Vocalisation tricks for people with laryngeal damage

Started by SueC, April 14, 2021, 03:55:13

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12 years after it happened and after years of DIY to get something of a conversational voice back, I finally got to see a speech therapist yesterday to help me with the frustrating matter of trying to speak with only one functional vocal cord.

Back story first:  I've got idiopathic right vocal cord paralysis - and idiopathic means nobody knows why it happened.  Basically, the nerve to the right side of my larynx randomly died.  I know exactly when it happened - I was teaching my favourite ever class of 15-year-olds back in late 2008, when suddenly I felt as if there were ball bearings in my throat and I couldn't get any words out, and to try to do so was like trying to talk underwater.  I had a cold at the time but knew this was something else (and the thinking of the diagnosing ENT is that the virus damaged the nerve).

I had to take time off work and deal with patronising GPs who told me to rest my voice because I had laryngitis.  I knew it wasn't laryngitis, but it's pretty hard to have a conversation about it when you can only whisper, are choking all the time and people are constantly trying to shush you.  As Murphy's Law would decree, this happened when my regular GP had just moved towns and so I couldn't talk to anyone who actually knew me - these days, I've got two excellent GPs who know me well, and they wouldn't dismiss me out of hand like I was back then (I have two I see in case one of them leaves so I don't have to start all over again).

I couldn't go back to work, and because of continued umming and aahing from various GPs, decided to see an ENT (ear, nose, throat specialist) off my own bat - I wanted someone with an endoscope to have an actual look at what was going on.  It took six months to get in - eight months from the original injury - meanwhile I couldn't speak above a whisper, was choking on food and drink, and getting very depressed because it's actually a huge deal to have voice damage, not only because I couldn't do my job with it, but also because of all the ramifications when communicating with other people.

The ENT said, "Well, no, not laryngitis, here's the news!" and told me chances of the nerve recovering were extremely low because if it's gonna, it's usually gonna in the first couple of months.  He also said I'd not be able to have normal conversations again without having an operation to have a plastic disc inserted into the paralysed side of the larynx, to prop it into the centre - but that these operations can also go wrong (and in any case, I'd never be able to project my voice again).  Not to mention - I didn't like the idea of losing half my airway (I've already lost about a third because the paralysed side of the larynx doesn't retract when breathing, it just hangs in space like a foreign object).

Anyway, I'm chemically sensitive as it is - I have all sorts of weird reactions to common industrial and household chemicals, so I'm not about to have a synthetic material inserted into my larynx - imagine having an allergic or inflammatory reaction to something in your larynx - it would not only make it even harder to speak, but could seriously compromise your breathing, swallowing etc - and then you'd have to remove the thing again and it would have caused all sorts of other damage.

Speaking of swallowing, it's impaired with this condition already and I have to sit pretty much bolt upright when eating and especially when drinking, so I don't choke as a result.  Having a cold is really bad because when I'm horizontal and trying to sleep, swallowing doesn't work properly and I can choke on saliva, mucus etc.  I'm at risk of aspiration pneumonia because of it.

12 years ago, the GP at the time said he'd try to organise speech therapy for me and then didn't, and at that stage I was depressed both at the diagnosis and its implications, and my experiences in the medical system around the diagnosis, and I just gave up on the medical system altogether for years.  I couldn't go back to my job (very sad not just because of loss of income - I loved my job), so my husband and I completely changed tack - we bought a small block of rural farmland to start growing much of our own food, and I designed an off-grid eco-house we then owner-built together on a shoestring (neither of us have robbed a bank or inherited money, we were average earners, and that's before I couldn't go back to my role).  We finished the build in 2016, but were living in it from 2013.

...this is the stage we were up to in 2016 when there was a Cure concert in Perth both of us completely missed, ho hum, we didn't even know it was on because to build your own house is like entering a side bubble in the universe...

A total change of tack is often a good thing when disaster has struck.  A friend of mine emigrated from South Africa to Australia 15 years ago with her husband and two little girls - why?  Because they had their own house and it burnt down, and they weren't insured, so this bankrupted them.  Had they stayed they would forever have been going, "If only..." - but seeing as they had to start over, then starting over in a completely different country meant they accumulated friends they'd never have met and saw amazing places that they'd never have seen if their house hadn't burnt down.

