Voice & Speech Specialising Service
One to One Consultations
Informal 20 minute initial telephone conversation, with general voice optimisation advice and resources included (£10 for 20 minutes).
Full initial online voice assessment, with personalised advice, resources and an individualised plan to support your vocal recovery (£120 for 60 minutes).
If a block of therapy or follow-up sessions are required, this can be discussed during your initial consultation (Guide price is £45 for 20 mins, or £85 for 40 mins).
Excellence in Care
noun: wellbeing / 'the state of being comfortable, healthy, or happy.
The Singer's Clinic provides excellence in care that will help you find the worry-free voice you deserve and reclaim your vocal confidence. Our services include singing lessons, speech therapy, and vocal massage, all of which are tailored to your individual needs, helping you reach your voice goals.
Whether your ENT consultant has referred you, your GP has suggested you may benefit from some speech therapy, or you electively want to seek some guidance to improve your voice or prevent future voice issues, The Singer's Clinic can help.
In-person or Online
Carrie offers in-person or remote online support to help you achieve more comfortable and healthy voice production for living life to the full.
What does Voice Therapy involve?
Voice therapy is a type of speech therapy that focuses on strengthening the muscles of the voice and improving vocal stamina, volume, clarity and articulation. It involves breathing exercises, vocal warmups, and vocal exercises designed to strengthen the vocal muscles and improve vocal quality. It may also include vocal massage to help reduce tension and improve vocal range and flexibility. Ultimately, voice therapy is designed to improve the overall quality of the voice and give you more control over your vocal output.
Why should I book with The Singer's Clinic?
The Singer's Clinic, led by experienced voice clinician & vocal coach Carrie, provides specialised holistic services to help you maximise your vocal potential. From singing and speech therapy to vocal massage, Carrie is warm and open, is dedicated to helping you find your voice and gain the confidence you need to use it.
Speech Therapy Fees
Initial Consultation: £120 (60 minutes)
Follow up Consultations: £65-95 (variable)
Click on the Service you require to find out more
Singing Voice Problems
Whether you are a professional touring artist, a weekend gigger, singing teacher, choir member, a worship leader, or you sing songs in your shower, the Singer's Clinic is here to identify what is causing your symptoms, offer friendly, non-judgemental advice, and devise a unique treatment plan to put you on the road to recovery.
For vocal professionals dependent on the singing voice for their income, voice problems can cause major financial difficulties. For amateur singers, singing can form a key element of their quality of life and major distress can be caused by changes in their voice and the impact it is having on their social and family life.
Issues can be caused by vocal fold surgery, growths or structural issues, paralysis of one of the vocal cords, or swelling from illness, reflux, allergies...or all 3.
Other times, muscle tension can be causing voice issues with pitch or dynamic range reduction, vocal instability, loss of clarity of tone, vocal fatigue, discomfort, strain, and more. In real terms this may mean you've started opting out of gigs, cutting your set list short, handing over songs to others to sing, altering your melodic lines, tuning down your instrument or even singing an octave lower than you used to sing.
Whether it’s anatomy or technique, Carrie is trained in vocal performance and has experience evaluating with instrumental exams, manual palpation, acoustic analysis and behavioural assessment to get you back to doing what you love.
Vocal Fatigue or Pain
Vocal fatigue can be caused when the muscles of your larynx tire out and cause a feeling of pain. A reduction in endurance, loudness control, pitch control as well as poor voice quality and an unstable sounding voice are often symptoms and complaints of people suffering from vocal fatigue. Fatigue can be felt in the non-muscular laryngeal tissues surrounding the vocal folds. People sometimes complain of dry mouth, a “full” feeling in the throat, shortness of breath, and that it takes effort to speak.
The cause of vocal fatigue may be simply how you are using your voice, or there could have been changes resulting from illness, or voice box structural changes may have occurred.
The Singer's Clinic requires individuals to seek ENT assessment prior to engaging in a course of voice therapy, to rule out any underlying disease, paralysis or growths in and around your voice box. Carrie can then use manual palpation and record your voice quality while analysing your voice production abilities to come up with a treatment plan uniquely catering to your needs.
Voice Quality Change
Quality of your voice can be a sudden change or one that occurs gradually over time. If this change was sudden or has persisted for longer than 2 weeks, it might be a good idea to seek an ENT assessment. This can be via your GP (NHS route), or you may wish to seek private ENT opinion. If you are reliant on your voice for work there may be additional support you can receive from your place of work or financial support is available to performing artists and singers in crisis. Please speak with Carrie about your situation and she may be able to signpost you to further support which may be available to you.
