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Aging Voice

As we age, our bodies work differently. Parts of the body and skills like breathing, voicing and muscles may begin to become deconditioned or change in shape and elasticity, as well as tonicity.

If you have been diagnosed with presbyphonia or vocal cord bowing/atrophy, voice therapy is a researched and proven effective way to improve your vocal quality, volume and quality of life.

PhoRTE (Phonatory Resistance Training Exercises) intervention is an effective treatment for older adults who are suffering from voice issues that are caused from deconditioning. 

Supported by the career research from Dr. Edie Hapner and Dr. Aaron Ziegler, PhoRTE provides older adults with behavioral voice therapy necessary to improve their voice performance or laryngevity (TM PhoRTE). 

PhoRTE is the only behavioral voice therapy for presbyphonia (aging voice/vocal cord bowing) that has been tested in a randomized, controlled clinical trial comparing it to other well-recognized treatments and a no treatment control group. It allows patients to work at an intensity level appropriate for them, for real gains. This lifts the overall burden of practice outside therapy and a required number of sessions, and allows engagement of the respiratory (breathing) and phonatory (voice) systems to treat presbyphonia. Aging is a relentless process of change to the musculoskeletal, endocrine, cardiovascular, and neurological systems that control life itself.

Let us help you with your Laryngevity by asking us about PhoRTE today!

Read More about PhoRTE

Chronic Cough

Millions of us get sick each year with some type of upper respiratory infection. We get a sore throat, we get sinus congestion, and we get a cough. Many of us have asthma, chronic bronchitis, or reflux and we get a cough as well, as we are treated with medication for these conditions. But, what if the cough persists? What if it’s been months, even years since you spent an entire day without coughing?


Chronic cough is a cough that has lasted more than 8 weeks. It can occur in around 10-20% of the general population, and can persist long after an illness or irritant is long gone. We believe it’s related to dysfunctional nerves, making the cough neurogenic. Coughing can disrupt sleep, making a person feel tired with trouble focusing attention. Coughing can drain a person financially and emotionally because they seek improvement and usually get multiple tests, from multiple physicians, with no answers. Plus, it’s isolating to have a chronic cough because others tend to stay away from the person for fear they are ill (or have a viral illness) and the person with the cough often avoids social gatherings because they don’t want to bother others. 


It is so common that people with chronic cough come to my clinic unimpressed and annoyed because they don’t have a clue why their physician referred them to “speech therapy” for their cough. 


They are then happily surprised, on most occasions, when after 1-4 sessions of voice therapy, their cough is gone. Speech-language pathologists are specially trained to administer vocal hygiene, education, cough suppression techniques, breathing techniques and hydration education. 

Sessions teach the patients to take conscious control of their cough, which results in:

Difficulty Breathing VCD

Vocal Cord Dysfunction, or Paridoxical Vocal Fold Motion, is the term used to describe a pattern of vocal fold adduction during inhalation or exhalation that is abnormal. Newly it has also been termed EILO (Exercise Induced Laryngeal Obstruction) and is mistaken for asthma. 

Normally your vocal folds are open in a “V” shape when you breathe. If the vocal folds are coming together when you are trying to breathe, the space between them gets smaller and the pathway to your lungs narrows or is completely occluded by the closed vocal folds.  

VCD is often misdiagnosed as asthma, and when the patient has no success in treating the shortness of breath with asthma medications, VCD is suspected. Shortness of breath will occur in episodes either induced by exercise (most common), certain components or smells in the air, or for no reason at all. These episodes are often frightening because the individual cannot take a normal breath. 

There is no known cause for VCD. It is most common in Type-A personalities, athletes, and adolescents. Treatment usually requires no medication, and is often resolved in just a few sessions with behavioral breathing techniques.

Breathing techniques are taught until the patient is able to produce them completely independently and can use them effortlessly under the extreme pressure of a breathing attack. Often times the Speech Language Pathologist runs or exercises with the patient to get the techniques going during the the activity that seems to bring on the VCD symptoms. Practice is important to maintain the body’s ability to remember and revert back to these rescue techniques.

Sources: Clinical Voice Pathology: Theory and Management 4th Edition Stemple, Glaze & Klaben

Excellent Resource on VCD

What is gender affirming voice therapy?

