A Singer Diagnosed With “Vocal Cord Dysfunction”

Recently a singing student of a colleague received a diagnosis of “Vocal Cord Dysfunction” from an ENT. The voice teacher asked on a forum what that meant. Those of us who work with injured singing voices responded that Vocal Cord Dysfunction wasn’t a diagnosis.

Any vocal fold injury or pathology creates “vocal cord dysfunction.” Right?? That is perfectly logical.

Evidently, in the medical community “Vocal Fold Dysfunction” is another name for “PDFM”–Paradoxical Vocal Fold Movement.

And, evidently, ‘Vocal Cord Dysfunction’ is not categorized the same as ‘Vocal Fold Injury.’ However, both affect movements of the vocal folds and the larynx.

PVFM doesn’t refer to one specific vocal fold injury diagnosis. It’s anything that causes “an episodic unintentional adduction of the vocal folds on inspiration.”  Which means the vocal folds are working backwards—they close when the patient tries to inhale. Normally the vocal folds open upon inhalation.

Can you imagine how awful that would feel? However, Kerrie Obert, a Clinical Voice Specialist at The Ohio State University and Dept. of Otolayrngology and co-author of The Owner’s Manual to the Voice: A Guide for Singer’s and Other Professional Voice Users, says

While scary, one of the things to know is that oxygen levels remain normal during an attack. People with this disorder feel they are not getting enough air but they actually are. It is one of the things that distinguishes it from asthma or other respiratory disease. It is basically a behavioral problem and generally remedied with just a few sessions with an SLP.

This voice disorder ALSO has other alias’, such as laryngeal dyskinesia, inspiratory adduction, periodic occurrence of laryngeal obstruction, Munchausen’s stridor, hysterical croup and irritable larynx syndrome….just to name a few!

Kristine Pietch, SLP at Johns’ Hopkins’ Dept. of Neck and Head in Baltimore and Bethesda, Maryland and a fine singer, noted that

We don’t like the term ‘vocal cord dysfunction’ in our clinic for the reasons you describe (very non specific!) but it is the one that most pulmonologists use and that our patients hear first! I see a number of these patients every week and on my handout have to write “vocal cord dysfunction AKA paradoxical vocal fold motion” and NOW I’m probably going to have to add yet another…ILO aka inducible laryngeal obstruction which has been taking off (especially outside of the US). Too many terms…..very very confusing….

Paradoxical Vocal Fold Movement is misdiagnosed frequently as asthma because the symptoms are:

  • Noisy or wheezy inhale
  • A feeling of not inhaling enough air when playing sports or singing but recovers quickly, within 5 minutes.
  • Asthma or allergy medications don’t help with breathing problems
  • Has a history or symptoms of acid reflux
  • Patient points to the throat more than the chest to indicate the area of tension

This condition seems to be most common in young females 11-13 who are competitive athletes and quite driven academically. It occurs more in females than in males. It’s really imperative that the student get a correct diagnosis (asthma or PVFM) and specialized therapy from a voice care clinic and an experienced Speech-Language-Pathologist.

Sometimes asthma and PVFM occur at the same time too.

The speaking and breathing need to be addressed before the singing voice.

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Please view my services as an Independent Singing Voice Rehabilitation Specialist and my qualifications:

I. Individual Singing Voice Rehabilitation

For individual singers after diagnosis from your doctor.

II. Cate’s Collegial Consults

For experienced voice teachers and their student together, for those who live in areas without access to the resources they need.

A Singer Diagnosed with Bi-Lateral Vocal Fold Paresis

It’s time to SHATTER the imbedded pedagogical view that “singing with the wrong vocal technique” causes vocal fold injury. That is true in many cases, but in equally as many cases it is not.

Please listen to my interview on the VocalFri podcast. We get into cool stuff every singer and voice teacher needs to hear.

Thanks for your precious attention and time!

