Symptoms of Vocal Fold Paralysis and Paresis

If you are a teacher of singing or a vocal coach, please learn to hear the symptoms of vocal fold paralysis and what to do and not do. As an experienced teacher and singer, not only did I miss the symptoms in myself, but my own teachers missed them. I also went to an experienced otolaryngologist about 8 years ago who missed the signs that were developing by not going far enough with the testing process. (Previous posts describe how I came to finally get a correct diagnosis and gather information for treatments.)

One guess as to why I developed paralysis is due to complications from endotracheal intubation, the breathing tube used for anesthesia in surgery.  But it is  quite a neurological mystery. The vocal folds themselves are in pristine shape.

I probably started out with paresis for many years before developing bi-lateral paralysis.

Here are the clinical symptoms, followed by my symptoms as I experienced them, starting as early as 2005.

Vocal fold paresis refers to partial, or reduced, neural activity of the vocal fold. The vocal fold is mobile, but movement is diminished. The degree of mobility is usually dependent upon the severity of the injury.

The larynx attempts to compensate for the underlying deficiency. This compensation often gives the appearance of glottic hyperfunction (supraglottic squeeze). Thus, the patient is often incorrectly diagnosed with a functional, or hyperkinetic voice disorder, when in reality the patient suffers from vocal fold paresis.

1. Weakened tones in part of the singing range. (Vocal fold paresis results in a vocal fold that can still move – albeit weaker and with less tone than normal.)
2. Voice fatigues very quickly.
3. Voice cracks and breaks.
4. Range diminishes.
5. Swallowing and breathing are, fortunately,  not a problem.

These symptoms can also be attributed to hormonal changes and a whole host of other things which makes it hard to diagnose as paresis without testing.

My Personal Experience:

1. Cracks, breaks and bleats in the middle register, from about middle C to the A above.
2. As I ascended in range, I got very dizzy.
3. There was a clear visual struggle throughout my system as my larynx, tongue and whole body attempted to try to phonate! My teacher and other teachers kept trying to fix it with body alignment, breath and resonance.  To be fair to my teacher, she had sent me to an ENT who totally misdiagnosed it and told me I was fine. But as things got worse, she kept trying to fix it with support and alignment, which, of course, are symptoms of a larger issue.
4. Extreme prolonged frustration and all that goes with that, from anger to self-blame to sadness.

Then, in the summer of 2012, I got a viral infection and I completely lost my voice–not even hoarse–but it totally cut out, for 5 days. This was the beginning of a full onset of paralysis as opposed to paresis. When I was able to speak again after about 5 days., I had about 6 low notes left, and they were weak. Everything from mid-C#- up was nothing but a “hissssssssss!!!!!”

I finally received a correct diagnosis in early 2013 after contacting Jeanie Lovetri, Founder of Somatic VoiceWork tm: The Lovetri Method. I went to New York City to have a session with her and she said “Get yourself to another doctor.”

So here’s what voice teachers and coaches need to know: If your singing student exhibits any the above symptoms regularly, and your guidance does not show improvement that “holds” after 3 or so lessons, refer them to an otolaryngologist who truly works with singers. (There is a practice here in Washington, DC, that says they work with singers, but they miss serious pathology all the time.  Contact me for details.)

This is assuming that the singer has been mindfully working your suggestions at least 3-4 times a week. You or your student need to know that the doctor must be interested in the full story of your experience, because this is how they determine what tests to do. They understand that tiny things that are not important for non-singers are HUGE for singers.

You also need to know that talking breathing and resonance is useless. It may help patch a singer together for a time until the situation gets worse. Lack of breathing coordination and resonance/tongue/jaw issues are often the result of poor vocal fold closure and registration imbalances which, in turn, create laryngeal malfunction.

The mind-body connection needs to be reestablished in an extremely patient, slow, deliberate and educated fashion, and frankly, most voice teachers are not equipped to do this. The current protocol is for the singer to work with a team of an otolaryngologist and a speech-language pathologist or singing voice specialist.

I have now been working 3 years with Ms Lovetri, in her role as a singing voice specialist, and have some function back after the medical community told me I would not sing again without surgery.  When I asked my surgeion how a neurological condition could be fixed by surgery, I was not at all satisfied with the answer, and was told it would be a “trial.”

There is improvement, and individual pitches are coming back along with a slightly freer singing quality.

The next post will be on the psychological and emotional work of reestablishing neurological connection.