A Clear Voice on Vocal Health

This month we talk about something we often take for granted — talking (or singing). From the UConn Health Voice and Speech Clinic, Dr. Denis Lafreniere, ear nose and throat specialist and head and neck surgeon, and speech pathologist Starr Cookman discuss voice disorders and the importance of maintaining good vocal health as they prepare to celebrate World Voice Day April 16.

(Dr. Denis Lafreniere, Starr Cookman, Carolyn Pennington, Chris DeFrancesco, April 2021)


Chris: We use it every day and it’s very easy to take for granted. And without it, our lives would be much different. It would make podcasts very difficult for one. It’s our voice.

This is the UConn Health Pulse, a podcast to help you get to know UConn Health and its people a little better, and hopefully leave you with some health information you’ll find useful.

With Carolyn Pennington. I’m Chris DeFrancesco. Many of us probably can’t imagine not having our voice function properly.

Carolyn: But when it doesn’t, often there are medical reasons, many of which are correctable. And to tell us more about that are Dr. Dennis Lafreniere, ear, nose, and throat specialist and head and neck surgeon, and Starr Cookman, a speech pathologist, both from UConn Health’s Voice and Speech Clinic. Thank you for joining us.

Starr Cookman: Thank you.

Dr. Lafreniere: Thank you.

Carolyn: So let’s start off by talking about voice disorders. What are they, how common are they? Give us some examples.

Dr. Lafreniere: Well, they’re extremely common, and they’re important for us to take care of because the voice is so much a part of who we are. Whenever we use the term “professional voice user,” everyone thinks automatically that it’s a singer or someone who’s performing, but a professional voice user is anyone that uses their voice to get through their day — teachers, doctors, parents — and when you cannot do that or you do it and it’s uncomfortable, then it can cause you a lot of problems.

Starr Cookman: What can happen sometimes, depending on how the voice is used, how much, or even how loudly, you can develop some injuries on the vocal folds themselves. These are visible using special scopes that we use, and a lot of times are treatable with rehabilitation therapy and sometimes medications.

Chris: And sometimes surgery, right? That’s when you get involved.

Dr. Lafreniere: Absolutely. We try to use that as a last resort. Most benign lesions of the vocal cords can get treated successfully with voice therapy. Most of what we create, those lesions, are due to the way we misuse our voice. And that happens because none of us are really taught how to use our voice, unless you are truly a singer and you go through voice lessons. But every day we use our voice and we don’t think about it. And sometimes you can get into the habit of using it abnormally, which can lead to problems

Carolyn: Is the voice and speech clinic unique to our region here at UConn Health?

Starr Cookman: Yes. In fact, we were the first professional voice clinic in Connecticut, where we were entirely dedicated to maintaining state-of-the-art equipment and speech pathologists on board that were working in tandem with voice dedicated ear, nose and throat physicians to meet the unique needs of the professional voice user. So yes, we do have people that come to see us from all around the region.

Carolyn: I was going to say, and some pretty well-known people, too, right?

Dr. Lafreniere: Yeah, absolutely. There are quite a few professional performers who — we don’t usually mention their names unless they give us permission to do so just because of privacy, but a good friend of ours, Javier Colon, who has actually performed for our World Voice Day in the past ,our World Voice Day celebrations, is one of our  more famou voices. Again, keeping people doing what they do for a living is our goal, and we’ve been very successful at that

Chris: World Voice Day is coming up, April 16. We’ve got some plans for that. Tell us about it.

Dr. Lafreniere: Sure. So we’re going to be doing another podcast. It’s going to be a an hour-length podcast. We’re going to be talking about the challenges that both providers have had in taking care of patients with voice and what we’ve done to adapt to that, to make it safe and effective for our patients, but also looking at the challenge — and the same goes for speech therapy, of course, because they’ve had the same kind of challenges that we’ve had as physicians — but also the challenges that performers have had. It’s been a really tough year. Broadway has been shut down. No voices had been singing. The act of singing is something that can be dangerous, or was looked on as being dangerous, and how they’ve adapted is going to be one of the things we’re going to touch on. We have Javier Colon, who’s going to come by and tell us the challenges that he’s had over those last year, and he’s also going to give us a little treat of performing for us at the same time.

