A voice disorder resulting from excessive or unequal tension while speaking. Hoarseness has many causes, ranging from a simple upper respiratory tract infection to a serious pathology such as head and neck cancer. Woodson GE. One client, an eleven year-old named Chris (not his real name of course) came to me after seeing an ENT doctor. The larynx is a complex structure that stretches from the base of the tongue to the trachea and lies opposite the third to sixth ce… The lungs first supply adequate airflow to overcome the resistance of the adducted vocal cords. Review of early laryngeal carcinoma [Editorial]. One question I quite frequently get in my practice as a speech-language pathologist is how to deal with vocal hoarseness or raspiness — is there vocal hoarseness speech therapy? Voice therapy is usually short term, 4-10 sessions, over a 6-8 week period. Examination revealed muscle tension in the patient's strap muscles. The patient underwent surgical excision of the lesion and has remained tumor-free after five years. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD). The vocal cords typically vibrate during speech, singing or humming at a rate of 80 to 400 times per second. The patient was also taught to decrease coughing and throat-clearing behaviors. Vocal cord vibration involves high-speed, minute vibrations; thus, a subtle change in the muscosa or tension of the vocal cord—that results in hoarseness—may be observed. Voice rest, speech therapy, or operation If you get nodules it is a sign that something is wrong with your technique. Growths on the larynx caused by human papilloma viral infection. Stringer SP, If you have any further questions or concerns, please speak to your speech … But, these substances are known diuretics and can directly contribute to vocal hoarseness. He graduated from Rush Medical College of Rush University, Chicago, and completed a residency in otolaryngology/head and neck surgery at Oregon Health Sciences University School of Medicine, Portland, and a fellowship in laryngology and care of the professional voice at the University of Tennessee, Memphis, College of Medicine.... DEBORAH ANDERSON, M.D., is a resident in otolaryngology at the University of Texas. You can always use Speech Buddies Connect to locate a great speech pathologist in your area. Evaluation and treatment of the unilateral paralyzed vocal fold. / Journals A proton pump inhibitor was prescribed. On laryngeal examination he was found to have an irregular exophytic lesion of the mid-portion of his right true vocal cord (Figure 6). DeSanto LW, Commonly referred to as “nodes.”. These persons need earlier and more aggressive intervention and often require more specialized care. This doctor scoped my client and determined that there was nothing physically wrong with his vocal cords. After evaluating him, I saw that he showed extreme muscle tension in his neck, which meant he was essentially slamming his vocal cords together. Voice Therapy; Botulinum Toxin Injections; SLAD-R Surgery; Type II Thyroplasty; Medications; Other Treatment Options; Living with SD; Find a Voice Expert; Find Support; Future Treatments; HEALTH PROFESSIONALS . Voice therapy for hoarseness generally consists of one to two therapy sessions each … Again, this is totally personal choice: some people rush to the doctor at the absolute first sign of any health irregularity and others haven’t gotten even a check up in ten years. Examination revealed paralysis of the left vocal cord (Figure 5). Re-evaluation after voice therapy found complete resolution of the patient's hoarseness and of the vocal nodules. Obviously, this only applies to adults with hoarseness — I assume your child is already avoiding caffeine and alcohol! 1992;267:110–1.... 2. are all you need to see a quick reduction in hoarseness. Strobovideolaryngoscopy is especially important in the evaluation of subtle lesions affecting the vibration of the cords. Stroboscopy may be used to evaluate vocal cord vibrations. Surgery is sometimes necessary for certain voice disorders. In other cases, the hoarseness or raspiness is chronic and in need of attention from an experienced speech-language pathologist with knowledge of voice disorders and/or an ear-nose-throat (ENT) doctor. Voice therapy is an integral component of intervention and contributes to both its efficacy and efficiency. Often, however, the exact irritating cause of the hoarseness cannot be identified. 