The Diane Rehm Show

Thanks for joining us, I'm Diane Rehm. Many of you know I've struggled with my voice for a number of years. The condition is called Spasmodic Dysphonia. It's just one of many different kinds of voice problems people encounter. Joining me in the studio to understand how the voice works, how we can improve the way we sound and treat some of the more common voice problems, Dr. Susan Miller, she's a voice and communications coach, she is a PhD. Dr. Nazaneen Grant is assistant professor in the Department of Otolaryngology at Georgetown University Hospital. Joining us from a studio at the Cleveland Clinic, Dr. Claudio Milstein, he's a speech scientist with clinical interest in laryngology and voice disorders.

I'm sure many of you will want to join us. Feel free to call us, 800-433-8850, send us your e-mail at drshow@wamu.org, feel free to join us on Facebook or Twitter. Good morning to all of you.

Good morning, Diane.

Good morning, Diane.

Thank you for...

Dr. Milstein, I want to start with you and ask you about voice day, World Voice Day. How long ago was that established and why?

World Voice Day, it was established in Brazil, of all places. They started with this concept of having one day to celebrate voice and vocal health and I believe this was about 10 years ago. And after their initiative, slowly, some other countries in South America, Europe and in the U.S. started picking this up and for the last five years, it's becoming more and more prominent in the U.S. where most of the well-known voice centers around the country have some activities to celebrate voice and to promote voice health. And...

Now, do you think in the last, I don't know, decade or whatever that we have seen growing numbers of people coming forward with voice problems, Dr. Milstein?

That's an interesting question. I'm not sure that we're seeing more people coming forward, but we may see that both the general public and professionals are more tuned into voice problems and people are getting more care than in the past.

Susie Miller, Dr. Susan Miller, who has been both a friend and coach to me for so many years, talk about how the voice works. I know you've been involved in so many aspects of voice treatment, voice coaching, the whole gamut.

Well, our voice is an instrument and it's important that we play it correctly and that means taking a breath before we speak. Not too deep a breath. Some people feel that they need to take a really deep breath before they speak and then they tighten their vocal folds and then they get a very high pitched, strained voice, so breath is very, very important. That allows our vocal folds to vibrate and the number of vibrations per second is our pitch and we're all born with a give pitch, according to the size of our larynx. So a bass male will have a larger larynx, his vocal folds will vibrate about 100 times per second, where a female soprano may vary at 200.

We all have about a two octave range, so as we go from low to high, ooh, our vocal folds stretch and they vibrate -- everyone has about a two octave range. That sound then resonates through our throat and our pharynx, or the back of our throat, so it's important to be relaxed, to relax our jaw, to open our throat as we speak and then to articulate clearly. Many speakers don't articulate, they don't move their jaw, they speak through closed teeth so you can't really understand them very well. so it requires all four of those systems, respiratory, vibratory, resonatory and articulatory.

And Dr. Nazaneen Grant, you are seeing and treating people who have various kinds of voice disorders. Give me a range of those problems.

Sure. Well, there are people -- many people who do strain or misuse the voice, abuse the voice in using it too much or inappropriately and all the lay people would know that just any acute laryngitis or having a cold will give you hoarseness. Other voice problems range from consequences of acid reflux, of developing legions or growths on the vocal folds, such as cysts or polyps or papillomas and then, of course, cancer. And as you well know, there's also neurologic problems that cause the voice to not be smooth.

And explain to me how hard it is to diagnose problems that may not be as serious as cancer or as serious as, you know, a multi-growth on the throat, but something like Spasmodic Dysphonia.

Sure. Well, the voice, as Dr. Miller already described, is just very, very complicated and it's -- even in its anatomy, if you think of the voice as an instrument, it's only a few cubic centimeters and yet its range and the beauty that it produces, in my opinion, is much -- is far beyond any human instrument that is created, so.

But in terms of diagnosing voice problems, first by just listening to the voice with a trained ear, one can pick up on a certain disorder, but the -- also it's necessary is just visualizing the vocal chords, or vocal folds is the more modern term, and that's done through a flexible scope or a camera that goes inside the mouth or the nose and we can visualize the vocal folds and at a higher level, we can use a stroboscopy, which is a strobe light that goes on the vocal folds that we can see the details of their vibrations. But no, it's definitely not straightforward and the treatment is -- often requires several different approaches.

