Billy Orton, 2006 Local Church Division Vice-President, Facilitator

Editor's Note: This is a transcript of of a recording of the Local Church Divisional Meeting held at the Baptist Church Music Conference in Nashville, Tennessee, June 4-6, 2006. Minor editorial changes have been made for clarity.

Wendell Boertje: It is my responsibility to represent the executive council in bringing nominees for representatives that will serve this meeting through 2008. We are to nominate representatives to serve from the West and from the East. The executive council is prepared to put nominees before you. The nominee from the West is David West -- how appropriate -- David has been serving almost five years at Christ Memorial Church in St. John, Missouri, which is the St. Louis area, and he has been filling an unexpired term, so we recommend someone to you who has experience. So we nominate him to fill this two-year term. Are there any other nominations from the floor? If not we entertain a motion that he be elected by acclamation.

Voice: So moved.

Voice: Second.

Wendell: All in favor, raise your right hand. David, welcome officially to our council.

The nominee from the executive council from the East is Roger McGee. Roger has been serving for some eleven years at First Baptist Church, Alexandria, Virginia. You may know Roger as our gracious and wonderful host at the 2005 conference in Alexandria. Roger, would you stand? Thank you for being here Roger, he's made significant effort to be here for this meeting. Are there other nominations from the floor? If not we entertain a motion that he be elected by acclamation.

Voice: So moved.

Voice: Second.

Wendell: All in favor, say "aye". It carries. Roger, welcome to the council.

Billy Orton: These three are persons -- and, Judy, are you rotating off?

Judy Barking: No.

Billy: In addition to Judy, who is also serving from the East? Guy Anderson. Guy and Judy are serving right now. Would you please stand? They deserve your hand, they've worked hard this week. Guy says "Bill," if you looked at the program, it was a great one. Guy was so happy just to have hair!

[laughter]

Billy: But Guy and Judy, David, Wendell, and now Roger, these five form an incredible team, not just to not only represent local church ministry in our conference, in our work, but to also shape future conferences. So if you have ideas about next year, speak to them or to me today, because tomorrow morning we will be working on next year. Wendell has already planned all of the conferences to be held at Disney World. Let's hear it for Wendell.

[laughter]

Billy: Most of them on the roller coaster. We are delighted today to have Dr. Thomas Cleveland as our guest speaker. I've heard of Dr. Cleveland for a number of years now, for the work that he's done with the voice. He is a true expert. I had the occasion, about a month ago, I was at Vanderbilt, I went by and found his office. He's the most gracious host you can imagine and he showed me around the voice clinic there. Some great stuff there. He is a faithful member of Wayne Causey's choir here at Forest Hills. You'll see him tonight, correct? You're singing with the choir?

But he knows exactly what we are doing with our choirs week after week. It is our honor to have you sir. Come.

Dr. Thomas Cleveland: It's a great privilege for me to be here with you today. David and Roger, I wanted you to know that I voted for you. I'm kind of an illegal in this area, but I did vote for you anyway.

Isn't it great to be at a meeting like this when you can renew friendships and talk about old times. Billy, I want to thank you for the privilege of coming here and being with you here today. It is a great honor to be here. This is a great church. We love this church. We love Wayne Causey for leading us and giving us direction in this church, and we look forward to having our choir come tonight and be a part of your program.

As I have thought about this meeting, prior to coming here today, I was thinking about the people with whom I've had a very long relationship, and some of those people are actually here, they actually came to this event and I'm very grateful to them for coming. Some of our paths go a long way back. I would say that Milburn Price has been a friend of mine for a long, long time. I'll always appreciate the advice he gave me about forty-five years ago, when he said, "Tom, I've found the next place for you to go to school, and that would be the University of Southern California and study there with Bill Bernard. That's really what launched me out on this entire journey. I said, "If it's coming from Milburn, it can't all be bad," so Milburn, thank you a lot for that.

When I went to USC [University of Southern California], I was able to meet Phil Landgrave, and you say "How did that happen?" Phil took a sabbatical from Louisville and went to Riverside, California, where I was teaching at the time while I was studying, and Phil came over and brought a musical, an opera, that he had just written, and he asked if I would come over and sing in that opera. And this opera was set around the theme that Christ would come back into this environment and we would watch the people stand around and react to Christ. One of the three environments was sending Christ back into a church business meeting, and seeing how the people would respond to him. That was a very interesting opera, so I was glad to be able to work with Phil in that time. And I was very fortunate to have as a member of one of my classes at California Bible College a young man named Terry York. I understand from Wayne that Terry is not here, he's at one of the other meetings, and I was telling Wayne, Terry has not changed a bit. He didn't come to my class then, and he didn't come today. Well, he really did, you know what kind of student Terry is, he was there. It was a great privilege for me to know him there.