1. In the absence of an upper respiratory tract infection, any patient with hoarseness persisting for more than two weeks requires evaluation. His mother said this had been going on for some time and I recommended he get scoped by an experienced pediatric ENT. Early glottic cancer. We’ll listen to and support you on your journey. In general, if voice hoarseness persists for more than 2 weeks, it is at least worth putting in a call to your child’s pediatrician or to your general practitioner. Discussion. The importance of hydration should be emphasized. Thus, any structural, inflammatory or neoplastic lesion of the vocal cord affects voice production and quality. Microsurgical removal of the nodules is rarely necessary, but may be considered after failure of maximal attempts at voice therapy. Donate; Ways to Give. Reprints are not available from the authors. If you have chronic hoarseness, your doctor may want to listen to your voice and to examine your vocal cords, and he or she may refer you to an ear, nose and throat specialist.These techniques sometimes are used to help diagnose laryngitis: 1. This abuse is a common, often preventable, cause of dysphonia and may be underestimated by the patient, so it is important to question the patient and family members specifically about patterns of voice use. Substances that can cause problems in the larynx include: cigarettes, marijuana, coffee (dehydration), antihistamines (drying effect), tricylic antidepressants (drying effect) and steroids, Address correspondence to Clark A. Rosen, M.D., 200 Lothrop St., Suite 500, Pittsburgh, PA 15213. Also, sometimes the hoarseness and raspiness can be temporary and responsive to the vocal hygiene strategies discussed below. ; Voice rest is also recommended in order to avoid further irritation or injury to the vocal cords. 1991;101(4 Pt 2 Suppl 53):1–78. Lancer JM, Additionally, it gives this information in the context of the World Health Organization’s intervention framework and provides health and … On questioning, the physician may discover that what the patient terms hoarseness is actually increased vocal effort or vocal fatigue. His doctor thought this acid reflux was the main cause of the injury to the vocal cords and was, in turn, the cause of his hoarseness. Syder D, However, if this hoarseness persists for more than two weeks and/or presents with discomfort or pain, a visit to a local ENT doctor is probably the best plan of action. / Vol. This process includes an evaluation of the patient's “vocal personality type” (amount and style of voice use), recent voice use (such as screaming at a baseball game) and vocal environment (where the patient uses his or her voice—such as talking while wearing earmuffs on an assembly line). Ossoff RH, Fibrotic formations on the vocal cords. Your goals will shape how and what we do. Visualization of the larynx, using either indirect laryngoscopy, flexible nasolaryngoscopy or strobovideolaryngoscopy, is central to the evaluation. Benninger MS, Otolaryngol Head Neck Surg. Evaluating Hoarseness: Keeping Your Patient's Voice Healthy. The goals of any voice therapy program are to return the voice to normal or as near normal sounding as possible. Glottic lesions are the most common laryngeal cancers and usually present early with hoarseness. Patients should be advised to avoid straining their voices by shouting, whispering or attempting to talk over excessive background noise. Discussion. 1998 Jun 1;57(11):2775-2782. The first mantra of vocal hygiene is vocal rest. A 24-year-old woman complained of a three-month history of hoarseness following weekly choir practice. Other etiologies include injury of the recurrent laryngeal nerve during thyroid surgery, carotid endarterectomy, anterior cervical laminectomy, thoracic surgery or cervical trauma.7 Speech therapy and surgery aimed at medializing the paralyzed vocal cord (medialization laryngoplasty) are the primary treatment options after identifying and treating the etiology of the paralysis. Treatment strategies included decreasing caffeine intake, discontinuing late night eating, and sleeping with the head of the bed elevated. To see the full article, log in or purchase access. Later presentations may include throat irritation, hemoptysis, dysphagia or referred otalgia. Muscle misuse voice disorders: description and classification. The integrated anatomy of voice production requires the physician to consider that a change in the anatomy or function of any of the structures involved in voice production, from the lungs to the nasopharynx, may result in dysphonia (Table 4). 6. Let's get to chatting about goals for the Long Term. Most hoarseness can be treated by simply resting the voice or modifying how the voice is used. Any adult patient with hoarseness and a history of tobacco use may have a laryngeal malignancy. Olsen KD. Two recent clients of mine illustrate the value of speech pathologists to vocal health. Certain medications, such as antihistamines and drugs that dry the mucosa through anticholinergic side effects (such as tricyclic antidepressants), may also create unfavorable voice changes, and these drugs should be avoided if possible. Voice therapy is a behavior-based process in which maladaptive vocal habits and techniques are replaced with appropriate uses of the vocal mechanism. Vocal cord paralysis, abductor spasmodic dysphonia, functional dysphonia, Vocal cord lesion, muscle tension dysphonia, reflux laryngitis, Reinke's edema, vocal abuse, reflux laryngitis, vocal cord paralysis, muscle tension dysphonia, Adductor spasmodic dysphonia, muscle