And it's certainly not consistent. I mean, one doctor may take this kind of examination, you're looking at or talking about and see one thing, another doctor may see another.

Sure. One part of that variability may be the training and then also the equipment that they have to visualize. But also, as you know from your own example of your story that you illustrated in your book, "Finding My Voice," that the medical professionals' understanding of voice disorders has very much evolved over the last 20 years. And you, unfortunately, were on both ends of that. You know, both when you weren't able to be properly diagnosed, perhaps, or it wasn't clear. And then later, when it was more clear.

How has the understanding of voice problems evolved over these last two decades?

Sure. Well, one is just in the way we can study the voice and the acoustic measurements and just in general how technology has expanded for us to examine both the structure of the larynx and then the sound of the voice, but also, even understanding the microstructure of the vocal folds and even surgery has evolved in terms of the importance of preserving the very, very delicate layers of the vocal fold. It was mentioned, the vocal folds hit each other over 100 times a second and there's no other body part that gets traumatized like that, even when we're walking...

Wow.

...the soles of our feet...

Yeah.

...you know, they get calluses on them, even though we're just walking, thud, thud, thud. But for our voice, if you can imagine, there're just these delicate tissues flapping together all day long and we don't even realize it and yet, voice disorders in general are not that common, in general, so that speaks just to the beauty of the human body and just the perfections that we have without knowing about it.

Yeah, that's really interesting because, as you describe it, you'd think there'd be many more indications of voice problems. Dr. Miller, I know you wanted to come in on that.

Over the last decade, we've become -- we have many more standardized vocal instruments than we have in the past and I know Dr. Grant utilizes different regimens, such as when a client comes in or a patient comes in, she'll have them sniff-e, sniff-e, sniff-e to make sure the vocal folds are opening and closing adequately and then we'll have them do some speech tasks, such as sustaining an aw sound, watching those vocal chords vibrate if you have stroboscopy. Then we'll have them say some sentences such as, Peter will keep at the peak with a lot of -- sometimes our vocal folds vibrate...

Say it again.

You've said this before under a flexible endoscopy many, many times. Peter will keep at the peak. Sometimes our vocal folds vibrate and sometimes they don't and that's what creates some timing disorders, such as stuttering. But when they don't vibrate, for Adductor Spasmodic Dysphonia, that helps your voice.

And explain the difference between Adductor and Abductor Dysphonia.

Adductor Spasmodic Dysphonia is when those voiced sounds, the buh, duh, guh, a-e-i-o-u, are over adducting and the voice is tight, so your name, had it been Sarah Smith, would've been easier to say than Diane Rehm, 'cause you have all voiced sounds, so that your strained strangle is very tough on your voice. I mean, it's a hard thing. Whereas someone with Abductor Spasmodic Dysphonia, those vocal folds are flying out, they're abducting.

Dr. Susan Miller, she's a voice and communications coach, Dr. Nazaneen Grant is at the Georgetown University Hospital, Dr. Claudio Milstein is at the Cleveland Clinic. We'll take your calls shorty, stay with us.

We have many callers waiting, but do want to talk a little more with our guests before we open the phones. Dr. Grant, talk about when or why somebody ought to seek help for the voice.

Sure. Well, if someone has had hoarseness or a change in their voice that lasts longer than two weeks, that would be a reason to see a physician who can inspect the larynx. Especially in a smoker, as we know, early detection of laryngeal growths that can turn into cancer is key. Also, if someone is experiencing voice fatigue or their voice quickly deteriorates, any breaks in the voice, if they have noisy breathing or difficulty swallowing, those are other reasons people should seek the attention of a otolaryngologist.

And Dr. Milstein, what about in your case? Why do people come to see you?

Well, people come with all kind of voice problems, anything that changes the sound of their voice or if they have an associated illness that is also affecting their voices. There's also a newer area in the study and treatment of the larynx which has to do with breathing problems that are caused by a malfunctioning or misbehavior of the vocal cords and this is an area that is gathering more interest around the country and we're seeing more and more patients that have shortness of breath caused by problems in the larynx.

Give me an example of what you mean, Dr. Milstein.

