vocal nodules

[Project Zipped Lips, Week 2] Big News

Untitled2

So I’m sure you remember this photo from the last post…

Today was my first voice therapy session with Ms. Kitchie Molina at St. Luke’s Medical Center–Global City. As promised, here’s the update about it.

To be honest, I had two different ideas of how this was all going to go. The first was going to be this super-anatomical, white-lab-coat, instruments and microphones shoved down my gullet approach where I would be examined and diagnosed much like how you’d be in a routine medical checkup. The other scenario was the gentle, touchy-feely, lie-on-the-couch, how-are-you-feeling sort of approach that is usually associated with the word “therapy”–stress and psychological well-being do play huge factors in vocal wellbeing, after all.

What I ended up having with Ms. Kitchie, however, wasn’t even remotely close to either. In fact, it bore more resemblance to a standard voice lesson/conservatory approach, like what I’d had before with (the person I consider my best teacher ever; probably wouldn’t even be in this mess if I’d kept seeing her) Jai Sabas-Arracama. Ms. Kitchie even knew Tita Jai, or at least knew of her, which was unsurprising given that they are both from the University of The Philippines School of Music. And, like Tita Jai, Ms. Kitchie had a rather infectious aura of joie de vivre, which I guess comes from making a career out of beautiful music. I kind of figured I was going to like her on sight.

As in a standard voice lesson, I was ushered into a little (and I mean little; it was probably the size of my mum’s closet) room with a piano and a mirror on one wall. Unlike a standard voice lesson, however, Ms. Kitchie didn’t immediately start me on vocalization. After glancing through my file (remember this post?), she asked me a couple of questions about my range, where I’d been singing, any changes in vocal behavior prior to the nodes, and other sort of standard voice/medicine stuff, then promptly launched into a short lecture on the physiology of the voice–something that, as an information junkie, I greatly appreciated.

Ms. Kitchie explained that the approach she would be taking with me was more physiological or, as she put it, “biomechanical” (sounds cool, doesn’t it). She outlined five areas of “machinery” that affected vocal performance: the motivator (your brain), the generator (your lungs, diaphragm, abs, and the muscles between your ribs whose name escapes me at the moment), the phonator (vocal cords), the resonators (the cavities in your head and chest that make your voice uniquely yours), and the articulators (teeth, tongue, hard and soft palate, lips). Then she explained how different problems in the use of each of the five areas could affect vocal performance, like using the wrong speaking pitch (speaking like an alto when actually a soprano, and vise versa).

I sort of brushed that issue off when she mentioned it, saying (in not so many words; I was more content to nod and soak in all the info) that I was definitely a confirmed alto and spoke like one.

After she’d explained some more about the physiology of the method she’d be using on me today–complete with a bit of a history lesson–we finally started the therapy proper. Explaining that the vocal cords were actually connected to all my facial muscles and the muscles in my neck and chest, she taught me a series of massages and stretching techniques to relax my face, Adam’s apple (girls have them too, apparently; it just doesn’t stick out), tongue, neck, and jaw. I found out that I had incredibly tense muscles everywhere, which is probably due to being a Dragon U student and not having very much time to breathe, let alone relax, but Ms. Kitchie assured me that with practice and regular use of the techniques my body would eventually adapt to its new normal.

Also, that “inner smile” technique I’d been using in my chorale singing days? Totally wrong. Apparently that just makes vocal tension worse, as does dropping (and locking) the jaw.

Once all that was done, she started working out what was wrong with my breathing. Which, apparently, was everything. This didn’t surprise me: I’d always had trouble grasping the concept of using the diaphragm in singing, although I had a vague idea it had to do with something contracting under my lungs. Turns out, I could pretty much let the diaphragm take care of itself–the real important player was the abdomen. Specifically, how it expands and contracts when I breathe. When you’re breathing properly in singing, your upper torso shouldn’t actually move. Instead, your belly shoots out when you draw in air, and then slowly pulls in as you exhale. Ms. Kitchie had me simulate “singing” by having me exhale in a steady stream then suddenly inhale, hands on my belly (I felt like a pregnant woman, guh) the whole time to feel it pulling in and shooting out. She also fixed my posture, particularly the placement of my head and neck.