But how wonderful it is to get back in to this setting and be able to share stories with people you've known for a long, long time, and I know you look forward to that particular aspect of this meeting.

I want to thank you for what you do. I want to thank you for standing up in front of us on Sunday mornings and leading us in worship. I want to thank you for getting your choirs together, helping us, teaching us, helping us to praise the Lord, and know how important your ministry is to us. One of the things I know the devil would like to do is discourage you and get you out of the pulpit. But let me tell you how much we appreciate what you do, and all of the time and expertise that you spend on our behalf to do that job. Thank you so much for giving us that experience. I want to thank Wayne, too, for inviting you here to our church. We have a wonderful church here, and I hope you have enjoyed it, being with some of the people that we have.

Most people want me to talk about vocal health and vocal hygiene. What I'd like to do is start this off by talking about how you can keep your voice healthy. Let me tell you a few things about voice. First of all, I think it's important that you realize where this instrument is. God placed it in a place that gets very busy. The voice box is part of the swallowing mechanism. When you swallow, things go past it. It has lots of nerves in it, so you can lots of neurological problems in that area. Smoke is very damaging. We realize that, and you and I know we need to stay away from it, and if we live long enough we can die from it, and it can affect your voice in a negative way, because every time you breathe in, all that smoke passes by those two little folds of flesh called the vocal folds. We can have neurological malfunctions in that area because that area is well supplied with nerves. We can make very fine tunings with those nerves in those vocal folds because we have so many there from which we can command precision. Spasmodic dysphonia, for instance. Some of you may have had people in your choir who have had this. It manifests itself in this way: [speaks haltingly] and what happens is there's too much neurological firing from the brain going to the vocal folds and they squeeze tightly and stop the air flow, and then they release. So if you have somebody like that, we have a treatment for it. We can make them almost normal. We can't really cure it, but we can help them. That's one of the things we do at the Vanderbilt Voice Center, we intervene in problems like that.

You can certainly have a chemical imbalance, not enough hydration, not enough water, too much caffeine, so our dear choir director took all the coffee out of the choir room and put water there. So he is practicing what he is preaching to the rest of us, that we get enough water. But what is the thing that we want most when we get to choir on Sunday morning? Where is the coffee? Well, caffeine is a great dehydrator. Dries us out. We need lots of lubrication to do what we need to do with our voices, so it would be best for us to abandon that coffee pot sometimes and substitute some good water.

Then, hormonal imbalances can make a great deal of change in your voice. It's a lot more crucial in the female voice than the male voice, but it certainly makes a big difference.

The treatment of the decade, and really more than a decade now, has been a disease they call gastro-esophageal reflux disease. It's heartburn, basically. What we discovered is, if you regurgitate stomach acid into the voice box area, then it can burn the delicate membranes there and give you what we call a reflux hoarseness. And a lot of people have been diagnosed with that, and I think we over-diagnose it. It's one of those things that, if you don't really know what it is, then try a little Nexium, and that may take care of it. So I think that that can be a very difficult problem.

Emotional trauma: you know you don't really want to cry right before you go up and sing, because you've lost control of your voice.

You can have a mechanical blow to your neck, mechanical trauma there, certainly, because it's in the front, it's very delicate, it's very susceptible to a very abusive bonk, and so we want to try to avoid that.

Illnesses are the main things that we wrestle with. Viruses, mainly, along with bacterial infections. Usually colds are a virus and they start out that way. It's not that we have so much difficulty from the cold, it's what our body does in response to the cold that makes it difficult.

And then, mechanical malfunction with misuse and abuse and over-use. Illness is not something we have time for. It costs us a lot of money, it costs us downtime. We expect in our medical culture that people can take care of it and that we'll be well immediately and not have to bother with it. When we fight illness, this is what happens: in the immune system, blood is delivered to the area of the infection with antibodies. This will cause us to have swelling and some redness. That's what causes us some difficulty. The body provides more heat, fever to slow the development of the invading organisms, and it also provides more mucus to trap and eliminate the organisms.

Let me tell you something fantastic about our body. You and I have little hair cells on the inside of the trachea, and when you produce mucus, those hair cells will always be sweeping in this direction. They are very tiny, and you can see them under a microscope. They sweep everything up, so it likes to have mucus to gather the bacteria and whatever foreign organisms that might be there, and then to sweep that mucus up. But the mucus needs to be thin enough so that those little hair cells can work. So you always want to keep yourself hydrated enough so those hair cells can do their work to eliminate the organisms that need to go. They sweep it up to your throat so that you can swallow it and get rid of it.

