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Vocal abuse is any behavior or occurrence that strains or injures the vocal
folds (or vocal cords). This may include excessive talking, throat clearing,
coughing, inhaling irritants, smoking, screaming, or yelling. Vocal misuse
is improper voice usage such as speaking too loudly or at an abnormally high
or low pitch. Frequent vocal abuse and misuse can damage the vocal folds and
cause temporary or permanent changes in vocal function, voice quality, and
possible loss of voice.
Voice is produced by vibration of the vocal folds. The vocal folds are two
bands of smooth muscle tissue that lie opposite each other. They are located
in the larynx or voice box. The larynx is positioned between the base of the
tongue and the top of the trachea (windpipe), the passageway to the lungs.
When at rest, the vocal folds are open to allow an individual to breathe.
To produce voice, the brain precisely coordinates a series of events. First,
the folds come together in a firm but relaxed way. Once the folds are closed,
air from the lungs passes through them, causing vibration and thus making sound.
The sound from this vibration then travels through the throat, nose, and mouth
(resonating cavities). The size and shape of these cavities, along with the
size and shape of the vocal folds, help to determine voice quality.
Variety within an individual voice is the result of lengthening or shortening,
tensing or relaxing the vocal folds. Moving the cartilages, or soft, flexible
bone-like tissues to which the folds are attached, makes these adjustments
possible. For example, shortening and relaxing the vocal folds makes a deep
voice; lengthening and tensing them produces a high-pitched voice.
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Disorders of vocal abuse and misuse are the most prevalent and preventable
of the types of voice disorders. Anyone, from infants to the elderly, who uses
his or her voice excessively may develop a disorder related to vocal abuse.
Lawyers, teachers, clergy, cheerleaders, and professional voice users such
as singers and actors often develop these types of voice disorders. Much of
the chronic hoarseness experienced by children is caused by vocal abuse or
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The most common disorders resulting from vocal abuse and misuse are laryngitis,
vocal nodules, vocal polyps, and contact ulcers. Health professionals who have
training in voice and voice disorders often refer to these conditions as "hyperfunctional
is an inflammation or swelling of the vocal folds. It
may be caused by excessive use of the voice, by bacterial or viral infections,
or by irritants such as inhaled chemicals or the backup of stomach acid into
the throat (gastroesophageal reflux). The voice of someone with laryngitis will
often sound raspy, breathy, and hoarse.
Vocal nodules, which are small, benign (noncancerous) growths on the
vocal cords, are among the most common voice disorders directly related to
vocal abuse. This condition is often called "singer's nodes" because it is
a frequent problem among professional singers. Vocal nodules are callous-like
growths that usually form in pairs, one on each vocal fold. They form at the
area that receives the most pressure when the folds come together to vibrate.
The nodules develop from damage caused by repeated pressure on the same area
much like a callous forms on areas of a person's feet that are irritated by
tight shoes. The voice of a person who has vocal nodules usually sounds hoarse,
low-pitched, and slightly breathy.
Vocal polyp. A vocal polyp, also called Reinke's edema or polypoid
degeneration, is a benign growth that is similar to a vocal nodule but is softer,
more like a blister than a callous. It most often forms on only one vocal cord.
A vocal polyp is often associated with long-term cigarette smoking but may
also be linked to hypothyroidism (decreased activity of the thyroid gland which
is involved in the growth and development of children and energy control in
adults), gastroesophageal reflux, or chronic vocal misuse. People who develop
a vocal polyp usually have a low-pitched, hoarse, breathy voice, similar to
the voices of people who have vocal nodules.
Contact ulcers are a less common disorder of vocal abuse. They are
experienced by people who use too much force when bringing the vocal folds
together for speech. This excessive force causes ulcerated sores or a wearing
away of tissue on or near the cartilages of the larynx that move to bring the
vocal folds together. These ulcers are also found in people who have gastroesophageal
reflux. People with this type of voice disorder often complain of their voice
tiring easily and may feel pain in the throat, especially while talking.
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Anyone who experiences vocal change or hoarseness for more than 2 weeks should
be examined by a physician, preferably an otolaryngologist (a physician/surgeon
who specializes in diseases of the ears, nose, throat, and head and neck).
While hoarseness is a common symptom of vocal abuse or misuse, it is also one
of the first signs of cancer of the larynx. A physician's visit is especially
important for people who smoke cigarettes, because smoking is closely associated
with laryngeal cancer. The otolaryngologist will examine the individual's vocal
folds and determine if a medical condition is causing the voice problem. As
part of the voice examination, the otolaryngologist will often look directly
at the vocal folds. This may be done by inserting a tiny mirror into the mouth
to the back of the throat (laryngoscopy). The otolaryngologist may also examine
the vocal folds by passing a small camera and light through the mouth or nose
and into the throat (fiberoptic laryngoscopy). This method is often preferred
because it allows viewing of vocal cord movement during speech.
Following an examination, the otolaryngologist may refer the individual to
a speech-language pathologist, a health professional trained to evaluate and
treat people who have voice, speech, language, or swallowing disorders that
affect their ability to communicate. The speech-language pathologist will evaluate
the pitch, loudness, and quality of the person's voice, and will also assess
vocal techniques such as breathing and style of voicing. A voice recording
is often made, and trial therapy techniques may be used to test their effectiveness
at improving the voice.
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Most disorders of vocal abuse and misuse are reversible. The best treatment
is to identify and eliminate the vocal behavior that created the voice disorder.
In many cases, a brief period of voice therapy is helpful so that the individual
can learn good vocal techniques such as proper breath support for speech or
eliminating forceful voicing.
In some instances, eliminating the abuse or misuse and voice therapy are not
enough. In these cases, medication to block the production of stomach acid
may be helpful. In some cases, an operation may be necessary to remove growths
from the vocal folds. Since most disorders of vocal abuse and misuse easily
recur following surgery if the vocal misuse continues, another period of voice
therapy by a speech-language pathologist after surgery may help prevent recurrence
of the problem.
Children with disorders of vocal abuse and misuse are often the most difficult
to treat because it is not easy for them to change their vocal behaviors. Fortunately,
most children outgrow these disorders by the time they are teenagers. For these
reasons, many surgeons do not operate on children who have disorders of vocal
abuse or misuse. A period of voice therapy, however, may help the child to
learn proper voice behaviors.
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Scientists are examining a multitude of issues related to vocal abuse and
misuse. They are conducting in-depth studies of the tissues of the vocal folds
to determine how various types of stress affect these delicate tissues. Scientists
are especially interested in determining why vocal behaviors in some individuals
lead to vocal nodules while similar behaviors in other individuals may lead
to mild laryngitis, vocal polyps, or little or no voice change. They are also
examining the tissue changes necessary for the development of laryngeal growths
such as nodules and polyps, as well as laryngeal cancer, and how various treatments
reverse those tissue changes. Speech-language pathologists are studying the
effectiveness of behavioral techniques including use of machines to help people
relearn proper vocal techniques such as good breath support or efficient use
of the larynx. Studies that will improve the treatment of hyperfunctional voice
disorders in children are also in progress. Of special interest is the long-term
impact of various treatments, especially medical and surgical treatments.
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For more information about vocal abuse or misuse, contact:
American Academy of Otolaryngology-Head
and Neck Surgery (AAO-HNS)
American Laryngological Association
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