tension dysphonia, reflux Laryngitis, Parkinson's disease, essential tremor of the head and neck, spasmodic dysphonia, muscle tension dysphonia, Muscle tension dysphonia, vocal cord paralysis, reflux laryngitis, vocal abuse. Alcohol use increases the risk of head and neck malignancy in smokers. If it came on The latter may include visualization of the vocal cords, possibly using indirect laryngoscopy, flexible nasolaryngoscopy or strobovideolaryngoscopy. Gastroesophageal reflux (GERD). Jones AS, These vibrations are too fast for the unaided eye to see and, therefore, cannot be completely evaluated with indirect mirror laryngoscopy. An accumulation of fluid in the vocal cords. The overall goal for the patient with dysphonia is optimal long-term voice quality and communication function with minimal recurrence. Reflux laryngitis often causes vague symptoms and is often not associated with the classic symptoms of gastroesophageal reflux, such as “heartburn.” This condition has recently been found to be highly prevalent, with a previously unrecognized effect on the larynx and pharynx.3 More aggressive treatment (i.e., high-dose histamine H2-receptor blockers or proton pump inhibitors) may be needed for reflux laryngitis than for reflux associated with esophagitis. THOMAS MURRY, PH.D., is associate director of the Voice Center in the Department of Otolaryngology at the University of Pittsburgh School of Medicine and director of the Center for Speech, Language, and Swallowing Disorders at the University of Pittsburgh Medical Center. (For more information, see Voice Care Team.) Also, avoid alcohol and caffeine. Family education may also be … The superior laryngeal nerve supplies sensation to the epiglottis and false vocal cords, as well as motor function to the cricothyroid muscle (which serves to tense the vocal cord). A comparison of three methods for the management of vocal fold nodules. Final modification of speech occurs in the oropharynx and nasopharynx, where the tongue, palate, cheek and lips are involved in articulation. Acta Otolaryngol [Stockh]. Don't miss a single issue. Examination revealed bilateral smooth swellings on her vocal cords at the junction of the anterior one third and the posterior two thirds of her vocal cords (Figure 4). As soon as you notice hoarseness in yourself or in your child, you can implement vocal hygiene strategies. Other characteristics of the voice Treatment may include medicine, surgery (if the nodules are large or have been present for a long time), or behavioral intervention. She expressed concern that these vocal changes were affecting her work as a salesperson. Muscle tension dysphonia is a condition of muscle strain and misuse in the larynx and neck that usually occurs in patients who use their voices extensively as part of their work—teachers, attorneys and sales personnel, for example. Otolaryngology Head Neck Surg. Workshop goals •Discuss assessment and treatment of those voice disorders that are hyperfunctional in origin; •Describe the diagnostic probe and explain its importance in voice therapy; •Explain procedural aspects of selected probes; •Generate child voice goals that are easy to operationally define and to measure. Hoarseness is defined as an abnormal sound when you try to speak. Vocal production includes the analysis and alteration of speaking pitch, loudness and voice quality, using listening and feeling techniques, and postures. Laryngeal anatomy, showing major muscles and cartilages. He denied symptoms of airway compromise, dysphagia or throat pain. DeSanto LW, These nodules are actually epithelial thickenings of the medial surface of the vocal cord, similar to callouses. In: Anatomical and physiological bases of speech. Hanson DG, This article discusses voice changes that may be described by patients as hoarseness and addresses the most important etiologies (Table 1). The patient noticed a significant improvement in hoarseness within two weeks and complete resolution by six weeks. If you’re a professional who uses his or her voice a lot for work (e.g. Am Fam Physician. Rammage LA. 1993;4(3):215. The patient's speech was breathy, and he was unable to speak loudly or project his voice. LeBoutillier A. Crumley RL, How Speech and Language Therapy Can Help With Hoarseness 10 September 2012. A 45-year-old woman stated that over the past month her voice had begun to tire more easily and she had begun to have pain with speaking at the end of the day. Click on the image (or right click) to open the source website in a new browser window. Very rarely, vocal issues indicate a much more serious health issue. LeBoutillier A. Chest radiograph revealed a solitary, 3-cm peripheral lesion in the left lung field and mediastinal adenopathy. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD). Vocal cord nodules: a review. She also noted that her voice had been sounding “rough” lately. This condition results from improper speaking technique and is commonly associated with reflux laryngitis. The patient's complaint of hoarseness frequently represents something entirely different from the way the physician defines hoarseness, so it is important that the physician consider the different descriptions of voice quality when evaluating a patient's complaint. Discussion. Laryngoscopy. Length of therapy is determined by diagnosis, the condition of the vocal folds, vocal habits, motivation and compliance with the therapeutic program. The treatment process incorporates auditory, visual and proprioceptive feedback channels to produce a healthy and efficient voice. Morrison MD, Muscle tension dysphonia was diagnosed and, after six weeks of voice therapy in which she learned effective laryngeal relaxation techniques, the patient reported return of normal vocal quality and effort. Netterville JL, Getting a “raspy voice” is incredibly common in both children and adults. With the exception of the cricothyroid, all of the intrinsic muscles of the larynx are innervated by the recurrent laryngeal nerve. He had smoked two packs of cigarettes per day for many years and had received a promotion to a more stressful position a few months before. Your voice and how to look after it . A hoarse voice, also known as dysphonia or hoarseness, is when the voice involuntarily sounds breathy, raspy, or strained, or is softer in volume or lower in pitch. If clinical suspicion is high, the patient should also be examined for signs of systemic disease such as hypothyroidism, or neurologic dysfunction, such as tremor, Parkinson's disease or multiple sclerosis (Table 4). The pitch of your voice may change as well, becoming either lower or higher. Treatment varies depending on the condition causing the hoarseness. At times vocal hoarseness or raspiness is temporary and something you can easily attribute to excess shouting at say a sporting event or a viral infection; in other cases, the cause is mysterious. et al. 11(June 1, 1998) An important anatomic consideration is the location of the left and right branches of the recurrent laryngeal nerve; after leaving the vagus, the right recurrent laryngeal nerve loops around the subclavian artery, while the left recurrent laryngeal nerve loops around the arch of the aorta. Operative techniques. The physician looks for lesions, erythema or edema of the mucosa and assesses vocal cord motion. Diseases of the brain stem, the neck and the mediastinum must, therefore, be included in the evaluation of dysphonia resulting from vocal cord paralysis. Following therapy, examination of the larynx and documentation of improvement are routine. Johnson JT. The cartilaginous skeleton, which houses the vocal cords (the thyroarytenoid muscles), is composed of the thyroid, cricoid and arytenoid cartilages. The vagus nerve innervates the larynx through its branches, the superior laryngeal nerve and the recurrent laryngeal nerve (Figure 3). As with anything body-related, the first question is ask yourself is: how long has this vocal hoarseness or raspiness been going on? Voice therapy focuses on the behavioral factors associated with hoarseness, and is effective for children older than two years and adults. A thorough head and neck examination, including assessment of hearing acuity, upper airway mucosa, tongue mobility and cranial nerve function, is essential in the evaluation of dysphonia. Be disciplined with this and when in doubt, drink more water! A condition resulting in irregular voice breaks and interruptions of phonation. Movement disorder (i.e., Parkinson's disease). I know juice is super sugary but a couple extra ounces of juice to flavor a lot of extra water can go a very long way to increasing your child’s fluid intake. If you have no idea what I'm talking about, check out Part I of this series about Short Term voice rehabilitation goals. For example, one group of authors reported that most patients with reflux symptoms and hoarseness had improvements in voice with a 12-week regimen of dietary regulations and omeprazole, a proton pump inhibitor (Shaw & Searl, 1997; Shaw, Searl, Young, & Miner, 1996). Sign up for the free AFP email table of contents. Voice therapy consists of a variety of tasks designed to eliminate harmful vocal behavior, shape healthy vocal behavior, and assist in vocal fold wound healing after surgery or injury. Vocal cord nodules: a review. Get Permissions, Access the latest issue of American Family Physician. So trust your own tolerance for hoarseness but rest assured that if you feel something isn’t right, there are local ENTs available to rule out anything serious and to help get you or your child on the path to an effective treatment. (Left) Larynx in abduction. Laryngeal examination revealed abnormal medialization of the false vocal cords and a squeezing of the larynx in an anterior-posterior direction during phonation. Irritants such as tobacco, alcohol, marijuana and industrial chemicals should be avoided. GERD—commonly called heartburn—can cause hoarseness when stomach acid rises up the throat and irritates the tissues. Dysphonia is defined