Well, this is a condition that is called paradoxical vocal cord motion or it -- there's another -- there are probably 50 terms that you can find in the literature that refer to this condition, but basically, it's a closure or an inappropriate movement of the vocal cords where they come towards the midline and they create an airway obstruction, so patients have periods where they have severe shortness of breath. And they -- this usually doesn't respond well to asthma treatment and that's where they get referred to ear, nose and throat doctors and then we can realize that this condition is not caused by problems in the lower airways or the respiratory system, but in this malfunction of the larynx and vocal cords.

Now, Dr. Miller, when I first met you, we didn't talk about Spasmodic Dysphonia. It seems to have become a more widely known and understood phenomenon, as Dr. Grant has said. But just how common is it?

Voice disorders affect 7.5 million -- there are 7.5 million people with voice disorders in the country. I'm not really sure what the incidence of Spasmodic Dysphonia is.

It may be around 30,000, but there are a lot of people with Spasmodic Dysphonia who have not been diagnosed. In fact, there's some people who have come to me and said that, I think I have what Diane Rehm has . And I said, that's why I'm here (laugh).

I see.

So you actually have helped significantly in people, you know, approaching medical help just because they know -- if you don't know that their problem is something that's treatable, then we haven't diagnosed them and we just don't know.

One of the approaches to treating Spasmodic Dysphonia is with the use of botulinum toxin. Explain that, Dr. Grant.

Sure. Well, Spasmodic Dysphonia has been explained as a problem where there's an overuse of the voice -- vocal folds, which are essentially muscles with a delicate tissue over them. So when we go to make a voice, the muscles inappropriately squeeze together, producing a voice that can be sometimes strained or choppy. Botox or botulinum toxin as we know more from the cosmetic world, is -- it's a -- it temporarily paralyzes muscle, so it -- when we inject it into the vocal folds, it creates a condition where you're still having the problem, you're still flexing the muscles 'cause that signal's coming from the brain, however, they're unable to squeeze too much and so that smoothes the voice out.

Smoothes the voice out temporarily.

Temporarily, yes. And it wears off after three or four months on average. And so people who get that treatment often need repeated doses of it in a few months.

And Dr. Miller, even after treatment with something like botulinum toxin or Botox, people still need voice coaching, don't they?

Yes. Especially because when that voice is smoothed out, there's a lot of breath coming through, so people won't be able to speak with as many words in one breath. They'll have to take replenishing breaths much more often and it's important that they don't try to force their voice out because then they start getting strain and that can lead to pain in the larynx, also.

Now, Dr. Milstein, where does stuttering fall into this whole block of voice disorders?

Actually, Diane, I want to make a comment on something that you brought up earlier...

Sure.

…'cause I think it's interesting. When we were talking about the understanding of voice disorders and now we're focusing on Spasmodic Dysphonia, if we look at the history of Spasmodic Dysphonia, in the past, it was thought to be a psychogenic disorder, so patients that presented with this kind of choppy voice, they were basically referred to psychiatrists.

That's what they told me to do.

And they -- yeah, and that created a very frustrated group of patients...

Yep.

...because they would go to psychiatrists and psychiatrists would not be able to help them and it would create a very frustrated group of psychiatrists 'cause they would get this group of patients that they couldn't do anything for. And so one of the great advances in the understanding of voice disorders is to recognize, particularly in the area of neural laryngology, where we started realizing that this is not in the patient's head, but there is actually a central nervous system or a peripheral nervous system problem and that really advanced our understanding and we were able to start treating patients much better.

On the other hand, we still do not understand the cause.

True. The cause of Spasmodic Dysphonia itself is definitely unclear. And although many people get it after some sort of a trauma or after a cold, many people just get it out of the blue. And it can run in families, but not always. It's thought, though, to -- the problem is thought to originate in the brain -- in a small area of the brain that controls movement.

So for example, Dr. Miller, people think I'm 105 years old because of the way I sound and yet I have to say that for years, from 1998 until last year, I was having botulinum toxin injections every four months and now I am having vocal coaching via Skype from Gary Catona, who is out in Los Angeles. Gary, are you there?

I am here (unintelligible).

It's good to have you with us, Gary. And I want to hear about your approach to not only people like myself with Spasmodic Dysphonia, but to others who, for example, I know you treat lots of opera singers. Your approach is totally different.

Well, let me say that most of my students are singers. Very few of them have vocal problems, but I discovered through working with singers, that the speaking voice is being affected by my process. And what I do is a process that I call voice building, which is a systematic development of the musculature of the larynx, pharynx oral cavity and soft palate.

And how do you do that, Gary?

