What do I need to know having spasmodic dysphonia during the COVID-19 epidemic?
You may be in one (or all) of the following situations: Your botulinum toxin (Botox) injection has been cancelled or indefinitely postponed and symptoms are getting more significant; you are being forced to work remotely which means more phone calls and virtual meetings which strains the voice and leads to difficulty being heard, having a smooth voice or projecting; you are dealing with more stress and anxiety during this time which is making your voice symptoms worse; you are worried that having spasmodic dysphonia makes you more at risk if you were to develop COVID-19. Let’s hopefully tackle some of these issues with some pertinent information.
You are worried that having spasmodic dysphonia makes you more at risk if you were to develop COVID-19
COVID-19 does NOT make you more susceptible to developing COVID-19. Further, if you are to develop COVID-19, having spasmodic dysphonia does not put you at greater risk. Spasmodic dysphonia is not a disorder that affects your airway or respiratory system. Some with SD may experience shortness of breath (particularly those with AB), when speaking or for those with AD after Botox injections. This is due to the fact for ABSD the vocal folds are opening too much, letting too much air escape during speech (thus the breathy voice quality and feeling of shortness of breath with speech). For ADSD, the botox temporarily creates a weakness in the muscles that close the vocal folds, also preventing full closure of the vocal folds during speech temporarily and allowing air to escape creating a breathy quality and possibly shortness of breath during the side effect period. Having SD does not mean that you have an affected airway and does not put you at greater risk for COVID-19.
Many voice centers are cancelling all non-urgent procedures for the unforseen future. This will typically include Botox injections. Some physicians may still offer injections depending on location, their access to protective equipment for themselves and patients, and the vulnerability of patients coming in for the injection. There has been a lot of question of whether or not patients should go in for the injection if their physician offers it. Although this is a necessity for some to be able to speak and to carry out job duties and normal day to day activities it is still an inherent risk going into the hospital or ENT office to receive these shots. Whether or not you can or should go for your injection right now is a discussion between you and your treating otolaryngologist and an evaluation of the factors listed above. If injections are not an option for the near future. Consider the options discussed below.
2. Your botulinum toxin (Botox) injection has been cancelled or indefinitely postponed
and symptoms are getting more significant. What do you do?
You can do voice therapy to cope with symptoms in the meantime. Some voice centers will have speech language pathologists that offer voice therapy through teletherapy but some will not. You can check with your physician who provides your injections to see if this is an option. If you cannot find a speech language pathologist specialized in SD who provides these services or cannot get access to teletherapy right now please contact me (email below) and I’d be happy to help direct you to the right provider.
3. You are being forced to work remotely which means more phone calls and virtual
meetings and you are dealing with more stress and anxiety during this time which is
all making your voice symptoms worse. How do you adjust and cope more efficiently with these symptoms to still be able to manage your day to day duties?
I’d recommend voice therapy and use of compensatory strategies (listed below) especially if you don’t know when the date of your next botulinum toxin injection will be. Below are some examples of voice techniques that you can try. Again, if you are doing any sort of voice work you really want to make sure to be working with a speech language pathologist/voice therapist to make sure that you are doing the techniques in the correct way, to be able to troubleshoot difficulties and challenges and to tweak techniques to specifically target functional speaking tasks you want to be able to complete more efficiently.
a. Resonant Voice Techniques:
The concept here is to bring your voice to a more efficient manner of production when you are voicing. You can start with what is called a resonant hum (holding out a hum “hmmmm”) where you try to bring the voice forward towards the tip of your lips and you attempt to feel strong energy and vibration at your lips and in the front of your face. The key here is to not feel anything in your throat when you do this. You want to make sure you are feeling relaxed in your throat. If you feel tension in your throat or effort when producing the hum, try using more airflow by doing a sigh with the hum moving from a high pitch to low pitch (“hmmm”) while releasing airflow in an easy way.