Materially, our change of tack is the best thing we've ever done for ourselves - we now live in a wonderfully comfortable and quirky house, and pay no bills for water or electricity.  The house self-regulates extremely well, staying naturally cool in summer and warm in winter (it's all about optimising sun angles, thermal mass, insulation and natural ventilation in your design - and I wrote two years' worth of articles about the how-to for the Australian Owner Builder magazine) - we have a wood fire on just two evenings a week in winter on average, because it works so well.  We have bees, beef cattle, fruit trees and a huge vegetable garden, and so the cost of feeding ourselves is less than 50% of what it used to be.  I now run an eco-farmstay out of our place part-time, on top of being our chief food grower, animal tender and all-round maintenance person.  We have lots more time for each other than before and live in a really peaceful environment.

While we were setting all this up, I also got serious about DIY vocal therapy - since nobody else was helping.  I used to sing in a choir recreationally, and decided it might be good physiotherapy to go through the motions of singing while in the shower - send the signals to the larynx and just let it process them.  It didn't sound good obviously, but I did find it very helpful at improving the various issues that come with having a half-paralysed larynx.

Over the course of a couple of years this really weak, watery voice came back, in fits and starts, and at first, it would pitch up like Mickey Mouse half the time - highly embarrassing.  Gradually though, that stopped, and I could sing (not well, but make the notes), which then meant I could start to do more when practicing my limited vocal range, which in turn made the voice a bit less weak.

It's still not great, but most of the time I can now hold conversations, without people necessarily being aware that there is a problem - I sound like a person who has a cold and speaks too fast and too monotone (and with a higher pitch than before).  The speaking too fast is a major bugbear - and I'll get into that later - but essentially, it's really hard for me to do glottal stops, so the spacing between the words has kind of fallen by the wayside - and I get less words out per breath because I obviously can't close the gap between the vocal cords properly, so on autopilot you tend to rush because of it (and I'm at the moment trying to work out how to counter these problems).

Anyway, ten years into this problem I sounded like this on a good day:

And this is a couple of weeks ago (after discovering my strawberry tart had suffered gravitational damage - how apt for a 50th birthday...)

Still not amazing, but much better than forecast with only half the larynx hooked up.

I'll continue this later...
SueC is time travelling


A lot of the stuff around a part of your body packing up shop is psychological.  There was the initial grief about loss of function, and then redesigning our lives to let me do something I could do, in place of the things I could not.  I threw myself into that - and in some ways, this parallelled the way I threw myself into homework and extended reading as a child, when I was growing up in a family where there was chronic abuse and neglect - it was something I was good at and from the time I was very young, I saw that as my eventual way out, my ticket to independence.  That's how it turned out - I was in university studying science by age 16, and university welfare staff signed the paperwork to emancipate me from my family, so that I could get out of that home environment and study independently on a student support allowance.

People with complex PTSD will know all about the great big wall children build inside themselves to survive childhoods like this.  You push all the things you can't process at the time over that wall just so you can get on with the physical things you need to do to survive and eventually get out of there.  One day if you're lucky, you'll get to look behind that wall and actually process your past - the emotional part of it, which is the bit that gets pushed over the wall.  I did that in my early 40s - five years after the vocal nerve paralysis.

It's actually an interesting question if I would have done that if my vocal nerve hadn't packed in.  I don't think I would have been able to work full-time in a job where I was interacting face-to-face with people all day long, while also dealing with vivid surround-sound nightmares every night, and then unpacking the implications of that for my past - the things I couldn't see at the time.  It was like when there's a huge plot twist you didn't see coming in a novel, and you have to go back to the beginning immediately to see how the trick was done - except that this time, it's not a novel, it's an actual life.  It was pretty all-consuming for a good half year, for me.  It was still pretty high on the list for the next 18 months after that.  It's changed things, and is still changing things, but for the better, I think.

