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CASE NOTES
Tuesday 1 January 2008, 9.00-9.30pm
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BRITISH BROADCASTING CORPORATION



RADIO SCIENCE UNIT



CASE NOTES

Programme No. 1: The Voice



RADIO 4



TUESDAY 01/01/08 2100-2130



PRESENTER:

MARK PORTER



CONTRIBUTORS:

LINDA HURST

JOHN RUBIN

DAVID RATCLIFF

VIVIENNE HOLSTEAD

GERALD BROOK



PRODUCER:

DEBORAH COHEN



NOT CHECKED AS BROADCAST





PORTER

Hello. Today's programme is all about the voice. Like most key bodily functions, we rarely give our voices a second thought - unless they let us down.



VIVIENNE

Until it happens to you, you don't realise that now I have to think twice about what I say and which words I'm going to get out. I'm doing fine here because it's quiet but when it's noisy I might start to say something, you know, I would like and I know the I is just not going to come out so I've got to sort of try and think of another way to say it. So that means it takes a while before you actually speak and you don't realise how normally if you're asked the question you'll just answer it but oddly I can't. A E I O and U are harder sounds are much more difficult to get out because I think it spasms on those.



PORTER

Vivienne has laryngeal dystonia, a neurological condition that causes spasm of the muscles in her voice box making it extremely difficult, and sometimes impossible, to talk. Later on we'll be finding out how a treatment better known for getting rid of crow's feet and frown lines has given Vivienne her voice back.



But first if you are a little husky after shouting over all the music and noise of that New Year's Eve party. Or your voice suffers because, like teachers and sergeant majors, you push it at work, then you may not be using it correctly. It's all about projection darling.



Linda Hurst is head of the vocal faculty at Trinity College of Music in London.



HURST

Singers need to use their voices properly because they won't have any left if they don't. For some people it's in the short term - if you use your voice really roughly you can have damage quite quickly. On the other hand the vocal folds, as we now call them, are robust, they're quite strong, it's only through misuse and a lot of scratching and mishandling that you can do damage. I mean you only have to think of someone like Rod Stewart who's been singing all his life in a fairly gritty way and can still do it, so that's not damaging.



PORTER

What about people who are using their voices a lot as part of their work, so somebody like a teacher who's standing in front of a class, maybe doing four or five hours a day where they're having to not shout but speak very loudly?



HURST

No, no and project all the time, teachers can get vocal damage because they sort of shut off and they talk from the neck upwards and they talk from the throat, as if the throat were the machine and the engine for the speech ...



PORTER

Forcing it out.



HURST

Forcing the voice out - I can do it, it's not a pretty sound, it's forcing it just from up here and putting an edge on it so that it carries. Whereas if there's more space it's a more attractive sound as well.



PORTER

Yes, you sound much more like an actor. Let's look at it from a practical basis. I come and see you, whether I'm a teacher or whether I'm an actor on stage, let's say I'm an actor on stage and I'm getting husky and hoarse where would you start to see where I was going wrong?



HURST

I'd listen - I'd listen very carefully to how you told me what was wrong, if there is a problem and that you're visibly producing the voice and using the throat as a strong engine, which it isn't, I would try and persuade you to breathe lower down in the body and to understand that the energy of what you do comes from down below and I would get you to breathe in on vowels - I might get you to go [Breathing in - Ahhhh] or [Breathing in - Ohhhhh] with real space, rather than just thinking Ah, Oh, which as you can hear just doesn't have the sort of well of resonance behind it.



PORTER

But when we speak it we tend not to think about our breathing at all, it's something that comes naturally so how do you get people to change that pattern, how do you get them to remember, I mean is there an exercise that you can do so that you differentiate between breathing from the top of your chest in front of you?



HURST

Yes with people who've never sung before and who've never thought about their breathing at all I sometimes advise that when they're lying down just to observe what happens with the breathing because you tend to breathe more deeply when you're lying flat and you're not doing anything energetic. Then when they're standing up in front of me I'd say just put your hand on your ribcage here, at the sides of the ribs rather than at the front, so the sides of the bottom ribs - the bottom ribs should really sort of swing out like bucket handles, so that you get the idea that the bottom ribs swing out as if you're lifting up a bucket, there is no bucket although you can imagine that the diaphragm area is the sort of bucket underneath there. They swing out. The diaphragm goes down and air drops into the body sort of automatically because you've created a space for the air to go. So breathing in doesn't actually have to be very active, if you create the right space the air drops in and then the resonance starts.



