extremely illuminating because the

01:02
things that you thought were sort of
01:03
Rough Vocal effects, collapsing in them potentially blocking
Distortion, Growl, Grunt, 01:05
off the airway we're actually vibrating
Rattle in patients 01:07
and sometimes it's the only thing that
https://www.youtube.com/watch?v=sx19Ki6 01:10
HY90&t=10s
was actually vibrating at all so you
01:13
00:09 might have been tempted to remove that
my day job is an ENT head neck surgeon 01:16
00:14 thing that was flopping down into the
and obviously I see voice patients as 01:17
00:18 airway but actually if I'd you know if
part of that but I see a lot of wide 01:19
00:20 you'd done surgery on that or if you
spectrum of people who have laryngeal 01:20
00:26 don't examine the patients to look at
disorders in its or broadest term so 01:23
00:28 the structures that are actually
people have got cancers of their voice 01:24
00:30 vibrating then you could actually damage
box people have had surgery to improve 01:27
00:33 the only voice that these people have
their their breathing and we're all very 01:29
00:36 heard have got it wasn't so I started
aware that you know some people have 01:33
00:38 doing the work with with Katherine and
some very abnormal voices as a result of 01:35
00:41 that actually began to appreciate that
of surgery and you know examine the 01:39
00:46 you could actually categorize these sort
patient's you see things moving and 01:41
00:48 of qualities of voice a little bit more
before I never really took a lot of 01:44
00:51 detailed in the literature that there
notice but since I used strobus kabhi to 01:45
00:53 been various descriptions of some of the
examine these patients you could 01:48
00:55 structures that are involved but I think
actually see what structures were 01:50
00:57 this is an attempt to sort of bring
actually vibrating and actually it was 01:52
01:00 together some of the findings that we
01:57 constrictions of the of the pulse cause
have seen with examining the singers and 02:56
02:02 particularly the area that it folds of
the very very vocal effects and also 02:59
02:03 folding in and this sort of really you
linking it to some of the clinical 03:02
02:06 can hardly see the vocal folds and some
findings but so see some of the quality 03:05
02:08 of the the more metallic clothes but we
of the images the videos I'm afraid of 03:07
02:09 know that they are actually vibrating
just a little bit poor but this is oh 03:09
02:11 underneath so and in speech actually
they're not very common these problems 03:13
02:13 they use use of the false cause is a
but hopefully I'll illustrate the sort 03:17
02:15 normal phenomenon in part so you don't
of similarities and dissimilarities so 03:19
02:20 use it all the time but use it for
basically we all know that 03:21
02:22 things like counting for long sets and
for normal voice you have your vocal 03:24
02:25 also for vocal effects if you just wanna
folds that vibrate and you have to have 03:26
02:27 do a bit of you know rather the voice
a passed by and of course and you have 03:29
02:28 when you use you bring in that the metal
the filter for the for the vocal tract 03:32
02:32 all considered that's a part of normal
the we know that the super glottis which 03:34
02:37 voice use and the effects are that it it
the super block is is basically the bit 03:38
02:39 does affect that use the super got
above the vocal cords as part of the the 03:40
02:42 essentially affects the way the vocal
voice box itself the larynx 03:41
02:45 folds vibrate and it also because of
we know that the supervisors can affect 03:44
02:47 that constriction it affects the
the voice in lots of different ways and 03:45
02:49 acoustics by narrowing that sort of the
we've already shown sort of 03:48
02:51 bit of the epiglottis and the submission
demonstrations of the effects of the 03:51
02:52 of super glosses so that can if if those
modes and how you get this sort of 03:56
02:54 patterns become entrenched then they can
04:00 04:58
actually lead to what we the commoners before but for singing you've got to get
04:02 05:01
voice disorder we see which is a muscle the mode right and then you can ally in
04:04 05:02
tension disorder and this has been well these sort of vocal effects here and
04:06 05:07
described in sort of the classic sort of basically the ones we've heard about
04:09 05:10
three types of those are that you get after the fix the common ones the ones
04:13 05:12
this sort of medial constriction of the I'm going to look at is packaged
04:15 05:13
both cords here then you get this sort distortions of growling grunting and
04:19 05:16
of anterior posterior constriction and rattle and we see all these effects in
04:21 05:18
then you can get the whole super glottis patients as well the tumor I'm not going
