Vocal Process Granuloma

One Performer's Experience

(A work-in-progress)

Note: I am not a doctor or any kind of medical expert.  I'm sharing my experience as a patient with voice process granuloma to help others who might have this condition, and to help other voice professionals to avoid this illness.  If you think you may have this condition, always consult a doctor who has experience with laryngeal symptoms and treatment, and the proper tools to diagnose them.

---

I make my living as a voice-over announcer.  I provide the voice for commercials, documentaries,  corporate and training programs.  I do a considerable amount of "long-form" narration, such as documentaries and corporate training programs.

Here's how I was sounding in mid-2008:

Late November, 2008,A client called me to find out if I could get a particularly large job completed in a short time-frame.  This particular program would require hours and hours of narration, and then the the client  needed match my narration to the picture in the program that was being produced. Getting the job quickly was really important. Although it was late November, my client's client needed to have the program completed by the end of the year. that meant that I had about a week-and-a-half to record two weeks’ worth of narration.

"Is the script ready?" I asked.

"Almost." was the reply. "It just needs final approval from our client, which we expect tomorrow."

I said "Yeah, I can pull this off. Just get me the script right away, and I'll start recording."

Well, client approval was not "tomorrow" or the next day. …Or the day after that. My client said they were having problems with "legal, which meant that the lawyers needed more time to justify their involvement in the project. When the script was finally sent to me, I had only five days to complete what I would normally record in two weeks. I said "I'll give it my best shot.  I'll send you pieces as I complete them. I'll do them as quickly as I possibly can."

I've accomplished "impossible" deadlines before. If my voice got hoarse, I'd just rest it a few days, and I'd be as good as new. On this project, I did my best to pace myself - drank lots of water and took plenty of breaks. After the first two days, I was pretty hoarse, but I pressed on. If I could pull this off, my client and I would look like heroes. I could compensate for the hoarseness by clearing my throat often, which I did. I finished the job only a day late. "Pretty good" I thought. My client thanked me and suggested I take a well-deserved few days off.

After I took the well deserved days off, the hoarseness went away, but something was different.  I could feel that something wasn’t quite right in my throat.  There was a little bit of a “clicking” sound when I talked, and there was often a feeling that “something had gone down the wrong pipe.”

A month later, I was called to narate a documentary.  The recording studio was located a few miles from the location where one of our famous "California Wildfires" was burning.  With al the smoke, compounded by my voice not seeming "righrt" in the first place, I had a tough time doing the narration.  I'm pretty sure that one, if not both of these events is what started my problem.

Still sounded pretty much like myself, but I could tell there was something missing... I couldn't say specifically what it was, but I could tell something wasn't quite right with my voice.

Over the next few months, my ability to record voiceover for long periods diminished and I noticed that my voice was getting a “softer” tone to it.  “Well, I’m Just getting older.” I thought.  In June, I found that late in the afternoon, every day, I was sounding terrible.  I would sound really hoarse and “fuzzy” after 3, but then it would always clear up about 7PM. 

Now, you can certainly tell there's some sort of a problem - It didn't seem to be going away. After two weeks of this, I decided it was time to go to the doctor. 

The First Doctor's Appointment

It usually takes two weeks to get an appointment with my HMO’s “Primary Care Physician”, so I went to the HMO’s “Urgent Care” center, which is kind of like an emergency room, only for less serious conditions.  The doctor said it was probably allergies, or perhaps a sinus infection.  The only way to determine if it’s a sinus infection is to get X-Rays.  She prescribed antibiotics, sent me to get X-rayed and told me to see my Primary Care Physician in two weeks. 

The sinus X-Rays came back “Negative” which means I didn’t have a sinus infection.  I took the antibiotics, but nothing improved, In fact, the condition seemed to be getting worse.  By the time I got in to see my Primary Care physician, I was hoarse almost all the time.  The Primary Care physician checked me out, said it was probably allergies, recommended Benadryl, and authorized an appointment with an Ear-Nose-and-Throat, or ENT, specialist.  I called for the ENT appointment.  The earliest they could get me in was 27 days away.  “I can’t wait that long – I’m losing work!” – “Sorry, can’t get you in sooner.”

