There can be a number of reasons why a voice becomes hoarse. If you remain hoarse for a long period of time you should always seek an opinion from a specialist and have your voice examined for a diagnosis. A medical voice specialist is known as a Laryngologist or Ear, Nose and Throat Surgeon specialising in voice problems or Phoniatrician. They should look at your vocal cords with either a small, rigid telescope introduced through the mouth or a fibre optic endoscope passed through the nose into the throat. It is really important that the specialist is able to examine the vibratory pattern of the vocal cords. To do this s/he must use stroboscopy, high speed digital imaging or videokymography. Most will use stroboscopy whereby a flashing light is used to examine the vibratory pattern of the vocal cords. You should ensure that your specialist uses one of these methods otherwise more subtle abnormalities may be missed. Most specialists should be able to record the images of your larynx onto a computer or video recorder so that you too can see the images if you wish. Some may be able to give you a photograph or digital image so it is worth taking a USB (memory) stick with you when you are seen in the clinic.
Hoarseness does not necessarily mean the voice is so strained that you should not use it. In most cases it is caused by new uncontrolled constrictions that have affected the voice but no permanent damage to the voice has been done. The singer sounds hoarse but the voice is not damaged. This uncontrolled constriction can usually be released within a few hours. When this is done the voice is fine and sounds normal.
The hoarseness can be due to:
• too much or inappropriate muscle tension (i.e. muscle tension imbalance) leading to constriction due to:
- singing or speaking with incorrect technique
• inflammation due to:
- irritation, such as smoke
- drying of the vocal cords
- acid reflux coming up from the stomach
- some medications
• structural changes in the vocal cords such as:
- the early stages of nodules on the vocal cords
- a cyst
- a polyp
- a bleed into the vocal cord
• nerve damage (very rare)
When the voice is strained
If you have severe and long term uncontrolled constriction the mucous membranes of the vocal cords can become irritated and swell (medical term ‘oedema’). This makes it difficult for the vocal cords to vibrate as rapidly as before resulting in a lower pitch and a darker sound. The swelling also prevents the vocal cords from closing properly, allowing air to whistle through them, creating the hoarse, dark and breathy sound.
Singing when the voice is hoarse
If a singer sings despite having a hoarse voice (perhaps because of a scheduled concert) s/he must strain to make the vocal cords close properly. This puts large amount of pressure on the cords, especially at the point of the swelling. It takes a lot of strength to ‘squeeze out’ a clear sound from swollen vocal cords. It is, however, possible. Many singers complete concerts even though the high notes may fail.
Singing with incorrect technique when the voice is hoarse usually makes your voice even more hoarse. The vocal cords may swell so much after a concert they are no longer able to vibrate normally and the voice simply goes. You often hear singers say, ‘How strange! I was hoarse before I went on stage. When I was singing it went all right but afterwards I couldn’t utter a sound’. This phenomenon is not so strange when you know the physiology of the voice. To sing, the performer has to ‘squeeze out’ notes from swollen vocal cords by constricting them uncontrolledly even more. The vocal cords react afterwards by swelling up even more.
A vicious circle
Many singers do not believe that singing with swollen vocal cords causes problems because the voice works when the cords are forced together, so the singer keeps on singing and uncontrolled constricting. But the swelling only gets worse the more the singer continues to irritate the vocal cords, especially at the area most affected by the uncontrolled constriction. Eventually this swollen part will stop the rest of the cords from closing properly. This sets up a vicious circle. Only the swollen areas come together which again increases the pressure on the swollen areas which again causes further swelling. At a certain time the vocal cords get a more or less permanent thickening opposite each other at the most swollen area. This thickening gets larger and larger and finally it stops the cords from working. Now the voice fails to the extent that the singer cannot continue her/his career.
The singer sees a doctor who diagnoses ‘nodules on the vocal cords’ or ‘singer’s nodes’. By definition, you talk about nodules when there are swellings on both vocal cords opposite each other.
Voice rest, speech therapy, or operation
If you get nodules it is a sign that something is wrong with your technique. You can try a period of complete voice rest, i.e. no singing, speaking or whispering for 4 – 7 (sometimes 10) days after which most nodules will have disappeared all by themselves. This is usually the fastest way to solve the problem.
You can also be referred to a speech therapist who assists the singer in performing exercises which either reduce the effect of the nodules on the voice or cause them to disappear. This is usually a prolonged process. The throat specialist might also suggest an operation where the nodules are removed from the vocal cords. About ten days after the operation the vocal cords are healed. The singer must not speak or sing during this period.
As a starting point I always recommend singers to take the period of voice rest as it works fast, is cheap, and has no side effects.
Whichever method is used, it is important the singer learns the correct technique so that s/he avoids damaging the voice in the future. Otherwise the singer will become hoarse again, continue to sing on the hoarse voice, get even more hoarse, and the voice fails yet again as the cycle is repeated. This may require another period of voice rest, more speech therapy or another operation.