b. Semi-Occluded Voice Tract Techniques:
One technique to get the vocal folds to be vibrating with less needed pressure and to work in a more efficient pattern is called a semi-occluded vocal fold technique. This is also a great technique to reset the voice or to warm up the voice. One popular example is performed with a straw. Put a straw in your mouth and try humming through the straw. When producing the hum you should feel vibration at your lips and consistent air moving through the straw, like a kazoo. Keep the hum at your natural speaking pitch and a normal volume and keep sound consistent and even. You should feel a lot of vibratory sensation at your lips and absolutely no push, tightness, or effort in your throat. This should feel easy and perhaps like it reduces tension. You can also try doing this same thing in a cup of water, which can increase coordination of airflow with voicing and can reduce some tension in the throat when phonating. Put the straw about an inch under a cup filled halfway with water. Starting with a hum at your lips through the straw, keeping vibration and energy feedback at your lips, again without tension in your throat. You will see bubbles form in the water if you are doing correctly. These should be consistent and even. You should not force any air out or push from your throat to make the bubbles. If you do not feel that this is easy or do not see any bubbles in the water try making the hum a breathier “whoo” through the straw.
See the webinar for details on how to produce. Here is also an example from the creator of the technique: https://www.youtube.com/watch?v=0xYDvwvmBIM
c. Flow Phonation
The concept of this technique is to use more airflow when speaking. You can try this by holding a tissue or your hand in front of your mouth while just blowing airflow out of your lips (envision blowing out birthday candles with pursed lips). You want to make sure the breath is flowing consistently against your hand or moving out the tissue evenly without any effort. It should feel easy, consistent, even. Then you can add a little voice to that breath flow by doing a very whispery, breathy “whooooo” sound with rounded lips, again feeling consistent airflow on your hand or watching the tissue in front of your mouth blow out evenly. Sound or airflow should not be choppy, you should not feel anything in your throat and this sound should feel consistent and even. The goal is to move through and avoid voice breaks by keeping consistent airflow. Once that feels good, you can move into sentences like “whooo are youuu”, “whooo is sueee”, keeping that same excess breathiness (think “Marilyn Monroe voice to get breathiness). Once you feel what excess breathiness does to keep your voice easy you can try to do a more natural production of “who are you?”, while still maintaining that easy airflow.
See the webinar for details or view here for additional context in an example provided by Sarah Schneider, CCC-SLP at UCSF:
d. Tension reduction
It’s no secret that everyone is dealing with much higher levels of stress and anxiety right now given the significant changes to life and stressors in this time period. It’s also no secret that those with spasmodic dysphonia have voices that are highly affected by anxiety and stress. To add more to this situation, those with spasmodic dysphonia can typically (even aside from these trying times) present with overlying or “secondary” muscle tension dysphonia as one attempt to compensate for the SD symptoms, which just serves to exacerbate voice symptoms. Essentially the perfect storm of ingredients to lead to a voice quality that is far less than ideal right now. One way to reduce muscle tension in the upper body and throat/larynx is to do some stretches and laryngeal massage. It is difficult to describe exactly how to do this with correct form but view the webinar to see a demonstration.
e. Other helpful tricks
It is well known that sensory tricks help relieve symptoms of spasmodic dysphonia. These can be singing, speaking in a higher pitch, whispering or emotional speech. While none of these are recommended patterns to consistently speak in, you can carry aspects of them into speech to make speaking slightly easier. For example, using exaggerated intonation (like a more sing-song voice) can help relieve tension/strain and practicing more intonation like if you were to read a children’s book or children’s rhyme can help establish a “smoother” voice quality. You can utilize a breathier manner of speech like mentioned above.
Easy onsets are a technique that can help those with ADSD. Think about easing into a word that starts with a vowel rather than starting it from strain in your throat. You can think about adding a silent or imaginary “h” sound at the start of these words (i.e. apple will be “hhapple”, and then you can gradually decrease the “h” sound and air in the beginning to make it sound more natural).