It was a whole lot to process, and I’m not sure I remember half of it (well, the breathing bit I’ve sort of forced myself to remember, for reasons I’ll mention later), which is why it’s definitely a good thing that I’ll be seeing her again next week.

Finally, after the massaging and the stretching and the breathing, we actually started singing. Vocalizing, to be specific, but after being silent for nearly two weeks being able to produce any sort of musical sound with my voice made me so happy I nearly got emotional. (Ms. Kitchie had to keep reminding me not to close my eyes and to watch myself in the mirror.) She gave me the usual series of loo-loo-loos and mi-re-la-etcetera fare that Tita Jai would have me work on, but I found it odd that she kept pushing me into my upper register instead of spending more time on me going low, as most voice teachers (excepting Tita Jai, who liked to shuffle pitches around in what was akin to vocal aerobics) usually had me do. I figured she was trying to see the extent of the nodes situation, as it usually affects the higher pitches more, so I went along with it, watching my breathing and trying not to wince when my high notes came out breathy and hoarse.

In the middle of a particularly varied phrase (where the notes go up then down instead of just gradually going up or going down), she stopped me suddenly with, “I don’t see you grimacing here. You’re not an alto.”

That floored me. “What?

“This key,” she tapped a relatively high noted on the piano, “would usually have altos tensing up and grimacing, even if they’re singing right. When you sing right, you don’t even wince here. You’re not an alto.”

Take note that since I started chorale singing at seven years old, I had always believed I was an alto. An alto with a very wide upper register, to be sure, but an alto nonetheless, with the capacity to boom out comfortable low notes. Apparently, though, I had been misled. Though habit had made me resonant in the lower ranges, my true “comfortable” range was closer to the high, soaring keys I’d often felt were impossible to me. Even my speaking voice was all wrong, causing me to “fry” my voice (when it gets all gravelly and gurgly in your throat) and irritating my vocal cords.

I’d had a clue that this was the case when, during the Miss Saigon audition season, Tita Jai had declared I was actually a mezzo-soprano (the story behind that here), but I’d always thought she’d meant that I’d managed to stretch myself so I could reach that range. What had actually happened was that my vocal cords had grown since I was seven–they in fact only stop growing at age twenty-one–and so over the years, I had been forced into an alto box when I was in fact slowly evolving into a soprano. A potential spinto soprano, in fact, though with the thick vocal quality of a mezzo. It was that thick vocal quality that lead people to believe I was an alto, but in truth my range was actually above it.

Years of singing and speaking in a lower pitch than natural had eventually taken their toll, leading to my pre-nodular swelling (apparently I don’t actually have full-blown nodes just yet). Acid reflux notwithstanding (that’s another factor, actually), it was the fact that I’d actually grown into a higher voice, quite without my knowledge, that was causing all the problems.

With therapy and practice, I’ll be able to make proper use of my newly-stretched vocal cords, which leads me to the big news…

Photo on 8-2-13 at 8.07 PM #3

Project Zipped Lips is, essentially, OVER.

I CAN SING AGAIN!

Photo on 8-2-13 at 8.07 PM

While total vocal rest was good for letting my vocal cords heal from the beating they’d taken for the past twenty years, in actuality they do very little to resolve my issue. In fact, I’m supposed to use my voice, but use it in the proper way. After Ms. Kitchie helped me figure out my new speaking pitch–nowhere near the low baritone that I apparently was merely faking all these years–I was given the directive to ditch the whiteboard and practice everything she taught me. Which I proceeded to do. With gusto. Who knew the hallways of St. Luke’s had such great acoustics?

Photo on 8-2-13 at 8.06 PM #3

Just happy I can sing again.

So my season of silence has, apparently, ended. While I won’t be leading worship for a while yet and my initial gusto at “practicing” has landed me with a bit of a sore throat (easy there, tiger), essentially I can once again resume communicating as a “normal” person, albeit with more attention to breathing and less intensity than before. And I think that’s a good thing, the new restrictions that are placed on how I can speak and sing. If anything, they’re freeing, because once I master them I won’t ever have to worry about losing the voice that, in the past two weeks of silence, I’ve learned to appreciate more and more. No more comparing myself to my friends or belittling my range–now, I’m just grateful to have what I have, weirdly-textured soprano and all.