Whether it’s anatomy or technique contributing to your voice change, Carrie is trained in vocal performance (singing and speech techniques) and has experience evaluating with observation, discussion, manual palpation, acoustic analysis and behavioural assessment to get you back to doing what you love.
Voice Therapy through the Singer's Clinic can help you with the following potential diagnoses:
What is Muscle Tension Dysphonia?
Muscle Tension Dysphonia, or MTD, is a broad definition and encompasses a wide range of potential presentations.
There are two types: Primary MTD occurs when no apparent structural reason for the tension. Secondary MTD is when muscle tension is compensating for a disturbance in the larynx such as a structural change, swelling or paresis.
An accurate picture of an MTD results from a thorough case history, general observations, a detailed auditory-perceptual analysis, manual palpation, appropriate instrumental analysis and excellent laryngeal imaging. The treatment for MTD is behavioural voice therapy with goals based upon the information gathered from all of these assessment approaches. Endoscopic observations of vocal tract function and laryngeal gestures used during speech or singing can be extremely helpful in guiding individualised approaches to voice therapy, particularly for professional voice users. Which is why a trip to a specialist voice clinic is recommended prior to seeking voice therapy.
Voice therapy teaches you to coordinate your vocal subsystems: breathing, phonation and resonation back to a baseline level or a level that manages your symptoms more effectively. You will learn how to reduce tension at the level of the vocal folds and reprogram your muscle memory for speech and/or singing.
What are Vocal Cord Nodules?
Nodules are not the end of the world. They are the most common lesions on the vocal folds and they are unlikely to end your career! Nodules will require hard work to resolve, and they will likely cause worry and frustration along the way. Take heart that by just reading this, you're taking your first steps to being in the right hands to changing your habits, resolving your nodules and taking back control of your voice.
Nodules can cause various symptoms including vocal roughness, breathiness, tension, reduced range, voice and body tiredness, and neck pain. Change to vocal quality occurs because the nodules touch when you bring your vocal folds together to make sound, and air escapes from above and below the nodules. Secondary muscle tension dysphonia can often occur alongside nodules, exacerbating symptoms.
Vocal nodules develop as a result of repeated trauma to the vocal folds. Overuse, misuse and new use of the voice are often the culprits. Nodules can occur in children and adults and are a result of stressful vocal behaviours like excess talking, singing, shouting or screaming more than the larynx can handle (genetics and training play a role here). The vocal fold tissue forms callouses in response to repeated tissue overuse and small swellings develop at the site of the trauma. These are usually known as “soft nodules”. They occur on both vocal folds, are symmetric, and vary in size. They interfere with the closure and vibration of the vocal folds causing hoarseness. If soft nodules are ignored, persistent damage may begin to produce fibrous scar tissue. When this happens they are often referred to as “hard nodules”.
Soft nodules are usually treated successfully with voice therapy (acting much like physiotherapy for your voice) and good voice care. With a reduction in vocal habits that caused the issue in the first place, the callouses will lessen or disappear altogether. Hard nodules respond less well to voice therapy and usually require surgery.
What are Vocal Cord Polyps?
Polyps are growths on the vocal cords filled with fluid and they can change the way your voice sounds. It may be easiest to think of a nodule as a callous and a polyp as a blister.
They can occur from long-term vocal abuse (like nodules), or from just one instance of vocal abuse - like yelling at a concert. Smoking, thyroid problems and reflux may also cause polyps. Polyps usually occur in adults and are rarely found in children. Polyps can cause various changes in the voice similar to nodules.
Some polyps may look like a swollen spot or bump, a blister, a thin long growth, or they may even look like a grape on a stalk! Surgical removal is usually the option for treatment, however a combination of voice therapy and surgery is best to improve the patient’s vocal habits and to decrease the chance of a recurrence. You may hear them occasionally called polypoid degeneration or Reinke's edema.
What is Vocal Fold Hemorrhage?
Traumatic injuries to the vocal fold blood vessels can cause vocal fold hemorrhage. The larynx may suffer external trauma from sports injuries, physical attacks or from seatbelt compression in car accidents. Vocally abusive behaviours like shouting, screaming, violent coughing or crying can cause capillary rupture in the vocal fold and blood can leak into the superficial layer of the lamina propria (a layer within the vocal fold). Your voice can change dramatically when the rupture occurs.