For ABSD, you can think about changing voiceless (silent) sounds to voiced sounds (i.e. think about replacing “p” with something that sounds more like “b”, replace “k” with “g”, “t” with “d”). All of these sound pairs are produced in the same articulatory manner but just differ in being “voiced” or “voiceless” sounds. By switching from the voiceless to voiced production you can compensate for the breathy break you’d normally have if you produce the voiceless version of the phoneme. You may also think about making consonants very crisp, shifting to forward focus/vibration at your lips, and using clearly articulated sounds which can increase speech clarity.
Tips for the phone:
When on the phone there is background noise, less clear acoustic transmission, there is no face to face interaction, no feedback of facial cues, and most people tend to project louder when on the phone. Forget about when people ask you to repeat or when there is a voice automated system. The phone and any virtual communication can be much more difficult for these reasons. Not to mention that the stress and anxiety in anticipation of having to speak on the phone can also have a great impact in making the voice more strained. Here are some helpful tips for the phone:
1. Warm up your voice before the phone
Use techniques described above like resonant hums and straw phonation to “warm up” your voice and establish a good groove and placement before getting on the phone. You will also be more confident going into the phone call.
2. If you know some things you will say, practice those in an easier voice
Practice your greeting like “hello” with the strategies above. Increased airflow (flow phonation) and easy onsets (above) can be particularly helpful for starting out with “hello” or “hi”.
3. Use headphones or a good headset
This will allow yourself better feedback to monitor your own voice. You also may feel less of a need to push your voice or shout with strain with a headset. You can even try only keeping one ear bud in to get a better feedback for your volume and voice.
4. Use speaker phone or put the input area (the place that picks up your voice) directly in front of your mouth
Using speaker phone allows for a more direct transmission of your voice into the phone rather than holding it up to your ear. So will a microphone attached to Apple headphones.
5. Try an easier manner of voicing rather than pushing & use clear articulation
It may be tempting to push more from your throat to work harder to be heard over the phone or in virtual meetings. Instead, try to increase your airflow and relax the throat (as counterintuitive as that sounds). Try to bring the energy and sound to the front of your lips and to the tip of your tongue (think clear and crisp articulation of the sounds).
6. Get projection/volume in a healthier way without strain
The key to projection without more effort in the throat is resonance (forward focus and energy/vibration, think what you feel with a resonant hum) and increased airflow (take a breath of air before you speak and USE that air). You can also think of overarticulating sounds with extra clear articulation at your lips and tongue (avoiding effort in the throat). This can often help cut through background noise with clearer sounds rather than you having to be much louder. Overall think, less throat effort is more here!
Helpful tip & reminders:
Less is more! Avoid straining your throat when speaking in conversation or projecting by using more airflow/breathiness, increased forward focus of the voice to lips and tongue, use clear articulation of sounds
Use speaker phone and headphones to help with phones and virtual calls
Try voice techniques above to warm up the voice, to reset, and to teach your voice to get into a more efficient way of functioning for conversation
Try hums and straw phonation as ways to “reset” your voice between phone calls or conversations
If you can, organize your speaking duties throughout the day to give yourself mini “breaks” between conversations
Always work with a speech language pathologist who is a specialized voice therapist (not all speech language pathologists are specialized voice therapists) who is familiar with SD in order to make sure you are doing techniques in the right way and best way for you
Practice voice techniques to make them more automatic
Keep in mind, these techniques are meant to help compensate for voice symptoms, not to cure the spasmodic dysphonia
Be easy with yourself! This is a very tough time for anyone and increased voice symptoms can make it that much harder. Recognize that your feelings during this time are completely valid
Engage in relaxation techniques and exercises for destressing and calming not only the mind, but decreasing tension in the body
See my webinar for demonstration of all of these techniques
Contact me for further questions or to learn more voice therapy to target these techniques