The Ann Arbor News
Anne Rueter
Wednesday, January 26, 2000

Actor James Earl Jones, singer Billie Holiday, college football announcer Keith Jackson - you don't need a face to know them: All it takes is a few words or notes. Rich and deep, lilting with a touch of sorrow, or tinged with a Southern drawl, their voices are their trademarks.

Probably most of us don't think of our voices as our essence. Yet many people count on their voices daily to earn a living. Teachers, lawyers, professors, ministers, and a few singers and actors come to the Vocal Health Center, part of the University of Michigan Health System, when hoarseness or a weak or breathy voice make them aware their built-in musical and speaking instruments aren't working as they should.

"Everybody tends to take the voice for granted until they have a problem," says Dr. Norman D. Hogikyan, director of the center, located in Livonia.

The clinic, which opened in 1996, diagnoses and treats patients with conditions ranging from a voice weaker from age or misuse to laryngeal cancer. Hogikyan, a laryngologist, may perform surgery for some conditions. Many patients also see Marc Haxer, a speech pathologist, and Leslie Guinn, a retired U-M music professor who knows first-hand about keeping a voice in top shape: As a classically trained baritone, he's sung Wagnerian arias and art songs in a 40-year career in America and Europe.

In the center's multidisciplinary clinic for vocal professionals, the three men help patients work on new strategies for using their voices healthily. Voice therapy, usually in six to eight sessions, is a lot like physical therapy for an injured knee or hip. Patients learn to avoid overuse and how to use their voices differently through breathing and other vocal exercises.

When we speak or sing, air from the lungs comes up the windpipe and vibrates tissues in the larynx, also known as the voice box. Two pairs of vocal folds (often called vocal cords), which are mucous membranes in the larynx, expand and contract to produce varying pitches. The sound then resonates in the throat, mouth, and nose.

"Bad habits can arise without the patient being aware of them," says Haxer. He helps patients learn to use the right muscles for inhaling and exhaling, and to coordinate exhalation with voicing a sound. Most of the time, people handle these tasks well naturally. But sometimes things get out of kilter: the voice's power and resonance aren't there.

Marian Cohen of Ann Arbor uses her voice as a social worker teaching residents in the U-M Medical School's family practice program, and also as a choir member at Temple Beth Emeth. She lost her voice in a case of laryngitis two years ago, after attending a friend's wedding where she had to talk over the sound of the band.

"It took a really long time before I got my voice back," she says. Even then, she was still hoarse and had trouble reaching higher notes.

Diagnosed with vocal fold nodules, she ended up at the Vocal Health Center. Guinn and Haxer determined she needed to change her habit of speaking in the lower part of her natural range.

"Dr. Haxer found a good pitch for me to aim for," she says. "There was a spot in my voice that was not being used enough." Gradually, by drinking water frequently to hydrate her larynx and doing breathing and vocalizing exercises, she's restored her voice and has no problems with hoarseness.

When a voice sends distress signals

The most common complaint Hogikyan hears is persistent hoarseness. Other patients notice their voices become tired more easily, or that they can't sing or speak in the higher range. A soprano may feel she ought to be singing tenor, or a father who reads to a child may not be able to mimic animal voices the way he used to.

Hogikyan stresses that people who find these symptoms persist should see a doctor, since they can indicate minor or serious conditions. "A voice change can be indicative of something as simple as a cold or as severe as cancer or a paralyzed vocal cord," he says. To diagnose a problem, he may listen to a patient read a text and use an instrument that allows him to look inside the voice box and videotape vibrations there.

Some voice disorders, such as smoker's polyps and nodules, result from voice overuse or abuse, while others don't. Viral or neurological conditions that bring some patients to the center include paralyzed vocal folds and spasmodic dysphonia, a neurological disease experienced by National Public Radio talk show host Diane Rehm. Botulinum toxin treatments successfully reduce the symptoms temporarily.

Dr. Ameed Raoof came to the center after he realized his voice, which he uses extensively to lecture to medical and dental students as an anatomy professor, was hoarse and not its normal pitch after he had a cold. Hogikyan diagnosed and removed a hemorrhagic polyp from Raoof's vocal fold. After three months of rest and voice therapy, Raoof considers himself fortunate.

"I haven't had my voice in this good shape for a long time," he says. He still practices vocal exercises in the morning or while driving.

Nodules on the vocal folds are an inflammation that singers and others voice specialists call "vocaholics" may experience if they overuse their voices. At the center, they learn to recognize signs they're pushing their voices too far and also better ways to produce vocal sounds. Nodules usually resolve with vocal therapy, but sometimes require surgery.

Patients coming to the center with a hoarse or gravelly voice, especially early in the day, may have another common problem, acid reflux laryngitis. It occurs when stomach acid backs up and irritates the voice box and vocal folds. "In the last five years we've really turned our attention to this (condition)," says Hogikyan. Treatment includes altering food and drink habits.

When Guinn sees a patient, he first listens as they talk in normal conversation. "Our voices generally reflect our personalities," he says.

He asks some questions, perhaps offering pointers on keeping the larynx hydrated or avoiding certain foods.

"Then I talk with them about breath flow. Do they talk on residual air? Do they even think to breathe when they speak?"

Guinn says helping a patient find the optimal way to use his or her vocal capacity is like coaching a tennis player to find the sweet spot. "That same process is available to singers, speakers, and actors," he says. "I help them awaken these sounds," he says.

As for people like James Earl Jones, do they come by their distinctive voice through special attention or luck? A bit of both, says Haxer. Someone like Jones is likely to care for a golden voice through training and good habits, but also has individual physical gifts: vocal folds of a certain mass or length and a fine resonating space in the mouth or nasal cavity.