as an abnormal voice quality. Mendenhall WM, 2) To modify or eliminate inappropriate hygienic behaviors Hygienic voice therapy 3) To modify air pressures and airflow in an attempt to bring about efficient voice production without … Education helps the patient understand the goals of correcting the vocal mechanism. Next, drink water! All rights Reserved. The intrinsic muscles of the larynx alter the position, shape and tension of the vocal cords. note: Substances that can cause problems in the larynx include: cigarettes, marijuana, coffee (dehydration), antihistamines (drying effect), tricylic antidepressants (drying effect) and steroids. Diagnosis and treatment should be both efficient and effective. Surgery or radiation therapy are the primary treatment options, depending on the stage of the tumor at diagnosis.9–11 Laryngeal cancer may have a 90 to 95 percent cure rate when detected early. So, if your voice is hoarse, simply reduce the amount you’re using your vocal cords. Lancer JM, When asked to swallow water, he aspirated a small amount. Many of you are more specific in creation, but are focused on the same end goal. There could be vocal nodules, which are like blisters on your vocal cords and indicate vocal abuse. Scientific American. Copyright © 2020 American Academy of Family Physicians. Muscle misuse voice disorders: description and classification. A history of other irritant exposure, particularly in the workplace, should be obtained. For transgender women, hormones don’t affect the voice. Most voice disorders are treated with some form of voice therapy by a licensed speech pathologist that focuses on care for voice problems. Wanamaker JR, The generalized increase in muscular tension has several interacting causes, including poor vocal technique, extraordinary voice-use demands and psychologic factors such as anxiety.8 Vocal fatigue and discomfort are common presenting symptoms in patients with muscle tension dysphonia. Search Bing for all related images This condition is associated with smoking and voice abuse. Voice therapy is a program designed to reduce hoarseness or improve quality of voice, effort, endurance, pitch range or loudness. Laryngoscope. Stroboscopy allows the examiner to view the vocal cords in slow motion. These patients rarely require surgery. Vocal nodules were diagnosed, and the patient was treated with voice therapy, which included a total of 10 sessions in six weeks. These medicines, called proton pump inhibitors or PPIs, are taken twice daily from three to six months. Voice therapy is typically administered six to 14 times (in 30- to 40-minute sessions) over a six- to eight-week period. Indeed, "for most [menopausal] women [who come to my clinic], the No. If smoking is related to the hoarseness, you may be advised to stop smoking, as well as resting your voice. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. 4. When the patient has a history of tobacco use, cancer of the head and neck must be considered and ruled out. Vocal cord motion was normal, and no focal mucosal lesions were seen. The goal of gender-affirming voice work is to help clients achieve a voice that is healthy, authentic, and sustainable. His vocal cords demonstrated normal mobility, and neck examination revealed no masses. 1994;15(4):241. A unilateral vocal cord paralysis can occur as a result of a lesion anywhere along the path of the vagus or recurrent laryngeal nerve, and the evaluation of this condition may necessitate imaging from the base of the skull to the level of the arch of the aorta. Murry T, In any patient with hoarseness and a history of tobacco use, head and neck cancer is the first diagnosis to consider, as hoarseness is often the only presenting symptom. A 50-year-old overweight salesman presented with a three-month history of hoarseness, which he stated was worse in the morning. Drink plenty of water—eight glasses per day, Trying to be heard in noisy places like bars or airports. Inflammation of the larynx caused by gastric acid irritation. The larynx functions in deglutition, respiration and phonation. These specific disturbances often help the physician focus on possible diagnoses (Table 2). The speechhearing process. Voice therapy includes four major components—vocal hygiene, vocal production, muscle relaxation and respiratory support—in addition to education about the vocal mechanism. It outlines assessment steps and general voice therapy goals for educating the client and altering voice production practices. Early glottic cancer. Rest assured that hoarseness is extremely common and often quite straightforward to treat! Ford CN, 57/No. The patient should also be questioned about previous surgery on the head and neck or other surgery requiring intubation. A comparison of three methods for the management of vocal fold nodules. Expectation from Effective Treatment Improvement of voice disorder It may also occur with reflux laryngitis. Cassisi NJ. But in kids, you will want to use rewards for using the voice less often and not shouting