What Aerosmith Can Teach Us About Vocal Injury

A fractured larynx?

That’s what’s done in Steven Tyler and forced Aerosmith to retire from touring. This month on we talk to two experts from UConn Health’s Voice and Speech Clinic to explain this and other voice problems they see, and to offer some tips on how to treat and prevent them.

Listen to Dr. Denis Lafreniere, chief of UConn Health’s Division of Otolaryngology, and speech and language pathologist Ann Clifford.

(August 2024, Ann Clifford, Dr. Denis Lafreniere, Carolyn Pennington, Chris DeFrancesco)

Listen now on Podbean.

Transcript

Chris: In case you hadn’t heard, Aerosmith is no longer touring because lead singer Steven Tyler hasn’t been able to recover from a vocal injury. Today on the Pulse, we talk about how something like this could happen and how we might be able to prevent it.

This is the UConn Health Pulse, a podcast to help you get to know UConn Health and its people a little better, and ideally leave you with some health information you’ll find useful. With Carolyn Pennington, I’m Chris DeFrancesco. Did you know you could fracture your larynx?

Carolyn: Well, that’s what’s to blame here. It happened during a show last year, and the band has announced it’s no longer possible for Tyler to come back from it.

Today, we have two experts from UConn Health’s Voice and Speech Clinic to shed some light on what can happen with our voices and how to keep them healthy. Ann Clifford, a speech and language pathologist, and Dr. Dennis Lafreniere, chief of the division of otolaryngology. Thank you both for joining us today.

Now let’s start with you, Doctor. What is a fractured larynx? How the heck do you get a fractured larynx?

Dr. Lafreniere: Well, 99 percent of the time when you get a fractured larynx, it’s from trauma. We’ve treated hockey players who’ve gotten pucks to the neck, and the larynx will fracture. It’s made out of cartilage. As you get older, that cartilage tends to calcify. It becomes a bit harder, and that’s where the majority of fractures happen, is with trauma.

With Steve Tyler, that happened because of wear and tear and aging of the larynx. It’s not the years, it’s the mileage that we say with the larynx like this. So he’s used his voice at the very top end, very high frequency, very high volume for years, and the muscles pulling on the larynx actually help to cause that, and that is extremely rare extremely rare. And so but his voice is also fairly unique, and —

Carolyn: I was gonna say, I mean he certainly has a specific like heavy-metal, hard-rock kind of delivery. Someone that’s just a more moderate singer, would’ve that happened?

Dr. Lafreniere: No. I’ve been doing this for three years 35 years and I’ve never had anybody get a fractured larynx from singing. So, but like I said, he’s a unique individual, a unique situation, and that’s what happened to him.

Carolyn: And there’s really nothing you can do?

Dr. Lafreniere: Well, there really isn’t, especially at his age, because it’s going to be hard to get that to heal. Now, it’ll heal and his voice will be normal speaking, but to sing the way he has sung, it’s going to be very difficult for him to hit the notes and the amplitude that he had before.

Now, he presented initially with a bleed in the vocal cord, and we see that all the time. And that’s from, people can misuse their voice, they can overuse their voice, the vocal cord will bleed a bit, and for us, that’s one of our only vocal emergencies. We’ll actually put them on complete voice rest, and hopefully most of the time that will all calm down. But that’s something that Ann sees a lot and will help us with.

Ann Clifford: Yes, I do. Yes. We always see these patients for voice therapy, usually after their period of voice rest, and we want to get them exercising so that the vocal folds don’t become stiff.

Carolyn: When you say bleed though, I mean, are they actually bleeding?

Dr. Lafreniere: Well, there’s actually a lot of vascular, a lot of blood vessels on the vocal fold, and one of them will pop, and what happens is they’ll get like a little blood blister. I tell people it’s like when you’re raking the lawn without wearing gloves, sometimes you’ll get a blood blister on your hands. The same thing can happen to the vocal cord. The thing is, we need that to calm down, because if it heals in that way, then it’s going to disrupt the wave motion of the vocal cords.

The vocal cords are strips of muscle covered by loose skin, and when the vocal cords come together, air has to go up between them, and it causes a wave to travel over the vocal cord. That can’t happen if there’s stiffness of that lining of the vocal cords. So that’s one of those things that is really a vocal emergency, especially for someone who’s using their voice professionally.

Chris: When you have someone on voice rest and then they come to see you, Ann Clifford, speech and language pathologist, what does voice rest mean and how long does one have to basically not speak in order to attain the goals here?

Ann Clifford: So I’m going to throw this one back to Dennis, since you’re the one that really determines how long a particular patient will be resting their voice for.

Dr. Lafreniere: So, with a vocal cord hemorrhage, we usually, I have them rest their voice for a complete week. And then they’ll come back and see me.

Chris: And that’s no talking at all?