What I discovered is that certain kinds of exercises that are called isoexpendic (sp?) exercises, which take muscles full -- through a full range of motion at intense levels, has a very effective result on the muscles of the larynx, especially vocal cord problems. Spasmodic Dysphonia, as you noted -- as your guest noted, is a mystery, but what is not mysterious is that the result of the condition is involuntary movement of the vocal fold muscles. What I discovered by applying vocal exercises to the vocal mechanism that you could strengthen the muscles and in a certain sense get around the spasticity or the spasming of the vocal cords.

What do you mean get around them?

Well, I don't claim to be able to cure this condition. It's always there. And if people stop doing the vocal exercises, the condition will return to some extent. But what I’m able to do is push the problem, so to speak, to the background where it's barely heard. In some cases, people who have undergone the process, the voices sound totally normal. Now, look at your case, Diane, how we worked, you know, day in, day out for a few weeks and your voice began getting slowly, slowly under control without the use of the Botox injections. Now, the problem is still there, it's just that as the vocal cords become stronger, it becomes less noticeable.

Dr. Milstein, I'd be interesting in your reaction to Gary Catona's approach.

I think that anything that you can do in terms of learning how to manipulate your vocal mechanism better is great. And any technique that can be used to help you sound better, I'm all for it.

And Dr. Grant, I'd be interested in your reaction.

Sure. With voice disorders, there is really a science and an art. And the science is limited and there are voice disorders, as you know very well from your own, that do not receive -- you know, that are not completely, I guess, managed to one's satisfaction with one modality alone. So as Dr. Milstein is saying, whatever works that is not harmful that will improve your voice, I think is definitely worth pursuing.

And that brings up the question of botulinum toxin and to what extent I or anyone else using Botox directly into the vocal cords should be concerned about that in the long run.

Well, I think we...

Well, my personal view is...

Sorry.

...the Botox should always be a last resort. I mean, after all, the Botox is the most dangerous poison known to humanity. Even though it's diluted, even though there's no clinical evidence that Botox has negative side effects, I'm not sure about that.

Dr. Grant...

Think about it. Just think about it, common sense would tell you that if you're injecting a poison at that level into your body every several months, I mean, there has to be some accumulation of it. That's just my opinion. And on top of that, why not just treat the problem through exercising your voice (laugh) ?

Dr. Grant.

Sure.

Go ahead.

So -- well, it's true that botulinum toxin is a bio weapon. You know, we can't carry it...

You bet.

...across the borders without approval. So on the other hand, there are many, many people with Spasmodic Dysphonia who couldn't even achieve almost normal voice with this treatment, but, you know, like we're saying, the voice disorders are a quality of life issue, so it's really a person's choice whether they want to pursue -- it's not a life and death issue and it's their choice of how they want to pursue it, but the safety of botulinum toxin has been well established in the doses that we use. And there are many, many more people who have it injected for cosmetic reasons who -- I mean, millions who have, just by force of example, proven its safety in those doses.

But at the same time, we must say that it has not been approved by the FDA for treatment of Spasmodic Dysphonia.

True. Yes.

It has been approved for cosmetic purposes. Dr. Miller, Gary Catona raised a whole issue of the quality of voice and the quality of life. You feel very strongly about that.

I do. The Greek philosopher, Galen, said that the voice mirrors the soul, so anytime we're sad, we're happy, we're fatigued, we're nervous, it shows in the voice. And we all want to have a strong confident voice. So if Gary's techniques in voice building helps someone to speak with strength, then I'm all for it. You know, when people listen to their voice on the answering machine, they don't like the sound of it.

Quite right (laugh).

They think they sound whiny or they sound too soft or too breathy or their voices inflect upward or downward. Well, the good news is that we can change those voices and people can be taught to speak much better.

Susan Miller, she's a voice and communications coach. And you're listening to "The Diane Rehm Show." Let's open the phones. We'll take a call from Chapel Hill, N.C. Good morning, Jean, you're on the air.

Hi. Thank you. My husband had several strokes three years ago and we had therapy at UNC until the Medicare ran out and we really can't afford to have a private person help us. He has short-term memory problems, so anything that we do, I have to remember. I just wondered is there any book or any kind of -- anything that I could read that would help me to help him?

Dr. Milstein.