04:23 05:21
actually collapsing down but what the to talk about overtones sort of singing
04:26 05:26
difference here is that these people go singing but I'm so are some patients
04:28 05:28
into this mode of speaking and it's tend to go into it a little bit as well
04:29 05:32
constantly like that or they were they so um the in speech as I said using the
04:33 05:38
relaxed at times super gothic structures this is not the
04:34 05:42
sometimes if they can otherwise you vibrating part with just the
know 05:43
04:37 constriction it can be habitual use they
they've got this sort of constant rough 05:46
04:39 just go into a habit of using that voice
sort of quality to the voice in general 05:48
04:42 and some people use it as character
or it depends on the pathology and we'll 05:51
04:44 voices as well
talk a bit about that so so these are 05:54
04:48 and that's sort of quite common but
the main sort of patterns but this is 05:56
04:49 often the ones we see called muscle
not with the vocal folds that the false 05:59
04:51 tension so news of them said and that
cause vibrating this is just purely 06:01
04:53 can be a primary muscle tension dystonia
constriction we know we've seen this 06:03
that's when you do it for when there's 07:13
06:06 these are we've looked at the vocal fold
no particular reason other than your 07:16
06:08 vibration underneath and it's just as I
your constricting 07:18
06:09 said it's an ally effect role on the
in the throat and that has the effect so 07:21
06:12 vocal folds and there are singers who
when they actually relax and breathe 07:22
06:14 use it routinely in performing and if
everything retracts and the lounge looks 07:27
06:16 it's done correctly I think the the
completely normal and you know this is 07:29
06:18 risks are small as as long as a good
where voice therapy comes in the course 07:34
06:19 precautions that are taking the so the
to to relieve that tension but it could 07:40
06:22 end of the study was basically threefold
also be due to compensation you have no 07:43
06:25 release and first was to look and see in
option the only way you can get your 07:47
06:26 our original study was
vocal cords to vibrate or to get any 07:48
06:28 look and see if we can identify sort of
louder is actually to squeeze really 07:52
06:31 vibratory patterns we've associated with
hard to overcome either a block of gap 07:56
06:34 with each of these sort of these terms
or problems of vocal folds by bracing in 07:57
06:38 this was the study we did several years
terms of stiffness or scarring so the 08:00
06:44 ago now we also use the AGG on the Inga
effects and theme use characterize some 08:04
06:49 graph and Christic recordings to look at
singers expressive style mood very 08:07
06:53 the vocal fold vibration and see what
emotion and they're basically added 08:09
06:56 the effect of that was surrogate measure
effects on top of a an underlying normal 08:11
07:01 of abnormal vocal fold vibration and the
in the CVT terms one of these modes of 08:16
07:04 third thing is just that we looked at
singing they there's always this 08:20
07:09 for patients who had similar sort of
argument about how dangerous they are 08:22
07:11 types of problem it was a rest
for the voice but the thing is that 08:25
retrospective study so we used the 09:36
08:27 about the teaser groups there so in
standard sort of endoscopic for the 09:41
08:29 distortion the thing that we noticed
equipment there and we we looked at 09:44
08:35 most was that the the false chords came
twenty singers trained singers and seen 09:46
08:38 in I don't know whether we can give the
teachers and you've seen this is the 09:48
08:40 light a little better just to sort of
same cohort of patients that we've 09:50
08:42 show the video because it's a little
reported on previously so and they had a 09:52
08:47 little dark I'll show you another one in
range of different sort of singing 09:54
08:48 a minute that and so essentially
styles some of them were familiar with 09:59
08:50 you can see that these are going to the
using the vocal effects and some of them 10:02
08:52 different modes and you can see that
want but they could have worked but they 10:04
08:54 particularly the false cords are
could actually teach the techniques so 10:07
08:58 vibrating but so they're looking at the
in terms of actually how many subjects 10:17
09:01 eg G which is this green trace there you
or singers that we were able to see you 10:22
09:04 can see this is thumb okay so if you
can see that distortion was the easiest 10:25
09:06 look at the spectrogram first of all
one for 17 out of 20 could could do that 10:26
09:12 which is at the top here and you can see
and then a lot could do the growl the 10:30
09:16 the sort of the overdrive mode here with