So that’s it for now! I guess we’ll have to be renaming Project Zipped Lips as Project Breathe, but since I’m still determined to limit my vocal activity, I’ll continue updates on new developments. I’m definitely excited to see what elsecomes up in the next couple of weeks! If today is any indication, it’s all up from here!

~aRoamingTsinay~

[Project Zipped Lips, Week 2] The One With The Nodes

I figured while documenting my inner journey is all well and good, it would probably be a bit more helpful if Project Zipped Lips also documented my outer, physical journey–that is, dealing with nodes.

In actuality, vocal nodules aren’t as scary as Pitch Perfect makes them out to be (or maybe I’m just telling myself that so that I don’t collapse in a blubbering heap).  Most of the time, surgery isn’t even considered an option, unless of course you’ve got hard nodules from years and years of abuse.  If you catch them at their early onset, such as mine were, the standard treatment is selective voice rest and therapy, or, as I like to put it, “checking into rehab for vocal abuse.”  (Sounds more hardcore, don’t it?)

Symptoms of vocal nodules include hoarseness, difficulty reaching original high notes, increase phlegm production, and dry throat.  If you lose your voice periodically, and for more than two weeks at a time, I suggest you do get checked out by an ENT because while nodules themselves are benign–they’re like calluses that form on the vocal cords–there can be similar growths on your vocal folds that can cause the same symptoms, such as polyps or cysts, which are more likely to involve surgical intervention.

The primary way of figuring out if you have a nodule, a cyst, or a polyp is a laryngovideoendostroboscopy, which is when they jam a camera down your throat with a strobe light attached to the end so they can see, in slow motion, the movements of your vocal folds, and the nodules in question.  Which leads me to the contents of this blog post: the results of my recent LVES examination, posted here in their entirety because, well, at least some of it is understandable to human beings.

Special thanks to the Voice and Swallowing Center of St. Luke’s Medical Center-Global City for their amazing service!

Patient Info

IMG_0631

(There was actually a photo enclosed with the report, but it was hideous, so I’m using this one instead.)

Last Name: Torres
First Name Middle Initial: Frankie
Gender: Female
Date of Birth: 03/07/1993
Patient ID: Out-Patient
Address1: <<actuallyfrankie.wordpress.com>>
Original Complaint: Hoarseness
Patient Primary Diagnosis: Pre-nodular swelling
Patient Secondary Diagnosis: Chronic posterior laryngitis (swelling of the larynx due to a degree of acid reflux)
Smoking: Non-smoker
Alcohol Consumption: Rarely (Try: NEVER)
Occupation: Student

Exam System Info – General

Exam Original Date: Tue Jul 30, 2013 08 28 40 AM Last Modified Date: Tue Jul 30, 2013 08 28 40 AM
Examining Facility: St. Luke’s Medical Center – Global City

Exam Detail

Vocal Fold Edge-Left: irregular Vocal Fold Edge-Right: irregular
Glottic Closure: 3. Posterior gap Amplitude-Left: 1. Normal
Amplitude-Right: 1. Normal Phase Closure: 2. Open phase predominates
Mucosal Wave-Left: 1. Normal Mucosal Wave-Right: 1. Normal
Vertical Level of Approximation: 1. Equal Vibratory Behavior-Left: 1. Always fully present
Vibratory Behavior-Right: 1. Always fully present Phase Symmetry: 1. Regular
Ventricular Folds (Symmetry): 1. Equal movement both folds Ventricular Folds (Movement): 1. Normal
Periodicity (Regularity): 1. Regular Arytenoids (Symmetry): 1. Equal movement of both arytenoids
Arytenoids (Movement): 1. Normal Hyperfunction: 1. Normal

Exam Summary

Examiner: Dr. Keith Romeo A. Aguilera Endoscope Used: Rigid Endoscope – Kay model 9106
Diagnostician: Dr. William L. Lim Exam Type: Laryngeal Endoscopy with Stroboscopy
Diagnosis: Pre-nodular swelling; Chronic posterior laryngitis Phonation Quality: Hoarse
Resonance: Normal resonance Breath Support: Needs improvement

And now for the parts that will make sense to you–THE PHOTOS.  If you’re squeamish, I suggest you look away.