I wrote about dealing with complex PTSD on the Music For Emotional Health thread a couple of years back - realising that this often hidden stuff is way more common than most of us realise, and that we ought to break the stigmas around it and talk about it openly.  Music has long been one of the things that was enormously helpful to me for coping with all that human-condition stuff.  And that's the case for the vocal paralysis issue as well, for me - not just that aspects of singing are DIY vocal cord therapy, but that music helps me cope with the psychological fallout from it.

It's interesting that part of my response to the vocal injury was to make a plan and then shovel the sadness behind a wall and throw myself into what I had to do in order to make an alternative life - because I'd done all that before as a young person.  This time it wasn't as if I had to go through all that alone and emotionally unsupported - but it's pretty obvious some emotions to do with this were still getting dammed away somewhere.  Because when I went to see the ENT last month for a follow-up endoscopy, I was unbelievably sad again afterwards - and the same thing happened yesterday at speech therapy.  I had to hang on to myself inside through the whole session, and when I got out, all I wanted to do was cry, it was that close to the surface.

I didn't go and see friends because I'd have cried all over them.  I don't think that's necessarily a good idea - I'd rather cry on my own, or all over my husband, if I have to do it in company - and he's up to date with what's going on in my life, so I don't have to explain anything to him.  So what I did instead is to take my dog for a walk on Mt Melville, with lots of uphill-downhill and a couple of friendly interactions with other walkers, and just felt my sadness quietly and in the context of a gorgeous natural environment, decent cardiovascular exercise, a happy dog, and the awareness of lots of other good things in my life.  One of the advantages of getting older is that you tend to have better perspective.

By the time we got home, I didn't feel like crying all over my husband, but that doesn't mean I won't at some point, about this (if you don't let it out it keeps going around).  Basically, at speech therapy yesterday, it seemed to me that a dozen years of the difficulties of living with this condition were rising up against some sort of levee bank, and threatening to break it.  It didn't help that the therapist was at first a bit like a music teacher who keeps focusing on your bad notes until you can't play a good one anymore - ever had a music teacher like that?  I thrive on encouragement and logic and possible strategies/alternative solutions for a problem - not on being told not to play a bad note, whether on an instrument or with my various vocal issues.

So it was extraordinarily unhelpful, when I'd written to this therapist in the first place saying one of my biggest bugbears was that I tended to rush my words and I needed techniques for slowing down, to come into the room and have her ask questions and when I attempted to answer, throw her hands up in the air and say, and not kindly, "Ehhhh - if I'm going to work with you, slow down!"  So why was I there?  If I could use my will alone to slow down my speech, I'd not be paying someone else to help me with it.  I've got air leakage I can't do anything about when speaking, and have huge difficulty with glottal stops, and when things go wrong, I get nervous and it causes laryngeal spasm.  That's why I'm keen to do speech therapy...

If you're teaching someone to find the notes on a violin (no frets, challenge number one), you can't do it by ranting at them to stop playing bum notes.  "Just stop it!" does not help your student actually find those notes - it just ruins the mood and steals their confidence.  If they're not tone deaf, they can hear their own mistakes, and part of constructive teaching is to help people over the hurdles, both physical and mental/emotional, of being bad at something to start with, and to be warm and encouraging and use humour and lower the overall pressure around a problem.  When everyone is happy and relaxed, things just go so much better.

I think my speech therapist may get there - nobody is perfect, she got better as the session went on, and by the end we were exchanging smiles - I don't think she's dealt with this exact condition before, and doesn't quite know what the problems are, but when we tease those out I think she's going to have some helpful input.  I'll talk about the technical things I learnt yesterday in the next post, and plan to use this thread as a sort of log for voice therapy, and also for a place to park any ideas I'm going to find online about it.