Hoarseness is the first sign that a singer is going wrong. If you continue to be hoarse or suspect the development of nodules, get a diagnosis from a specialist. If the specialist diagnoses nodules, whether they are early or permanent, there are plenty of things you can do and maybe avoid an operation.
Prevention is better, give the voice a rest
It is better to prevent damage before the voice gets misused and hoarse. If the voice is strained, the vocal cords need rest!
Just like getting blisters, the voice needs rest for swelling to disappear. If you keep irritating the vocal cords they will remain swollen. To get rid of a blister on the foot you should give the foot a rest by not wearing the tight shoes that caused the problem. Treat your vocal cords the same way. Do not speak, let the voice rest and spend a few voiceless days without saying a single word – writing notes to the world.
If you have been diagnosed with nodules on the vocal cords I recommend a period of total voice rest for 4 – 7 (sometimes 10), depending on how established the nodules are. By total voice rest I mean DO NOT MAKE A SINGLE SOUND! Do not whisper because that tires the voice even more than ordinary speech. Even avoid clearing your throat. Give the vocal cords a rest and write notes instead. This method is very effective and has no side effects. Many discover that it is actually a valuable experience not to speak for two weeks. You may find a whole new side to yourself.
If it is absolutely necessary to speak, do so clearly and with conviction with plenty of support and no uncontrolled constriction. It is not a good idea to whisper or be ‘cautious’ because often singers put more uncontrolled constriction on the voice as a result. By doing this, singers often forget all about supporting the voice when they speak quietly, but it is difficult and requires good technique to speak quietly in a correct manner. It is better to add a bit more sound and remember to support well.
Relax the voice
You must avoid uncontrolled constriction in the throat even when you are not speaking or singing. This is also important when the voice is healthy. Try to relax, inhale deeply, and imagine that the throat is opening up during the inhalation. Hold on to this openness when you exhale and generally be careful not to tighten the muscles around the throat.
It is important not to be too worried about the vocal cords. The throat instantly reacts to our emotions. You know the sensation when you are sad: you get an uncontrolled constriction or a ’lump’ in your throat and lose control of the voice. Try to think positively and send happy, warm thoughts to the vocal cords.
Exercise while resting the voice
You do not have to sit still during a voiceless period. You may use steam inhalations and it is a good idea to use the time to work on breathing and supporting exercises as these do not involve the cords directly. You can also work on body awareness and strengthening the muscles to supply you with the stamina to protect your vocal cords in the future. Be careful not to tighten the throat muscles during physical exercise. If you remain focused about your work throughout a voiceless period you will improve your singing technique more rapidly when you start singing again.
After a week or two you should get reviewed by your specialist:
- If the nodules are gone you can start to exercise the voice using correct technique to avoid problems in the future.
- If small areas of the nodules or the swelling remain, you could try a further week of voice rest until they are completely gone.
- In only a few cases, if nothing has changed, may an operation be necessary. But even if it is, the period of voice rest will not have been in vain if you had worked on your technique during the time.
Avoid uncontrolled constriction
When the vocal cords are back to normal, either due to the voice rest, speech therapy or an operation, you must learn to use the voice without the uncontrolled constriction that caused the problem in the first place. If you avoid this straining constriction it is possible to sing without ruining the voice again.
Uncontrolled constriction can be avoided by using the three overall principles. Imagine that you are creating a circus ring, a large opening, or a fortress wall around the vocal cords so they have plenty of room to stretch. The vocal cords can cope with extensive use for long periods of time but CANNOT endure working under the extra strain of uncontrolled constriction.
Too much mucus
If a singer has too much mucous on the vocal cords, it may be because the mucous membranes of the vocal cords are being irritated. When the mucous membranes dry out or become irritated, mucous is automatically produced to protect the cords. You must find the reason for this irritation; it might be due to a slight infection, an allergy, or uncontrolled constriction.
Constantly getting mucous on the vocal cords might be sign of incorrect technique. It is quite common for the voice to protect itself by producing large amounts of mucous, for example after a strenuous performance. If you suspect your technique might be wrong you must remember the three overall principles: use support, use necessary twang and avoid protruding the jaw and tightening the lips.
At the initial stages of an infection you should avoid straining the voice. Sing and speak as little as possible and gather strength to fight the infection. Depending on how ill you are, you may need to see a doctor and get a prescription for antibiotics. If at all possible you should avoid singing when you have a fever.
If the singing sounds as it should, if the singer does not feel any discomfort while singing, if s/he does not feel ill or have any pain in the throat, then too much mucous may be caused by an allergy. Try to find the cause of the allergy. Perhaps you already have a suspicion of what you may be allergic to? When did the symptoms start? What changes might be related to the symptoms? Try to eliminate whichever factor(s) you think may have caused the allergy and observe if your condition improves. Try to find out what your body is sensitive to and avoid it. Perhaps consult an allergy specialist who can test you for allergies.