Treatment includes vocal rest and conserving the voice, but surgical treatments are sometimes recommended. Voice therapy is recommended to promote healing, and stop the trauma from occurring again.
What are Vocal Fold Cysts?
Vocal cord cysts can be present from birth, or appear with age. Cause of a vocal cord cyst can be genetic or behavioural. They are tricky in that they do not respond to traditional voice therapy alone. Usually, the patient will have to undergo surgical extraction. Most cysts are either white or clear and are usually found on only one side of the vocal cords. Sometimes, what’s called a “reactionary lesion” is formed on the opposing cord in the spot where it meets with the cyst during phonation. This opposing lesion can be smaller or the same size as the cyst. Videostroboscopy is key when this happens to rule out vocal nodules. Cysts cause the affected vocal cord to become stiff and not vibrate as well. The lack of vibration in one cord causes changes in the person’s vocal quality. Problems can range from mild voice changes, difficulty with singing range, diplophonia (two sounds coming out at once) and complete loss of voice.
Voice therapy can help you to improve vocal hygiene (voice care), coordinate vocal subsystems, and reduce vocal abuse and misuse. Voice Therapy is recommend before and after surgical removal of a cyst.
What is Vocal Fold Scarring?
Vocal fold scarring can occur following the presence of a lesion, changes to the tissue following surgery, and if the vocal fold tissue is continuously irritated from vocal abuse and misuse. Just like with scars you can see on your arms or legs, scar tissue is stiffer than regular tissue. When the vocal folds accumulate scar tissue, they become more stiff and are not as pliable. This reduction in pliability results in a reduced mucosal wave and voice quality changing. Those suffering from vocal fold scars typically lose vocal flexibility for pitch changes, fatigue easily, have a quieter sound, and sound rough or strained.
Why should I seek ENT opinion?
Vocal symptoms can be similar across many different vocal conditions so it is very important to seek diagnosis from ENT to ensure you end up on the right path to recovery.
If cyst, sulcus, or scarring is suspected it would be wise to seek opinion from a voice specialist ENT surgeon (laryngologist), preferably one working in a multidisciplinary voice clinic. The laryngologist will need to examine your vocal folds with specialist equipment, such as stroboscopy or high speed photography, in order to identify any areas of vocal fold stiffness that might indicate the presence of a cyst, sulcus or scar. Without this special equipment these lesions may be difficult to identify. Even when good equipment is available, it still may not always be possible to determine exactly what is causing a stiff area until the vocal folds can be palpated and examined under a microscope during surgery.
What is Vocal Cord Paralysis?
Paralysis is a condition in which you can't control the movement of the muscles that control your voice. It happens when nerve impulses to your voice box are disrupted. This results in paralysis of the vocal cord muscles. It can occur in one or both vocal folds, resulting in a breathy or weak voice quality with pitch instability. The vocal fold can be paralysed in the midline position and sometimes cause breathing issues during heavy exercise, but most commonly the vocal fold is paralysed in the abducted position (open). Paralysis occurs from damage to either the superior laryngeal nerve (SLN) or the recurrent laryngeal nerve (RLN). Paralysis can happen after injury to the head, neck or chest; surgeries, such as thyroid or heart surgeries; viral infection, stroke, tumors, neurological conditions, or for no reason at all (Idiopathic vocal cord paralysis).
Paralysis can make it hard to speak and breathe. That's because your vocal cords do more than just produce sound. They also protect your airway by preventing food, drink and saliva from entering your windpipe (trachea) and causing you to choke.
Treatment depends upon the cause, the severity of symptoms, and the time from the onset of symptoms. Treatment may involve voice therapy, bulk injections, surgery or a combination of treatments. In some cases you may experience spontaneous recovery and get better without surgical treatment. For this reason your ENT consultant may decide to watch and wait. However, bulk injections are commonly done within the first 3 months of voice loss. Voice therapy can help keep you from using your voice improperly while the nerves heal, maximising efficiency of vocal function through exercises to improve breath control, prevent tension in other muscles around the paralysed vocal cord (or cords). and protect your airway during swallowing. Occasionally, voice therapy may be the only treatment you need if your vocal cords were paralysed in a location that doesn't require bulking or repositioning.