You've got another set of hair cells on this side, up here above your throat. They sweep the opposite direction. They sweep back down to your throat. This is an amazing thing to me, because if we just came together the way some people say we did, then it's amazing that these little hair cells got where they are, got to be the size that they are, and got to be in that location to sweep in a certain direction. But we know that those things don't just happen, they are part of the plan. And so, we have a very active disease fighting system that operates all the time to keep us in good health.

The swelling, of course, can lead to hoarseness because when your vocal chords get a little bit bigger, they get kind of boggy, they don't vibrate quite as quickly, so you can have a loss in pitch range, the pitch gets lower. I hope that happens to my voice tonight so I can sing bass, get a little swelling there, I can get a couple more low notes. So I may have to go smoke a little bit.

[laughter]

So, and then, the fevers that we get create fatigue and lethargy and the mucus can create roughness in the voice and make it difficult for those vocal folds to vibrate.

Rather than going through a whole scenario of things, I've come up with six things that we need to do to keep our voices healthy.

Drinking plenty of water is one of them. Somebody has said you need to consume one ounce of water for every two pounds of body weight, up to about one hundred ounces. That's a lot of water, and I would say that might be a little too much. But we certainly need to take in about eight glasses of eight ounces of water a day, because we are mostly water and the electrical impulses that are so important in our body depend upon the water to make their connections. So we need to have that.

We need to avoid liquids with caffeine, because caffeine tends to dehydrate us. You know what it's like in the morning, when you get that cup of coffee at home, you hurry to work as fast as you can because you can't wait to get to work and evacuate that coffee that you had early that morning. And it seems that you are getting rid of more than you actually took in, and so that caffeine's just running through your body, looking for water to get rid of, so here it comes and it evacuates it.

Probably avoiding liquids with carbonation will help us too, in a lot of ways. I can say this, for those of you who need a little bit more lubrication -- and that's why we need this moisture in our bodies, because our vocal folds are mechanical instruments that need to be lubricated, and we're not getting enough lubrication there -- the vocal folds are going to have a more difficult time vibrating. Some of the studies say that if you are not hydrated well enough, it takes more air pressure to set them into vibration, and that can cause us to have some bad habits. So we want good lubrication to make those piston-like vocal folds able to function easily. So, if you need to start out in the morning with a little more lubrication, there are a couple of things I suggest. Pastilles come from a couple of companies, and they make them with glycerin as a base. The glycerin won't dry you out, the glycerin actually won't be a harmful agent as the menthol is sometimes. So you want a glycerin based lozenge, and a couple are Grether's and Dr. Doolittle's. If any of you live close enough to a Trader Joe's, you can get them there. You want the glycerin base, not something with menthol. And if you want enough lubrication before you sing, take one of these five minutes before you sing. That will add to your confidence, knowing you've got what you need to keep your chops well-oiled.

Caffeine - there are positive things about caffeine, we can't overlook that. We have great rehearsals with Wayne on Wednesday nights, and we always ask him, "What cup is this rehearsal coming from, Wayne? Three, four or five?" So, gives you lots of energy, reduces fatigue, increases alertness, improves mental performance, and sometimes reduces asthma symptoms.

But here are the negatives: caffeine can cause anxiety in some people, can be related to panic attacks, causes sleeplessness, and can be addictive. It can be quick laxative in some people, but can cause diarrhea in other people. It also seems to promote gastric reflux, the regurgitation of the stomach acid.

Here's another point, though, that's extremely important, and that's washing your hands and keeping them clean. The market is flooded with antibacterial soaps, but we should avoid those because when we use them we are strengthening those strains of bacteria that are resistant to the antibiotics in that soap. So we're making some of the bacteria stronger by doing that. Best thing to do is wash our hands in plain soap and water, or if you like these new products that are on the market like Purell and Endure that are a 62 per cent alcohol, those are great. Be sure you have the moisturizer in the hand solution, and that it's 62 per cent. The others at 42 per cent are shown that they are not as viable. They come in little bottles and you can take them wherever you go. This is extremely important for you as you meet your choirs and as you meet your people on Sunday morning, because sometimes people come to church on Sunday morning with a cold, and they can't wait to run up to you and hug you and shake your hand and tell you how great it is to see you again. They may walk up to you with a sneeze in their hand and say, "Brother, I love you with all my heart." What you've got to learn to do is not to put your hand to your face and rub your eyes. We've got to learn to rub our nose like we did when we were three years-old [demonstrates with back of hand, sleeve]. Just like that. Get that bottle of Purell and kill those organisms.

This is something that people are catching on to more and more, because some of the food stores here in Nashville now have these little handi-wipes that you can get to clean your hands as soon as you walk into the store.