PORTER

But one of the difficult things, particularly if you're presenting on radio, is that you might have a long paragraph to read that requires breaths throughout and it's much easier to take a shallow breath, it seems, than it is to a - to refill right down to the base and start the next sentence.



HURST

That's true, I think that's absolutely true and quite often you just take a little breath to refuel on the way, it's a short stop, and then when you've actually come to the end of a paragraph or you can release the breath, there's usually a bit of breath left at the end of your using it, you can release that bit and take a proper one.



PORTER

So let's go back to the singing, can you give me any examples of where singers might go wrong?



HURST

There are so many unexpected pitfalls I think I'd just start, when a singer comes to me for the first time for a lesson I usually start with an exercise a little bit like this: so I say speak first and then sing and so what I want them to do is ya yeh and then [singing] ya, ya, ya, yeh, yeh, yeh. I might get in return: ya yeh [singing] ya, ya, ya, yeh, yeh, yeh which again just is the sound that's sort of sitting just behind the tongue and it's just sitting in the mouth, it's not interesting ...



PORTER

Sounds like it's coming, sounds almost thin as if it's coming from the top.



HURST

Yes because it's not - it doesn't have a column of air. A human voice is sort of essentially a wind instrument and the bore of the - the core of the body, the centre of the body, is like the bore of a wind instrument really. And if you imagine that that's all there and you know it all is there and that the breath goes down there and that you're supplied you don't get [singing thinly] ya, ya but you get [singing] ya, ya, ya and the throat is open, particularly if you breathe in on the vowel. And if you don't lock the back of your neck, interestingly because singers often want to stand absolutely still and in so doing they grip or hold something and you can't move them and they're shoulders are rigid and their neck's rigid, so you have to sort of make sure that everything is moveable. And yet the central column of the body is sure and true and standing rooted and able to lengthen as well.



PORTER

Another commonly used analogy is to think of the vocal cords, or folds as doctors prefer to call them, as the mouthpiece of a trumpet. Air forced up from the lungs under pressure is chopped by the rapidly vibrating folds, in much the same way as it is by the lips when you blow into the trumpet. Only much faster - around a hundred times a second, or up to a thousand times in a diva hitting the top notes.



So the basic sound produced by the larynx is a high pitched version of the noise you get when you blow into the mouthpiece on its own. [Demo]. Add in the resonant effects of the rest of the trumpet - the cavities of the throat, nose and mouth, and the ever changing positions of the walls of the throat, cheeks, tongue and lips and you get the finished product. [Demo] becomes "My name is Mark Porter".



Time to see it all in action. John Rubin is an ENT consultant at the Royal National Throat, Nose and Ear Hospital, and lead clinician of the voice disorders unit. Just the man to help me examine my own larynx.



Using a special video endoscope that can look around corners, John is able to look down on my vocal folds from the back of my throat. The scope uses a strobe light because the folds vibrate too fast to be seen under normal light. The strobe acts a bit like the version used in night clubs that makes everyone look like they are dancing in slow motion, and it allows John to watch my folds in action on a screen. But you need to keep still - something that's easier said than done when someone in pulling on your tongue, and inserting a small telescope into the back of your throat.



RUBIN

Okay take one coming up. Let's put the strobe on. So I'm going to have you leaning towards me, tongue's going to be out, I'm going to want a surprised look on your face.



PORTER

Yep.



RUBIN

That's it, exactly and when I ask you a certain falsetto I'm going to want you to say - Ehhhhhhh - and hold it for as long as you can.



PORTER

Ehhhhhhhhh.



RUBIN

Yeah but I'll tell you when, let me get my stuff set. Okay, tongue out just a bit. Get ready. Get set and go.



PORTER

[Long noises] [Coughing]



RUBIN

Excellent first take, excellent first take.



PORTER

It wasn't as bad as I thought actually.



RUBIN

When you're in falsetto it's the easiest but it doesn't necessarily give us the most information. So what we're going to do this time is we're going to go into falsetto - would you turn off two of those lights - we're going to go into falsetto and then I'm going to have you come down to upper chest - so we're starting Ehhhh and then come down to Ehhhhhhh, keep a very bright forward sound. Ehhhhhhhh.



PORTER

Ehhhhhhh.



RUBIN

Perfect, perfect. Okay take two. Excellent first take, you get the job. Okay tongue out, there we go ready, head up just a touch. Go.