Meanwhile, my voice has degraded to sounding like this:

The Second Doctor's Appointment

Patricia Shanks, my long-term fiancée, is a voice and music teacher.  For several years she's been saying that  I’ve been straining my voice.  She has offered, many times, to give me pointers to reduce the amount of strain on my vocal apparatus.  Since I never seemed to have a problem, I, naturally, didn’t bother to listen.  Patricia had a sinus infection a few years ago, and after getting recommendations from several singers in Los Angeles,  Several years ago she went to see a doctor in Century City, after her HMO doctors weren't able to  help her with what appeared to be some sort of sinus infection.  This doctor had developed a reputation for helping singers when their HMOs didn’t seem to help. I called that doctor, and I was able to get an appointment that very afternoon.  The doctor took a culture and sent it off to the lab. The next day, it was confirmed that I did indeed have a sinus infection – staph. and, acid reflux. He prescribed some very expensive drugs, and I left, expecting to quickly improve.  I seemed to get a little bit better the first week, but after that I didn't notice much improvement.

My voice continued to degrade. 

I was now sounding like Winnie the Pooh in the Disney cartoons:

The Appointment with the HMO's Ear, Nose and Throat Specialist

Finally, it was time for my appointment with the HMO's ENT.  I was lucky that I could find and select a specialist who had a specialty in voice problems.  As soon as he heard my voice, the ENT doctor asked the assistant to set up the stroboscope. In a few minutes, he stuck a silver tube down my throat, while he watched a computer screen.  He asked me to say "eeee" a few times, and removed the tube. 

The doctor said "You have something called 'Vocal Process Granuloma'".  He then explained that vocal process granuloma is a condition where a lesion forms after an injury, then acid reflux causes the lesion to expand. Often it is initiated by "hard glottal attacks" - closing off the airstream by closing the vocal cords.  When the lesion gets large enough, it keeps the vocal cords from coming together properly, which is what was causing my hoarseness. The doctor recommended surgery as the fastest way to get rid of my problem.  I was lucky, he said, because he had an opening just three weeks away.  The doctor wanted me to  understand, however, that after surgery, the granuloma often returns, often as soon as a year later.  I also would not be allowed to speak for at least a week after the surgery.

I asked him if there was anything I could do to help me speak in the meantime, since my livelihood depended on being able to talk.  He told me that he could prescribe Prednisone, which might help.  There was a small chance the Prednisone could work well enough that I wouldn't need the surgery.  I said I was surprised that the first ENT doctor I saw didn't find the granuloma.  The HMO doctor said that without the special stroboscope, the first doctor never would have seen it.

I went home and got on the computer to learn as much as I could about Vocal Process Granuloma.  Everything I read online from what appeared to be reputable sources pretty much agreed with the HMO ENT doctor.  EXCEPT - most of the medical literature I could find indicated that more than half-of-the-time, the granuloma returns after surgery.  On the other hand, when treated through other methods, nine-out-of-ten times, the granuloma does not return.  Much of the literature indicated that surgery should be considered only after other treatment attempts failed.

 

Time for a second opinion.

Since my voice is may career, I decided I needed to find the best doctor I could.  Patricia and I had attended "DR. Hans Von Leden World Voice Day" at Cedars Sinai Medical center a few times.   Dr. Von Leden is a respected expert on the voice and symptoms and treatment of vocal conditions.  I decided to locate Dr. Von Leden's practice, and, though I didn't expect to be seen by Dr. Von Leden, I would probably be in good hands with one of his associates.

I was led to the Osborne Head and Neck Institute, located in the Cedars Sinai Medical Center offices.  They were able to get me an appointment just two days away.  I met with the Doctor Reena Gupta, who had recently moved from New York.  Although she was young, Dr. Gupta seemed to know a great deal about my condition, its treatment and likely outcomes.  She explained that, if we could get my reflux under control, the granuloma will probably go away.  On the other hand, if I had the surgery, I would probably take just as long to get my voice back, and I would need the surgery again, six-months-to-a-year later. 

 I had to limit myself to one cup of coffee per day, pay special attention to my diet, and go on a routine  of aggressive reflux medications. 

After about two weeks, I started to hear improvement in my voice.  My voice improved a little bit each day. I needed to be careful not to strain my voice, keep spices out of my food, take my medications, and most importantly,  I could not go to bed until at least three to four hours after eating - anything.  The Cedars Sinai doctor also prescribed an inhaled steroid.  She said that the problem with the inhaled steroids is that nobody knows for sure if they help in the treatment of Vocal Process Granuloma.  Although many doctors think they may have helped their patients, there have been no formal studies to determine if inhaled steroids actually help cure vocal process granuloma.