Well, this is a joke isn't it? How are going to do this with your schedule: getting plenty of exercise. We need to, though, and if you've got a gym in your church or some place you can work out, I encourage you to do it. Do strengthening exercises as well as aerobics, and do it four or five times a week. Or if you just get to walk, get you a pedometer and try to hit ten-thousand steps a day, but do strengthening exercises at the same time.

Maintaining a healthy diet - when I was on the personnel committee years ago and we were talking about the insurance company we were going to get for the personnel here in the church. I was talking to the pastor we had at the time, and I said, "Jerry, it must be very easy for us to get insurance, we have so many ministers and so many pastors, it must be so easy to get an insurance policy." He said, "No, Tom, it's just the opposite. Our group eats more fried chicken and more fried foods and more potato salad, and all these things, that it's hard to get coverage for our population of people, because so many people in church work die in their fifties from a heart attack."

We need to be aware of that and change those habits, as many of you have, so we keep ourselves in better health, not only with our exercise, but with our diets.

Getting plenty of rest: we need probably about eight hours every night. It is well-known that people in the United States generally are lacking in their sleep and in sleep habits.

And then, of course, the last of the six is to use your voice correctly. Avoid yelling and screaming, use loudness appropriate to the surroundings. When I am at the clinic in the day, I know the problem that I have when I have a patient who comes in and they are this far away from me, and they say, [speaks very loudly] "I'm so glad I'm in your clinic, I've been needing your help for a long time." I know that they have no awareness of their surrounding. They are shouting at me so much that I feel like I need to back up.

Many of you are probably using microphones in your churches. We encourage people to use microphones for their rehearsals as well as in the sanctuary and other locations. But you overlook the most important part of a microphone if you don't have a good monitor system. That's the most critical element of a microphone for you, is having a good monitor right there next to you on the platform, so you can hear how loud you are. Let the sound man adjust the loudness for the people in the congregation, but if you can't hear yourself, we know you are going to talk louder until you can. And using your voice should always be thought of as spending money, because when you use your voice you are spending money. If you can't do that next performance, you might not get paid for it, and if that's because you misused your voice, then that misuse caused you to miss your paycheck.

We used to have a young lady who would fly from Los Angeles to Vanderbilt, and I could see her on the plane as she flew - she was performing on the plane. She loved to perform. She loved to make people laugh. When she got here, she would be exhausted. Her voice would be rough, and here it is, she just gave away that voice to all those people on that airplane, but when she got here she didn't have anything left for the people who were going to pay.

Be sure you use your voice like it's money, Because it is. Be sure you spend the interest of it, and never spend the principal. Always ask yourself, "Is what I'm about to say worth what it's going to cost me to say it, or am I just bumping my gums and causing some problems for my voice. 

Use that monitor with your microphone so you can hear your voice well, and avoid those noisy places like restaurants where the noise is so great you have to yell just to have conversation.

When you have artists at your church, it's very important for them to be able to use their microphone system and monitors, and so many have in-ear monitors now, and that's a great thing. What we are finding through studies, though, is that they are not saving their hearing quite like we thought they would, because they are turning them up just as loud in the ear as they did the stage monitors. But ear monitors can be beneficial to you because wherever you go there's no dry spot. You can always hear yourself extremely well. Remember that's one of your goals, to be able to hear yourself extremely well.

I wanted to show you some pictures of normal vocal folds [shows video], and watch these as they vibrate. You can see how they open, then close. These have been slowed down immensely by the use of the stroboscopic light. Vocal folds will open at the bottom first, then open at the top, then close at the bottom and close at the top. It takes a certain amount of air pressure underneath the folds to overcome the resistance of the closed part of the vocal folds, and then they open and close. How often do they do this? In the male voice, if you are speaking at say around 110, which is a typical speaking frequency for a male, that's 110 vibrations per second. Normal females would be above that by a good octave, 220 times a second, but think about your sopranos who are singing those high notes. Here we have A-440, which is the A above Middle C, the next A is 880 cycles per second, and we do that from time to time, so those sopranos' vocal folds are vibrating 880 times per second.

I worked with a whistle voice, taking some measurements, and measured 1420 times per second. That's a marvelous creation, something that will give you the wide variety that the human voice will give you.

What I thought you might like to see are some problems that might exist. If you look at this one, you can see some mucus. Mucus loves to live at the point on the vocal fold that's vibrating the most. You think, "If the vocal fold is vibrating, then why doesn't it toss the mucus off?" Well, it doesn't like to be tossed off, it likes to cling at the point of the most vibration. So if we aren't hydrated enough, that may be one of the signs, that the mucus is thick, not thin, and it can't go anywhere else.