PORTER

[Long noises] [Laughing]



RUBIN

Terrific, well done. Definite first take. Okay let's take a look and see what we've got. Here's image one and what we're looking at is we're looking down at the vocal folds, so what we see is we see the two tube vocal folds in front of us which have a slight whitish quality and right next to them are structures that we call the false folds. And we can see the black areas actually just below that is the trachea and below that of course ...



PORTER

That's the gap between the two.



RUBIN

Exactly and it would take us down to the lungs if we were to keep looking down. And right behind the vocal folds are the arytenoids and the arytenoids are mainly cartilaginous structures that house a lot of the muscles to the larynx. Okay? And what we're seeing here as we're looking at your vocal folds in general is that they're white, they're clear, there's no vocal fold pathology on them - the edges are nice and straight.



PORTER

Good.



RUBIN

So now we're going to take a look at your larynx in a second and there are a few questions that we always ask ourselves when we see a patient, when do this kind of analysis. We're going to ask ourselves are the vocal folds red, are they inflamed. So one asks about the quality of the actual vocal folds. We're going to ask ourselves about the closure pattern - as the air comes through them do they close along their entire length or do they only close along part of their length. Okay. We're obviously going to ask ourselves is there any pathology on the vocal folds which you don't have I'm happy to say. And we're also going to ask ourselves a question about the quality of the mucus - it's very important because for the voice to be excellent and smooth and consistent you need a very thin, very fine, layer of runny mucus in the vocal folds. Are you ready?



PORTER

I'm ready.



RUBIN

Here we go. So let's go to our video, we've got two videos, so here's our first video, take one. So here's our tongue base, here's our epiglottis and now we're going to see the vocal folds in motion - can you see okay?



PORTER

Yeah, I've just got a slight bit of - let's just take that, that's got it.



RUBIN

So you can see the vocal folds vibrating and opening and closing. Now a very, very interesting phenomenon that we see - the vocal folds themselves look fine but behind the larynx is the area where the oesophagus comes at the back of the pharynx, the opening of the oesophagus and what we see here is a series of bubbles and this could very possibly represent some reflux.



PORTER

That's froth coming up from the ...



RUBIN

From the oesophagus.



PORTER

Yeah well I do have - I'm sure I do have reflux, so this is - the valve's gone at the top of my stomach is what you're saying?



RUBIN

It could well be, it's a very common finding in our voice clinic.



PORTER

Acid reflux - where the contents of the stomach leak back up into the lower end of the gullet - is a common problem, particularly in pregnant women, smokers, people over 40 and anyone with a hiatus hernia. Symptoms include indigestion or heartburn, a husky voice, and constantly needing to clear your throat. It can also cause a persistent cough that's typically worse after eating, or while talking on the telephone.



David Ratcliff is a retired Anglican priest.



RATCLIFF

My experience is that I was a chorister as a young lad and after that I was ordained and therefore do quite a lot of public speaking and also still singing and now in retirement I find that the hiatus hernia, which I have, diagnosed a long time ago, for which I take tablets, varies according to whether or not I'm regular with taking the tablets. Sometimes I take them very regularly but sometimes I feel that because of the side effects I like to stop taking them but then I find that this has quite a long term effect upon the voice and I become more hoarse, I don't have the wide range that I have in my voice and it's just very uncomfortable.



PORTER

A hiatus hernia occurs when a small part of the stomach slips through the diaphragm into the chest disrupting the valve at the lower end of the gullet and encouraging reflux.



RATCLIFF

It's hoarseness, but it's also slightly sore and it feels very uncomfortable when I'm trying to reach either end of the range of my voice. So that it sounds slightly hoarse perhaps even now as I speak.



RUBIN

Almost anything that tastes good causes reflux - heavy cream, English breakfast, deep fried food, spicy foods - all of those things in one fashion or another are irritants for the larynx.



PORTER

And what effect would that reflux, that acid coming back up into the - you can just see it at the back of the voice box there - what effect would that have on my voice?



RUBIN

Well it can have multiple effects. The acid doesn't actually have to come up and actually touch the vocal folds to have an effect, just as the acid comes up to the upper portion of the oesophagus it affects the mucus and it can cause the mucus to become stickier, which you can hear perhaps with roughness in the voice.



PORTER

So - and that's the same effect you get with dehydration as well, this sticky mucus gives you a rough voice?



RUBIN

Exactly, exactly. And were any acid at all to get near the vocal folds it could actually cause the vocal folds to slam together, what we call the [indistinct words] but that's very unusual because the whole purpose of the larynx is basically to keep everything out - keep food away from the lower airway, to keep acid away. So the larynx works very well. So we wouldn't expect to see acid to actually touch the vocal folds per se.