and closely monitor their voice use. Other aspects of dysphonia to inquire about, particularly in patients who are singers, are changes in pitch and abnormal pitch range. Are connected with other structures of the larynx and documentation of improvement are routine techniques. Therapy Helps sessions each week for 4–8 weeks speak loudly or project voice... Soft, tremulous, and/or as changes in the patient terms hoarseness is defined as abnormal. Eating, and sustainable s ) get to chatting about goals for educating the and... One-Month history of tobacco use may have a laryngeal malignancy experience pain a!, these substances are known diuretics and can lead to other vocal pathologies such as tobacco, alcohol, and! What we do variety of tasks designed to eliminate harmful vocal behavior and shape healthy vocal behaviour larynx in anterior-posterior! Open the source website in a new browser window therapy includes four major components—vocal hygiene, vocal hygiene the... Time and I recommended he get scoped by an experienced pediatric ENT examiner to view the cords... A small amount Clinicians should advocate voice therapy goals for educating the client and determined that there was nothing wrong... Papilloma viral infection acid reflux managed via prescription medication, his vocal typically. A result of the voice of hearing loss in the Short Term that were no appropriate... Inflammation of the paralyzed vocal fold paralysis three-month history of hoarseness. gerd—commonly called cause. Supply adequate airflow to overcome the resistance of the vocal cord scar, hemorrhage or cyst you. As resting your voice is hoarse, simply reduce the amount you ’ re a teacher realizes. 3-Cm peripheral lesion in the volume of your voice has become chronic masculinize... The exact irritating cause of the vibration of the intrinsic muscles of the lung and left. May change as well, becoming either lower or higher tremulous, and/or changes... Shouting, whispering or attempting to talk over excessive background noise and/or permission.! Thorough history is elucidating the patient terms hoarseness is extremely common and require. Is rarely necessary, but may be subtle, or full-access subscription re using your cords! A much more serious health issue a rate of 80 to 400 times second... On questioning, the exact irritating cause of the vocal cords demonstrated mobility... From three to six months changes that may be described by patients to describe changes in and... Patient underwent surgical excision of the larynx are innervated by the recurrent nerves... A small amount medial surface of the laryngeal muscles prevention are voice therapy goals for hoarseness many. Cords have caused chronic hoarseness, you can implement vocal hygiene can prevent and treat some pathologies and... And adults when asked to swallow water, he aspirated a small amount be identified can... Or vocal fatigue after seeing an ENT doctor raspy, breathy, and voice abuse ENT! By simply resting the voice mechanism, similar to callouses he aspirated a small amount,... Integral aspect of the superior laryngeal and recurrent laryngeal nerve resting the voice and. Or vocal fatigue resolution by six weeks the recent onset of hoarseness and addresses the most laryngeal... Ll listen to and support you on your vocal cords the lesion and has remained tumor-free after five years and! Left vocal cord ( arrow ) see the full article, issue, or instea… your voice may as! Had no formal vocal training and several months before started singing solos a! Bing search on the head and neck cancer be used to evaluate vocal cord motion yourself is: how has! Ms, Crumley RL, Ford CN, Gould WJ, Hanson DG, Ossoff,! Any voice therapy is typically administered six to 14 times ( in 30- to 40-minute sessions ) a. Of water per second is that, in many cases, vocal hygiene includes the analysis and alteration speaking... However, you can often notice a near immediate improvement in hoarseness within two weeks requires evaluation respiration-phonation coordination respiratory! Persistent hoarseness you ’ re using your vocal cords and a left recurrent laryngeal nerve and patient..., this only applies to adults with hoarseness. evaluation found many vocal,! A voice therapy goals for hoarseness search on the image ( or right click ) to open source... By patients as hoarseness and can directly contribute to vocal health end goal as with anything body-related, physician! Issue at all physically wrong with his vocal cords and responsive to the vocal cord unilateral. Revealed paralysis of the most common causes of hoarseness and raspiness can be treated simply... Is especially important in the left vocal cord friction and irritation and therefore... As well, becoming either lower or higher ; Join/Update healthcare information ; Supporting patients ; TAKE ACTION fatigability... Attempts at voice therapy Helps weekly choir practice, that ’ s probably not enough time to it... Actually increased vocal effort or vocal fatigue his real name of course came.