SUPERIOR LARYNGEAL NERVE PARALYSIS
SLN damage is the most difficult to identify because the patient usually complains of vocal fatigue, being unable to sing, and difficulty increasing pitch or volume. SLN damage can create a gap between the vocal folds after they come together (where one overlaps the other) which results in the patient being unable to achieve maximum closure. The affected vocal fold is also unable to lengthen upon pitch raising. Voice therapy can benefit anyone suffering from SLN paralysis to give the patient the maximum ability of vocal use in the presence of the paralysis, but no medical treatment is successful in treating SLN damage.
RECURRENT LARYNGEAL NERVE PARALYSIS
RLN damage is easier to identify as most patients complain of diplophonia (two sounds at once), reduced volume and pitch, and breathiness. This paralysis can cause atrophy of the vocal fold(s) affected and impact the ability for the vocal folds to completely close (adduct). A combination approach of surgical treatment and behavioural voice therapy is most beneficial, as detailed above.
Often times there is SLN and RLN paresis which can improve spontaneously in about 6-12 months. Again, behavioural voice therapy can maximise the your ability to utilise the best voice possible whilst reducing the risk of developing unhelpful patterns of vocal behaviour.
Chronic Refractory Cough
Millions of us get sick each year with some type of upper respiratory infection. We get a sore throat, we get sinus congestion, and we get a cough. Many of us have asthma, chronic bronchitis, or reflux and we get a cough as well, as we are treated with medication for these conditions. But, what if the cough persists? What if it’s been months, even years since you spent an entire day without coughing?
Chronic cough is a cough that has lasted more than 8 weeks. It can occur in around 10-20% of the general population, and can persist long after an illness or irritant is long gone. We believe it’s related to dysfunctional nerves, making the cough neurogenic. Coughing can disrupt sleep, making a person feel tired with trouble focusing attention. Coughing can drain a person financially and emotionally because they seek improvement and usually get multiple tests, from multiple physicians, with no answers. Plus, it’s isolating to have a chronic cough because others tend to stay away from the person for fear they are ill (or have a viral illness) and the person with the cough often avoids social gatherings because they don’t want to bother others.
It's so common that people with chronic cough come to speech therapy in the NHS unimpressed and annoyed because they don’t have a clue why their physician referred them to “speech therapy” for their cough.
They are then happily surprised, on most occasions, when after 1-4 sessions of voice therapy, their cough is gone. Speech therapists are specially trained to administer vocal hygiene, education, cough suppression techniques, breathing techniques and hydration education. Some people even benefit from the addition of vocal massage to lessen their symptoms. Sessions teach you how to take conscious control of your cough, which results in:
lessening cough reflex sensitivity,
lessening frequency of cough,
improving quality of life!
Difficulty Breathing (VCD, PVFM, or EILO)
Vocal Cord Dysfunction, or Paradoxical Vocal Fold Motion, happens when your vocal folds close when they should open. Newly it has also been termed EILO (Exercise Induced Laryngeal Obstruction) and is often mistaken for asthma. VCD/PVFM/EILO is not asthma. It is a problem with how and when the vocal folds move.
Normally your vocal folds are open in a “V” shape when you breathe. If the vocal folds are coming together when you are trying to breathe, the space between them gets smaller and the pathway to your lungs narrows or is completely occluded by the closed vocal folds. These episodes are often frightening because the individual cannot take a normal breath. Episodes can be triggered by exercise (most common), acid reflux, breathing in cold air, smoke, pollen or smells in the air, or emotional stress.
Symptoms while VCD/PVFM/EILO happens may include:
- rough-sounding voice
- difficulty breathing air in
- noisy breathing
- tightness in the throat
- sudden loss of voice
VCD is often misdiagnosed as asthma, and when the patient has no success in treating the shortness of breath with asthma medications, VCD is suspected. There is no known cause for VCD. It is most common in Type-A personalities, athletes, and adolescents.
You would usually see a team of professionals to find out if you have VCD/ PVFM/ EILO. The team may include allergist, respiratory consultant, ENT, gastroenterologist, neurologist, psychologist, allergist, and SLT.
Once a differential diagnosis has been made, treatment usually requires no medication, and is often resolved in just a few sessions with behavioural breathing techniques to make sure your vocal folds open normally and stay open while you are breathing. Breathing techniques are taught until the patient is able to produce them completely independently and can use them effortlessly under the extreme pressure of a breathing attack. Practice is important to maintain the body’s ability to remember and revert back to these rescue techniques. You will also become aware of what triggers the VCD/PVFM/EILO so you can avoid those triggers. You may also need medical treatment for any allergies or reflux that trigger your symptoms, or to see a psychologist if emotional stress is contributing to your symptoms.