PORTER

They look a lot softer than I imagined, I thought there were going to be very hard things that sort of slam together but there's quite a sort of rhythmic - it's gentle - looks gentle.



RUBIN

It is, that's the whole function of the larynx because the vocal folds vibrate so often, in the old days when people were initially thinking about how the larynx worked they were thinking that the muscles would cause them to open and close. But actually what happens is that they vibrate many too many times a second for that, so they're held close together and they just very softly just vibrate ...



PORTER

Because we're watching it on the strobe so it's all being slowed down tremendously but it almost looks like they're in water, they're like fronds in the water that are gently touching together. So, so far, so good, everything looks fine, bit of reflux and that's it?



RUBIN

Bit of reflux - more water, less coffee.



PORTER

More about my voice later. At the beginning of the programme we heard from Vivienne Holstead who lost her voice because of Laryngeal Dystonia - a neurological problem that leads to spasm of the larynx, strangling the voice.



HOLSTEAD

It sounds as if it's really painful, it's not, it can be an effort to get words out particularly the harsher words or the vowels. And sometimes when the treatment is wearing off I can't get them out but I still want people to talk to me. It's a neurological condition, so you can't control it and in a situation like this where it's quiet and if I relax the voice can get a lot better, in fact it is but if I'm anywhere where there's any noise because you automatically, without realising it, will try and talk above noise, as soon as I try and do that it gets much worse because you just can't - I can't project I suppose, I'm not sure what it is and I sound a bit like a dalek.



PORTER

Dystonia is the medical term for involuntary movements or spasms of muscles, and almost any part of the body can be affected. From the muscles around the eye - causing twitching or blepharospasm - to the hand - so called writer's cramp. In vocal dystonia it's the muscles of the larynx that are affected.



The cause remains poorly understood, but dystonias are thought to be due to a glitch in a part of the brain known as the basal ganglia responsible for initiating and controlling movement.



Vivienne, a sales woman, used her voice a lot for her job and her developing dystonia soon became a problem.



HOLSTEAD

What I didn't realise was there are ways that you can overcome it up to a point. If you come out of your normal speaking voice and do something you don't normally do like for instance singing or lifting it higher then you can get fluency. And so for a year I was coping with my job by lifting up and going - Excuse me, sir - you know - can you stop for a minute I've got something I'd like to say to you. But as soon as they asked me a question and I went back into normal I would struggle. But that then became the norm, and so I got to the point where I couldn't say it anymore, the voice just [indistinct words] so I had to stop. So then we started going down the route of working out what it was.



PORTER

There isn't a cure for vocal dystonia but paralysing the muscles responsible for causing the spasm using injections of botulimum can provide temporary relief. Although best known as the anti-wrinkle treatment Botox, botulinum toxin was initially used for treating dystonias. Mr Gerald Brooks from the Harley St ENT Clinic, is one of the pioneers of the treatment, which is a lot less drastic than previous therapies.



BROOKS

Over the years patients had been treated with a number of different types of surgery, which might involve crushing the nerve that supplied the vocal fold or even cutting it to paralyse half the larynx. And although the patients could actually speak to some degree they certainly didn't have a normal voice and quite a lot of them tended to develop the current symptoms after a few years so that other treatments were really not effective at all. And as a result we hardly saw these patients, they weren't treated, they were a sort of lost tribe of patients. And so when we started off treating we weren't sure what sort of dosage to use and it was a bit of hit and miss really, it would be very difficult actually, 20 years on if we actually approached an ethics committee to say what do you think about us injecting the most potent neuro toxin in patients with funny voices what would you think about it, we'd never get ethics approval, we never would. But that's the background to it and fortunately we had some patients who were keen and initially the patients, well the first patient we treated as inpatient because then we had no idea what exact effects it would have and whether it would affect their breathing pattern and the rest of it. But in fact obviously now it's an outpatient treatment under local anaesthetic and we've got much more control and knowledge about dosage and the adverse effects. So I should emphasise it's actually now a very safe treatment.



PORTER

Sally Myers was one of the first patients in Britain to be offered botulinum toxin in the late '80s.



MYERS

Oh in - actually in those days I was a guinea pig actually, I think I was the third person in the world to have the injection. And there was a problem with the needles and everyone was learning. I remember one occasion when Mr Brooks had ooh about 10 goes, through no fault of his own, it must have been the second, probably my second, injection and he wanted to send me home but I just knew the effect the injection was going to have and I wouldn't let him. And eventually it was okay.