growls actually Peaks ready to be 10:33
09:18 the harmonic structure here and this is
difficult to visualize and we docked a 10:36
09:20 when you've added in the distortion
hint of what was going on from that the 10:38
09:23 effectively switched off there this is
rattle quite a few only that five could 10:41
09:26 the contact patient here at the vocal
do that the grunt could eleven could do 10:45
09:30 folds and you can see there's sort of it
it but only three was suitable for sort 10:47
09:33 kept fairly constant but there's just a
of analysis and I'm not going to talk 10:50
little bit more of the variance in it 11:49
10:52 variable effect depending on what the
and if you look at one particular point 11:50
10:54 pathology was if we look at the
in detail there when there's no 11:52
10:57 character voice first of all and so
distortion you can see this is the mic 11:57
10:58 taking off internet that's that the top
for the very driver type of waveform 11:59
11:01 ten actors with the most annoying voices
that we see but basically if you look at 12:03
11:03 it's it's quick listen I think this
the green trace that's the very graphic 12:07
11:05 ranks pretty high myself but I well you
trace you can see that with the 12:28
11:07 anyway you've got the idea of it is sort
distortion that the waveforms actually 12:30
11:09 of basically that is sort of age with
preserved although the amplitude of it 12:33
11:10 Distortion
is a little bit variable so so in terms 12:34
11:16 on top of it but he's made a lot of
of actual clinical cases where we see a 12:35
11:20 money as I said from that voice this is
distortion or distortion light effect 12:41
11:23 so case incapable practice this is chap
again it's in patients who use services 12:44
11:26 who's got very scarred vocal cords and
individually and the character voices 12:48
11:28 you can see the false cords vibrating
and we can see it in these sort of two 12:51
11:31 there he's got some fence guard you can
cases particularly and it gives a very 12:56
11:33 see them coming in like that so he's got
rough quality to it depends if there's a 12:59
11:36 a very breathy
glottal gap as well if there's a bottle 13:05
11:37 you can hear okay so rattle now we can
gap then you get a breast in this on top 13:33
11:39 hit more about this later but basically
of the rough effect but we see this 13:34
11:41 it's the carotenoids molarity noid
medial constriction you see this 13:37
11:44 mucosa that vibrating and if we just
irregular close-ups of periodic 13:41
11:46 play that
vibrations of both vocal cords and a 13:43
[Music] 15:32
13:52 different example it's a bit dark but
[Music] 15:34
14:04 you'll see it this is a lady who had a
Yeah right 15:37
14:08 carcinoma a cancer of the vocal cords
[Music] 15:40
14:13 she'd had radiotherapy for that which
so raffles got a different quality sound 15:42
14:16 unfortunately wasn't successful but she
it's more of a raspy quality it can 15:44
14:19 was actually adamant because the next
actually be used with Distortion and 15:46
14:21 stage is to actually remove the voice
there's something as he is it sort of 15:48
14:23 box incompletely but she was adamant
routinely in clerical practice again 15:49
14:26 that she didn't want that understandably
it's the same sort of things it's why 15:51
14:29 so there is an operation which is called
people develop one problem one way of 15:53
14:32 the super cricoid laryngectomy where you
finicky compared to another depends on 15:56
14:34 actually remove the the vocal folds
the the actual underlying problem to a 15:59
14:37 themselves but keep the supraglottic
degree and how they compensate but I've 16:01
14:41 structures and then you have to use
got two examples clinical examples one 16:03
14:44 those two to speak unfortunately she had
the first one is a patient who's got a 16:06
14:47 a vote when the vocal cords wasn't
psychogenic muscle tension problem and 16:08
14:49 moving as well but she actually learned
he just came in with the most bizarre 16:10
14:50 to speak and so she brings in the vocal
voice and do you only get glimpses of it 16:23
14:54 fold on that side but that doesn't
here but he you can see hopefully the 16:25
14:58 actually contribute it's the actual the
vocal fold vibration 16:26
15:09 the one that's not moving on the
so she's counting 16:28
15:17 left-hand side that you can see the
I ate oh it's a little rattle across 16:31
15:26 arity noid it's vibrating but she's got
there sorry okay and this is a patient a 16:34
a very breathy quality on top of that 17:58
16:36 we took from that in doing a part of it
because she's got no vocal folds there 18:00
16:38 showing Justin rolling
and she had to be careful with her 18:05
16:41 [Music]
swallowing but she could she didn't 18:13
