A Singer with Vocal Fold Atrophy and Type One Thyroplasty

Vocal fold dysfunction has been cloaked in secrecy and shame for far too long.  It’s a source of unimaginable frustration for people regardless of whether or not they sing.

But it has been the singers that felt it was somehow their fault, that they weren’t trying hard enough or their technique was faulty.

Fortunately, this attitude is changing. And it is one reason why I have been so vocal in my journey through bi-lateral vocal fold paralysis and paresis. It is my desire to help change the stigma and provide useful information for people who need it.

Vocal fold atrophy, otherwise known as Presbylaryngitis is a common as people age.  What follows is one case study of a student with whom I have worked for many years.

“Marco” and I have an interesting 11-year history together as student and voice teacher. He made his way to my studio in 2006 after Vanderbilt Voice Clinic diagnosed vocal fold atrophy and had performed a Type One Thyroplasty .

His background is important:

Marco was a 65 year old jazz singer, pianist and band leader who had suffered from chronic voice problems for ten years before we began working together. His vocal health history between 1994-2005 shows how long and hard he searched for medical and vocal help. He went from otolaryngologists and speech language pathologists to voice teachers and back around again. Nothing worked for him.

He had difficulty speaking, stopped singing professionally and began leading his jazz trio and big band from the piano. His voice felt like sand paper was rubbing over his throat and he sounded like Louis Armstrong with a 4 note range.

After 9 years of searching with multiple ENTs and otolaryngologists, he was finally diagnosed with a glottal gap stemming from an atrophied left vocal fold. Why this was so hard to diagnose, I will never know. As a result, his false vocal cords had become hyperactive as he tried to push his sound out.

He tried a collagen augmentation which did improve things for about 5 months, but he stopped working with the speech-language pathologist he had been assigned because he felt their work was not helping. Then the collagen wore off. Instead of getting another injection, Marco chose to go to  Vanderbilt Voice Clinic for evaluation. It was there that he received a similar diagnosis of atrophied left vocal fold but decided to have the suggested procedure called a ‘Type One Thyroplasty.’

The operation involves inserting an implant next to the vocal fold to push the fold towards the midline. That way, the left fold can supposedly meet the right fold when it vibrates.

Marco made his way to my studio after Vanderbilt surgeons had performed the thyroplasty and had cleared him to study singing again.

In my initial intake, where I ask prospective students questions related to work ethic, motivations, medications and personal life style habits, Marco told me he smoked weed fairly frequently. I asked him if he’d be willing to cut his smoking by half for at least 6 months while we worked and keep a record of when he smoked, when he didn’t, and when he did the exercises. He agreed, for the first 6 months he did do this.

We started with breathing, which I do with pathology patients because by the time they get to me they are a mass of nerves, frustration and anger. Also, Marco would need tools to relax his parasympathetic nervous system while he was cutting down on weed.  We worked out 3 breathing “meditations,” which at first were really hard for him to focus on but they became more fluid after just a few weeks. He was diligent.

Then we moved into working standard kinesthetic responses like feeling the inhale as a “release” and feeling the air naturally rebound into the lungs. He then exhaled on non-pitched lip trills while pulling the abdominals in to lift up the chest. This action was used just to stimulate coordination.

Then we moved into pitched patterns of lip trills such as 1-1-1 and 1-2-1 slowly moving to 1-3-1 and 1-3-5-3-1. For the first two weeks he tired easily and a haunted look would come into his eyes. At which point we would talk about his vocal health habits, diet choices, how much drinking alcohol he was doing during gigs, etc.

It was during these times that I found out his singing and jazz piano were a second career after 30 years as a parole officer in the prison system, barking out orders to the inmates through a bull horn.  DA-DING DA-DING YEOWZA! Which means, he probably had a longer history of vocal dysfunction that he realized. Marco was working with a therapist on many personal issues, including depression.

I just noted that and moved on within the scope of my work. But these short rest talks served to help him trust me with his most vulnerable self.

All initial exercises were to find a balance between starting to phonate and releasing various throat muscles that had become bound.

We segued into the following kinds of vocal exercises:

Phonating on “mm” in his speech range, repeating on one pitch “mm” “mm” “mmmmmmm” and then moving those into 1-2-1, 1-3-1, 1-5-1. Eventually, after about a month, he was able to do a glide from one pitch to the next without excessive abdominal “pump” movement.

Clearly he was working at the paced schedule I wrote out for him. He took it seriously.

We used the syllable “ung,” riding gently on the “ng” through various short intervals. He was moving in a slurred legato from pitch to pitch! VICTORY! Celebrate small improvements always!

Then we moved into singing the syllable “They,” on one pitch, starting with a gentle vocal fry (a speech-language pathology tool, which is considered the lowest vocal register that needs little breath pressure to do) and moving into the diphthong of “ey.”

My rational was:

  1. The voiced “TH” helps get the folds to come together without involvement of the false vocal folds which had become hyperactive and overtaken the role of the true cords.
  2. The first part of the dipthong encourages thyroarytenoid contraction, which has been proven to aid in vocal therapy. HERE is an article that supports this kind of working.  It was written by speech-language pathologists at the Department of Speech-Language Pathology and Audiology at the University of Federal of Santa Maria, Brazil.
  3. The second part of the dipthong (the ee vowel) needs awareness on the part of the singer to keep his folds together, even for a split second.

So as you can see, Marco’s singing voice rehab went very slowly, very specifically, and it took about 6-8 months of hard work and consistency on his part to be able to sing some jazz standards again. He started with songs with a limited range.

Then, after a year of consistent work together, (twice a month,) he decided to cut an album before, as he put it, “his voice went again.”  We spent the next 8 months working on the full album. He hired good people and the end result was something he could feel really good about.

But the story doesn’t end there. After about 7 years of working together consistently after the first thyroplasty, Marco suddenly lost all progress. He had begun to heavily smoke weed again, although it is unclear to me if that had anything to do with what happened with the implant.  His voice went right back to where it had been when we started. I sadly told him he needed to go back to Vanderbilt which he did. The implants had slipped out of place, and one fold was vibrating lower than the other. So he had another Thyroplasty.

We started the whole process all over again. This time I had more therapeutic tools, and he was in much better vocal shape vocally beforehand, so the improvement was much faster. He cut back on the weed and alcohol again and lost 20 pounds. Over the next year he actually got some head mix going and flipped into a weak falsetto. He recorded another album. And he was regularly gigging in the DC area.

Marcos’ journey reminds me of the phrase from JoAnna’s song “Green Finch and Linnet Bird” from Sweeney Todd.

If I cannot fly

Let me sing!.”

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If you found this post useful, please like, share or comment. Thank you for reading!

Please Note:  I am an Independent SVRS and do not work in a medical setting. However, I do work on referral from speech-language pathologists and otolaryngologists after a singer has been diagnosed and treated.

 

 

 

 

 

 

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