PORTER

Good to be a guinea pig.



The injections are given through the skin over the front of the throat so Gerald has to work blind - he can't actually see the tip of the needle or the muscles into which he must place it. So to help him hit the right spot, the needle is connected to a machine that monitors electrical activity. Put simply when he hits the right spot, the monitor picks up the extra electrical noise, heard as a rise in the background static.



BROOK

So we'll have a look and she's nicely relaxed at the moment and we often ask them to swallow and then just hold it and relax. Could you just take a swallow a moment? So then next thing is we introduce the electrode through the skin. Now if I pushed it too far we get feedback because it's in the air mostly, so we know that's gone too far, so we withdraw it slightly, rotate the needle 20 degrees laterally, 45 superiorly, just gently introduce .... and say he, again, again. That's better okay. So you're going to do a nice big he and g response there in the muscle, so we're now going to inject. Very good. Smooth injection. That's very good. That side's fine.



PORTER

But the benefits are only temporary and both Vivienne and Sally need repeat injections at least three times a year.



BROOK

The nerves plug into the muscles like a plug in a socket, literally, so it's a very good analogy. And the drug blocks the - where the pins plug into the socket and stop the nerve impulse being conducted to effect the muscle movement. So the toxin remains active but the problem is it's one of those situations where the body thinks it knows best, realises that there's a nerve blockade and does its best to overcome that by regenerating some extra nerve shoots because it doesn't realise that you're actually wanting to block that. And so the nerve shoots then grow round, re-innovate the muscle and then it becomes active again, the patients invariably develop recurrent symptoms. And the time it takes for that depends partly on the dosage that the patient's being given but there's also the personal effect - it depends how rapidly they re-innovate and that is something that we can only determine by treating the patient, seeing the - assessing the results of the duration of benefit and then adjusting the dosage.



PORTER

Gerald Brook who injected Vivienne Holstead's larynx a fortnight ago. It generally

takes around two weeks for the full benefits to become apparent, so what does Vivienne's voice sound like now? Well she joins me on the line from our studio in Leeds. Vivienne, has it worked?



HOLSTEAD

Yes it has, yes.



PORTER

You sound noticeably different.



HOLSTEAD

Oh yes, yes, it's wonderful to just be able to open your mouth without thinking about it, knowing the words are going to come out, even if at the moment they're not as strong as I think they will be in a week or so.



PORTER

So you'd still expect further improvements on this?



HOLSTEAD

Yes I do, yeah. It did go actually extremely well this time and you go through this period of what they call breathless type of voice, where it's actually quite soft and in a noisy situation then it might be difficult to be heard and then gradually it starts to sort of tone up more and then in about four weeks I would say you get the full strength of the voice.



PORTER

And how long do you think it'll be before you start to notice it weakening again, as it wears off?



HOLSTEAD

I'm hoping, because I think it's gone better this time, that it will last a bit longer, probably three to four months in total before I need another injection but what I seem to find is roughly every month it takes a downward turn, it appears to me to be on a level for about a month and then suddenly it'll start becoming a bit more difficult and I'll get the catches or I'll open my mouth and it won't quite come out.



PORTER

Well thank you very much Vivienne for letting us watch the procedure and I'm glad it's worked.



HOLSTEAD

You're welcome.



PORTER

Vivienne's voice has returned and, back at Trinity College, I seem to have got the knack of projecting mine, according to voice coach Linda Hurst.



I'm Dr Mark Porter and you're listening to Case Notes on BBC Radio 4.



HURST

Well I thought that sounded really authoritative. What I would ...



PORTER

That's years of being a doctor that did that for me.



HURST

I was nervous that it was going to sound sort of pushed out but actually it sounded really authoritative and as if maybe there were a crowd of people and you might have been out of doors, I mean that was what I immediately pictured. I don't think there's very much wrong with it actually.



PORTER

Actually it's interesting you say that because when you're presenting on radio that's the way that you think I suppose, that you're speaking to lots of people, so you need to try and remember that.



HURST

But it was also quite an attractive vocal quality, I mean it wasn't squeezed - you didn't make it narrow and squeezed in order to project it.



PORTER

So you suspect that I could probably do that on a daily basis.



HURST

And it wouldn't do you any harm at all.



PORTER

So we don't need a microphone anymore?



HURST

No I don't think so no.




ENDS

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