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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CHECK UP
Programme no: 7 - The Voice
RADIO 4
THURSDAY 03/01/08 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
RUTH EPSTEIN
PRODUCER:
NOT CHECKED AS BROADCAST
MYERS
Hello. People who use their voice professionally, like singers and actors, expect to look after it, the rest of us don't pay that much attention to our voice until it begins to let us down. Now if you've got a cold and you lose your voice, that's not such a big deal, but what if your voice is croaky most of the time? Persistent hoarseness should never be ignored, it could be the sign of something more serious. More often though you may feel that your voice is simply letting you down - it's sounding wobbly and frail, there's not enough volume or range.
Well if you've got questions about looking after your voice or how to get treatment for it you've come to the right place. In the Check Up studio with me today is Dr Ruth Epstein, she's a consultant in voice disorders at the Royal National Throat, Nose and Ear Hospital here in London.
Our first caller has joined us, he's in London too, he's Malcolm and he's a lecturer with a problem with his voice, so what's the problem Malcolm?
MALCOLM
Well good afternoon. I lecture at a university in London that requires lecturers to do quite a lot of teaching to different size groups and that can range from a 180 students in an auditorium size room to a middle range group of 40-80 students to smaller tutorial size sessions. And some of these rooms have microphones and some don't and occasionally the microphones actually aren't working. So my main strategy to preserve my voice is to take into lectures a mug of Earl Grey tea and occasionally sip that during lectures. But what I notice is that I'm now 57 and at the beginning of term I have fits of coughing as lectures begin that appear to disappear after a few weeks of using my voice. So my question to Dr Epstein is are there better strategies to preserve the vocal cords than relying on Earl Grey tea?
MYERS
What about that - is Earl Grey tea the answer or is there something a little bit more useful do you think in this case where Malcolm's got a lot of lecturing to do to various groups?
EPSTEIN
Right. First of all Malcolm is what I would classify as a professional voice user, in other words he uses his voice for his livelihood. As such his profession makes him already quite vulnerable from a vocal point of view and I think that one thing that he's done, which is very well, is first of all to be aware of how his voice responds to the needs of his profession. Earl Grey is not the ideal answer, I'm afraid. What I would say instead of Earl Grey you could try to take frequent sips of water, in other words my recommendation would be for you to sip water approximately every 10 minutes or so and through the day my expectation would be that you would go through approximately a litre and a half to two litres of still water per day. The impact of both tea or coffee is in fact quite damaging or negative as far as the voice production is concerned, simply because both coffee and tea are diuretics and as such you will not retain a lot of the liquid that you are taking in and in other words so you would not benefit from it from the point of view of hydration and lubrication. And also if you take too much coffee and tea it could result in problems such as stomach reflux - acid reflux.
MYERS
Okay, let's leave it at that for the moment. Malcolm thanks for the call, stay listening because Katya joins us, she's also in London, uses her voice as a professional voice user, she's an interpreter and again is interested in how to use her voice in an easeful way so that she doesn't end up perhaps going hoarse. So what are you finding when you've been talking all day and every day Katya?
KATYA
Yes hello. Interpreters tends to use our voices very, very, very much for prolonged periods of time and for instance in normal conversation when two people are talking there will be a natural pause when the other person is talking but if you're an interpreter you talk all the time and this can go on often for 10 sometimes 12 hours at a time in our job.
MYERS
What effect is it having on your voice would you say?
KATYA
I tend to lose my voice very easily - four or five times a year - at the slightest cold I lose my voice for up to three or four days at a time.
MYERS
Let's ask Ruth to comment on that, I mean that is using the voice a lot - I take the point about it if you're an interpreter you have to keep talking - is there anything Katya can do to make sure that she doesn't keep losing her voice?
EPSTEIN
Well partly I think Katya's problem is mainly the high vocal load, in other words the burden on her voice again being a professional voice user. In Katya's case I would say, again, same advice as I gave Malcolm and the other thing is to give her voice downtime, in other words frequent periods of voice rest because she's using her voice continuously like an athlete, and you are in fact a vocal athlete, you need some pause, you need some rest and you need to make sure that your throat is well hydrated and when you socialise to try and also think about not socialising in places where you will be competing against background noise.
MYERS
Well I don't know whether it's realistic though is it to not speak for a day or a week - how long would you need to rest your voice? I've got another e-mail here, which is - if I can throw this in at this point - from a caller who's speaking on behalf of her daughter who's got a sore throat. She knows it's caused by over-using her voice - she shouts and sings as a cabaret performer, or has done. And the question comes: Should my daughter be resting her voice for a long period, would that help? Is that the answer - do you need to literally convalesce when you've been straining your voice?
