Doc I need help with my voice

With longer life expectancy, more elderly Singaporeans are discovering to their dismay that their vocal cords are wearing out before they do

After a lifetime of talking and communicating easily with others, Mr LBK, 80, found himself without a voice.

The problem was vocal fold weakness, an issue with old age, said ear, nose and throat surgeon David Lau of Gleneagles Medical Centre.

The elderly man put up with it for about three months. But when he could no longer talk on the phone, speak clearly at gatherings or sing karaoke, he sought help.

Though his voice loss was too severe for speech therapy alone, surgery was not feasible either, said Dr Lau. General anaesthesia and an invasive procedure for someone his age was best avoided.

Instead, Dr Lau recommended a non-invasive procedure, done under local anaesthesia in the clinic, in which hyaluronic acid would be injected into Mr LBK's vocal folds through the neck.

An endoscope, a device with a light attached that is used to look inside a body cavity or organ, was passed through his nose so Dr Lau could see where to inject the hyaluronic acid.

The material bulks up the vocal folds, also known as vocal cords, to help them close properly, and help the person produce sounds.

Vocal cords need to be pliable and to come together to vibrate thousands of times a minute, producing the puffs of air that help to produce sounds.

But, like other parts of the body, as they age, they may lose bulk and become thinner, and so do not close properly, which affects the voice.

After the injection, Mr LBK's voice - and quality of life - took a turn for the better.

As Singaporeans live longer, more elderly folk, like him, are finding out to their dismay that their vocal cords are wearing out before they do.


Age alone can take a toll on the delicate folds that make up the vocal cords, leading to presbyphonia, an ageing voice, said Dr Lau.

People at risk are those who have lost a lot of weight and muscle mass, which can occur with age or after a chronic illness.

Some may be affected more than others, depending on factors such as the severity of the physiological changes and one's vocal demands, said Dr Han Hong Juan, a consultant at the department of otolaryngology and director of the Voice Clinic at Singapore General Hospital (SGH).

The way a person uses his voice does not affect the likelihood of his getting a voice disorder.

But professional voice users may abuse their voices more, predisposing them to voice disorders, said Dr Han.

Some examples are singers and teachers.

Speech therapy can help restore one's voice. But some people may find the process too slow, or their condition may be too severe for this method to be effective on its own.

Surgeons may then offer a procedure that plumps up thinning vocal cords, using the same types of fillers that doctors use to smoothen wrinkles on faces. One can also opt to have implants inserted into the voice box.

Unfortunately, surgery for this condition is not universally successful, although it can be helpful in certain cases, said Dr Lau.


There is no local data on the incidence of presbyphonia, though figures from the West indicate an incidence of 12 to 35 per cent.

The latest United States study on this topic shows that around 29 per cent of the elderly have vocal disorders. This mirrors Singapore's experience, said Dr Han.

About 25 per cent of cases can be attributed to ageing, and without other serious medical issues, said Dr Han. Some people with medical conditions, such as stroke or cancer, can have voice disorders regardless of their age.

And the incidence of those aged 60 and above seeking treatment for vocal disorders is rising, he added.

This is probably because people now stay longer in the workforce and need to use their voices to conduct business, and also because people are generally more socially active into their later years now, said Dr Han.

He has noted a steady 2 per cent annual increase over the past five years in the number of patients seeking help at SGH's voice clinic for this problem. A few of them are only in their 50s.

Currently, he gets about 100 new patients a year. Some 30 per cent want to know if they may have a dangerous medical condition, such as cancer, that may have caused their voices to fail.

Once they are assured that they are healthy and their voice changes are due to ageing, they decline further treatment.

Another 30 per cent have medical issues which occur at the same time as their voice issues. Gastric reflux, for instance, predisposes the voice to hoarseness, a sensitive nose or a persistent cough, which can impact the voice, while laryngitis can cause muscle tension in an ageing voice box, said Dr Han. The underlying health condition must be addressed before their voices can be improved.

The remaining 40 per cent have changes to the voice purely due to ageing, and are encouraged to have voice therapy.

If that does not work, they may be offered injections or surgery.

At National University Hospital, people usually come for help when they cannot be heard by others, said Ms Sharon Raynor, a senior speech therapist at the hospital's department of otolaryngology, head and neck surgery. They are also offered voice therapy.