Well, the problem with stroke is not a specific voice problem. I would suspect that your husband has a speech or language impairment. And certainly, there are a number of treatments for speech and language therapy that help stroke victims. I would encourage you try to seek them out. Maybe there's somebody in the community who can do some kind of trade if you don't have insurance. That would be my advice.

Dr. Miller.

If money is an issue and often after someone's had a stroke and it's been a period of time, you're no longer able to have therapy, there's some great online software. If you just go in and Google stroke rehabilitation, you'll find some software references that I think would be very helpful to you.

And here's an e-mail from Penny in Northport, N.Y. who says she was diagnosed with a paralyzed vocal cord. Can anyone comment on the causes of this? Eventually it got better by itself. Dr. Grant.

Sure. So vocal fold paralysis is when one of the -- one or actually both sometimes of the vocal folds no longer works. It can often produce a very breathy voice. There's three main topics -- three main causes. One is traumatic, usually actually from surgery related to thyroid or chest surgery. The other can be just from a cancer, from laryngeal cancer, or cancer in the chest that affects the nerve that works the vocal cord. And then also for -- well, a third of them are completely unknown.

Dr. Nazaneen Grant, she is assistant professor of Otolaryngology at Georgetown University Hospital.

And we have several guests with us today to talk about voice problems. Saturday was World Voice Day. Here in the studio, Dr. Susan Miller, she's a voice and communications coach. Dr. Nazaneen Grant is a professor of Otolaryngology at Georgetown University Hospital. Dr. Claudio Milstein is a speech scientist at the Cleveland Clinic. Gary Catona is a voice builder. He is out in L.A.

Let's go back to the phones to Natalie. Good morning, you're on the air.

Hi, thank you very much. I'm calling to ask where my husband, who used to have a four octave singing range, can go for help with his vocal fold problem. It was after we moved to Maryland, it was discovered that he had one lax fold, but that was 15 years ago and the only suggestion was surgery that wouldn't restore his singing voice and he didn't want that.

Gary Catona, any thoughts on that?

As we all know, any vocal problem is either directly or indirectly the result of the movement of vocal musculature. Vocal range, obviously, like every else about the voice is controlled by muscles and the most effective way to improve a voice, for any reason, including improving a range or restoring a range is through vocal exercising.

I recommend either your husband comes out to Los Angeles for voice building or wait patiently. I'm developing an app that I'm going to call voiceapp.com, which people will be able to download in to exercise their voices. I don't believe it's in most in cases, surgery is required to correct a vocal problem, unless it's clearly an organic problem. Vocal exercise, voice-building exercises is the most effective way to build a person's voice back for whatever reason.

And how do you see it, Dr. Grant?

Well, certainly after 15 years, it would be worth that person being re-examined just to visualize their vocal folds again before pursuing, just to know exactly what the problem is. But then proceeding with voice therapy may be the best way.

And Dr. Miller?

That would be the question, a lax fold, does that mean that it's not moving or does it mean that it's not closed and it's bowing? Do you know that?

It's not closing and it's bowing.

Okay.

But that was 15 years ago.

I agree with Dr. Grant, to visualize it again and there's some great resources up in Baltimore at GBMC and also at John Hopkins, the speech pathology department's just excellent there.

But would you also agree with Gary Catona that a surgery is not what's called for here?

No. I would definitely agree with Gary and to work on breath and also to work on getting those vocal folds to close more forcefully, to get that musculature going.

I'm going to have a comment about those whole pre-occupation with breathing. It seems whether you're studying voice for singing or whether you're having a vocal problem and you're seeing a voice therapist, this pre-occupation with the breathing mechanism, I think, is completely misguided. We talked, someone mentioned earlier about the breathing problems, it's called the paradoxical vocal fold movement, is that what it was called, doctor?

Yeah, that's the name.

Yeah. How do you resolve that problem is once again, is introducing exercises to the vocal mechanism that coordinates and strengthens the vocal folds, breathing exercises are useless, from my experience, with the singers and with people with vocal conditions. The best way to improve a breathing condition is by improving the strength and power of the vocal folds that close sufficiently.

Interesting. Dr. Miller?

I might disagree with that one. The vocal cord dysfunction or paradoxical vocal cord motion that Dr. Milstein talked about, I see it quite a bit in young athletes. It may be on the lacrosse field, on the soccer field and what they feel when they're running is that the voice is closing off, that the vocal folds are closing off and I work with them on opening up the larynx, getting it more relaxed, getting the breath going through with an open throat and these people respond very well to that.