EPSTEIN
I would say that the answer is not as clear cut as this simply because research that was done into this area has shown us that just resting the voice and doing nothing else is not going, in fact, to resolve any problems. Similar to an athlete who might have a swollen ankle, if he was just to sit on a couch and not move for 12 or 24 hours once he starts walking or sprinting again the problem will come back. In other words what we're talking about is really common sense. If in a period of an hour if we can actually have about 10 minutes of voice rest and to do this frequently, we also - it's not only just a voice rest it's what we do with our voice in the interim. So, for example, if the person clears the throat this excess throat clearing could also have a damaging impact and to cause hoarseness. And of course there's a lot to be said about the technique that we will touch upon I'm sure later on.
MYERS
Well let's bring in the question of throat clearing because Mary is calling from Stratford and I think that's something that's bothering you, a constant need to clear your throat, what's actually happening there Mary?
MARY
Hello, good afternoon. I noticed a few years ago that I needed to be clearing my throat a lot before I started speaking and especially if I haven't spoken for half an hour or so. As I work from home and use the telephone a lot it can be a problem because I sound like I have a heavy cold until I've actually gone through that process of clearing my throat. I realise that the problem is probably catarrh but as it is so persistent and not linked to having a cough or a cold necessarily I'd love to know what the remedy is, apart from Earl Grey tea I suppose.
MYERS
Well Earl Grey tea was not recommended - sips of water apparently. Ruth what would you say then?
EPSTEIN
Okay. Well throat clearing can in fact result in trauma to the vocal folds, so this is quite a bad habit that we try to discourage people from using but I do appreciate that sometimes we clear our throat and most of the time we tend to clear our throat spontaneously because there is no other way for us to be able to carry on using our voice. The reason for people to clear the throat can be multi-factorial. First of all it could be as a result of allergy to various substances or to dry atmosphere, it could be related to poor hydration, it could be merely habitual because we know that it works and what else can we do from clearing our throat and it also could be as a result of reflux. The actual treatment or the recommendations - simple straightforward recommendations - would be to try and take a sip of water when you - rather than clearing your throat try to take a sip of water. Another strategy would be to swallow hard - long hard chin tuck swallow - to try and clear the need or just get rid of the need to clear the throat again. Steam inhalations may also be useful, especially if you've got a cold, so if you just - warm water or if you just have a steam shower for the best part of five minutes, this would be another very useful strategy. And if indeed we see that the problem does not go away you should be tested for either allergies or to try and find out whether indeed the problem may be reflux.
MYERS
Can you say a little bit more about reflux, you've mentioned that, this is where acid comes back into the throat, could that be the cause of the mucus that you're trying to clear away - or Mary does - when she coughs?
EPSTEIN
Yes indeed. In fact reflux occurs when acid, like you said, from the stomach flows back into the gullet or the throat which irritates the sensitive lining of the throat and can affect your voice. In fact most of us - reflux and we're not even aware of it. Reflux may occur during the day, during the night but most people are likely to perhaps experience symptoms after meals. Some of us would experience it after eating particular substances, such as very fatty products or fried food or a variety of other substances that place a burden on our digestion.
MYERS
Let's just ask Mary, if you're still there, whether you think that that might be something that might explain this need to clear your throat all the time?
MARY
I can't particularly say that I do because I have the feeling that there is catarrh there all the time, I mean is that the feeling I could expect to have with reflux?
EPSTEIN
Yeah. In fact what you would - one of the symptoms that we look at would be persistent throat clearing, excessive throat mucus and sometimes people feel that they've got like a lump in the back of the throat. Indeed when we examine them we don't see a lump there but the lump is there because they keep contracting the muscles of the throat when they swallow or when they throat clear and this can give you this symptom.
MYERS
So are you saying Ruth then that you see this a lot in clinic and it is reflux and you have to deal with that - with the acid regurgitation, you can do - give medicines for that of course?
EPSTEIN
Yeah, in the event that it is reflux what we do is we first of all give some people some advice about simple changes that they can make in their diet and lifestyle, such as eating small quantities rather than large but frequently, avoiding excess intake of coffee and tea, addressing smoking habits if indeed they smoke, not to dine too late at night and of course alcohol can also have an impact on reflux. If appropriate we recommend for them to take a course of antacids and in the event that they do not respond to all these interventions this will lead to a referral to a specialist - a gastroenterologist.
MYERS
I've got another e-mail wondering whether acid reflux can actually cause permanent damage to the vocal folds - could that be the case, could you sort of acid burn them?
EPSTEIN
Well it can cause irritation, we've seen some redness, it can sometimes lead to the formation of lesions such as granulomas but - and in some research that was carried out it was - there is an indication that it may even lead to carcinoma, to cancer. But I think that we're still looking to see more kind of conclusive research on that.