When you wake up in the morning the voice often sounds ‘woolly’. You have been drawing air back and forth over the mucous membranes all night, maybe you have even slept with an open mouth. This may have dried out the mucous membranes. When you wake up and speak, the dried out mucous membranes cannot make the rapid vibrations which produce a sonorous sound, causing the sound to be husky and irregular – known as the ‘morning voice’.
You should let the natural production of mucous take its course. The mucous membranes will soon be moistened and the voice will sound normal again. If you start to clear your throat which dislodges the mucous off the membranes, they will only produce more to cover the exposed, dry area. This makes some singers clear their throat again, compelling the mucous membranes to produce yet more, which the singer dislodges again, and so on. The singer and the mucous membranes can keep each other occupied like this for the rest of the day.
Clearing the throat
When you clear your throat you dislodge the mucous off the mucous membranes of the vocal cords. It is not damaging to clear your throat. It can be a function of vital importance if mucous is entering the windpipe, but it might irritate the mucous membranes if you do it too often and too vigorously. Instead of clearing your throat to clear mucous let it remain there until it has covered the dry spots on the membranes. Go ahead and use your voice and disregard the woolly sound. Start by humming or speaking, carefully at first, and soon the rapid vibrations of the vocal cords will shake loose the excess mucous. There is another safe way of making excess mucous disappear. Closing your mouth and nasal passage (or block the nose) and at the same time suck inwards and swallow. This creates a partial vacuum that sucks the excess mucous off the vocal cords.
Prevention and Emergency Aid
Even though a singer’s voice might sound as if it is strained or that it has perhaps completely disappeared, it can often be repaired within a few hours. A large part of our work at Complete Vocal Institute is to give ‘Emergency Aid’. This means I am called out to recording studios or concert tours where singers needs help, either with technically difficult assignments or because they have acute vocal problems. What needs doing depends on the circumstances, but first I ask the singer to see a specialist who can make a diagnosis by looking at the vocal cords, using either a rigid or fibre-optic endoscope and ideally stroboscopy.
- Often the report from the doctor is that s/he actually cannot see anything wrong, even though everyone can clearly hear the singer is hoarse and unable to go through with the concert. In this case, just a few hours of working on removing uncontrolled constriction restores the voice as if nothing happened. The support however, will require more physical strength. If the singer is strong and able to supply this extra strength there is no reason why the concert cannot go ahead.
- Often the vocal cords are inflamed and irritated, but there are no distinct signs of damage. Also in this case releasing uncontrolled constriction may avoid further irritation to the vocal cords and allow the singer to fulfil the concert engagement.
- Sometimes the vocal cords show sign of strain, perhaps with developing nodules. There is not much that can be done as the vocal cords need rest! These days, doctors can administer medicines to reduce the swelling for the singer to get through a concert. It is not always to be recommended as the vocal cords ideally need rest and the condition may be prolonged or may be worsened if the singer keeps on singing.
Even very experienced singers can suddenly create uncontrolled constriction around the vocal cords, sometimes to such an extent that s/he can not utter a sound.
Emergency Aid over the phone
Sometimes there is not enough time to get to the singer before a concert so we have to work over the phone. In order to be able to give Emergency Aid over the phone it is helpful to have worked with the singer previously.
The reason for vocal problems
Dried out mucous membranes, too much mucous and bad monitoring systems (loudspeaker systems used on stage so the singer can hear her/himself) can give the impression that the voice is not working as it should and the singer can be knocked off course regarding the technique. When the voice does not respond normally, the singer often compensates with uncontrolled constriction. This uncontrolled constriction hinders the voice in working even more which again can lead to even more uncontrolled constriction.
It is important not to go astray and start this vicious circle where good technique is replaced by uncontrolled constriction.
The importance of physical strength
Often problems occur because a singer runs out of strength. If a singer starts getting tired on tour or during extended recording sessions, s/he will lack the necessary strength to support the notes to avoid uncontrolled constriction. Many singers experience this at the end of a concert. With no more physical strength left the voice feels tired. The uncontrolled constriction puts a strain on the vocal cords and you have to use even more strength to sing with this uncontrolled constriction which is yet more tiring. Typically, the high notes are the first to fail and the volume decreases.
If a singer does not remove uncontrolled constriction by having a good rest and gathering new strength, new uncontrolled constrictions develop. The singer begins to feel hoarse and the hoarseness grows worse over time. Finally, the voice might become so hampered by uncontrolled constriction that Emergency Aid is required to avoid cancelling the rest of the tour or recording sessions.