Carolyn: Oh, that’s great.

Chris: Excellent. I’m curious, when you mentioned that we were the first to have a dedicated voice and speech clinic, how far back does that go? How many years?

Starr Cookman: I came here in 1997.

Dr. Lafreniere: I started doing voice work in about 1993, 1994 right after my residency program. I was able to hire Starr, she came to us from Iowa, one of the better voice therapy programs in the country. And the two of us started from scratch to put this together. And it’s been very successful and we have, uh, a good regional reputation now.

Chris: Ok. I have to ask, coming from Iowa, how different two people speak here as opposed to there?

Carolyn: Hey, I’m from South Dakota, I’m a native South Dakotan, and so I think we are just fine.

Starr Cookman: Exactly, it’s so similar.

Carolyn: We have the basic American speech.

Starr Cookman: Exactly.

Carolyn: That’s why so many newscasters are from the Midwest, right?

Starr Cookman: That’s right. I was going to say, Iowans sound like Carolyn.

Chris: Well, you could do a lot worse than that

Starr Cookman: Exactly. Exactly.

Chris: You had mentioned earlier, Dr. Lafereniere, about us not using our voice properly and that’s commonly a reason for voice disorders that you encounter. What does that mean? We’re not breathing from our diaphragm. We’re putting too much strain in the upper part of our, our, how does that work?

Dr. Lafreniere: Sure. It’s sort of all of the above. Sometimes people decide to create their voice right from the throat, or they’re pushing the voice like this to get a voice out. I sometimes have teachers who will have a bad cold, and they’ll have a laryngitis. They show up to school anyway. And Johnny in the last row has to hear them, so they’ll start to push their voice, to get through the laryngitis. And then they’ll come in and see us six months later saying, “Doc, it’s the worst cold I ever had.” Well, the cold went away a long time ago, but they got into the habit of using their voice abnormally. And that’s where Starr and the rest of our speech pathology team can work with them to get them, to use their voice in a more natural and efficient way.

Starr Cookman: I think to add to that too, is that once a problem starts that on the vocal chords, oftentimes the person will start to do tension or other compensations for the injury that then continue to make the injury worse. So once it starts, it can get worse pretty quickly. And if I could mention, this last year has been a real challenge for the voice because we are all speaking, as we all know, through masks of different densities and we are now all Zoom users. So we are all speaking to others through our computers and our cell phones more than ever before. And that has really brought a lot of issues to the fore because people are experiencing things like vocal fatigue for the first time and wondering what they’re doing wrong.

Dr. Lafreniere: And it’s also been a challenge for us as providers, because what we do is, we’re looking in people’s noses and throats, which is very aerosol generating. And we’ve heard that on the news, that’s a dangerous piece with COVID. So it’s been a challenge for us to be able to evaluate people who have voice problems, and it’s been a challenge for them because a lot of singers can’t sing, not because they can’t physically do it, but singing is not happening because it creates aerosol and that could lead to increase infections. So one of the things we’re going to be doing as a podcast coming up soon, looking at the challenges that we have had over this last year in the pandemic, how we as providers have adapted what we’ve done to try and be able to evaluate patients and, hopefully, how soon we’re going to be able to get choirs back together that get them singing again.

Chris: You’re listening to the UConn Health Pulse. Dr. Dennis Lafreniere and Starr Cookman from the UConn Health Voice and Speech Clinic are our guests today. Why is there a World Voice Day? Obviously this is your line of work, it’s important to you, but why is it important for the world to recognize and observe this?

Starr Cookman: World voice day actually started in 1999 in Brazil, and it was called International Voice Day and the world voice community thought it was such a great idea that we adopted it and expanded it to World Voice Day each year on April 16. There’s a different theme and the theme this year is “One World, Many Voices.” And it absolutely is a public awareness type of event and it encourages events across the world, including flash mobs and conferences. And we’ve hosted half-day workshops in Keller Auditorium here on UConn Health campus, really trying to get the word out about how to take care of your voice, how to keep your voice healthy for as long as you live.