We here about vocal nodules. We don't see as many nodules as you would think we might see. We see a lot of polyps, we see a lot of cysts, but we do see some nodules. What do they look like? Here's this little elevated bump, on this chord, here's another. What makes this happen? We don't know, but certain screaming will create this problem. Possibly producing your voice in a pitch that's inappropriately low might do the same thing. Let's watch these as they vibrate, and you'll notice that when they come together, they come together right where the nodule is, and they don't close very well, but just where the nodule is. There's space in front of it and there's space behind it, and that's why you hear breathiness sometimes when there's a lesion on the vocal fold, like a nodule. There's a leak in front and a leak behind.

Here is what we would call a polyp. It sticks it's head up above that vocal chord. It's what we call a pedunculated polyp. It's like it's on a stalk, hanging on to the edge of the vocal fold, and flopping from the top side to the bottom side, all the way through, creating some roughness in that voice. Not a pretty sight, something we don't want to happen to our voices.

Here's another kind of polyp. Both side of the vocal fold have a polyp on them. I can tell you that this typically is typically in a female voice, and in a female that uses her chest voice really high. When they take that chest voice and they push it up too high, then it seems to make the vocal folds vibrate at frequencies at which they weren't designed to vibrate on the lower leading edge, and polyps tend to develop there in that area.

Chest voice. Years ago, right after Milburn left USC and I got there, we had the same teacher for pedagogy, and one of the questions of the test was, "What is the unused female register?" The right answer to that question was "chest voice." This was a test given back in the sixties and early seventies, and hardly any females used that register in that time. If we asked that same question today, the answer would probably be "head voice." With the Bee Gees and all of those groups where the guys who raised their voices a lot, with people like Shirley Bassey, who sang Goldfinger, bringing her voice down, getting into chest voice sounds, we started to make chest voice more popular. Everybody started going there, and this has been a real cultural change over the past twenty-five, thirty years. It seems in our society, we like the "raw" things better than the things that give us real beauty, and we can hear that rawness in the chest voice.

Where we probably couldn't have had a voice center forty-five or fifty years ago, because we didn't have enough abuse in the culture, we can't keep up with it today. We have more patients than we can handle because of the popular styles. This is one of the problems that we usually see every day, polyps on the female voice, polyps on both sides, and we will work with these people to try to get them to go away, but usually this is a surgical answer here, and ends up being quite an ordeal for the singer over a three-month time.

Voice: Could you say something about the effects of females just talking too low? It seems like every sixteen year-old girl is trying to sound as husky as she can...

Tom: Yes, that's a similar thing and I'm glad you brought it up. The voice of authority in our society is a low-pitched voice, and now that males and females are vying for similar positions in the workplace, the female voices are going down to be that voice of authority so they can compete. I don't know if that's the complete ideology of that problem, but that's certainly a part of it. We have these high school girls, then, following mom's example, or following the example of everyone else in the high school, getting down here as low as they can, and at the end of the phrase dropping it down into what we would call a pulse phrase or a vocal fry. It's rampant in our culture. I just left a patient this morning, who, when she came in -- she had driven in from Mobile this morning -- and when she came in, she was displaying exactly that problem. She had lesions on both chords, and was probably wondering, "Why is my voice so rough, why is this happening to me." It's a very prevalent problem in our world.

Voice: Are polyps extremely painful?

Tom: No, this is another incredible thing about the way you and I are put together. We have touch in the places that we need to have the sensation of touch. We have it in our hands, we need it in our bodies, our skin, in certain places. We need it in our tongues, in our swallowing mechanism to a certain point, but then we don't need it any more. Once you swallow your food, for instance, once it's past here you don't feel the swallowing any more. When God made us, he did not put sensory nerve endings in our vocal folds. He put the nerve endings that we need for all the mechanical actions and for very, very fine tuning, but not sensory endings in our vocal folds. Now we can imagine what a great gift that is, because if I took my finger and I did this [hammers finger repeatedly] all day long, I can feel it. As I told you a few minutes ago. Your vocal folds are coming together and going apart hundreds of times a second. If that happened, you would feel every single time they came together, if you had sensory nerve endings there. It would drive you crazy, and you would think about singing shorter solos because you wouldn't want to feel that.

We do have some sensory nerve endings at the back of the vocal folds where they are connected, and sometimes you can get a little discomfort from another kind of problem. I'll show you that in a minute.

This is a problem called polypoid chorditis. I'm sure Louis Armstrong had this on both vocal folds. You can see how that one vocal fold is so swollen and so large compared to the other. It gives us a sound like Louis Armstrong because of what it does to the change in the pattern of the vibration. This comes from smoking and from inappropriate voice use.

