.png){kind=small}
.png){kind=small}
BackTable / ENT / Article
Treating Voice Disorders: Vocal Hygiene, Voice Therapy & Medications
Iman Iqbal • Updated Jan 20, 2025 • 35 hits
Treating voice disorders often requires a multifaceted approach, as the underlying causes of vocal issues can be diverse and complex. While some patients may benefit from simple voice therapy and better vocal hygiene strategies, others may require additional interventions, such as physical therapy, medications, or even surgery.
From understanding the nuances of muscle tension in the cervical region to determining the best course of action for vocal pathologies like polyps and cysts, proper diagnosis and tailored treatment plans are essential. This article details the various treatment options for voice disorders, including voice therapy, surgery, medications for allergy-related voice issues, and the importance of vocal hygiene in maintaining long-term vocal health.
This article features excerpts from the BackTable ENT Podcast with otolaryngologist and voice disorder expert Dr. Mark Williams. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Staying hydrated with regular water intake is vital for maintaining healthy vocal folds. Caffeine, spicy foods, and reflux can negatively affect the voice, so these should be monitored.
• Excessive muscle tension, particularly in the neck and shoulder area, can contribute to voice problems and even swallowing difficulties. Voice therapy is typically the first line of treatment, with physical therapy added if needed.
• Vocal nodules do not require surgery in most cases and can usually be treated with voice therapy, while vocal polyps and cysts usually need surgical intervention.
• Voice therapy addresses vocal issues, not speech disorders like stuttering.
• The first step in treating allergy-related voice issues is controlling allergens through nasal steroid sprays, with oral antihistamines used cautiously due to their drying effects.
• First-generation antihistamines like Benadryl should be avoided, while second- and third-generation antihistamines are less drying but sometimes less effective. Singers are treated more conservatively with medications like Singulair.
• Voice rest is often recommended after surgery, with specialists typically suggesting up to a week of rest.
Table of Contents
(1) Key Aspects of Vocal Hygiene
(2) The Role of Voice Therapy in Treating Voice Disorders
(3) Microlaryngeal Surgery vs Voice Therapy
(4) Managing Allergies in Voice Disorder Treatment
Key Aspects of Vocal Hygiene
Vocal hygiene is crucial for maintaining healthy vocal function and preventing voice disorders, especially for those who rely heavily on their voice, such as singers. It starts with staying well-hydrated, as water is essential for vocal fold health. However, drinking water just before singing isn't as effective as maintaining consistent hydration over time. Bubbly or carbonated water is generally not harmful, but plain water is preferable. Caffeine consumption should be monitored as it can dry out the vocal folds, especially for those who are not regular caffeine drinkers. Diet and lifestyle also play a role in vocal hygiene, particularly avoiding acidic, spicy, and greasy foods and refraining from lying down after meals to prevent reflux, which can irritate the vocal folds. While moderation is key, it's important to understand how certain habits and foods may affect the voice and make informed choices accordingly.
Physical and mental well-being also contribute significantly to good vocal health. Regular exercise and mental health care help with overall vocal performance. In some cases, voice rest may be necessary, especially post-surgery. While there is some debate in the field, many voice specialists recommend up to a week of voice rest following surgery, though this can vary. Interestingly, some cultural and linguistic factors may influence voice recovery, with certain speech patterns potentially leading to complications like cyst recurrence if not managed properly.
[Dr. Gopi Shah]
Talk to us about what is meant by vocal hygiene. Does that drink a lot of water?
[Dr. Mark Williams]
Drink a lot of water.
[Dr. Gopi Shah]
Oh, and don't talk? What does that mean?
[Dr. Mark Williams]
That's usually what it means for me. I try to keep it simple. [laughs] Just drink a lot of water and do your exercises. Exercise the voice. It's a wide range of things. It's drinking plenty of water. Obviously, that's the number one place is make sure that you stay well hydrated. I'm amazed at how many singers every time I go to speak at a conference or something with singers, they always want to grab a bottle of water right before they sing. I'd say, this is not the time to drink it. You can drink it now if your mouth is dry. Your goal is to have this homeostasis, a steady state of hydration. Just drinking this water right before you sing is not very helpful for you. Drinking the water--
[Dr. Ashley Agan]
Speaking of water, what about bubbly water? Does that count, or are we talking about just straight up water?