If you feel your voice doesn’t match your outward or inward appearance or identity, some individuals seek treatment to augment the vocal abilities to improve this mismatch. Pitch is not the only component that might want to be changed. Individuals might desire to sound more or less feminine, more or less masculine, or have a variety of sound abilities.  

Gender affirming voice sessions can guide people in navigating the changes in pitch and how resonance works and how they can improve the congruence of self and voice.

What is Puberphonia?

During puberty the voice box changes dramatically in size for every person. Sometimes, the changes to the mechanisms don’t feel comfortable and the person maintains the muscular coordination from when the mechanism was smaller and not as mature.

This can result in voice quality being high pitched with pitch breaks with subsequent discomfort not only in the throat but in daily vocal activities. Sometimes this is because of embarrassment or because it feels odd for the new muscle activations to be used with the lower pitched voice.

Voice therapy uses exploration, muscle tension reduction and visual feedback to help the person feel more comfortable with the newly-sized laryngeal structures. 

Neurologic Voice Problems

Neurologic Voice Change

There are some voice issues that are neurological in nature, and not within our conscious control. These include things like vocal tremor and spasmodic dysphonia.

Vocal Tremor

There are some voice issues that are neurological in nature, and not within our conscious control. These include things like vocal tremor and spasmodic dysphonia.

Spasmodic Dysphonia

Spasmodic Dysphonia (SD), or Spastic Dysphonia, occurs when the larynx spasms with no other accompanying motor speech disorder or laryngeal issue. It is a focal dystonia of the larynx where the larynx spasms involuntarily during speaking. It occurs only when the patient speaks, as there is no evidence of laryngeal spasms during vegetative vocal behaviors like coughing, crying, or laughing. Stress seems to make symptoms worse. SD usually appears around age 40, and most often in females. A combination approach to treatment is most effective, involving pharmacological treatments and behavioral voice therapy to reduce laryngeal tension, regulate breath flow and decrease effort during speaking.


Adductor Spasmodic Dysphonia is the most common form of SD with a strangled quality to the voice during speech as the vocal folds hyperadduct (come together more than necessary) and spasm. Public figures including Diane Rehm and Robert Kennedy Junior suffer from adductor SD and have brought the condition into the media. You can view this here. Sometimes those who suffer from SD also suffer from vocal tremor, about half in fact. Individuals with adductor SD find their symptoms worsen during speech that is voiced (like the sounds /m/, /b/, /d/, and /g/) versus voiceless (like /s/, /p/, /t/, or /k/). Shouting is difficult for patients with adductor SD and some find that talking in a higher pitch will briefly reduce the frequency of the spasms.


Abductor Spasmodic Dysphonia is the least common form and is the exact opposite of adductor SD. The vocal folds involuntarily separate during phonation and give the person a breathy sound in the middle or sounds, words and sentences. Voiceless sounds are worse here, (/s/, /p/, /t/, /k/.) It takes maximum effort to speak and fatigue is ever present, as patients have a hard time keeping the vocal folds closed during phonation requiring more air use because of the uncontrolled air escape.


Botulinum toxin, or Botox, is used to treat SD by inhibiting acetylcholine release and temporarily paralyzing the vocal fold muscles (thyroarytenoid) or surrounding muscles, depending on the type of SD a patient has. There have been over 100 studies recently with variable methodology showing positive effectiveness of using Botox to treat SD. The injections usually last 3-12 months, and it may take up to 2 -3 weeks for a positive effect to be noticed.

Sources: Clinical Voice Pathology: Theory and Management 4th Edition Stemple, Glaze & Klaben.        

Watts,C, Whurr R, Nye C. Botulinum toxin injections for the treatment of spasmodic dysphonia (Review), (2010) The Cochrane Collection. 

Laryngeal Evaluation: Indirect Laryngoscopy to High-Speed Digital Imaging. Katherine A. Kendall and Rebecca J. Leonardk, Thieme publishing. 2010.

National Spasmodic Dysphonia Association (NSDA)

Singing Voice Problems

Whether you are a touring artist or a weekend gigger, a worship leader, or you sing songs in your shower, a tempo Voice Center has experience to evaluate you and come up with a unique treatment plan to identify what is causing your symptoms and put you on the road to recovery.