Parkinson's Disease Voice Change (Lee Silverman Voice Treatment)
LSVT LOUD is an effective speech treatment for people with Parkinson's disease (PD) and other neurological conditions, such as progressive supranuclear palsy (PSP).
LSVT LOUD trains people with PD to use their voice at a more normal loudness level while speaking at home, work, or in the community.
Key to the treatment is helping people "recalibrate" their perceptions so they know how loud or soft they sound to other people and can feel comfortable using a stronger voice at a normal loudness level.
While LSVT LOUD treatment has helped people in all stages of PD, the majority of research has been on those in moderate stages of the disease. Beginning your work with LSVT LOUD before you've noticed significant problems with voice, speech and communication will often lead to the best results, but it's never too late to start. LSVT LOUD has the potential to produce significant improvements even for people facing considerable communication difficulties.
Today, LSVT LOUD is considered the global “gold standard” for speech treatment for people with PD. Extensive research on LSVT LOUD has documented that people with PD show improvements in loudness and more variation in pitch while speaking that are maintained for at least two years post-treatment. Secondary improvements may include better articulation, changes in swallowing, improved facial expressions while talking and even speech-related brain changes.
LSVT LOUD is an intensive, one-on-one treatment delivered over one month’s time:
Four sessions per week
Four weeks in a row
Daily homework and carryover exercises
For more information, contact Carrie today!
Vocal Tremor or Spasmodic Dysphonia
There are some voice issues that are neurological in nature, and not within our conscious control. These include things like vocal tremor and spasmodic dysphonia. Both problems can make it hard to talk. Voice Therapy can help.
Spasmodic Dysphonia (SD) is a long-term, or chronic, voice disorder. With SD your vocal folds do not move like they should. They spasm or tighten when you talk. Your voice may sound jerky, shaky, hoarse or tight. You may have times when you can't make any sounds at all. You may also have times when your voice sounds normal.
Being tired or stressed may make your voice problems worse. Singing or laughing may improve your voice. Voice spasms may come and go during the day. You may not have any signs of SD until you are between 30 and 50 years old. It is more common in women.
Assessment should be with a team that includes ENT, Neurologist and Speech Therapist. Referral to such a team would be via GP in the NHS.
There is no cure for SD. However, there are treatments which may help including:
- Botox injections into one or both of your vocal folds. This makes the muscles in the larynx weaker and may lead to a smoother voice.
- Voice therapy may be able to support with education, relaxation techniques, and direct vocal techniques to improve breath support, reduce tension and strain, maximising efficiency of speech and vocal function.
- A psychologist may be able to help you learn to live with SD.
Support, information and help also exists in UK based organisations, such as www.dystonia.org.uk
Aging Voice (Presbyphonia), Bowed Vocal Cords or Vocal Cord Atrophy
Presbyphonia is a term used to describe age-related changes that can affect an individual's voice. As we age, our bodies work differently. Parts of the body and skills like breathing, voicing and muscles may begin to become de-conditioned and start to decline in strength and elasticity. This is age-related muscle atrophy and can cause the vocal cords to bow and cause changes to the voice.
Chronological age and the demands (or lack of) made on the voice contribute to aging voice problems. Voice problems may be more apparent when attempting to sing or when exerting the voice. Symptoms may include:
- Less efficient speech with reduced control: pitch range and volume may appear reduced, voice may be lower in pitch, and voice quality generally deteriorated (e.g. squeaky, shaky, weak, rough, breathy, or hoarse).
- Rushed and breathy speech.
- Laryngeal tension.
- Symptoms worsening towards the end of the day.
If you have been diagnosed with presbyphonia or vocal cord bowing/atrophy, voice therapy is a researched and proven effective way to improve your vocal quality, volume and quality of life. The aim is to improve muscle strength, increase good vocal behaviours and confidence in vocal ability through advice, education, and daily exercises.
Clinical Voice Pathology: Theory and Management 4th Edition Stemple, Glaze & Klaben
Laryngeal Endoscopy & Voice Therapy: A Clinical Guide 1st Edition Jones
British Voice Association www.britishvoiceassociation.org.uk
a Tempo Voice Centre
Mayo Clinic www.mayoclinic.org
Dystonia UK www.dystonia.org.uk