Untitled1

My vocal folds, covered slightly by my epiglottis–the flap of skin that makes sure when you swallow stuff it doesn’t go down your windpipe instead of your esophagus.  You can’t see the nodes yet, but you can sort-of see the swelling that’s causing my voice to be hoarse.

Untitled2

THE MONEY SHOT!  Note the bump on the vocal fold that’s to the right in the photo (actually the left vocal fold because the photos are, apparently, mirrored) and the slight, wobbly sort of depression just across from it.  The bump is the node, and the wobbly depression thing is what’s known as a contact lesion, which is basically a bit of irritated skin from the node rubbing against it.

Untitled3

 

Montage sequence!  This is what my vocal cords look like trying to reach high notes.  Usually, they should meet completely and smoothly, producing a nice, clean sound.  However, due to my nodes, they can’t meet smoothly, resulting in all kinds of nasty, pig-getting-slaughtered noises (I’m uploading the video to my Youtube page as soon as I can get my net running fast enough.).

So there you have it, folks!  Those are my nodes.  I promise this will be the last post with a whole lot of squicky photos of my internal anatomy.  I’m going to have my first voice therapy session on Friday, at 10AM, with Ms. Kitchie Molina, so I’ll probably update you after that as to how everything’s going.

~aRoamingTsinay~

[Project Zipped Lips, Week 1] Welcome to The Project

From my Evernote diary, dated Tuesday, July 23, at 5:53PM

Just came from the ENT at Clinica Manila.  Had a camera stuck down my throat.  The verdict?  Confirmed.  I have vocal cord nodules.

They appear to be what’s known as “soft nodules,” but to confirm I will be getting further testing from The Medical City.  I’ve been prescribed a round of steroids (once again!) and acid inhibitors, and I most likely will need voice therapy.  I’ve also got to cut back on vocal use to only 10% of my average usage.  This means I am not allowed to sing, host, or do any speaking more than necessary for the next three months or so.

Hopefully I won’t need surgery.

Hopefully.

I’m trying not to get depressed over it.  After all, the nodes are there, and no crying will change that.  (In fact, as crying is vocal stress, they’ll become worse.). But it is deeply troubling that I can’t sing for three months, and that for all intents and purposes my voice may be permanently compromised.

I won’t break down.  I won’t.

IMG_0584

The vocal cord nodules in question.  They’re nothing like how Pitch Perfect makes them out to be.

It started a few months ago, when I started inexplicably getting hoarse and losing my voice for weeks on end.  Sometimes, this would be accompanied by a hacking cough, sometimes colds.  More often than not, it was just an unexplainable case of dry, scratchy throat, along with a severely limited vocal range that stayed quite stubbornly within my chest-tone register.  This had happened only once before–during the run of LI(F)E Auditions last year–but I figured it was nothing more than a natural extension of my perennial allergy problems.  I dealt with the issue as I had during those ViARE musical days–dosing myself obsessively with Throat Coat, tea, and Sinutab–and expected that it would all work out as it had before.

Only it didn’t, and after I’d gone to Brazil and back and my problems still had not gone away, I began to be concerned, especially when what had previously been my one “ace-in-the-hole”–my broad range, with its classical high upper register, also known as “head tone”–slowly began to fade.  This became obvious when I sang the opening bars of the title aria of The Phantom of The Opera, only to find I was unable to do so with my usual clear, bel canto timbre.  Adding to my worries was the fact that my reliable cure-all, Throat Coat Herbal Pastilles, had been phased out by Healthy Options.  With no more back-up plan, I decided to consult an ENT, hoping that it was nothing serious.

…as is obvious from the distraught Evernote entry, it definitely was.

IMG_0540

Vocal nodules have a stigma in the singing community.  Thanks to horror stories such as Julie Andrews, Ryan Key, and José José, they’ve gained a reputation as a career-ending, or at least a career-altering, vocal injury.  In recent years, Pitch Perfect has added to that perception, with its famous subplot involving one of the Bellas having been diagnosed with the dreaded disorder.