Sometimes structural issues are the cause, including growths on your voice box, paralysis of one of the vocal cords, or swelling from sickness, reflux, allergies, or all 3. 


Other times, muscle tension can be causing the issues with range reduction, pitch instability and more. This can cause you to cut your set list short, tune down your instrument or sing an octave lower than you used to sing. 

Whether it’s anatomy or technique, a tempo Voice Center’s staff are trained in vocal performance and have experience evaluating with instrumental exams, acoustic analysis and behavioral assessment to get you back to doing what you love.


Further reading about muscle tension and structural issues (link to the Voice Quality Change Page)

Vocal Fatigue

Vocal fatigue can be caused when the muscles of your larynx tire out and cause a feeling of pain. A reduction in endurance, loudness control, pitch control as well as poor voice quality and an unstable sounding voice are often symptoms and complaints of people suffering from vocal fatigue. Fatigue can be felt in the nonmuscular laryngeal tissues surrounding the vocal folds. People sometimes complain of dry mouth, a “full” feeling in the throat, shortness of breath, and that it takes effort to speak. 

These are not the only symptoms of vocal fatigue, but the cause may be how you are using your voice, or how your voice box structures have changed due to disease, paralysis or a growth. 

 A tempo Voice Center can effectively evaluate you with a slow motion video exam of your vocal cords, and record the voice quality while analyzing your voice production abilities to come up with a treatment plan uniquely catering to your needs.


Sources Clinical Voice Pathology: Theory and Management 4th Edition Stemple, Glaze & Klaben

Voice Quality Change

Quality of your voice can be a sudden change or one that occurs gradually over time. If this change has persisted over 2 weeks, it might be a good idea to seek an evaluation with your ENT or with a tempo Voice Center.

 A tempo Voice Center can effectively evaluate you with a slow motion video exam of your vocal cords, and record the voice quality while analyzing your voice production abilities to come up with a treatment plan uniquely catering to your needs.

Here are some educational tidbits about issues that could cause a change in voie quality.

What is Muscle Tension Dysphonia?

Muscle Tension Dysphonia, or MTD, is what we call a disturbance in the voice without any pathology present. It is caused by tension you can see and feel in the throat and upper body. 

There are two types of MTD:

Primary Muscle Tension Dysphonia- no apparent structural reason for the hyperfunctional muscle use and tension

Secondary Muscle Tension Dysphonia- muscle tension pattern that is compensatory and is adopted after a disturbance in the larynx such as a lesion, swelling or paresis.

There is excessive tension present as the front and back of the larynx press together. The left and right sides also compress and constrict, resulting in a voice that sounds dysphonic or even aphonic (no vocal sound.) People often report their voice sounds strangled, pressed and pushed. Symptoms can include strain, reduced ability to speak at different pitches and loudness levels, fatigue, and aphonia (no voice). The treatment for MTD is behavioral voice therapy to improve coordination of vocal subsystems. 

Voice therapy teaches you to coordinate your vocal subsystems: breathing, phonation and resonation back to a baseline level or a level that manages your symptoms more effectively. You will learn how to reduce tension at the level of the vocal folds and reprogram your muscle memory for speech.

What are Vocal Cord Nodules?

Nodules are when the vocal fold tissue forms hard callouses in response to repeated tissue overuse. They are the most common lesions on the vocal folds. They occur on both vocal folds, are symmetric, and vary in size. Nodules can be chronic or acute, and can cause varied changes in the voice including roughness, breathiness, tension, harshness and pain. Hoarse vocal quality occurs because the nodules touch when you bring your vocal folds together to make sound, and air escapes from above and below the nodules. This is called diplophonia, or a two-toned sound. Nodules result in an hourglass closure of the vocal folds. They can occur in children and adults and are a result of stressful vocal behaviors like excess talking, singing or shouting/screaming more than the larynx can handle (genetics and training play a role here.) 

Nodules usually can be remediated with voice therapy alone. When treatment does not improve, a surgical consultation is usually the next step (not necessarily for removal, but other options.) It is important to know that voice therapy can be a useful tool in treating these types of lesions because they are like callouses on the vocal folds. With a reduction in vocal habits that caused the issue in the first place, the callouses will lessen or disappear altogether

What are Vocal Cord Polyps?

