What is Voice?

What is Voice?

Voice is the sound wave that makes speech and words to form language. Our voice is as unique and individual to us, as our own personality. Tone of Voice is profoundly more powerful and efficient at conveying meaning, than the actual words we speak. Words actually convey less than 10% of meaning. When we speak about voice we are referring to the movement of air, passing through tiny, flexible, rapidly vibrating muscles (vocal chords) that produce sound in the voice box (Larynx) in the throat. The voice box (larynx) is made of cartilage, muscle and mucous membranes, sitting at the top of the windpipe (trachea). See what normal phonation looks like below: (Sean Parker Institute for Voice)

When we speak about voice we are referring to the movement of air, passing through tiny, flexible, rapidly vibrating muscles (vocal chords) that produce sound in the voice box (Larynx) in the throat.

There are three main systems involved in voice production and each system is equally important.  Voice production involves the synchronisation of over 100 muscles in the body, it is dynamic and complex. It involves breathing using your diaphragm. As air moves up from the lungs, it brings the vocal cords together causing the vibration of the vocal cords to make sounds. These are then shaped into words by the cavities of the mouth and nose. 


Our voice is designed to last us a lifetime with due care and respect, however a range of variables can affect it. If your vocal cords become inflamed, develop growths or become paralysed they won’t work correctly and you may develop a voice disorder.

We know that some people are more likely to develop voice problems due to physical, emotional, personality, occupational factors and illness.  Vocal changes such as hoarseness (breathy, rough, raspy or strained sounding voice) or vocal fatigue (voice sounds normal but may be effortful to produce daily and very tired after prolonged speaking) are the most obvious initial signs of a voice problem.

Causes of voice problems/disorders can include:

  • Illness e.g. colds or Upper respiratory tract infections
  • Inflammation caused by gastroesophageal reflux (sometimes called acid reflux, heartburn, or GERD) or allergies e.g. sinus (post nasal drip)
  • Vocal misuse and overuse (includes throat dehydration, talking over background noise, whispering, yelling, constant throat clearing, constant effortful vocal projection, smoking)
  • Scarring from neck surgery or trauma of the front of the neck (Growths on the vocal folds, such as vocal nodules or laryngeal papillomatosis)
  • Laryngeal lesions
  • Cancer of the larynx
  • Neurological diseases (such as spasmodic dysphonia, vocal fold paralysis or Parkinson's disease).
  • Psychological trauma/ Stress
  • Aging

Voice Disorders

Voice Disorders

A voice disorder is a persistent change in someone’s voice quality (persistent hoarseness). The voice may often be hoarse, rough, strained, husky or soundless (aphonic). Frequently the voice will be weaker and less powerful. Many report they have a feeling of discomfort/ tightness / tension, dryness or a lump in the throat feeling.  Voice Disorders can range in severity from mild to severe. Partial voice loss is known as dysphonia, while complete voice loss is known as aphonia. Voice problems can affect anyone of any age, including children.

Voice disorders can be caused by a wide range of factors, they can be explained as being:

  • Organic: Caused by physical changes affecting the larynx.

     (a) Structural e.g.inflammation, (laryngitis) or the growth of nodules, aging

     (b) Neurogenic (involving the nerve innervation to the larynx) e.g. vocal cord paralysis ( post surgery), laryngeal cancer.

  • Functional: The physical structure of the larynx is normal but difficulties arise from speaking frequently too loudly with too much force and tension, possibly without being aware of it. It can be a habit of poor breathing technique or speaking at the wrong pitch / register. e.g.Vocal fatigue and Muscle Tension Dysphonia.
  • Psychogenic: The voice can become hoarse, cracked or silent following a distressing event/ persistent stress or mental illness e.g. depression. Stress can also contribute to the voice.
People with voice disorders often experience difficulties in day-to-day life, such as talking on the telephone, in social situations, at school or in fulfilling their employment

People with voice disorders often experience difficulties in day-to-day life, such as talking on the telephone, in social situations, at school or in fulfilling their employment particularly when their voice is used throughout the day. People who experience voice disorders frequently report feelings of isolation, frustration and stress, that others may not understand in relation to their voice. Most voice problems can be reversed by treating the underlying cause or through a range of behavioral and surgical treatments. Occasionally vocal changes can indicate more significant changes or serious difficulties. 

Some common causes of voice disorders include:

Laryngitis is temporary swelling of the vocal folds due to a cold, or acute upper respiratory infection, or allergies.  It is the most common cause of hoarseness.  Your doctor will treat laryngitis according to its cause,e.g. For (1) a cold or upper respiratory infection, your doctor might recommend rest, fluids, and nonprescription pain relievers. (2) Allergies might be treated similarly, with the addition of over-the-counter allergy medication.

Cheering at sporting events, speaking loudly with force in noisy situations, talking for too long without resting your voice, singing loudly, or speaking with a voice that's too high or too low can cause temporary hoarseness.Treatment usually includes resting, reducing voice use, and drinking lots of water, which should help relieve hoarseness from misuse or overuse. 