But this post was about the associated psychological stuff.  Just before I sat down to write this, I was working in the garden listening to music, and came across the perfect song for how I felt yesterday, and for what it's like to be dealing with this stuff:

What a song like this does is to acknowledge the fundamental difficulties you confront as you live your life, rather than gloss over this stuff.  It's a place you can go which says, "This is real, and it's OK to hurt."  It's somewhere you can feel what you feel, and be honest, and just be, instead of putting on a good front for everyone else.  Most of the time I'm positive and constructive, but OMG I couldn't be those things if I was never allowed to feel the despair or the pain and acknowledge them as real.  Feeling like this isn't just about aspects of our individual situations, it's the whole thing - society, the state of the biosphere, the whole mess we're in on so many levels.  Because that's as true as the beauty and the joy we can find, and because I live a lie if I can't acknowledge darkness as well as light.
SueC is time travelling



Baselines for holding sounds

We timed how long I could hold various sounds (at this stage):

aah (11 seconds)
s (35 seconds)
z (8 seconds)

This is starting with lungs completely filled and at conversational volume - best of three attempts.

When you make the "s" sound you're not using your larynx, you're just breathing out; it's an indication of your lung capacity and breath control.

The "aah" sound requires you to vibrate your vocal cords - apparently children average that sound for about 12 seconds and adults for 20.  Because I've got a gap between my vocal cords that the left cord is always straining to cross the laryngeal midline to try to close, much more air escapes when I make that sound than in someone who can properly bring both their vocal cords into apposition in the centre of the larynx.  Any alignment I do get is imperfect - since the right cord is a passive, paralysed object - it can't medialise or retract, it just hangs there - and it can't lengthen or shorten either, so it's kind of like having an out-of-tune string as well.

When I'm trying to hold the "aah" sound I also seem to need a lot of "push" to do it, and to stop the sound from breaking up at the end.  (This ties in with the general feeling that phonation used to just flow before the paralysis, while now it's taking a lot of effort and "push" - early on I used to say to people, "It feels like trying to speak underwater and it's a lot of effort.")

When I'm going against a timer, I find that the more I can relax my speaking equipment while I make the sound, the longer I can hold it.

The "z" sound engages the larynx and is less passive than just the open vibration of "aah" - so I struggle to hold this one, and it kind of sounds silly, especially towards the end.

Physio for swallowing

Working with a semi-paralysed larynx is like working with a back injury - and I also happen to have one of these - a lumbar injury acquired at age 21.  This injury can be almost completely compensated for by strengthening the lumbar and core muscles - i.e. with regular Pilates - so that the ligaments I stretched in an accident - the ones that attach the spine to the pelvis - are backed up muscularly.  That way, the bones don't slip out of position and I don't get nerve pinching.

So here's a neat trick I had no idea about:  Poke your tongue out between your teeth, hold it there, and try to swallow.

It's harder to do that with your tongue partly extruded - which makes it a good exercise to strengthen the muscles at the base of your tongue, etc.  I've got to admit that I cheat by holding the tongue between my teeth so it doesn't retract when I swallow, but apparently that's OK.  The further you poke out your tongue, the harder it gets to swallow - and I can't do it with my tongue poked out as far as it will go, but neither can my therapist.

Do not do this on public transport or at work meetings.  :angel

Yawning, with a big sigh at the end

Apparently this is amazing for relaxing the larynx, and is being suggested as a strategy for countering laryngeal spasm.  Until now, when I got laryngeal spasm (either by using my voice too long or because of stress) I just used to shut up shop and stop speaking, and wait for a "reset" to happen - anywhere between a couple of minutes and several hours - drinking water could help - just as it does when my swallowing malfunctions, to get that to reset. (One of the really annoying things about this condition is that swallowing doesn't work properly when I'm horizontal, so I can choke on my own saliva when I'm sleeping.  Sometimes I just wake up with a frog in my throat and unable to swallow, and it's impossible to sleep like that, and has caused me to make so many middle-of-the-night cups of jasmine tea I've lost count.)

Anyway, great:  Now I've got something I can do to counter laryngeal spasm directly.  (And it's going to be so much fun to yawn in the middle of conversations when my voice gets edgy.  :evil:)

So there's yawning to relax the larynx when necessary (and the rest of me too, apparently)...

...and there's yawning with a big sigh at the end as a regular exercise, to really open up the back of the throat as much as possible - before exhaling with a classic sigh that people normally produce in a full yawn that's not been silenced for social reasons.

Breathing in through the nose...

