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The Breathy or "Lost" Voice

by , last modified on 4/14/21.

This section will go over a variety of lesions that leads to a voice with poor volume with a breathy or airy quality. Often, the patient is unable to talk more than a few words at a time. Treatment depends on the cause of the breathy voice. Depending on the cause, surgical interventions and/or voice exercises are available to restore/improve the voice.

Unilateral Vocal Cord ParalysisBowed Vocal CordsCOPD
Muscle Tension AphoniaGlottic Mass

Click here for audio & video of what normal looks like.
Photos displaying abnormalities can be found in the Photo Library.
Watch a video explaining the 4 Underlying Causes of a Hoarse Voice!

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

Example 1: Unilateral Vocal Cord Paralysis, Cancer

Audio - Standard Passage

Note that the LEFT vocal cord (your right), does not move where as the right vocal cord does. Notice the gap between the vocal cords which is the root cause of the breathy voice quality. In this case, the vocal cord is paralyzed due to a large thyroid cancer that invaded the nerve responsible for left vocal cord movement.

Sometimes, the paralysis can partially affect the vocal cord. In this example, there is a partial paralysis on both sides causing a breathy and harsh raspiness.

Sometimes, there could be a complete bilateral vocal cord paralysis as shown in this example.

At other times, it may be difficult to say whether the vocal cord isn't moving due to arytenoid dislocation versus nerve paralysis. Look at this example to help determine which it is.

Read more about the treatment of vocal cord paralysis here.

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Example 2: Bowed Vocal Cords (Presbylaryngeus)

Audio - Standard Passage

Note that both vocal cords have a curve to them which prevent a tight closure resulting in air escape. Normal vocal cords are straight and come together tightly to prevent any air escape. This condition is initially treated with voice strengthening exercises. If the vocal exercises fail to produce adequate improvement, surgical options are available.

Example provided courtesy of Dr. James Thomas.

Read more about the treatment of bowed vocal cords here.

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Example 3: Severe COPD (lung disease)

Audio - Standard Passage

This patient has a breathy voice, not due to anything wrong with her voicebox, but because the patient has severe lung problems. So severe, in fact, that she barely has any breath to power her voice. The lungs are what gives power to a voice. Weak lungs = weak voice. Imagine taking a breath in and than completely exhaling. Now try yelling out loud WITHOUT taking a breath in first. Very hard... For this patient, as the lungs get stronger, the voice will improve.

In the video, you may notice that the false vocal cords come together. This is a type of compensatory muscle tension dysphonia, but obviously fails as the brain erroneously attempts to get more vocal power and volume by trying ever harder to squeeze the vocal cords together.

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Example 4: Muscle Tension Aphonia (Mixed Lateral and AP Squeeze)

Audio - Standard Passage

Another example of muscle tension dysphonia to the point of no voice (aphonia). This patient's aphonia started after a viral upper respiratory infection. In the video, note that the anatomy is all normal. However, on phonation, there is a very tight squeeze of the false vocal cords which completely blocks the true vocal cords from being seen. Also note that the front and back of the voicebox comes close together as well (AP squeeze). The muscular squeeze on the true vocal cords is so strong that the vibration that creates the voice is literally smothered.

This patient regained her voice after 15 minutes of voice therapy focused on relaxation of the neck muscles and focussing on pitches where her voice became most audible and clear (upper register). The following is the same patient after self-directed voice therapy for one week:

Audio - Standard Passage after Voice Therapy

Note in the second video the complete resolution of the lateral and AP squeeze. Whereas before, one was unable to see her vocal cords, they are now easily visible. The colors appear different between the 2 videos due to different light sources used (first video used halogen light, second video used a xenon light source).

Click here to read more about muscle tension dysphonia.

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The video below is after 1 week of self-directed voice therapy.


Example 5: Anterior Commissure Glottic Mass

Audio - Standard Passage

This patient (17 years old female) has a dampened and weak voice due to a large glottic mass (granulation tissue) at the anterior or front part of the voicebox right between the vocal cords. This mass prevents the vocal cords from coming together precisely and also dampens the vocal cord vibrations from mass effect resulting in her weak voice. When she tries to phonate, she exhibits a supraglottic squeeze as her voicebox muscles tries (in vain) to obtain a normal voice by squeezing ever harder to get the vocal cords to come together. In this particular scenario (unlike Example #4 above), the muscle tension is compensating for an underlying problem (in this case, a mass). This case is another example of a type of compensatory muscle tension dysphonia.

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Voice amplification products for patients with a weak voice:

megaphone voice amplifier electrolarynx whistle

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