[Dr. Gopi Shah]
Can we get a Topo Chico going or is it just still flat, doesn't matter?
[Dr. Mark Williams]
There are three categories. There are things that are definite no's. There are things that are definite yes, like water. Then there are things that I say, it may help, may not help and it may not harm. As long as it doesn't harm, I don't know that the bubbly water that there's any scientific evidence that I'm aware of, at least that carbonated water will impact the vocal folds. I prefer it just be regular water instead of even, for that matter, the water sweeteners or flavors that you put in. If it's not going to cause any harm, if that's the only way you're going to get the water in, I'd rather you get it that way.
Then the caffeines. Then there's a whole discourse of whether or not caffeine really has an effect on the vocal folds. The academicians are debating this now, whether or not. If you're used to drinking caffeine all the time, then drinking caffeine is probably not going to be harmful to your voice. If you're not a regular caffeine drinker, then obviously you take a big caffeine load, it dries the vocal folds out. These are things that my response is, it's better to just avoid the caffeine. If you can, just avoid the caffeine. That would be part of vocal hygiene.
Watch what you eat and when you eat and how much you eat. For my patients, I'm telling them, try to avoid lying down within three hours of eating. If you have to sleep, sleep with the head of your bed elevated, let gravity help prevent some of the reflux. Avoid the spicy, greasy, acidic foods. They hate it when I tell them to avoid the alcohol, all those things that can contribute to reflux.
For me, for a really great Friday night, a happy hour. I usually say take all things in reason. Take all things in moderation. It doesn't mean that you can never have these things. I would never go that far, but understand where your voice is and understand the impact of some of the things, your behaviors, some of your diet and lifestyle, how those things impact your voice. You have to make the determination whether or not it's worth being very extreme about it or if you can get by with a couple of cheats here or there.
There was another thing that I was going to say about voice hygiene that we often don't think about as it relates to voice hygiene, but I think it is just mental health and staying in good physical shape. Staying in just good physical shape, obviously, if you can't breathe, you can't sing. Keeping good physical and mental health, those are things that I think do contribute to helping to maintain good voice production and good voice performance for those of us who depend on those.
[Dr. Ashley Agan]
When do you have to tell somebody to do voice rest and how long do you tell them to do that for? Does that mean you can't talk at all? Does that mean a couple of days, a week? How does that play or how do you tell them to do that?
[Dr. Mark Williams]
That's an evolving area of voice science as well, and you've got different voice specialists who practice differently. There's a general consensus that nobody should be on voice rest for longer than one week. Certainly after surgery, I usually do put my patients on voice rest for one week. There's evolving thought to say, two days is probably long enough, and some people say, maybe you shouldn't put them on voice rest at all. You should just immediately get them back to using their voice.
I haven't gotten that courageous yet, so I still like to see that my patients are on voice rest. Complete voice rest, no whispering for a full week. I find that it works best after their surgeries, just maybe more anecdotally. Now, do all of my patients comply with that? Of course not. You get people who are still speaking right after the surgery, and they heal just fine as well.
Although, I will say that I have noticed some cultural differences in the way that people who speak different languages, how they talk. Certain languages require a very guttural and forceful phonation that I see if they start talking after the surgery, just because of the way that they normally talk in their language, it can start causing poor healing.
I've got particularly one patient who I find that I'm going to have to take back to the operating room because she talks the exact same way now that she talked before we removed the cysts. Guess what? She's got a cyst again. I'm saying, how do you change this cultural or language problem that's contributing to the voice disturbance? I just don't have a good answer for that one.