Sometimes people whose jobs depend on their voices—such as teachers, singers, or public speakers—develop hoarseness that won't go away. 

If you use your voice for a living and you regularly experience hoarseness, your doctor might suggest voice therapy by seeing a Speech & Language Therapist. In voice therapy, you'll be given vocal exercises and tips for avoiding hoarseness by changing the ways in which you use your voice.

GERD, commonly known as heartburn can cause hoarseness as stomach acid rises up the throat and irritates the tissues. Usually hoarseness caused by GERD is worse in the morning and improves throughout the day. In some people, the stomach acid rises all the way up to the throat and larynx and irritates the vocal folds. This is called laryngopharyngeal reflux (LPR). LPR can happen during the day or night. Some people will have no heartburn with LPR, but they may feel as if they constantly have to cough to clear their throat and they may become hoarse. GERD and LPR are treated with dietary modifications and medications that reduce stomach acid.

These are benign (noncancerous) growths within or along the vocal folds. Vocal nodules are sometimes called "singer's nodes" because they are a frequent problem among professional singers. They form in pairs on opposite sides of the vocal folds as the result of too much pressure or friction, much like the way a callus forms on the foot from a shoe that's too tight. A vocal polyp typically occurs only on one side of the vocal fold. A vocal cyst is a hard mass of tissue encased in a membrane sac inside the vocal fold. 

The most common treatments for nodules, polyps, and cysts are voice rest, voice therapy, and surgery to remove the tissue.

This occurs when a blood vessel on the surface of the vocal fold ruptures and the tissues fill with blood. If you lose your voice suddenly during strenuous vocal use (such as yelling), you may have a vocal fold hemorrhage. Sometimes a vocal fold hemorrhage will cause hoarseness to develop quickly over a short amount of time and only affect your singing but not your speaking voice. Vocal fold hemorrhage must be treated immediately with total voice rest and a trip to the doctor.

This is a voice disorder that occurs when one or both of the vocal folds don't open or close properly. It can be caused by injury to the head, neck or chest; lung or thyroid cancer; tumors of the skull base, neck, or chest; or infection (for example, Lyme disease). People with certain neurological conditions e.g. stroke, may also experience this. In many cases, however, the cause is unknown. 

Vocal fold paralysis is treated with voice therapy and, in some cases, surgery.

Diseases and disorders which affect areas of the brain that control muscles in the throat or larynx can also cause hoarseness. Hoarseness is sometimes a symptom of Parkinson's disease ( due to reduced breath support), or a stroke. Spasmodic dysphonia is a rare neurological disease that causes hoarseness and can also affect breathing. Treatment in these cases will depend upon the type of disease or disorder. 

These can both cause hoarseness. Hoarseness may sometimes be a symptom of laryngeal cancer, which is why it is so important to see your doctor if you are hoarse for more than three weeks. Hoarseness is also the most common symptom of a disease called recurrent respiratory papillomatosis (RRP), or laryngeal papillomatosis, which causes noncancerous tumors to grow in the larynx and other air passages leading from the nose and mouth into the lungs.

How To Tell if Your Voice Needs Extra Care and Attention?

Do I have a Voice Disorder? If you answer yes and have concern about one or more of these, you should seek reassurance and medical advice from your doctor.

  • Does your voice sound hoarse or raspy?
  • Does your voice sound deeper/lower than it used to be?
  • Does your throat feel tight,raw or sore?
  • Are you experiencing discomfort or pain in your throat?
  • Does speaking require increased effort (especially if you have to talk for long periods)?
  • Do you clear your throat frequently?
  • Have you experienced reduced pitch range while singing(difficulty reaching the high notes)?


  • Are you aware of a change in your normal voice quality that is persisting for longer than two - three weeks (in the absence of a cold or obvious infection)?


  •  Your Doctor will then examine you to determine any underlying cause of these changes and recommend if you need to be referred to an Ear, Nose and Throat Specialist. (ENT) 
  • An ENT may visualise your larynx using the specialist investigations as detailed below.

  • Laryngoscopy. This allows a SLT or Doctor to view the throat. With indirect laryngoscopy, the healthcare provider holds a small mirror at the back of the throat and shines a light on it. With fiberoptic laryngoscopy, a thin, lighted scope called a laryngoscope is used. The scope is put through your nose down into your throat, or placed directly down into your throat.  
  • Laryngeal electromyography, or EMG. This test measures electrical activity in the muscles of the throat. A thin needle is put into some of the neck muscles while electrodes send signals from the muscles to a computer. This can show nerve problems in the throat. 
  • Stroboscopy. This test uses a strobe light and a video camera to see how the vocal cords are vibrating during speech.

Imaging tests. X-rays and MRI can show growths or other tissue problems in the throat.