MYERS
Let's go to another caller, we've got John waiting to speak to us, he's in Milton Keynes, and he's got an older voice and is a little bit worried about it, John tell us a little bit about it.
JOHN
Oh good afternoon to you both. I'm John and I'm 71, I was an engineering lecturer for 25 years so I had to speak over these machine tools most of the time and I gave the job up in 1993. And the problem as you can hear is my voice is getting more weedy and when I use the phone everybody thinks I'm a lady. I do drink a lot of water, mostly boiled water, I don't drink a lot of tea or coffee.
MYERS
Right let's see if there's any expert advice to help with what you feel is a sort of weedy - weedy voice, a reedy voice, whatever. Ruth, if John wandered into your clinic what would you be doing for him?
EPSTEIN
Okay, I think that what John complains about is in fact a high pitched voice quality which he does not feel reflects his appropriate sex, in this particular case, especially on the telephone when there is anyway sort of some distortion of the voice. And indeed as a clinician I would carry out a variety of instrumental assessments which will allow me to have an idea of the mean fundamental frequency. And if indeed we find that the mean fundamental frequency is inappropriate in this case I think that I would recommend for John to be assessed at a local voice clinic and if appropriate he would benefit from some trial of voice therapy, which means some voice exercises carried out by a speech and language therapist who is specialised in voice. And also possibly a consideration of a minor surgical intervention, phono surgery, by a specialist surgeon who is used to dealing with voice disorders to slightly augment or change the tone or the actual tightness of the vocal folds. In other words to make them slightly shorter.
MYERS
So in fact there is actually plenty you can do if you do go along to a voice clinic. I mean I don't know, John, whether you're concerned enough to go to a clinic and try and get it sorted, would that interest you or do you feel it's just something you've ended up with perhaps as a result of trying to have to speak over machinery, I think you said, in the past?
JOHN
I would actually like to go to a voice clinic and see what they could do yes.
MYERS
Well so it's not a matter then Ruth of just saying to someone like John, well okay you're over 70, it's no great age these days, but I'm afraid you just have to live with it, your voice does change as it gets older, I mean I think it does change doesn't it, we can agree that...
EPSTEIN
Yes indeed.
MYERS
So a man's voice would tend to go a little higher, a woman's voice a little bit lower.
EPSTEIN
Absolutely so but I think that in the event we can actually hear exactly what John's problem is - I'm sure the listeners can share the same impression - so I think that rather than just accepting it as a natural outcome of the ageing process, which indeed it may be, I think that he would benefit from going and seeing the specialist at the voice clinic.
MYERS
John, I hope you follow that through, thanks for your call. We'll go to another caller now and we've got Sylvia - Sylvia I think is also concerned about the ageing voice, what's it doing to you?
SYLVIA
Well I used to be a singer but now when I open my voice and try and sing I get this horrible sort of [indistinct word] mangled sound that comes out, I can't actually focus on a pitch.
MYERS
I don't suppose you'd like to give us an example?
SYLVIA
No I'd rather not.
MYERS
Okay, fair enough.
SYLVIA
But it sort of wobbles and I don't seem to have any control over the vocal cords at all anymore.
MYERS
And do you enjoy singing or did you enjoy singing?
SYLVIA
Well yes I used to very much indeed but I wouldn't dare open my mouth now.
MYERS
Which is a shame because if you are enjoying singing what a thing to lose.
SYLVIA
Yes absolutely.
MYERS
Well let's see what Ruth's got to advise.
EPSTEIN
Okay. Well indeed first of all I think that I would encourage you to continue to sing and at least pursue your ability to sing, simply because that's quite good exercise for the vocal folds especially as far as the ageing voice is concerned. It increases stamina, it's like you know vocal aerobics. However, I do understand and appreciate that you're used to hearing a certain type or quality of voice and the current voice does not sound acceptable. So again my advice to you would be either to perhaps have a few singing lessons with a singing teacher or indeed again you would benefit from consulting the specialist at a voice clinic because we can again examine the vocal folds and then if appropriate either recommend voice therapy in the form of voice exercises to enhance things like breath support and control, in other words to remind you of some breathing exercises that you can use as warm up and cool down exercises in your daily routine. And indeed to give you some exercises to improve the tone and the closure of your vocal folds.
SYLVIA
Does the voice also get lower, I mean I used to be a contralto but I think I could probably quite cheerfully join the bass section of a choir now.
EPSTEIN
Yeah. As we mentioned before one of the effects of ageing on the voice in females is the lowering of the vocal pitch, yeah.