Singing and Teaching From an Undivided Self

We have more academically-educated singers and voice teachers now than at any time in the history of vocal expression, and dare I say it? Very little teaching from an Undivided Self, which means very little useful and true wisdom.

Learning to get to this place this requires TIME.

It’s a sort of alchemical process to find personal, musical and pedagogical ah ha’s! amid the deafening noise of information, data, and a cult of personality. These things don’t work well with singing. Because singing is about first finding silence of stillness and then becoming a channel for bio-electric energy, all human expression and divine connection.

I think many teachers ‘head’ know this–but they don’t FEEL it or EMBODY it.

There is a crying need for a 1:1 Experiential Learning Program outside of academia to allow teachers and singers the time they need to create this alchemical process. To learn to teach WHO they ARE as well as WHAT they KNOW.

I’ve put together what may be the first program of its kind, “The Alchemy of Teaching Singing,” to fill a hole in the Continuing Education of Singing Teachers.

We’ll work with practical and useful steps towards integrating your singing, passions, pedagogical foundations, teaching interests and needs to create your undivided Self.

I’ll also help you honor every facet of your life experience, which creates a space of immense coherence and strength to hold student, learning, and your Self.

THAT’s where the magic happens.

Special thanks to Palmer Parker and his brilliant book “The Courage to Teach.”

A Singer With Muscle Tension Dysphonia (MTD)–One Case

This is my first blog post as a singing voice rehabilitation specialist.

It is important to state that I do not work in a clinical setting, but privately, on referral from Speech-Language Pathologists and other Singing Voice Rehabilitation Specialists. This is one case, one approach. For every singer recovering from MTD, there will be different needs, different reasons for the condition, and different exercises.

If you’d like a good article on MTD and solutions, read “Collaboration and Conquest: MTD as Viewed by a Singing Voice Specialist and a SLP,” by Goffi-Fynn and Carroll. (PubMed) Communicating in a unified medical language can be important, so that the team of an otolaryngologist, speech-language pathologist and voice teacher can communicate about their patient-student.

Roz is in her late 20’s and has already experienced more than her share of vocal pathology and vocal issues. She holds a BM degree in vocal performance and is a professional chorister with excellent musicianship and a beautiful voice. She loves to sing early Western choral music and was employed at a large cathedral as a soprano in their octet. She is an event photographer as her day job.

She recently left her church job to seek medical help when her voice started skipping pitches. She also was not able to phonate the beginnings of phrases that started with vowels. Then her singing became breathy and cut out at about C-5. Her speaking voice was starting to catch in the middle of phrases.

Roz’ SLP  forwarded me her diagnosis and history, which included treatment for reflux, pre-nodules, partial paresis of the left vocal fold, vocal fold scarring and a non-vocal surgery. This history had left her ultra-aware of when to seek help.

Right now, the suggested standard medical protocol for a singer with vocal fold dysfunction is to first see a qualified otolaryngologist who truly understands a singers’ needs. This is still a rare thing.

Many otolaryngologists and ENT’s do not have this sub-specialty, and even those who say they work with singers often are inexperienced and just making guesses or don’t use the right equipment to view vocal fold behavior. Then a speech-language pathologist, usually associated with the voice clinic, sees the patient for “voice rehabilitation.” Some speech-language pathologists are singing voice specialists, and many are not. (Just like some voice teachers are singing voice specialists and many are not.)

I had been teaching singing for about 27 years before I began to move in this direction, and it became a way to turn lemons into lemonade after I was diagnosed with bi-lateral vocal fold paralysis in early 2013. My singing voice specialist is Jeanie Lovetri, founder of Somatic Voicework tm: The Lovetri Method and The Voice Workshop in New York City.