This is complicated for me.  My nose got smashed up in an accident when I was nine and I could never breathe properly through it afterwards.  My parents didn't think it was necessary for me to get medical attention for my damaged nose, and because nobody was checking my breathing, I had to start breathing through my mouth for the rest of my childhood.  (My parents didn't seem to think it was necessary for me to get medical attention for all sorts of other things, including concussion, a badly mangled leg, and pneumonia which nearly killed me at age three - I'm only alive because a neighbour with medical training came over of her own volition and gave me antibiotics - and she told me all about this when I was in my 20s. :unamused:)

As a young adult it occurred to me that others were breathing through their nose without complications, and I tried to see what would happen if I did that.  Basically, there was so little airflow that if someone had held my mouth shut I would have suffocated.  So when I had saved enough money, at age 25, I saw a reconstructive surgeon with the hilarious name of Dr Gilette (talk about nominative determinism! :beaming-face), and he fixed the damage to my nose - grafting excess cartilage into the airway to hold it open.  (On the public system, I'd have waited for years for that.  My husband has a deviated septum and the wait list for that is several years if he wants it fixed.)

These days I would be able to survive with my mouth closed, but not when I'm doing cardiovascular training - so I'm still supplementing through my mouth when there's high demand.

And speaking is now a high-air-demand thing for me, so whatever autopilot my brain made when I learnt to speak again on half a larynx, it decided, probably for good reasons, that I needed to breathe through my mouth to get air back as rapidly as possible when speaking.

My speech therapist wants me to breathe through my nose before doing phonation exercises and before speaking.  It takes more than twice as long to fill my lungs via my nose than via my mouth, and it's more noisy unless I breathe in quite slowly.  The consequence of that will be longer pauses between sentences, and after commas, but it won't help me with making longer gaps between words - that's a different kettle of fish.

At home we talked like Daleks that evening because they have pronounced spaces between their words - but they're doing it very monotone, or with rising inflection.  It was a fun way of practising glottal stops - but not one my speech therapist instigated.  :angel

Next session is May 11, but I've got lots to think about just from what's floating around my own mind in consequence.
SueC is time travelling


This week I had my third session with the speech therapist, and I hadn't done much "homework" from the second session because we had a month from hell with all sorts of problems and curveballs involving livestock, extreme weather events and their consequences, bureaucratic stuff-ups, lots of useless paperwork, a generator and inverter not talking to each other, breaking something in the process of fixing something, stress, etc etc. But I went to the next session anyway, and we just worked on something else while I catch up on the other things.

Some really good news: I usually lose my voice (it breaks up) during periods of stress, but that didn't happen even once for the whole of the last month. I also didn't choke at all on any food/drink at any point, or on saliva while asleep; that's not happened for nearly two months.

One thing that's been extremely helpful in that improvement is the laryngeal "reset" exercise I was taught in Session One back in April - the "big yawn" (laryngeal deconstriction), in which you ultra-widen your mouth, airway etc. I tried it out every time my larynx began to go into spasm, and it interrupted the spasm - previously I would have coughed and spluttered and tried for anywhere between a minute and several hours to get my voice back. Totally excellent circuit breaker.

The other thing the "big yawn" is great for is assisting in clearing the airway, and "frogs" in the throat. Things kind of hang off the paralysed vocal cord in the morning and after eating, because it can't be moved muscularly. Drinking liquids was one thing that used to help, particularly hot tea which I'd make in the middle of the night when I'd often wake up unable to swallow properly because of "froggy throat" - but the "big yawn" is incredibly effective for fixing that, which is so good because I don't have to have middle-of-the-night tea ceremonies anymore.


Slow deep breathing

When we're at rest we don't use our full lung capacities, we just partly inflate our lungs and breathe in a rather shallow way. Part of what we're trying to do in speech therapy is to make me take deeper breaths as a matter of course before speaking, so I don't run out of air and start to rush to the next punctuation or other suitable place for a part-breath. (That's because my vocal cords don't align properly when I'm speaking, and so I lose more air than a person with a normal larynx during speech.)