SYLVIA
Yeah, okay many thanks.
MYERS
Thanks for your call. And you - Ruth of course you're running a specialist clinic here in London but there are specialist voice clinics I think throughout the country.
EPSTEIN
Oh absolutely, there are approximately 102 - over a hundred clinics now throughout the country and there is also the British Voice Association that anybody can access over the internet with a lot of information about where to and how to access specialist voice clinics around the country.
MYERS
And we'll give some details about that in a moment. But let's go to Pamela who's been waiting patiently to talk to us about something that she's found helpful, can you explain Pamela?
PAMELA
Well when I was a teacher and in my late 50s I would be in front of the class and teaching music, would you believe, and my voice just used to disappear and I had great difficulty in keeping it going even perhaps as long as I'm speaking to you now. And I accidentally found an Alexander teacher and I went there and quite frankly it was complete magic. I don't know how many people know about the Alexander technique but basically it gets you to reassess the way you breathe and hold yourself, there's no drugs, there's no physical jerks involved although you do need a teacher. And it teaches you to think a lot about how you hold yourself and how you breathe and the effects were amazing. As you can see I can keep talking to you but there are other benefits as well. For instance, I used to wake up with my teeth clenched - all that tension has gone.
MYERS
Ruth is nodding in recognition of what you're saying, obviously it really has helped and so this is a therapy that you'd be happy to recommend, it's considered a complementary or alternative therapy but very useful?
EPSTEIN
Yeah I would like to congratulate Pamela for bringing up this point, simply because posture is of great importance for voice production and indeed interestingly for some of the listeners who may not be aware of it Alexander himself was an actor who kept losing his voice and on the back of this he basically invented the Alexander technique which deals with body - appropriate body alignment and indeed it is good for voice disorders, it is also good for people with back problems, with poor posture, for musicians, for athletes and so on.
MYERS
And what is it about getting the right posture, is it to do with the breathing, is it to do with the way the vocal cords are held in - what is it about posture?
EPSTEIN
It's basically to do with - more with the musculoskeletal system, in that what we need to do is to keep the shoulders down, we need to sort of be aware of not tucking the chin down or extending the head forward. We've done quite a lot of research at the Royal National Throat, Nose and Ear Hospital which demonstrates that postural issues can indeed result in muscle tension dysphonia, which is in fact voice disorders that are there simply because of poor posture and excess musculoskeletal tension being put on the small laryngeal muscles. So what we need to do is enhance the understanding that we need to use, for example, the large abdominal muscles, stomach muscles, to help support the small muscles of the voice box. Most of us tend to use the small muscles of the voice box to support themselves and when they get tired this is when we run into trouble.
MYERS
As you're speaking I am altering my position and trying to sit properly. Thank you for that. Let's got to Angela in Fareham who goes hoarse in noisy situations, what sort of situations are bad for you Angela?
ANGELA
Well I work as a volunteer walk leader and I have to run evening activities. Now this includes calling for country dancing and the problem is I cannot make myself heard over the music and I end up going hoarse. Now I was wondering are there any exercises that I can do to improve the strength and the projection of my voice?
MYERS
Ruth.
EPSTEIN
Indeed Angela there are but before I tell you about the exercises I would like just to recommend perhaps that you consider using personal amplification, which I think would be my advice to Malcolm, the lecturer who called us earlier. There is interestingly recent research has shown us that a lot of people who are professional voice users, such as teachers, lecturers, auctioneers, lawyers, tend to suffer from voice disorders simply because they need to project their voices for a long period and sometimes to strain it against background noise, which is the case that you're describing here. So in the first instance I would recommend that you try to make some enquiries about using regularly a personal amplifier so that you do not need to strain your voice against background noise and that other people can actually hear you quite easily. And with regards to exercises there are in addition to things like relaxation of the head and neck, shoulder exercises, you can also think in terms of doing some breathing exercises. And this is merely an exercise where you simply take a breath in through the nose and very gently let the air out through the lips on a ... like a long hissing sound. And what you want to think about is the longer duration - increasing the duration of the sound while avoiding making any vocal effort.
MYERS
And there we run out of breath, we will have to leave it, we've run out of time of course. Thank you very much indeed to everyone who has phoned and e-mailed and thank you to my expert guest today Ruth Epstein. If we haven't managed to answer your question then feel free to contact our confidential help line, the number is 0800 044 044. You can of course as usual get more information from our website that's at bbc.co.uk you follow the prompts to Check Up where you can listen to this whole programme again or you can download it as a podcast.
Next week I hope you'll be joining us we'll be taking calls about polycystic ovary syndrome. It's the last in the current series of Check Up, that's next Thursday at 3 o'clock.
ENDS
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