Listen to the Full Podcast
Stay Up To Date
Follow:
Subscribe:
Sign Up:
The Role of Voice Therapy in Treating Voice Disorders
When evaluating patients with voice disorders, muscle tension is a common issue, particularly in the cervical region. In some cases, patients experience excessive tension not only in the laryngeal muscles but throughout the neck and shoulder area, which can contribute to voice problems and even swallowing difficulties (dysphagia). For these patients, voice therapy is typically the first step, with the voice therapist often identifying the need for additional physical therapy. If the tension is severe, particularly if the patient is also complaining of neck pain (cervicalgia), a referral to physical therapy may be made. The voice therapist usually plays a key role in assessing whether physical therapy is necessary and can request the referral if appropriate
[Dr. Gopi Shah]
For your mentioned patients, in addition to voice therapy, do you ever send them to physical therapy or for a massage or anything like that?
[Dr. Mark Williams]
Occasionally, we do have some patients who have horrible muscle tension. It's not just in the extrinsic muscles of the larynx, but the entire cervical group of musculature and their shoulders there really need some additional physical therapy. I've even had several patients who've had problems with dysphagia because they've had so much tension in the neck. Usually, most of-- I send them to my voice therapist first and my voice therapist is usually the one who will request that they see the physical therapist afterwards. Then I'll just make the referral after that. Unless, of course, they're presenting with complaints of cervicalgia.
[Dr. Gopi Shah]
That's similar to what we see in our practice too.
Microlaryngeal Surgery vs Voice Therapy
The decision for microlaryngeal surgery is primarily guided by the type of vocal pathology present. Vocal nodules typically do not require surgery and can usually be treated with voice therapy. On the other hand, vocal polyps and cysts almost always require surgical intervention, as voice therapy is not effective for these conditions. Occasionally, there may be cases where distinguishing between a cyst and a nodule is challenging even with advanced imaging techniques like rigid or video laryngoscopy. In such cases, voice therapy is often attempted first. If there is no improvement, surgery is pursued, and further examination may reveal that the issue was a cyst, which appeared similar to a nodule.
When discussing voice therapy with patients, it's essential to clarify that the therapy is aimed at addressing voice issues, not speech disorders like stuttering. Many patients may initially misunderstand the purpose of voice therapy and need reassurance that they will be performing exercises that may seem unusual but are effective. Emphasizing the importance of compliance with the exercises is crucial for achieving optimal results, as patients may initially doubt the benefits of certain techniques. Voice therapists are well-trained and can guide patients back to vocal health with consistent and dedicated practice.
[Dr. Gopi Shah]
What are the indications for microlaryngeal surgery? How do you know which singer needs to go?
[Dr. Mark Williams]
It's all dictated by the pathology, I think. Vocal nodules rarely require surgical intervention. Usually, those can be addressed with voice therapy. The other end of the spectrum is vocal polyp, it's almost always going to require surgery. That voice therapy is not going to be helpful for it. Vocal polyps and cysts, those are definitely going to require surgery. Then occasionally, we'll have vocal nodules. We have to do something for vocal nodule.
Truth of the matter is sometimes even with a rigid laryngoscope, video laryngoscope, it's difficult to distinguish a cyst from a nodule sometimes. If I look at a patient and I think they may have a cyst, I'll send them to voice therapy first and see if they get better. If they don't, then I'm taking them to the operating room and say, oh, yes, that's why, because it was a cyst with some reaction on the other side to make it look like a nodule.
[Dr. Gopi Shah]
In regards to voice therapy, what's your spiel when you're talking to patients about sending them for voice therapy? Because I feel like sometimes I'm like, "Oh, we're going to send you to our speech therapist, voice therapy, it's going to help. You're going to get better. It's going to be great." Then they're just looking at me like, what are you talking about? What does that even mean? [laughs]
[Dr. Mark Williams]
I slip up often and say speech therapy. When I say speech therapy, my patients immediately go to stuttering. "I don't have a stuttering problem. I'm articulate." They're thinking about articulation disorders as opposed to a voice issue. I try to remember to use the word voice therapy in that regard. I also forewarn them that they will have to do some-- they'll probably require that the patient do some exercises that seem silly. They probably seem like it can't possibly do anything.