Dr. Lafreniere: That’s no talking at all. It’s one of the only things now that we have complete voice rest. We do a little bit post-surgery, but there’s debate over how long you need to do that. But this, we really want the lining of the vocal cord to calm down, so that blood blister to get resorbed. And once that happens, we go and look at the vocal cord again. Instead of being a red lesion, it ends up looking like a brown or yellow lesion, and the lining looks normal, and the wave motion starts to look normal again. Then we get them to speech therapy because we want to make sure that what they did to get this to happen doesn’t happen again and that’s where Ann comes in.

Chris: So where do you come in with that?

Ann Clifford: Yeah, so we come in and we sort of still advise that the patient be extremely careful with their voice use. We usually put them on modified voice rest, so they can use their voice just a little bit, but not very much at all, and we get them exercising. So just like an athlete might go to physical therapy after injury, we want our voice patients to come to us for speech therapy or voice therapy to improve the mobility of the vocal folds, make sure that everything remains flexible as they’re healing and looking at their behavioral patterns. Is this a singer? How are they singing? Are they supporting their voice? Are they smoking? It could be causing some irritation.

So we sort of look at the whole picture and try to figure out what our patients need to make sure this doesn’t happen again. And we’re, getting them exercising from the first day that we see them in the clinic.

Carolyn: But it depends what kind of occupation they have, so you would, if it was a teacher, you would just be having them speak as they do to a classroom?

Ann Clifford: No, absolutely not. So even our teachers, they might require some extra time off of work. We do need to be very careful with these patients. So if it’s a teacher, we want to make sure that they are resting whenever they can during their workday. We see a lot of teachers in the clinic for this reason because they’re at high risk of developing a voice issue because they are professional voice users, they use their voice all day, often having to raise their volume. So for our teachers, we might recommend using a microphone in the classroom, hydrating…

Dr. Lafreniere: And a lot of them don’t use that microphone. Young voices are the ones that are challenging for us as well because they’re always, will I be able to sing in the spring play, and I always revert them back to Ann because Ann’s going to let them know when they can go further. So they’ll start with, with lower level, just making sure that everything’s sounding clear. And the more they can take on, she’ll release them and let them do more and more. But usually within a six-to-eight-week period, we usually have people back to where they should be.

Carolyn: So you’re even having really young people come in having issues?

Ann Clifford: Sure, yeah.

Dr. Lafreniere: Absolutely, especially those that haven’t necessarily been trained. They have very nice voices, and somebody may have helped them with some lessons, and they sing in this play, and they sing in that play, and the next thing you know, they’re hoarse at the end of every performance. That’s not a good sign, and often times we have to step back and retrain them to get them to a point. They’re oftentimes very talented, but they have to have the technique to be able to use that instrument.

Ann Clifford: And it is quite common. I think something like 46 percent of singers develop a voice disorder in their lifetime. So I do think that just raising awareness that voice issues do happen even to the best of singers, and not to be afraid to kind of come in and get things checked out if you’re noticing a problem. And like Dr. Lafreniere is saying, patients do tend to do pretty well with voice therapy.

Chris: Do you have any very basic things that you could convey in this format that would be something technique wise that possibly could help somebody who maybe hasn’t found the proper technique yet, that someone listening could take from this and maybe alter the path that otherwise would have taken them to you?

Carolyn: Yeah, like prevention tips?

Dr. Lafreniere: Well, I mean, there’s, there’s always really good hygiene, right? So staying well hydrated. Avoiding caffeine, alcohol, all of those things will dry you out and it can lead to reflux. Reflux is very common in singers because you’re using abdominal support to project your voice and oftentimes it’ll send some stomach acid up and irritate it. So, hydration, rest, good diet, you’re not eating right before you go to bed, you’re not eating right before you’re singing or exercising. All of those things really do make a difference.

If it was a training issue, then we oftentimes encourage them to get a teacher. Ann will help — and she can be a teacher, she just has a fairly busy clinical volume and doesn’t necessarily have the time to do that — but we’ll refer them to people that help them actually learn how to sing. Oftentimes people just pick it up naturally and it’s not necessarily technique that’s going to help them have a longevity in doing what they’re doing.

Carolyn: Well, I can see singing to be able to, but if someone’s just like talking, how do you change how someone talks or delivers?

Ann Clifford: Through exercise. The vocal folds are tiny little muscles. So just like a runner might alter their gait to prevent a hip injury, we’re going to work with our patients, have them do different voice exercises that are similar to singing exercises that you might be familiar with. And they’re therapeutic though, so they’re sort of, we’re training vocal efficiency. We’re trying to optimize their vocal energy so that they’re not overusing their vocal energy and developing a problem. So we have them do tiny little voice exercises that really have a big impact.

Dr. Lafreniere: And sometimes what can happen is we can have very highly trained vocalists who sing beautifully. I’ve had some operatic sopranos who perform in operas around the country, but their speaking voice is really bad. And they get into trouble because they’re not using their speaking voice correctly. They’ll start to use glottal fry, which is very low-airflow speaking style. You hear it all the time where people will talk and they have this sort of gravelly quality.

Ann Clifford: Mm-Hmm. It’s very common.

Dr. Lafreniere: It’s very — exactly — and so oftentimes, we’ll send to speech pathology to get them to use their speaking voice correctly.