  • SLTs and ENTs frequently collaborate and work together to help people with voice problems. 
  • ENTs diagnose voice disorders or structural changes and provide treatment if necessary. In a minority of people surgery may be needed.
  • ENTs regularly and routinely refer you to see a Speech and Language Therapist who can help you improve how you use your voice. An ENT report is required by the Speech & Language Therapist in advance of issuing an initial Voice Therapy appointment.
  • Some Specialist Voice Clinicians work directly within Hospital ENT Departments. Frequently SLTs consult with ENTs, neurologists and gastroenterologists regarding diagnosis and treatment.

How can a speech and language therapist help?

How can a speech and language therapist help?

Speech and language therapists (SLTs) have an important role in diagnosing voice conditions using comprehensive assessment, treatment and promoting a healthy voice.

The SLT will meet with you to explore and actively listen to your description of the vocal problem by taking a case history and performing clinical assessment

SLT Assessment may include 

  • Asking you questions to understand how the voice symptoms began, medical status, including medications and other personal & lifestyle factors that may be influencing your voice. 
  • Listening and observing how you produce voice and evaluate the sound of your voice. 
  • Asking you to complete some speaking or reading sentences aloud, which may be recorded. 
  • Observing your breath pattern, assessing your posture to determine if you are using excessive muscle tension to produce voice. 
  •  From this information the Speech & Language Therapist will make recommendations. Not everyone needs direct therapy; advice and information may be adequate.  
  • Voice therapy may commence if deemed appropriate. A block of voice therapy if needed will be offered. This is usually between 4 to 8 sessions lasting 45 minutes to an hour. 

The aims of voice therapy are:

  1. Education about the voice.
  2. Helping you understand what factors are contributing to the vocal disorder, so you can improve your voice.
  3. Provision of various exercises, strategies and guidance regarding lifestyle changes. 
  4. Support you to participate in everyday activities related to communication.
  5. Your progress will be actively reviewed with you and adapted as necessary. 

What You Can Do (Self Help for Voice)

Healthy habits to take care of your voice

  • Drink plenty of water, 6-8 glasses, sipping regularly throughout the day. Because the vocal cords vibrate several hundred times per second when you speak and even more when you sing. Drinking water helps thin out the mucus that lubricates and protects your vocal cords as they vibrate.
  • Reduce your tea/coffee or alcohol intake,as these can cause dehydration, 
  • Keeping hydrated will also prevent you having to clear your throat frequently and further irritate your throat. 
  • Use a humidifier in your home, especially in winter (when central/oil heating is on for long periods) or in dry climates. 
  • Avoid or limit use of medications that dry out the vocal folds, including some common cold and allergy medications. If you have voice problems, ask your doctor which medications would be safest for you to use.

  • Don't smoke, and avoid second-hand smoke. Smoke irritates the vocal folds.
  • Include plenty of whole grains, fruits, and vegetables in your diet. These foods contain vitamins A, E, and C. They also help keep the mucus membranes that line the throat healthy.
  • Wash your hands often to prevent getting a cold or the flu.
  • Get enough rest. Physical fatigue can have a negative effect on voice.
  • Exercise regularly as it increases stamina and muscle tone. Correct posture and breathing, is necessary for proper speaking.
  • Exercise can help relieve stress. Other activity ideas to promote relaxation may include : yoga, pilates, mindfulness and progressive relaxation. 
  • If you have persistent heartburn or GERD (gastro-eosophageal reflux),talk to your doctor about diet changes or medications that can help reduce flare-ups. Avoid eating spicy foods. Spicy foods can cause stomach acid to move up into the throat area. 
  • Avoid mouthwash or gargles that contain alcohol or irritating chemicals.
  • Consult your Doctor, if you have any signs of  low grade infections in the nose, sinuses, tonsils and gums.

  • Try not to overuse your voice. Avoid speaking or singing when your voice is hoarse or tired.
  • Rest your voice when you are sick. Illness puts extra stress on your voice.
  • Avoid using the extremes of your vocal range, such as screaming or whispering. Talking too loudly and too softly can both stress your voice.
  • Maintain good posture. Practice good breathing techniques when singing or talking.Support your voice with deep breaths from the chest, and don't rely on your throat alone. Talking from the throat, without a supporting breath, puts a great strain on the voice.
  • Practice simple warm-up exercises for the voice in advance of prolonged talking periods and practice cool-down techniques at the end of the day. 
  • Avoid cradling the phone when talking. Cradling the phone between the head and shoulder for extended periods of time can cause muscle tension in the neck.
  • Avoid persistent, deliberate throat clearing, if you can’t prevent it, make it as gentle as possible. Taking dry swallows or small sips of cold water can  help to suppress the urge to cough. Whispering should also be avoided. 
  • Consider using a microphone when appropriate. In environments such as exhibit areas, classrooms, or exercise rooms, a lightweight microphone and an amplifier-speaker system can be of great help.

Voice problems in Children


Covid-19 and Voice

Tips to support communication while wearing masks & for people with voice problems post covid