This one would be what's known as a full chord bleed. You can see the blood in that right vocal fold. The person who experiences this is typically a female. They usually say, "I went for this high note, it wasn't quite right the rest of the night, but that's all I can tell you." This is what you see. We put them on rest and give them steroids for a while, and they end up looking like this in about ten days. Where you see the red blood, that's a fresh bleed there, but where you see orange, that's blood trying to dry up, not a new supply of blood. Females are more subject to this, perhaps because of the high pitches they sing, but also because of the change of the hormonal cycle, because there are estrogen receptors in the vocal folds. When these hormonal changes occur in the body, they can also manifest themselves in the vocal folds as well. So if you have a lot of bloating in a period time, that bloating can occur in the vocal folds as well. Females who are susceptible to this will know it after they begin to experience periods, they can tell you "at this particular time, my voice just doesn't feel the same." And this is a time you probably don't need to ask them to sing a solo at church, because they are going to have to work a little bit harder. It's not going to affect every one of them, but a minority. There are people who sing opera, where it's listed on the program, "this person will not be singing at this particular time." So what we tell people in school studying, if this does affect you and your voice, don't do your recital about that time. Don't do your voice jury on that day. It will affect them three to five days before the onset of menses.

With reflux, these are some of the things that may occur: you develop in the back a possibility of a contact granuloma. There may be some thickening of the skin back here, and there may be some reddening back in this area. This redness is red not because of reflux, but because of arthritis in this particular singer. This singer has great looking vocal folds, but the voice was as shaky as you can imagine it to be, and the reason is the arthritic condition that is manifesting itself in the rear connection for the vocal folds and the arytenoid cartilages.

Voice: How do cysts differ from what you've shown us?

Tom: Let me see if I can locate a picture of a cyst for you. A cyst is usually a growth that occurs within the vocal fold itself. It upsets the balance of the vocal folds, makes it have a little more heavy load to it, and is usually resolved only by surgical intervention. This is a really interesting polyp right here [shows photo], it's a polyp that lived on top of another polyp. I'll keep trying to find that while we take another question.

Voice: During the cold, when there is that drainage, clearing your throat is not good for us, besides being hydrated well, what are our options?

Tom: I can tell you honestly that there's not one paper that's ever been written showing the harmful effects of throat clearing. We think it's harmful, we don't know it for sure, but we think it's harmful. Those people who clear their throats with a very hard clearing, it's harmful, but those who use a gentle clearing, it may not be as harmful. Keep yourself well hydrated so that when you sense there's something in your throat you need to get rid of, you can swallow and clear it away. Most of our throat clearing is really habit. When we get that slight sensation, we just clear our throats out of habit. Swallowing should make that sensation go away.

Another thing you can do while you're talking, is if someone is speaking and they are down on their chords as we've been talking about today, it can make you feel like you need to clear your throat a little bit, and so you will try to clear your throat. The best thing you can do is raise the pitch some where it feels more comfortable, and the sensation to clear your throat may go away.

Voice: I can give a testimony, that if anyone here wants to go through surgery, I've been through it and it's no fun.

Tom: Yeah, that's so true, and the people who come out of surgery in our clinic really try to do the things we want them to do after the surgery, because they say they really don't want to have to go through that again. Because it takes away the instrument that you prize so greatly, that you use for communication. At our clinic, after surgery, we put you on voice rest for at least a week, maybe for two depending on your surgery. That is tough for "type A" people who direct choirs. I mean, it's tough to be without your voice for two weeks. Then we gradually reintroduce the speaking voice and over a two month period we gradually reintroduce the singing voice. I'm delighted you got good results from yours. Thanks for telling us that.

Voice: If a person were to see about having some folds reduced in their throat as a result of a sleep apnea situation, are there any dangers to the voice, is it better to consider that surgery, to stay with a [unintelligible] or to gradually control it with diet and exercise?

Tom: I'd say it's better to control it with diet and exercise if you can. My wife uses a baseball bat to control snoring and sleep apnea. Works pretty well.

[laughter]

The vocal folds usually aren't involved in that surgical procedure. It's usually to take away the vibration that occurs in the soft palette, because when you relax that palette and the breath comes in over it, it vibrates. Some of the strategies are to stiffen that soft palette area by putting scar tissue in it, and you have to damage it in a certain way to do that. It's better to go any other route than to do that. But if it affected your voice in any way, there used to be a procedure that people don't do much any more, removing the uvula and carving away some of that tissue right at the soft palette. One of the things that we've got to do there is to maintain the seal that occurs between the soft palette and the nasal pharynx right there. You need that seal and the pressures in your mouth for proper articulation. You have to be really careful not to damage the seal so that it leaks. Otherwise, there's no getting close to the vocal folds.