It is essential to get enough sleep, especially on demanding tours. Without enough sleep the vocal cords do not get time to recover from the irritation that might have developed during the day. Sleep is also necessary for rebuilding physical strength vital to support. How much sleep a singer requires varies. You must know and respect your needs if you want to survive a demanding period.
Eating and drinking
Many singers are flooded with well-intentioned advice if they become hoarse, e.g. “a raw egg yolk with Tabasco”, “warm milk with honey (you know, honey lubricates so well)”, “a few drops of ink taken in a glass of water”, “definitely not chocolate”, “always something hot”, “always something cold” and so on. How is one supposed to know what advice works and what does not? It is not possible to try them all!
If you are familiar with anatomy you will know the vocal cords are at the top of the windpipe (trachea) and that everything you eat and drink enters the gullet (oesophagus), not the windpipe. Food and drink, therefore, never come into contact with the vocal cords unless it goes down the wrong way and you choke. And I have heard many suggestions but I have never heard THAT suggestion! So it is not logical that food and drink should be used to lubricate the voice. On the other hand, certain foods and drinks can have an effect on some singers. It could just be comforting or have a psychological effect. You are the best judge of whether it helps to eat or drink something or not. If you feel that it helps, then carry on as long as it does no harm.
Breathing in steam means that moisture goes straight to the mucous membrane of the vocal cords. If you are hoarse you may ‘steam’ your cords and mucous membranes by inhaling the steam from a bowl of hot water with camomile or other herbs such as thyme added. Experiment to find out what suits you best.
Use a bowl, a large towel, and an alarm timer. Put a handful of camomile flowers into the bowl and pour boiling water over them. Set the timer for a maximum of ten minutes, put the towel over your head and inhale the steam. Be careful not to burn or scald yourself but do not let the water cool off before you put your head above it. Within the first ten minutes various essential oils are released into the steam which are beneficial to the mucous membranes. Inhale through the nose and mouth.
You must wait at least thirty minutes before speaking after the inhalation as it is important to let the membranes rest. When you begin to speak, do it softly to start with. Do not clear the mucous off the membranes, i.e. by clearing your throat. Let it stay even though the voice may sound strange. When the membranes are ready, they will loosen the excess mucous. You may steam the vocal cords as often as you think is necessary, but remember not to speak for thirty minutes afterwards. Let the excess mucous remain until it loosens itself and stop the steaming approximately four hours before you have to sing.
Alcohol can make singing more difficult as it dilates blood vessels. After a big ‘night out’ the whites of your eyes often turn red because blood vessels that are not usually visible dilate and become visible. The blood vessels in the mucous membranes of the vocal cords also dilate and the vocal cords become slightly swollen. Some singers will experience this as increasing difficulty and requires more strength to reach high notes.
How much alcohol a singer can take before their mucous membranes swell varies from singer to singer. Some are aware of difficulties after just a couple of beers, while others seem to be able to drink inconceivable amounts without problems. You must get to know your limits and respect your body’s warning signals.
When smoke is inhaled it comes into contact with the mucous membranes of the vocal cords causing them to become irritated and dry increasing the likelihood of developing uncontrolled constriction. Avoiding smoke is difficult in the music business. How different mucous membranes react to smoke varies a great deal. I know singers who cannot tolerate a single cigarette and others who inhale cigars all day long with no audible effect on their voices. You must know your limits and respect your body’s signals.
I must emphasise that I do not recommend that singers smoke but if you are a smoker, you should be aware that it is not necessarily a good idea to stop just before an important assignment such as a studio recording or a tour because also the sudden ABSENCE of smoke may have an intense effect on the voice of a smoker. If the mucous membranes of the cords are continuously exposed to smoke they compensate by producing more mucous to counteract the drying effect of the smoke. As a result the balance of the smoker’s mucous membranes are maintained. If you then stop smoking the cords will continue to produce the same amount of mucous but this will now be too much as there is no drying effect from smoke. Therefore there will be too much mucous and the cords will be harder to control. This means that even though a singer may want to give the voice extra favourable conditions in preparation for a demanding job it may be counter-productive.
All things being equal a non-smoker is generally healthier than a smoker, not only their voices, so there are definite advantages to quitting smoking. The voice’s adaptation to new conditions is variable and can take anywhere between a few weeks to three/four months.
Stick to correct technique
The best you can do as a singer, whatever challenges you are subjected to, is to stick to techniques you are familiar with and KNOW work. Even if the voice does not sound normal, keep using your technique. If you are becoming hoarse and the notes require double the normal amount of strength, give them double the support and maintain the sensation of singing without uncontrolled constriction. Likewise, if the monitoring conditions are bad, you should do as you usually do. Try not to sing more powerfully just because you cannot hear yourself. Get used to singing more on the basis of the physical sensation of correct singing rather than just on what you can hear. That way these hurdles will not lead you astray.