In Session Two we did some reading exercises where the focus was on creating more pauses than just at punctuation, doing word emphases, and generally slowing the words. Sort of when you're reading out to people for whom your language isn't the standard language, or to very young children. I'll write more of than when I do a belated Session Two recap next post. Working on the actual breathing ties in with this.

So here's what you do: You spend five minutes breathing in an entirely different pattern to what the body runs subconsciously at rest, by slowly fully inflating your lungs and then immediately slowly exhaling again (a nice smooth constant air flow, no breaks or breath-holding at any point). If you don't do this slowly, you'll get the same effect as when you're hyperventilating - because if you breathe more deeply, you have to breathe more slowly to exchange the same amounts of oxygen and carbon dioxide.

We sat there with a timer to make sure we did five minutes, and also timed how many breaths per minute I was taking when I had the rhythm right (6-7, which is about half the breaths you'd take with shallower breathing).

This exercise makes you pay attention to your breathing instead of letting it autopilot, and encourages assimilation of deeper inhalation in your autopilot breathing at rest. (Have you ever worn a posture corrector? You don't have to wear it much to become more conscious of what proper posture actually feels like. Same principle.) It also exercises your diaphragm.

A really nice side-effect is that if you do this properly, it's incredibly relaxing, like the "big yawn" (laryngeal deconstriction) - and the speech therapist says relaxation is a big thing in improving the performance of my mangled larynx. So, I'm to do this five minutes morning and night, and whenever I think it might be helpful, including around speaking.

It's easy to do this exercise as you're settling to go to sleep at night, because the relaxation goes with drifting off to sleep. In the morning, we've got tea on a timer and I can do this waiting for the tea to brew. And of course, I've also been doing this if I wake up at night (if the dog wants to go out etc), because it's really helpful in getting back to sleep - and I'm starting to use it when I want to relax during the day, as well. So, like the "big yawn" I'm already finding this exercise becoming adopted into the general repertoire.

Humming with pitch changes / humming with volume changes
(...and then aaahing with pitch changes / aaahing with volume changes - and even la-la-la...)

This was going up and down scales to see where the limits were. I've lost the three top notes as a result of my vocal cord problem, and the three next highest notes I can still reach sound strained and weak and are around half the volume of the notes below those. My speech therapist says it's much harder to make high-pitched sounds than low-pitched, especially if you have a problem with muscle spasm or the vocal cords not aligning (both apply in my case). At the same time, I'm now pitched between one and two notes up from where I used to be "before" when speaking generally, but we're actually talking about having me make an effort to start from a lower point when I'm speaking to see what that does!

The humming exercises are attempts to improve resonance - you're trying to reverberate the sound through all your sinuses etc. The aaahing is an attempt to work with an open airway. In both cases you can do scales up and down, or you can go up and down like a rheostat - like doing a long sliding note up and down, instead of incremental steps (notes).

You can also work on really soft sounds, and to the other end, which is projecting - with everything, at the moment I'm better in the middle - middle notes are easier than top or bottom so you work on top and bottom, medium volume sounds are easier than soft sounds or projecting so you work on those, but gently, and you're not allowed to strain to do it - you abort immediately when you get strain.

That's a big thing I've learnt through three speech therapy sessions: Don't try to push through when you hit a rough spot. Stop, deconstrict the larynx, breathe, try again more gently and consciously. If I do that, I don't lose my voice to laryngeal spasm.

Another thing I've learnt, just thinking about it: Summertime is fabulous for doing these kinds of gymnastics. I learnt it in choir about 20 years ago, a really slow version, and always loved singing it for its held notes, tempo changes, and just the going from note to note the way that particular song does - it's really mesmerising to sing. When I lost the nerve to the right vocal cord, that was one thing I kept coming back to trying to sing when the voice recovered sufficiently to try it.

It's sort of like when you're doing Suzuki method violin, too - instead of doing endless scales, you do actual fun projects, because who actually wants to play scales?

Interesting thing I noticed: If you're aaahing up and down the scale...the old la-la-la is easier than aaah-aaah-aaah. I'm encouraged to do both. Something about the "l" sound seems to make it easier to get the "aaah" sound out. Your whole tongue moves to do it and it is like a mini-deconstriction!
SueC is time travelling