Voice: I had a [unintelligible] procedure done as part of my thyroid cancer, and my voice changed in its timbre, and also range. Do you find that fairly common?

Tom: For these cases in which you have thyroid surgery, the problem is that the thyroid lives here and here on both sides, and the main nerve running to the vocal fold with either course along the side of the thyroid gland or may be living inside of the thyroid gland. When you remove the thyroid gland, sometimes that nerve can be damaged, sometimes it can even get cut. If the nerve is stretched just a little bit, it can weaken that nerve. It's one of the side effects of having a thyroidectomy or playing around in that area. It happens with mainly with three surgeries: it happens with open heart surgery from time to time, it happens with cervical spine surgery where there's an anterior entrance, and it happens with thyroid removal. And you say "open heart surgery, how does that work?" Well, the nerve courses down this way and on the left side runs under the aorta of the heart and runs back up to the voice box, so when you get it here it can be stretched and damaged. Same way with cervical spine with an anterior entrance. When they come in here they want to pull this back to get it out of the way, and when they stretch it they can damage it in that way.

Voice: I'm now working with the second person that has had heart surgery, that I was told because of tubes put down his throat that he would not sing again. It took one about two and a half years to get his voice back, and the other one was just this spring and I don't know how long it's going to take. Is there anything being done to alleviate, down the road, when people have surgery, what we do to their throats?

Tom: As far as the intubation is concerned? Sometimes they can breathe during the surgery by a different device, and if they are singers they might explore that with the anesthesiologist, but what happens in most of them is that they have to be intubated, and the tube has to be inserted between the vocal folds, right here in the back. One of the things they can consider is, making that breathing tube a half size smaller than some people might dictate. Also, the big problem is the length of time that it's left in. That's what does more damage than anything else. But if they tell you this, you've got a choice, you can either breathe during the surgery or you can be this way, you probably want to breathe during the surgery so that you can be that way after the surgery, but still, precautions can be taken. You've got two things going on in that particular case, not only with the recurrent nerve here, but you've also got the damage that may occur within the voice box itself with the tube. That can manifest itself in a couple of different ways. We don't know how, but sometimes it can damage the nerve, but it can certainly damage the tissue around it. If a nerve is damaged, we give it about a year to come back. If it's not back within a year, most people think it's not going to come back, so if we can intervene, we need to intervene with it. I'm glad to hear that yours was about two and a half years out, and they still got a better voice. It's most likely then, that it was damage in the voice box, and not in the nerve.

Voice: What happens if the vocal chords in a senior singer when their voice continues to waver and waver, more vibrato all the time? What's going on in the vocal chords?

Tom: That's a great question. What happens to us when we get older is that the tissues begin to relax more. Unfortunately, if we see ourselves sagging on the outside, we probably are sagging on the inside as well. And so we are getting a sag in the vocal chords. I'm very familiar with this sagging stuff, it's happening more and more all the time. But the vocal folds are starting to relax more, and where you get a wave across the vocal fold, you may get a big wave across the vocal fold. Even the ligament inside the vocal fold can relax more. Typically, we will see what looks like a bowed vocal fold because of the relaxation, which means, then, we're not going to be able to get enough power to the voice to get a real loud sound because we can't get the same degree of closure anymore. Because we are losing tone in that muscle, it's beginning to vibrate a little wider and so on. I hope that helps.

Voice: I was asking for some of my friends.

[laughter]

Tom: That's great.

Voice: Can it be reversed?

Tom: I wish that it could, because I'm getting to that point myself, so wish that I could tighten it up, but we haven't gotten to the same place with chords that we have with faces.

[laughter]

Voice: When a part of the vocal chord does not close completely - I forget what it's called - is there any advancement in that?

Tom: We don't have the same organic material that God has when He puts it in the chord. We can go in there and find out what it is, but we still can't duplicate it. We are left to other things that we can put together here to put into that vocal chord. Let's just say that we have these vocal chords here, and they are not meeting as they should, to the midline to meet. For a long time the practice was to inject Teflon into this vocal fold, and Teflon was great because it could fill up that chord and make it match with the other chord. But a few years after that, most of the chords started reacting negatively to the Teflon and started building granuloma tissue there, and that tissue would grow and become the oddest shape that you could imagine. It would be red, and your voice was actually worse.

I have a funny story to tell you. We had a group of doctors that came here from Sweden three or four years ago to learn how to take this Teflon out, but he announced that evening, "Twenty years ago we came to Vanderbilt to learn how to put Teflon into vocal folds, and now we are back at Vanderbilt to learn how to take it out."