16:42 I love that last little so in growling -
actually suffer much from aspiration 18:34
16:50 for practice we see again some people
[Music] 18:36
16:53 use it as the same reasons the cases
then the ground but but what you can see 18:39
16:59 that we have I've seen it particularly
there is say 18:42
17:16 is a vet patient with a vocal cord palsy
so you can see there's an anterior 18:48
17:18 not moving
posterior marry you get these sort of 18:58
17:22 and that's how the exactly taught me the
aryepiglottic folds sort of by draping 19:01
17:24 growl that's uncommon for vocal pauses
normally you can't see that with most of 19:05
17:25 but it's obviously another technique
the patients we other thing as we 19:07
17:27 that people use see grunting it's used a
examine because the epiglottis is far 19:12
17:29 lot in sort of death metal type of
back that's why it's got a slightly more 19:14
17:31 singing and we haven't got time to show
sort of gruntal tone but there's exactly 19:18
17:33 you example of it but perhaps but I can
the same thing that was happening there 19:20
17:35 show you here you see is sort of chaotic
and we've got other examples of of 19:26
17:38 sort of vibration the whole of the Sigma
grunting which which is slightly 19:29
17:40 process there and depending on the
different but so this was placed who you 19:32
17:45 extent of the grunting and if we look at
heard earlier he was amazing and we one 19:40
17:48 that unfortunately got a patient with
of our studies was we put an endoscope 19:43
17:49 that but I've got once again
down and he played the his piano while 19:46
17:53 demonstrating it during scene
singing and this was the the video that 19:51
[Music] 21:29
20:16 puts the stent in to widen it so they
[Music] 21:31
20:22 can breathe but unfortunately the
[Music] 21:33
20:32 downside of that is that they can't they
okay in grunting it does occur and in 21:36
20:36 don't often have a good voice but
the places we've seen it the patient 21:38
20:39 children are you know if they want to
sees who have had a brainstem stroke so 21:41
20:41 communicate they do they find ways and
what happens there is that the vocal 21:44
20:43 they a lot of them use their super
folds end up open they can't bring them 21:45
20:45 glottis but these are the children you
together at all so the ones who haven't 21:47
20:48 come in and they've got a really deep
had serious neurological consequences 21:49
20:50 gravelly voice you know in a
coming to thee who want to actually 21:51
20:53 five-year-old or whatever which is not
speak they way they can learn is to 21:53
20:56 normally of course that has to be that
actually use their super glottis to do 21:55
20:59 they're using their false cords to do
that obviously they end up with a very 21:58
21:00 that just so in summary basically for
breathy voice and they can only get our 22:05
21:03 distortion it's mostly the false cords
words out but they can some of them can 22:07
21:06 that are vibrating in rattle it's more
learn to communicate that the other 22:09
21:08 posterior mucosa over the RIT nodes in
group that we see is the again patients 22:13
21:11 the growling it's more aryepiglottic
have had extensive laser surgery to the 22:16
21:13 folds cuneiforms
vocal cords so they don't come together 22:19
21:16 and an in grunting it's more as the
and the third group is in children who 22:22
21:20 super glosses in general obviously their
have had some narrowing of their of 22:25
21:24 variations on this and some people use
their larynx usually from intubation so 22:27
21:27 more than one sort of part of their
they have an operation which basically 22:32
super blockers 23:37
22:33 voices and these sort of difficult
so in clinical practice we see all these 23:39
22:37 situations so thank you very much
and virtual character voices and muscle 23:46
22:42 you
tension dysphonia but what we do is Inglés (generados automáticamente)
22:45
these patients come in and we have to
22:47
try and determine whether it's a primary
22:49
problem or a secondary problem and their
22:52
voices are not pure rattle distortion or
22:54
whatever because often they got other
22:56
underlying problems either with a
22:58
glottal gap or they've got poor
23:00
respiratory support or other
23:01
neurological problems so that's why it's
23:03
a bit more complex than just the pure
23:06
forms but I think having looked at it
23:12
it's much easier to work out what's
23:14
going on and to classify these sort of
23:16
the ways that these supraglottic voice
23:19
uses and I think one of the other things
23:25
that advantages of this is there may be
23:29
that the techniques that that the
23:31
teachers use to train singers could
23:33
actually be useful for speech
23:35
pathologists to show them how to regain