All right. On that very thought, let's go to Wilmington, N.C., and to Ben. Good morning, you're on the air.

Good morning, thank you. I had heard something on the topic of breathing. I'm 28 years old and for about 10 years now, I've struggled with some breathing issues. They used to be periodic when I was younger and over the years, it's become an everyday thing where I feel a tightness, kind of a tightness and shortness of breath in my upper chest, lower throat area. I've sought treatment about it just from primary care and had breathing tests for lung issues, x-rays for heart issues. Haven't had any answers, so it was interesting to hear that it could potentially be something that perhaps I should see an otolaryngologist about and I just wanted to bring that up.

Dr. Grant?

Sure. There are other conditions, such as even acid reflux that even young people, can cause those sorts of problems.

All right. Thanks for calling, Ben. To Orlando, Fla. Good morning, Susan.

Hi, good morning. I am about to have a thyroid surgery at John Hopkins to remove a large tumor on the right nodule of the thyroid, but this nodule has now moved into my throat area as well and I'm already having voice changes and the breathing problems have started and I'm very concerned about, you know, the possibility of it damaging the vocal cords if it's wrapped around -- you know, this tumor is wrapped around. What can you comment about on that issue?

Dr. Grant?

Sure. Well, it's obviously great that you're going to have the surgery soon because it appears that the growth is affecting your voice box in some ways. And you know, the nerve that goes to the vocal cord is a very sensitive nerve, but miraculously, most of the time with thyroid surgery, there's actually no problem with the voice afterwards.

However, in some cases, the vocal fold can become temporarily or permanently paralyzed afterwards. But you know, these also, as we know, have some treatment if, in the rare case that that does happen, that can be treated in other ways, so I would be very, you know, happy that you're able to get this treatment soon and any bumps down the road I'm sure will be able to be smoothed out.

Now, I would wonder, Gary Catona, whether after such surgery, one might be able to turn to strengthening the voice to ensure that that voice comes back to full force?

Of course. Any kind of situation where a person's voice is weak or breathy or hoarse, any situation like that would benefit greatly by having the vocal fold muscles and the voice muscles in general strengthened through voice-building exercises.

Good luck to you, Susan. Thanks for calling. To Adamsville, RI. Good morning, Henriette.

Good morning, Diane, thank you for taking my call.

Surely.

Love your program.

Thank you.

Mine is a breathing problem. I'm a polio survivor of 60 years ago. I'm going to be 84 and polio has been extinct in this country for a long time, since 1955. And I'm living too long, all the polio are dead and mine is diaphragm problem. The diaphragm does not get the impulse from the nerve to go up and down and when I get up in the morning, I can't talk. It's really not a voice problem, it's a diaphragm problem.

Dr. Milstein, any comment?

Well, the diaphragm can get affected and as we know, the diaphragm is the prime source of breathing and the power source for voice is breath. So if you have a diaphragm problem, where the diaphragm is lax, you may get very little air to support a good and strong voice. My recommendation for you is to a good respiratory therapist. There may be some exercises that you can do to improve the strength of other muscles that will come to aid in that weakness that you have in the diaphragm and there's also some devices that you can use to support your abdominal muscles that may also help with your breathing. So my recommendation is that you see a good pulmonary doctor.

Dr. Miller?

I was going to mention bands that could be put around the diaphragm that a respiratory therapist could help with, might help.

That's interesting. Dr. Grant, any comment? All right. Let's go then to...

I have a comment Diane.

Sure. Go ahead, Gary.

What we haven't mentioned is that the diaphragm is only utilized when you're breathing in. When you're breathing out, such as when you speak, sing, the diaphragm is totally disengaged. So putting a band around your waist will not aid the diaphragm, it aids your abdominal muscles, which are primarily the muscles that are engaged when you're singing or speaking. So this whole -- you know, again, this idea of the diaphragm, the diaphragm, the diaphragm, it's also, it's over exaggerated. Of course, it's a significant breathing muscle, it's one we use when we breathe in, but during the act of speaking or singing, it's totally disengaged. So singing from diaphragm is a meaningless concept.

Gary, you're sort of off on another tangent from the rest of the doctors we've got here. Why is that?