I was one of those people who bought into the hype of Pitch Perfect and Julie Andrews, and so when I visited Dr. Karen Capuz at Clinica Manila, I was hoping against hope that it was not, in fact, vocal fold nodules, although I had tried to reassure myself that modern medical technology–at least, according to what a Google search told me–made it so that nodes weren’t as serious as the hype allowed.  Still, when I received my diagnosis, I felt like I’d been hit by a cement truck, the numb feeling continuing as my prescription was read out:

“…vocal rest…”

“…no talking or singing for three months…”

“…steroids…”

“…potential surgery…”

IMG_0539

It’s pretty obvious from how long my blog posts can run that I usually have a lot to say.  I’m a talker.  It’s something I’ve been known for every since I was a little girl, and for the most part, I’ve been, if not proud of the fact, then accepting of it.  That I can run my mouth a mile a minute at a drop of a hat has been pretty much one of the key facets of my personality.  In fact, it’s gotten to a point where I feel like I’m counted on to speak up, whether it’s for class recitations, or presentations, or simple meetings–my ability to talk my way out of and around things usually has me taking the role of spokesperson, representative, PR person, and pitch-woman, all rolled into one.  Being talkative has been my primary way of being useful.

So when I was told, quite bluntly, that I’d have to cut my talking down to a mere ten percent of average–to, in fact, avoid speaking at all if I could help it–I was floored.  I wasn’t sure I could shut up for three minutes, let alone three months!

Still, I had very little choice.  If I was to get back into fighting form, then I had to do whatever I could to reduce the stress on my vocal cords, at least until I could seek therapy.  So the very next day, I got myself a whiteboard, and proceeded with what I dubbed Project Zipped Lips.

IMG_0550

Actually, it wasn’t supposed to be much of a “project” at first.  I’d planned to just go about my daily business, albeit minus the ability to speak.  But as I went through the motions, toting my whiteboard around, using sign language, and adjusting to my new normal, I discovered that I was beginning to feel changes in my personality, some of them…actually kind of good.   I began to wonder: had talking become such a huge part of my life that it had gotten in the way of me figuring out the rest of it?

Curious as to what I was noticing, and deciding to put a positive spin on my self-imposed silence, I decided to make my three months of verbal exile a sort of experiment, posing the following questions:

1) Will having only a whiteboard and sign language as primary forms of communication drastically change not just my habits, but my character?

2) What will happen to my thought process when the Queen of Babble can’t babble quite so much?

3) Who is Frankie really, sans the ability to talk?

IMG_0567

IMG_0581 IMG_0624

So welcome, then, to my new normal for the next ninety days.  It’s been a little over a week, and while further consultation has resulted in my restrictions being made slightly lax (selective versus total voice rest–this means I can talk, but only when I need to, and only in a really low, quiet voice), I’ve mostly stuck with the original resolution to not talk.  Mostly.  Admittedly it gets really hard often and sometimes I can forget myself for stretches, resulting my my throat feeling really sore.

It’s slow going, but hopefully as the weeks progress I’ll get more and more used to it.  Already, I’m discovering that I don’t actually have to talk as much.  I’ve realized that feeling compelled to talk was my own little manifestation of my inner control-freak–by making sure I was heard, I somehow exercised power of a situation.  Essentially, now, I don’t have that option, other than a bit of board-waving and frantic scribbling.  At first, that realization was tough to swallow, but now I’m actually learning to enjoy it.  In fact, I’m actually learning how much I don’t like talking.

No, seriously, I’m not kidding.

The fact is, keeping quiet has allowed me to slow down, decreasing my stress levels by a small (because I go to Dragon U and therefore am always stressed) but significant bit.  The less I speak, the less I feel pressured to, and the more I find I enjoy the silence.

Will the wonders never cease?  Well, who knows.  There are still eleven more weeks to go, after all.  Stay tuned for (regular?  We’ll see.  School is insanely busy.) updates about my Project Zipped Lips (or on shutting up and living with nodes) journey!