I encourage them just still to remain compliant, no matter how silly the instructions seem to you. Because if you really want to get better, you have to be compliant with their recommendations. They really do know what they're doing and really can help nurse you back to good voice health.
Managing Allergies in Voice Disorder Treatment
When treating patients with voice disorders related to allergies, the primary goal is to manage the allergens and prevent the drying effects of certain medications, particularly antihistamines. The first treatment step usually involves nasal steroid sprays, which are preferred over oral antihistamines for their targeted effect and minimal systemic side effects. If these don't suffice, nasal antihistamines may be added, and if needed, further allergy testing and immunotherapy might be considered.
The use of oral antihistamines is approached cautiously due to their drying and sedating effects, particularly first-generation antihistamines like Benadryl and chlorpheniramine. These are generally avoided unless necessary. Second- or third-generation antihistamines like Allegra and Claritin are less drying but may be less effective in controlling allergies for some patients. For singers, an even more conservative approach is taken, with a preference for medications like Singulair before resorting to oral antihistamines. The overall goal is to reduce dependency on allergy medications and work toward long-term desensitization through allergy treatments.
[Dr. Gopi Shah]
Just moving on to maybe treatment options, we talked about some different things that you see, postnasal drainage and laryngopharyngeal reflux. Can you talk about different treatment options that you're using in your practice? Particularly, I would be interested to hear how you counsel your mucus patients. [laughter]
[Dr. Mark Williams]
Interesting, because we get a lot of patients in who will come in with allergies. Being here in Nashville, allergies are a huge problem for us down here. Number one is any patient who's having voice issues, I want to get their allergies under good control. Even if it's not directly contributing to their voice issue, I think that if you're not taking care of all this resonator, you're not going to get the best voice that you can possibly get anyhow. If you didn't present to me with that complaint, I'm screening for it as well and make sure that I initially start off with just a nasal steroid spray.
I'm a big fan of the nasal steroid sprays. I prefer that they use that over an oral antihistamine any day. In fact, before I put you on an oral antihistamine, I'll put you on a nasal antihistamine if the nasal steroid is not sufficient alone. By the time I have you on a nasal steroid and antihistamine sprays, if you're still having problems, we need to be allergy tested. I need to get you tested. We'll perform the allergy testing and look at getting people started on immunotherapy if appropriate.
The goal is I like to avoid as many antihistamines as possible, whether they're nasal or especially oral. Of course, the first generation antihistamines, I really try to keep all of my patients away from the diphenhydramines, chlorpheniramines and the over-the-counter cold and sinus medications like Tylenol or Advil. I try to keep them away from that one at all costs.
Now, some of the second or third generation antihistamines, the Allegra's, the Claritins and Xyzals, all of those have a less drying effect, but often they're less effective in controlling the allergies for our patients. Unfortunately, we sometimes have to get patients on some of those more drying and sedating courses, but we have to control the allergies however we can.
My goal is to have a long-term perspective with treating that. I counsel the patients to say, listen, we don't want to keep you on these drugs all the time because they will impact your voice. Our goal is, gradually, to get you desensitized to those allergens. That's how I approach it with allergies, first starting with the nasal steroid sprays and then adding in an antihistamine spray. I may allergy test you even before I add the antihistamine spray into it. My last resort is going to be something like Zyrtec or/and then Benadryl even beyond that.
If I had to put you on an antihistamine, I'm usually starting with a Singulair, especially a singer, I'd much rather add Singulair. I know it probably won't do very much good, but if you are a singer who's already having voice problems, before I even put you on an Allegra, I'd really rather put, as a third line, something like Singulair and see if we can get some results with it. Because if we can't, then we just, of course, have to move over to an oral antihistamines. Yes, I discriminate against our oral antihistamines.
Podcast Contributors
Dr. Mark Williams
Dr. Mark Williams is a practicing Otolaryngologist at his solo practice, Ear, Nose & Throat: Specialists of Nashville.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, August 3). Ep. 28 – Music, Medicine, & Ministry [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
Diagnosing Voice Disorders: An In-Depth Guide