The Voice with Normal Speech, but Loss of Upper Range Quality

by , last modified on 5/21/16
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This section will go over a variety of lesions that leads to a raspy voice in the higher pitches of voice. However, speech is usually normal although a person may describe the voice as being intermittently raspy as well (see Raspy Voice and Laryngitis section). This particular scenario is what singer's fear and is the most common presenting complaint to an ENT office. In order to evaluate these patients, the entire vocal range needs to be investigated. The best way is to have the patient sing the first line of a universally known song, "Happy Birthday" very softly at different pitch ranges and listen for pitch breaks, onset delays, and diplophonia. Treatment depends on the cause and may include surgery and/or voice therapy.

Small PolypLarge PolypSaccular & Ventricular CystVocal Cord Nodules #1
Vocal Cord Nodules #2Vocal Cord Cyst
Vocal Cord SwellingDiplophoniaPitch Breaks

Click here for audio & video of what normal looks like.
Photos displaying abnormalities can be found in the Photo Library.

How Were These Images/Videos Obtained??? By a Procedure Called Fiberoptic Trans-Nasal Endoscopy...



Example 1: Small Polyp

Audio - Standard Passage

Audio - "Happy Birthday"

Note that the voice breaks in the upper range of singing Happy Birthday which indicates a mass on the vocal cords. In the video, this suspicion is confirmed by a small polyp developing on the free edge of the left true vocal cord with reactive swelling on the right true vocal cord.

Read more about vocal cord polyps here.

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polyp


Example 2: Large Polyp

Audio - Standard Passage

Audio - "Happy Birthday"

As in example 1, note that the voice breaks in the upper range of singing Happy Birthday as well as moments of diplophonia which indicates a mass on the vocal cords. On the video, there is large polyp on the left vocal cord.

Treatment is by surgical excision with perioperative voice rehabilitation.

Read more about vocal cord polyps here.

Example provided courtesy of Dr. James Thomas.

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polyp


Example 3: Saccular and Ventricular Cyst

Audio - Standard Passage

Audio - "Happy Birthday"

Note the normal speech but voice breaks in the upper range. On the video, there is a cyst bulging near the front and on top of the right vocal cord (saccular cyst). There is also another cyst on top of the mid-left vocal cord (ventricular cyst). In the upper range, the cyst touches down and interferes with the vocal cord vibration resulting in pitch breaks and onset delays.

Read more about vocal cord cysts here.

Example provided courtesy of Dr. James Thomas.

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saccular


Example 4: Vocal Cord Nodules

Audio - Standard Passage

Audio - "Happy Birthday"

Note the normal speech but voice breaks in the upper range. On the video, there are nodules bilaterally along the mid-vocal cords. However, the left nodule is bigger than the right.

Treatment is voice therapy with possible surgical exision.

Read more about vocal cord nodules.

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nodule


Example 4 Cont'd: Vocal Cord Nodules #2

Audio - Standard Passage

Audio - "Happy Birthday"

Yet another example of vocal cord nodules with a slightly different apearance in a different patient. Onset delays are quite prominent at the higher pitches. The video was obtained with a rigid 70° endoscope.

Treatment is by surgical excision with perioperative voice rehabilitation. Read more about vocal cord nodules.

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nodule


Example 5: Vocal Cord Cyst

Audio - Standard Passage

Audio - "Happy Birthday"

Note the normal speech but voice breaks in the upper range. On the video, the cyst is located in the mid-right vocal cord free edge.

Treatment is by surgical excision with perioperative voice rehabilitation.

Read more about vocal cord cysts here.

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cyst


Example 6: Vocal Cord Swelling

Audio - Standard Passage

Audio - "Happy Birthday"

Vocal cord swelling is perhaps the most common cause of upper range hoarseness in singers and in people who generally like to talk a lot. It is considered the very first stage before further injury leading to nodule/cyst/polyp formation. If you listen to the happy birthday song, one can hear onset delays and pitch breaks most notably in the upper ranges suggesting a mass/swelling on the vocal cord. The picture displayed shows the classic hourglass gap indicative of this swelling. No obvious mass (ie, nodule/cyst/polyp) is apparent. The video will show the swelling and how it affects the upper ranges with a very clear pitch break towards the end. Vocal cord swelling is treatable with voice therapy; in singers, preferably by a trained voice pedagogue familiar with vocal cord swelling. Overall strategies to address vocal cord swelling are outlined here.

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swell

 


Example 7: Diplophonia Due to Vocal Cord Masses

As you may also have realized, if one hears diplophonia (two different tones simultaneously), that finding alone does indicate a vocal cord mass. The two tones occur as the vocal cords behind the mass vibrate at a different frequency than the vocal cords in front of the mass. In essence, it creates a situation where there are 4 vocal cords instead of 2.

For many of these, treatment is by surgical excision with perioperative voice rehabilitation.

Examples provided courtesy of Dr. James Thomas.

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nodule


cyst


Example 8: Specific Frequency Pitch Breaks

Another suggestion that there might be a vocal cord mass is a pitch break at a specific frequency. Note that the voice sounds good except at certain pitches where the voice breaks.

Example provided courtesy of Dr. James Thomas.

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swell

 

 

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