Roz’ SLP saw her for one session, during which Roz was shown how to do neck massages  to begin to unwinding her tension responses. After this session, she began her work with me and I took the work deeper: I introduced her to Vibrant Voice Technique and the use of a vibrator to help make the manual massages more effective. We studied neck muscle anatomy so she could become knowledgable about how to apply the massage and began to understand her own throat. The wise use of a vibrator helps relax muscles that do not belong in the singing process, and allows “the right” muscles to begin to work before strengthening them.  In pathology patients, it is not an instant fix but improvement is seen and felt almost right away. After her session with me, the SLP felt she had improved enough to discharge her.

MTD’s pathology is not life-threatening and can be solved, but is insufficient to explain the degree of dysphonia is causes. There are many reasons why someone can develop this frustrating condition. In Roz’s initial consultation with me, she shared that she had been singing in an abusive situation. She knew that she was reacting to, and recoiling from, the abysmal choral conducting and not-so-subtle emotional abuses of the church organist who was also the choral conductor at the cathedral where she sang.

Singers who have not had an opportunity to learn how to deflect this kind of negativity will have it reflect in their bodies and throats. In her case, over time, her effective vocal technique became unable able to respond to the glorious music, collaboration with other singers and the conductor. She also was stiffening and collapsing muscles in her throat to create the stylized “no vibrato” sound and was anxious because she could not follow the director’s waving and stabbing of his fingers in the air as he played the organ. And she was cowing under his constant criticism of the sopranos, of which she was one of two. While it is possible to sing in the musical style she loves with minimum vibrato, it becomes impossible under this kind of conductor unless you can focus solely on what you need to do and block out everything else that does not serve your goals.

“Learned vocalization for speech and song is developed by auditory input of one’s environment but not in the mammalian system.  In many people these two systems are often disassociated.”  (Christy Ludow, Communication Sciences and Disorders, James Madison University.)  I based all of Roz’s initial vocal exercises on sounds that come from our limbic system. (involuntary sounds made when we have not been severed from the spontaneous expressions of anger, fear, desire, surprise, etc.)

In Roz’s case, her muscles were in hyper-function, but this masked hypo-function. Her voice stopped speaking somewhere along the line so she kept forcing vocal fold closure in order to get sound, which eventually led to the dysphonia.

In her case, the exercises were kept very short, often on whatever pitch came out as opposed to specific pitches, using the syllables “thack” or (thae.) Roz had a great deal of anger and disappointment left over from her experience, so all the exercises were preceded with physical expression of those emotions by punching a pillow for a minute, or punching the air, etc, followed by one sound of emotional expression on that specific syllable.

A week later we removed the “th” and went through a similar procedure. Every single time, she phonated on a vowel when she allowed it to come from her emotional motor system! (limbic part of the brain.)

Pacing of the lesson was important to ensure she didn’t get tired or discouraged and she used the vibrator off and on all through the lessons. After about two lessons she was able to phonate short pitch patterns, moving up and down the scale, stopping for frequent short breaks. She could sing certain vowels over short intervals, which enabled her to really feel her progress.

After 3-4 lessons, the tongue attachments to the hyoid bone and  were sufficiently released that we could add tiny squeaks and squeals to help activate the cryco-thyroid muscles. This had to be done slowly, with her using the vibrator and me manually massaging the back neck muscles to watch for a return to hyper-function of the neck muscles, but she progressed. Then we moved from one tiny squeak down an interval of a third. Then we moved to exercises involving more than one syllable like “ihi-(eehee)-ihi-ihi-ihi” on one pitch or a pattern, coordinating with conscious use of transverse abdominals to get things going.  She had no trouble accessing and isolating various abdominal muscles, which was a testimony to her former technique.

From there we moved to a sustained (i) over short traditional vocalize patterns. When the voice skipped, she’d rest, repeat all the patterns in sequence. and take off again. She is almost ready to move into the standard voice therapy exercises (Stempler, semi-occluded variations, straw bubbling in water, etc.) We absolutely could not start with those.

Slowly her beautiful voice is reemerging, and she realizes she will sing again before the year is out. But now she will look for a choral situation that is what she knows the experience can be!

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