Polyps are lesions on the vocal cords filled with fluid. They occur suddenly and grow quickly because they have an active blood supply. Acute vocal fold trauma is usually the cause. Polyps usually occur in adults and are rarely found in children. Polyps can cause various changes in the voice similar to nodules. Some polyps are pedunculated and have a stalk. Surgical removal is usually the option for treatment, however a combination of voice therapy and surgery is best to improve the patient’s vocal habits and use and to decrease the chance of a recurrence. 

Vocal Fold Hemorrhage

Traumatic injuries to the vocal fold blood vessels can cause vocal fold hemorrhage. Vocally abusive behaviors like screaming, coughing or crying can cause these lesions. Hemorrhage occurs suddenly when a capillary ruptures in the vocal fold and the blood leaks into the superficial layer of the lamina propria. Your vocal folds can vary in color based on how long ago the bleeding began. Your voice can change dramatically when the rupture occurs which can be very debilitating. Treatment includes vocal rest and conserving the voice, but surgical treatments are sometimes recommended. Voice therapy is recommended to stop the trauma from occurring again.

Vocal Fold Scarring

Vocal fold scarring can occur following the presence of a lesion, changes to the tissue following surgery, and if the vocal fold tissue is continuously irritated from vocal abuse and misuse. Just like with scars you can see on your arms or legs, scar tissue is stiffer than regular tissue. When the vocal folds accumulate scar tissue, they become more stiff and are not as pliable. This reduction in pliability results in a reduced mucosal wave and the voice sounding dysphonic (unpleasant to the ear). Those suffering from vocal fold scars typically lose vocal flexibility for pitch changes, fatigue easily, have a quieter sound and sound rough or strained.

Vocal Fold Cyst

Vocal cord cysts can be present from birth, or appear with age. Cause of a vocal cord cyst can be genetic or behavioral. They are tricky in that they do not respond to traditional voice therapy alone. Usually, the patient will have to undergo surgical extraction. Most cysts are either white or clear and are usually found on only one side of the vocal cords. Sometimes, what’s called a “reactionary lesion” is formed on the opposing cord in the spot where it meets with the cyst during phonation. This opposing lesion can be smaller or the same size as the cyst. Videostroboscopy is key when this happens to rule out vocal nodules. Cysts cause the affected vocal cord to become stiff and not vibrate as well. The lack of vibration in one cord causes changes in the person’s vocal quality. Problems can range from mild voice changes, difficulty with singing range, diplophonia (two sounds coming out at once) and complete loss of voice.

Voice therapy will benefit a patient by improving vocal hygiene, coordinating vocal subsystems and reducing vocal abuse and misuse. We recommend this either before or after surgical removal of the cyst.

Vocal Cord Paralysis

Paralysis can occur in one or both vocal folds, resulting in a breathy or weak voice quality with pitch instability. The vocal fold can be paralyzed in the midline position and sometimes cause breathing issues during heavy exercise, but most commonly the vocal fold is paralyzed in the abducted position (open). Paralysis occurs from damage to either the superior laryngeal nerve (SLN) or the recurrent laryngeal nerve (RLN). This can happen after thyroid surgeries, heart surgeries, or for no reason at all.


SLN damage is the most difficult to identify because the patient usually complains of vocal fatigue, being unable to sing, and difficulty increasing pitch or volume. SLN damage can create a gap between the vocal folds after they come together (where one overlaps the other) which results in the patient being unable to achieve maximum closure. The affected vocal fold is also unable to lengthen upon pitch raising. Voice therapy can benefit anyone suffering from SLN paralysis to give the patient the maximum ability of vocal use in the presence of the paralysis, but no medical treatment is successful in treating SLN damage.


RLN damage is easier to identify as most patients complain of diplophonia (two sounds at once), reduced volume and pitch, and breathiness. This paralysis can cause atrophy of the vocal fold(s) affected and impact the ability for the vocal folds to completely close (adduct). A combination approach of surgical treatment and behavioral voice therapy is most beneficial.  


Often times there is SLN and RLN paresis which can improve spontaneously in about 6-12 months. Again, behavioral voice therapy can maximize the patient’s ability to utilize the best voice possible.

Sources: Clinical Voice Pathology: Theory and Management 4th Edition Stemple, Glaze & Klaben

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