is your input?

Claudio_F._Milstein,_PhD,_CCC-SLP_: If I understand correctly what you wrote, you have a unilateral vocal fold paralysis. This is a condition that unfortunately we see often in our clinic. There are several options to correct one vocal fold that is not moving, so I would consult with a voice specialist who has experience in surgeries for vocal fold paralysis. In my experience, it would be very rare to have the other side become paralyzed as well.

Botox® for Spasmodic Dysphonia

Bess: I was diagnosed with spasmodic dysphonia. I was told by the doctor to have Botox® (botulinum toxin) injected in the muscle of my vocal chords. Is is there a different procedure that will help my voice? I strain when I talk.

Claudio_F._Milstein,_PhD,_CCC-SLP_: The most effective treatment we have for spasmodic dysphonia is injections with Botox®. There are some surgical options as well, but very few doctors around the country are doing these surgeries, and I believe that you have to try Botox® first to be a candidate. There is a lot of excellent information about this disorder on the National Spasmodic Dysphonia Association website: There you can find description of treatment options, find out who are the experts in each state, and connect with other patients with a similar condition. Good luck with your treatment.

Vocal Cord Augmentation Surgery

Rads: I am a 67-year-old male with left side facial paralysis caused by an acoustic neuroma that was removed 37 years ago. A 12-7 hypoglossal-to-facial nerve transplant done 35 years ago likely resulted in severing of the recurrent laryngeal nerve. I am plagued by a weak voice and frequent hoarseness. Examination of my vocal folds indicates no irregularity, and no acid reflux. I am now required to do a lot of public speaking, but unable to project for long periods of time. Any help would be appreciated.

Claudio_F._Milstein,_PhD,_CCC-SLP_: You may be a candidate for a vocal fold augmentation procedure or a medialization procedure. These are two surgical approaches that can be very useful to improve quality of voice in cases where one vocal fold is paralyzed. I recommend that you see a voice specialist that can determine the current status of your vocal folds and recommend the most appropriate treatment for you.

There is an excellent voice center at the University of California at Sacramento with expertise in vocal fold repair surgeries for vocal fold paralysis.

deb123: I have vocal cord paresis and have seen two ENT (ear, nose and throat) doctors numerous times about my voice for the past two and one half years. I have been misdiagnosed twice—once for acid reflux and the other time for stress. I was finally diagnosed with paresis. I have had voice therapy and stress therapy. Three weeks ago I had a bulk injection in my left vocal cord that did nothing to change the sound of my voice. Well there is a slight improvement, but not enough to change my choking or breathy, quiet and strained voice. It now hurts to swallow on the right side of my throat. My voice therapist took a video of my vocal cords after the procedure to prove the injection did not work. I am so frustrated! Do you have any thoughts about what procedure I should consider next?

Claudio_F._Milstein,_PhD,_CCC-SLP_: There are many factors to consider regarding a vocal fold augmentation for paresis. Perhaps the vocal fold was not bulked up enough, or perhaps you have a vertical level difference between both vocal folds. The recommendation would be to have your ENT doctor look at the follow-up video carefully to determine why the injection did not work, and then plan the next step accordingly.

Reinnervation of Vocal Fold Nerve

Rads: Would it be possible to reconnect the severed recurrent laryngeal nerve to restore voice function?

Claudio_F._Milstein,_PhD,_CCC-SLP_: Yes, surgical reinnervation of a damaged vocal fold nerve is possible. We do this procedure routinely at Cleveland Clinic. The success of this surgery is very dependent upon factors including how old is the injury, the age of the patient, and the cause of the paralysis. There are several laryngologists around the country with expertise in this procedure. A consult with any of them will help clarify your question further. Given that your injury is greater than 35 years old, it makes you a less likely candidate for reinnervation.

Provider Selection

dcsstudent: I want to preface this with I am a singer and speaker—not professionally, but it holds a significant place in my life. I have had a team like you have mentioned above and saw some improvement, but not enough. I suffer constant embarrassment because of coughing. People think I am spreading germs. I never know if I am going to cough in the middle of singing or speaking. I have some reflux, post-nasal drip even after sinus surgery, asthma and my vocal chords don't close completely. I am 60 years old now and know that it probably won't all ever get fixed. The medications (nasal sprays, inhalers, etc.) are very expensive. I saw someone in the medical field almost weekly for more than a year. I just got “doctored” out. Again, I am better. I can go an hour maybe without coughing most days. But the prospect of continuing this way is more depressing than I can tell you. I stopped seeing my "team". Should I just continue the course?

Claudio_F._Milstein,_PhD,_CCC-SLP_: Have you considered another consult with a different team? There may be other treatment options to help you.


Moderator: I am sorry to say that our time with Dr. Claudio F. Milstein is now over. Thank you for sharing your expertise and time to answer questions today.

Claudio_F._Milstein,_PhD,_CCC-SLP_: Thank you for taking the time today to participate in this educational activity. World Voice Day was April 16. This is a day to celebrate our voices and disseminate information about vocal health. Most voice centers around the U.S. held related activities, such as health talks, concerts, lectures and free voice screenings. Help spread the word about keeping healthy voices.

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 Voice Disorders
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.

On Your Health

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A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit

Reviewed: 04/14

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