 

Back to Work

Due to the length of time it took to get a correct diagnosis and the time it took  to get better, I was effectively out of work for over four months.  I was fortunate in that a few of my regular clients still  hired me for several projects, even though I was sounding like Winnie the Pooh.  In fact, some of my clients said they actually liked my "Winnie the Pooh" voice. There was a spot running in Los Angeles for about a month for a touring Broadway show.  The spot sounded like it was voiced by Sterling Holloway, the original voice of Disney's Winnie the Pooh - the spot somehow sounded pretty good. -That was me, with Vocal Process Granuloma.  Before I got my diagnosis, I told my doctors that if it appeared that my voice was going to stay this way, just let me know, and I'll cut new voiceover demos, sounding like Sterling Holloway.  Six months before I realized there was something seriously wrong with my voice, I was having problems recording auditions.  Though part of my financial downturn has been the economy,  this illness has cost me tens of thousands of dollars in lost work .  I'm also out about 4-thousand dollars in medical costs, which aren't covered by my HMO.

After about three months, I started to sound like my "old" self again. I couldn't work for very long before my voice started to give, and I needed to be very careful not to strain my voice.  I had to use care not to yell or scream, and I still needed to limit myself to one cup of coffee per day.  Eating anything after 8PM is forbidden, and the food that I do eat has to be pretty bland.  One positive aspect is I've lost 15 pounds so far, without even trying.  - The result of not being allowed to eat anything for twelve hours per day.

Recovery Progress:

Progress has been slow, but steady.  The samples below don't tell the whole story.  After the first month, I started to sound better, but I couldn't work for more than a few minutes.  I was fortunate in that a few of my regular clients had some short projects for me, like spots and tags, to work on.  Also, saying a phrase which contained a "P" and a "T" would immediately force me to stop - the result of the granuloma lesion being forced up against the vocal cords.  I had to edit the audio afterword to make those phrases work. 

Beginning of October (1 month treatment):

End of October (2 months treatment):

Middle of November(2-½ months treatment):

Middle of December (3-½ months treatment):

 

Things to know about Vocal Process Granuloma:

NOTE: This information is what learned during my experience with vocal process granuloma. Some of this information came from unconfirmed internet sources, some from doctors that I received treatment from.   I am not a doctor, nor an expert in this condition.  Everything you read here should be verified by your physician.

1. In the general population, Vocal Process Granuloma is an unusual condition.  Among people who use their voice professionally, it is not uncommon.
    Actors, Professional Speakers, Singers and others who make a living with their voice are much more likely to get Vocal Process Granuloma.  There are two reasons for this: (A) People who speak for a living are more likely to injure their "Vocal Process" - the area which surrounds and helps support the larynx. (B) These people tend to work late in the evening, which means they have a tendency to eat late, which is a primary cause of severe acid reflux.  The combination of these two factors, leads to Vocal Process Granuloma.

2. Symptoms of Vocal Process Granuloma:
     Typically, vocal process granuloma causes a sensation of something in the throat, hoarseness and voice breaks. The feeling that there is something in the throat is likely to provoke throat clearing or coughing, which can worsen the irritation which originally caused the granuloma. This can start a cycle of irritation and granuloma formation which makes the condition worse. Hoarseness is typically breathy, and it is difficult to raise the volume of the voice. As a result, a person may try harder and harder to speak loudly, thereby  worsening the granuloma. Many times, the granuloma can flip in and out of the way of the vocal folds and cause intermittent voice breaks rather than continuous hoarseness.

3. Because this condition is rare in the general population, most doctors are not able to diagnose Vocal Process Granuloma.
     This condition requires special equipment in order to be seen and diagnosed. Few Family Practice doctors, and not all Ear Nose and Throat specialists have the training and equipment needed to diagnose Vocal Process Granuloma.

4.  There are many other conditions which can produce the symptoms of vocal process granuloma, especially at the onset, including post-nasal drip, swollen or irritated vocal cords, viral and bacterial infections, and others.
     If you depend on your voice for a living, and you experience hoarseness (laryngitis) for an extended period of time, it is important that you see a physician qualified to diagnose these conditions, along with vocal process granuloma.

5.  Your doctor or HMO might not consider your laryngitis to be a serious condition.
    One doctor explained to me that many doctors and HMOs consider laryngitis to be more of an inconvenience than a serious condition.  It took my HMO 90 days to get me in to see a doctor who could diagnose my condition, even though I specifically explained that I was effectively out-of-work until my condition could improve.  If I had a broken ankle, I would have received diagnosis and treatment much sooner.

 

Links

Below are some useful links I found in the process of researching my condition. The Osborne Head and Neck Institute is where I received diagnosis and treatment.  The other sites contain information I found useful.

Osborne Head and Neck Institute: 
www.ohni.org

The Voice Foundation - Focal Fold Granuloma

----------

This page prepared and maintained by Travis - www.VOTalent.com