And mostly to celebrate it because the voice is such a versatile and vulnerable part of us. It’s made to express ourselves and also our innermost feelings. It’s a really fascinating part of the body, and we, of course, I feel that way. There’s a lot of people who feel that way too, and so across the world, we’re all going to celebrate this fantastic instrument that we have inside our body altogether.

Dr. Lafreniere: In most of our World Voice Day celebrations, we’ve always had some entertainment at the end, usually from some, some local artists who’ve been able to help us celebrate because that’s what it’s all about. We want to learn, we want to learn how to take care of it, but we also want to celebrate it.

Chris: And see living proof of what can happen when you properly take care of your, your voice, right?

Starr Cookman: Absolutely.

Carolyn: Whether you’re a teacher, a performer, a phone operator, what if you are experiencing problems? Are there any warning signs that you should be looking out for?

Starr Cookman: Oh, that’s a great question, Carolyn, because it’s listening to the early warning signs and adjusting your lifestyle to treat those early warning signs that can keep you from getting into much bigger trouble. So one of the first early warning signs is that you all of a sudden feel like you’re having to put in more effort to talk. Something that was easy or something that you didn’t really even think about all of a sudden becomes more effortful. That’s one. Another one is feeling fatigued, vocally fatigued at the end of the day. So if you get to the end of your day and you’re feeling like, “Oh, I don’t want to talk any more,” that’s vocal fatigue. And that can be an indicator that you have a voice disorder. And then for people who use their voices to sing, usually, if there’s some type of problem with the vocal folds themselves, their high pitches become problematic first. And in particular, their high and soft pitches become what we call aphonic, which means that they go to sing something and nothing comes out. So that’s a real good early warning sign. Their speaking voice might be fine, but when they go to do that high-pitched light sound, nothing comes out. That’s a really good early warning sign that something’s wrong.

Dr. Lafreniere: Another warning sign is pain. If people are having any discomfort, uh, we want to take a look at that, especially if it lasts more than just a few days or more than a couple of weeks, I want to take a look. If someone’s a smoker, we want to make sure there’s not an early cancer, things like that. Oftentimes if someone strains their voice or screams, you can get some bleeding under the lining of the vocal cord, which can be immediately painful. Those are things you want a doctor to take a look at.

Carolyn: Are there healthy tips for your voice? I mean, are there things we should be doing everyday to keep our voices well?

Dr. Lafreniere: Absolutely. Staying well-hydrated is probably the number-one thing, which is very difficult for us, especially when people are really busy and they’re not by a water fountain. And in new England, we have the heat on in the winter time and very, very drying. So staying hydrated, about 64 ounces of water per day, is very, very helpful, having a good diet, making sure you’re getting your rest. Vocalists are athletes. So you have to treat your larynx like you would if you were an athlete, and taking care of yourself and having good nutrition and having good rest to get yourself through any sport using the larynx, especially professionally, is very similar to that. So you have to approach it in the very same way.

Starr Cookman: To add to that, the larynx can get kind of accosted by a couple internal body mechanisms. One of them is postnasal drip, that can cause problems with the voice. And the other one is reflux, which sometimes acid comes up from the belly, it spills over a little bit onto the larynx and that can cause problems. So you might think that you’re having a digestive problem, but then that could turn into a voice problem. And Dr. Lafreniere can help to manage that problem, starting at the source, which would be to manage the reflux.

Chris: Before we say goodbye, one last reminder, World Voice Day is April 16, and like we talked about, you can look for that World Voice Day special on our UConn Health Pulse podcast feed, including a performance from the first winner of the NBC television show “The Voice,” Connecticut’s own Javier Colon. Thank you so much, Dr. Dennis Lafreniere, ear, nose and throat specialist and head and neck surgeon at UConn Health, and Starr Cookman, speech pathologist at UConn Health’s Voice and Speech Clinic. Thank you so much for joining us.

For Starr Cookman, Dr. Dennis 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.