[laughter]

So that's what they were doing, they were taking the Teflon out of vocal folds, and special procedures were developed to do that.

Now, what do we use? We use fat, for one thing. They will harvest fat from around your navel, if anybody has any. They will harvest fat -- now, Wayne, don't look funny, now -- they will harvest fat from around your navel and take that fat and inject it into the vocal fold, and that can plump it up. They can take Silastic, a kind of plastic, and put that plastic into your vocal fold, and that will shim it over so you can speak better. It may give you a better speaking voice, but it's not anything like what God gave you to start out with, and there's not much it can do to help singing voices. There's a special kind of string that can be piled in there to create a closure, but it's still not as good as the original. We can help some, and we're trying to figure out how to help more.

Voice: What is known about the Julie Andrews case?

Tom: Not anything that can be said. Somebody else?

[laughter]

It was unfortunate that that is the bottom line, but she did it to herself because she had always sung extremely well, and had great voice production, but then she did that Broadway show called Victor Victoria, where she had to use her chest voice in a lot of that show, and using her chest voice created the problem, and you probably know the story from there on.

Voice: In relationship of a sore throat to the vocal folds [unintelligible].

Tom: The vocal folds can get very red and swollen, and that's why you get the hoarseness, and that's why you lose the pitch range, because they are so red and so swollen. They swell, they get larger, that makes you have a lower pitch. That can create an irregular curvature on the folds, and creates the hoarseness that we have. Gargle if it's comfortable, but the gargle is not going to get down to the vocal folds or throat, because anything we swallow is not going to go there, it is going to hydrate from within. If it affects your voice negatively, then limit the amount of use for your voice and drink a lot of liquids, because our job, when we get liquids, is first of all, all the soldiers in your body to get that invading organism. So when they get to the battlefield, they get killed and lie in the battlefield. That's why the mucus gets thick, and so now you've got to clean up the battlefield, and the best way to do that is to wash it. So keep yourself very hydrated so you can keep that lubrication thin enough to keep washing the battlefield.

Voice: If we have a big concert or something in three days and you are non-vocal, are any emergency things we can do?

Tom: Yes, it would be good to stop using your voice, and it would be good to go somewhere where they can look at your vocal chords under stroboscopy. If you have a bleed or a vascular polyp that has anything to do with blood, and you are probably shut down. But if it's just some swelling on the vocal folds and some redness, then you could get steroids -- if you don't take them too often -- and the steroids will reduce the inflammation and give you a better voice. If you have an illness at the time, it will probably lengthen your illness by a day or two, but if you get your voice, that may be okay for you. But you can take a dose pack or get steroids injected in your body that will reduce their swelling and we do it quite often. We have patients, though, who go all over the world getting steroid shots wherever they are, so we have to keep a close watch on that.

Voice: Is there a code of remedies that would go along with that? Inhaling steam...?

Tom: Won't hurt at all to inhale steam, to use a nasal douche, not going to hurt anything at all. Sucking on some lozenges won't hurt, because you are swallowing a lot and that helps clear the vocal folds.

Voice: You were going to show us a saline wash...?

Tom: Let me give you that recipe: eight ounces of water, half-teaspoon of salt, a half-teaspoon of baking soda, and half-teaspoon of Karo syrup. The baking soda buffers the salt. Sugar (the syrup) is a great mucalytic. You know these commercials where you have the Heinz catsup and the Del Monte catsup, and they put them on the page and the Del Monte runs down the page faster? If you put sugar on mucus, mucus becomes the Del Monte catsup because it runs faster.

Voice: Are there some times you should never sing?

Tom: If it feels uncomfortable in your throat when you sing, and it usually doesn't, then that's a good sign that you shouldn't sing. If it's affecting you so much that you have roughness in your voice, then you shouldn't sing.

Voice: Presence of fever?

Tom: Not necessarily. If it's not affecting your voice, then it's probably okay to sing.

Thank you so much for being here today.

[applause]

Billy: Is there a website?

Tom: Yes, we are the Vanderbilt Voice Center [www.mc.vanderbilt.edu/health/centers/voice.html], and all we do is take care of voice problems of all types. I know many of you have sent people our way, and we are happy to help any way we can. So we would love to be able to help and have that opportunity. Thank you for being here and for your attention.

Billy: Once again, let's offer our thanks to Dr. Cleveland.

Billy Orton is the Minster of Music for First Baptist Church of Huntsville, Alabama.

Dr. Thomas Cleveland works with the Vanderbilt Voice Center in Nashville, Tennessee (www.mc.vanderbilt.edu/health/centers/voice.html).