"If the patient chooses to do the therapy as instructed, they almost always indicate that they feel that their voice has improved," said Ms Raynor.


Madam S Tan, 55, suffered an increasingly weakening voice after she became a kindergarten teacher three years ago.

For the first time in her life, the former housewife found herself having to use her voice a lot. She also found herself running around after young children. The job caused her weight to drop from 50kg to 42kg.

"I think that was the main cause of my problem. If I hadn't lost so much weight, my muscles wouldn't have shrunk and maybe I wouldn't have lost my voice," she said.

Her problem got so bad that her husband complained he could not hear what she was saying, even at home.

Madam Tan never knew when a phlegm build-up would occur - another complication of her condition - and render her voiceless.

"Sometimes, when I am about to order something at the hawker centre, I suddenly cannot talk. It's very embarrassing and everyone looks at you," she said.

After struggling for about two years, she quit her job early this year and started voice therapy at SGH.

"I am learning how to project my voice and not just to strain it by speaking from my throat. It is a new skill and I need time to practise and incorporate it into daily life," said Madam Tan, who has attended 10 voice therapy sessions so far.

Her voice has improved by about 40 to 50 per cent, she said.

Dr Han has offered her the injection or implant surgery if her voice does not improve further.

She hopes not to have either of the treatment.

"I might as well continue to put in the time and effort on doing my voice exercises and I hope that it will be enough," she said.

Ways to fix an ageing voice

Presbyphonia, or an ageing voice, comes about when the vocal folds thin out, to the extent that they are unable to close strongly during speech.

This results in a weak, breathy voice, said Dr David Lau, a specialist ear, nose and throat surgeon at Gleneagles Medical Centre.

Add to that years of abusing the voice from talking too much, too loudly or too little, smoking or various health problems, and a person's voice quality can diminish - and along with it, one's quality of life.

Fortunately, it can be fixed.

Non-surgical treatment involves voice therapy, which utilises a variety of techniques to improve voice quality and symptoms, such as vocal strain and effort.

Research has shown that voice therapy can significantly improve one's voice quality as well as his voice-related quality of life, said Dr Han Hong Juan, a consultant at the department of otolaryngology and director of the Voice Clinic at Singapore General Hospital (SGH).

For instance, a programme called Phonation Resistance Training Exerciseaddresses complaints of reduced loudness and increased vocal fatigue.

It involves high-intensity vocal exercises - repeating different sounds loudly, to the point of muscle fatigue, said Ms Laura Chua, a speech therapist at SGH.

One will be asked to project different sounds, such as "aaa"; or common phrases such as "hey!" or "where are you?".

For a start, the patient does four exercises twice a day. Subsequently, for maintenance, the frequency can be lowered, said Ms Chua.

At SGH, patients typically undergo combined therapy to optimise voice quality and efficiency.

For example, he may be taught Phonation Resistance Training Exercise on top of other exercises, such as trills and hums.

Lip trills are like blowing lip bubbles or "blowing raspberries".

Little children often do this. They produce a motorboat or "brrr" sound.

Tongue trills are similar, but have a "rrr" sound, while hums are akin to humming a tune, usually with an "mmm" sound.

These exercises help to release unwanted tension in the larynx and engage one's breathing and voice.

They are excellent warm-ups and cool-downs for the voice, and are useful for many types of patients with voice disorders, said Ms Chua.

Another programme which has been shown to be beneficial involves vocal function exercises (VFE).

This is a sequence of voice exercises aimed at balancing and strengthening the laryngeal muscles.

Patients perform four exercises to warm up, stretch and strengthen the vocal folds and laryngeal system. They do this by making various vowel sounds, such as "eee" or "woo" and sustaining them for as long as possible.

When speech therapy fails or does not work well enough, one can turn to clinical procedures.

Doctors can inject fillers into the voice box to try and close the gap between the vocal cords when the person is speaking, said Dr Han.

Patients can also undergo surgery to have a permanent surgical implant fitted in the throat.

To date, about 80 per cent of his patients have reported good outcomes after these procedures.

However, more data is needed to assess the relative effectiveness of these two techniques, said Dr Han.

This article was first published on May 21, 2015.
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