Unless you are a performer or your job requires you to talk a lot, you probably do not give much thought to your vocal health. However, vocal cord damage is more common than you may think as it affects as many as nine percent of adults nationwide. And, experts say the increase in video and phone chatting during the COVID-19 pandemic will only make matters worse.

Sarah Brown, MS, CCC-SLP, a speech-language pathologist at the Grabscheid Voice and Swallowing Center of Mount Sinai, has seen a marked increase in the number of patients with vocal strain or fatigue over the past six months.

“People tend to speak louder on video or phone calls when they think they can’t be heard well. Over time, this can set someone up for a vocal injury,” she explains. “On the other side of the coin, elderly patients who are not talking as much during the pandemic, are losing vocal stamina.”

To help patients prevent vocal cord injury, Ms. Brown explains how the injury occurs and provides tips for proper ‘vocal hygiene.’

What causes injury to the vocal cords?

The vocal cords are two bands of elastic muscle tissue located in your larynx, or voice box, that join together to form a V-shape. These cords, which are about the length of your thumbnail, are constantly at work—they come together and vibrate when you speak and open up each time you breathe.

Like other parts of the body, your vocal cords are prone to wear and tear. The area that is most susceptible to damage is the outer layer of the vocal fold, called the epithelial layer or the muscosa of the vocal fold. When the cords rub together too hard, or for too long, the tissue becomes damaged. The most common vocal cord injury is a benign mucosal lesion—a callus-like growth also referred to as nodule, polyp, or cyst.

Who is at risk of vocal cord injury?

While anyone can injure their vocal cords, it is more common in certain careers.

“Vocal damage can occur anytime you take your voice past the realistic limits of what it can do,” explains Ms. Brown. “It is like when you repetitively lift weights or wear uncomfortable shoes and then develop a callus on your skin.”

Ms. Brown treats many performers, news anchors, teachers, and lawyers who sing or talk all day at work. She also sees a lot of parents with big families and young people who yell or raise their voice often.

How do you prevent vocal cord injury?

If you are at risk of vocal strain, Ms. Brown recommends that you establish adequate ‘vocal hygiene’ by abiding by the following:

• Use an efficient speaking voice. Adequate breath support allows for your voice to resonate well. Try to avoid excessive glottal fry, also known as vocal fry, especially when projecting.
• Stay hydrated. Vocalists have a phrase, “sing wet and pee pale.” Drink two to four liters of water each day for optimal vocal health. As a result, urine should be light and odor-free.
• Limit substances. Do not smoke cigarettes and limit alcohol use as both can dry out the vocal cords, increasing your risk for vocal injury. Excessive amounts of coffee, and other caffeinated beverages, can also lead to vocal dryness. If you are a multi-cup-a-day coffee drinker, make sure you compensate by drinking extra water.
• Exercise regularly: Cardio and strength training helps maintain stamina. Don’t hold your breath when lifting! Use proper breathing techniques when hoisting weights.
• Stop behaviors that increase vocal strain. Avoid excessive yelling, screaming, or talking; beware of noisy environments such as bars and restaurants; and limit throat clearing and coughing.
• Warm up and cool down. Learn exercises to safely start and stop prolonged vocal use such as resonant humming, lip trills, and straw phonation.
• Take breaks. During peak vocal demand, take six vocal naps—a 15 to 30 minute period of vocal rest—throughout the day.
• Use appropriate audio set up for video calls. A combination of headphones and microphone will ensure that you can hear yourself and your speaking partner clearly so that you don’t speak excessively loud.

Every patient is different. Unlike many other practices, Mount Sinai Health System laryngologists and speech pathologists work collaboratively to evaluate patients and develop an individualized treatment plan for vocal cord injury.

“Since much of what causes vocal cord injury is behavioral, it is important to include medical, surgical, and rehabilitative perspectives,” explains Sarah Brown, MS, CCC-SLP, a speech-language pathologist at the Grabscheid Voice and Swallowing Center of Mount Sinai.

To assess the condition of your vocal cords, Mount Sinai uses videostroboscopy—a cutting-edge procedure that allows the care team to visualize the vocal cords in great detail. Similar to when your doctor uses a tongue depressor to see the back of your throat, a tiny instrument with a small camera is placed into the mouth. The laryngologist may also use a different technique using a flexible camera through the nose.

Voice Therapy: A Non-Surgical Approach to Care

Most patients benefit from voice therapy before pursuing surgical options. In some cases, voice therapy can eliminate or reduce the extent of surgery needed. Mount Sinai specializes in minimally invasive procedures. These include in-office laser and microlaryngoscopy, which uses high-energy beams of light to remove lesions under local anesthesia in the office.

During one-on-one treatment sessions, speech pathologists teach exercises that balance resonance, improve airflow, and enhance vocal technique. The goal of voice therapy, Ms. Brown explains, is for patients to learn to speak or sing in a new way that protects their vocal cords. The exercises allow patients to feel more confident in their conversational or singing voice.

Mount Sinai Voice Therapy Techniques 

Semi-occluded vocal tract exercises (lip trills, straw phonation, cup bubbles), which help manage airflow and resonance by teaching patients how to properly close their vocal folds without over-squeezing them.

Resonant hums/resonant voice therapy, which increases voice comfort by using gentle humming focused on vibrations in the lips and nose rather than the throat.

Flow phonation, which focuses on maintaining vocal balance through airflow using exercises such as saying “whoooooo” and watching a tissue blow in front of you.

Reducing muscular tension, in which patients are guided through laryngeal massage as well as tongue, shoulder, and neck stretches.