Chris: I’d like to cover a couple of other potential vocal disorders that you see in the Voice and Speech Clinic, other than fractured larynx, because that seems like one of the less common ones. But Carolyn, you wanted to ask about something.

Carolyn: Well, certainly we don’t need to talk about politics here, but I think anyone who has heard Robert Kennedy speak, and I know he has a certain condition, it’s such an unusual sound. What is his issue? And is that something that’s preventable or fixable?

Dr. Lafreniere: So he has a, it’s called spasmodic dysphonia, and it’s a dystonia. So it’s an abnormal muscle contraction that happens in the larynx. You might notice it more in tremor. Tremor is also a dysphonia and that was Katharine Hepburn, the “ah, ah, ah, ah” kind of quality of the voice. This is different. This comes in spasms and it happens to men and women, more women than men. And we do have treatments for it. We can do speech therapy, which can be helpful, but it typically doesn’t cure it. But we will give Botox injections into the vocal cords to stop them from spasming. And that therapy works very well. And so, it comes from an abnormal signal from the brain, and the brain’s telling the vocal cords to contract when it really shouldn’t.

There’s a lot of research going on now to look at a way of trying to prevent that centrally. And so, a lot of people suffer from that. We see a lot of folks with that.

Carolyn: Oh that’s a common issue?

Dr. Lafreniere: Yeah. It used to be, it took years for people to actually get the diagnosis, because people always thought that, “Oh, you’re being stressed and we want you to relax and go do this or that.” And once we were able to get to the diagnosis quicker, we were able to get them relief from that.

Chris: What are some examples of other things you might see in the Voice and Speech Clinic? And what are kind of the early warning signs, so if someone who hasn’t been to you yet notices these types of things, it could trigger the thought, “Well, maybe I should come in”?

Dr. Lafreniere: Sure. So if you’ve had hoarseness for more than three weeks, in that three-to-four-week range, somebody should be taking a look at you, especially if you’re a smoker, if you have risk factors for cancers. Besides the neurologic issues, there are a lot of things. People with Parkinson’s will have trouble with their voice. We have people who’ve had surgeries or traumas or even a bad cold and their vocal cord will stop moving. That’s vocal cord paralysis. Those are things that we would treat as well.

Ann Clifford: I think we talked about lesions, like vocal fold nodules, little calluses on the vocal folds, and polyps, which are almost like a little blister like bump on the vocal fold. We see a lot of muscle tension dysphonia, which can present as just a consistently strained voice. And a lot of patients with muscle tension dysphonia, which is really just like having muscle tension build up in your throat, complain of discomfort as well. So, even if you’re feeling something, it’s worthwhile to come on in and see the laryngologist.

Dr. Lafreniere: That’s right. And of course cancers, we see a lot of early cancers. And the beauty of finding cancers early in the larynx is that they’re curable. So we can treat them either with lasers, et cetera, but if you wait too long, then it gets too big, then it becomes a big deal to try and treat that, and a lot more complicated. So we do encourage folks, if it’s over three weeks, somebody should take a peek at you and we see what’s going on.

Carolyn: So hoarseness is the biggest thing.

Dr. Lafreniere: Yeah, that’s right. If your voice is hoarse, if you have pain. Pain for sure, you want the doctor to take a look at it. If it’s just hoarse or you’re noticing that you’re having trouble swallowing, any of those things are things you don’t want to waste a whole lot of time on it, waiting for it to get better. I think that three-week, four-week period is important. Don’t turn those weeks into months, just to make sure that there’s nothing else going on.

Sometimes what happens, you can have benign things and people get into such a habit even like the vocal cord paralysis, they start squeezing their larynx so bad that even if you fix their vocal cord, we have to unload them. We have to get them to release things. So getting in to see a doctor and then subsequently a speech pathologist is important.

Carolyn: The voice and speech clinic has always been such a prominent thing for UConn Health. Is there any other clinic like this in the state? Toot your own horn a little bit here.

Dr. Lafreniere: Well, sure. I mean, we were the first in the state to do that. And we deal with the majority of professional voice users in the state. We take care of the Hart School of Music, the University of Connecticut. Folks come to us because we’ve been here first. There is some voice care that’s going on down at Yale. Our colleagues down there are, are very well trained as well, but we were the first ones on the block.

And the other thing we didn’t mention is there’s a difference between a voice trained speech pathologist and a general speech pathologist, because all Ann does is voice, and the same thing with Janet Rovalino, and that expertise is something that sets us apart.

Chris: All right, Dr. Dennis LaFreniere and Ann Clifford from UConn Health’s Voice and Speech Clinic. Thank you so much for being here.

Ann Clifford: Thank you.

Dr. Lafreniere: Our pleasure.

Chris: That is our time for today. For Ann Clifford and Dr. LaFreniere, and Carolyn Pennington, I’m Chris DeFrancesco. Thank you for listening to the UConn Health Pulse. Be sure to subscribe so you can catch us next time, and please share with a friend.