Well, why is that? I mean, it's one of the mysteries of life, you might say, that a lot of the practices that are carried in the vocal profession should be properly placed in the Middle Ages. You know, injecting poisons into your body, you know, misconceptions about the voice. You know, someone mentioned a minute ago that release the breath through your vocal cords is a source of speaking, when in reality, when a proper phonation occurs passing the vocal folds or holding back breath and the whole concept of breath control is a misconception because the voice does not travel on breath.

It travels through air in sound waves, so the idea of controlling your breath really has no meaning, although you hear this concept continuously from voice teachers and voice therapists and voice doctors. It's not breath control that we're concerned with, it should be vocal fold control. Vocal fold control, once that's under control, everything else will flow, no pun intended, very smoothly.

All right. Dr. Milstein?

Yeah, I want jump into something that Gary mentioned with injecting poison into the body. I've had numerous patients with Spasmodic Dysphonia that came to me terrified about treatment with Botox. They have tried voice therapy and voice therapy didn't work. They have tried holistic approaches and they really couldn't find anything to improve their voices. They really had a real fear of injecting Botox because of this widespread notion that Botox is a poison and actually, after you convince them that we have been treating patients for more than 35 years successfully and safely with Botox, they go for their injections and they have a dramatic improvement in their quality of life because finally they can talk for the first time after years. So I really want to minimize the notion that there is a danger of Botox.

Dr. Claudio Milstein, he's speech scientist at the Cleveland Clinic and you're listening to "The Diane Rehm Show." And I have to say that until I began working with Gary Catona, as I said earlier, I've had Botox since 1998, thank goodness, with no side effects, other than losing my voice for a period of time after each injection. If it hadn't been for Botox, I could never have continued my radio career.

Dr. Grant, you are one of the few people here in Washington who administers Botox. What has been your experience?

Sure. Well, as Dr. Milstein and yourself have said, there are many people who get that treatment without any side effects and so, you know, if it's...

If it works, it works.

Yes. If it's broken, then fix it in the way that we can safely, so -- and I just also wanted to say that your example of your life story over the last, say, 25 years should be a really wonderful example to others with any medical condition that prevents their fullest expression. You had developed a voice problem that effectively derailed your career temporarily. You sought professional help, which was frustrating at first, but you pulled through it. Medical science evolved and eventually was able to help you. You had the help of wonderful voice therapists such as Dr. Miller and not only were you able to rehabilitate yourself to have this show where you provide, it's a forum for people to offer balanced perspectives on things, which is helpful for millions of people.

But also, you've also helped other people with voice disorders in creating a support group, so I think the example of your life really should be an example for people for voice disorders and for anyone with a chronic medical condition. This is a very healthy way to approach life.

Well, I thank you so much for those words, Dr. Grant. And I have to tell you, if it had not been for Dr. Miller, who said to me early on, you must go on the air and tell your listeners what the problem is and I was totally reluctant to do that.

But we're so glad you did.

And I'm so glad I did and I'm so glad I have spoken with Dr. Milstein at the Cleveland Clinic and so glad I'm now working with Gary Catona because there is a whole range of solutions out there and you have to find what works for you. Dr. Miller?

Vocal teams are so important. I have Dr. Grant to rely on, Dr. Milstein to call if I have a question. I'll be learning some of Gary's technique. It means so much to everyone that we be educated and be flexible in our training.

And of course, Gary Catona, you'll continue to do your work. Dr. Milstein, I gather you're expanding your own field?

Yes. One of the things I wanted to maybe if we can talk briefly about...

I'm afraid we're almost out of time.

I wanted to give some tips on what things can do to improve voice for World Voice Day.

Very quickly.

Very quickly. If you smoke, don't smoke. If you scream or yell too much...

Stop.

Please try to stop. Hydrate, drink plenty of water. Know when to rest your voice. If you need a microphone, use it and recognize when you're doing things to that harm your voice and stop doing them.

Dr. Claudio Milstein, Gary Catona, Dr. Susan Miller, Dr. Nazaneen Grant. Thank you all. Thanks for listening, I'm Diane Rehm.

"The Diane Rehm Show" is produced by Sandra Pinkard, Nancy Robertson, Susan Nabors, Denise Couture, Monique Nazareth and Sarah Ashworth. The engineer is Toby Schreiner. Dorie Anisman answers the phones. Visit drshow.org for audio archives, transcripts, podcasts and CD sales. Call 202-885-1200 for more information.