“Hey Andy, what’s up with your voice?”

Once I had a big voice. In my younger days, I sang bass in various choirs, acted a bit, and did some public speaking when necessary. I had to project my voice to the back of the room, and it worked. It’s a Box family trait. My dad, his brother and sister, and their parents all had strong voices. Perhaps I wasn’t always in tune, but you could hear me!

Things changed in January 2021. My voice became softer, hoarse and raspy, sounding like I had seasonal allergies most of the time. No specific start date or event comes to mind. I just started noticing a change. When my father-in-law and brother-in-law mentioned one night at a noisy Chili’s that I sounded sick, it became time to start looking for answers. My biggest fear was a tumor that was compressing a vocal nerve.

Spring 2021 – What’s Wrong?

I started with a local ear, nose, and throat (ENT) specialist. I’ll leave the office nameless because I’m not thrilled with how things went. After numbing me up, the doctor stuck a camera up my nose and down my throat to look at my vocal cords in action while I breathed, sniffed, and made various sounds. This is called laryngoscopy. A bit awkward, but not too bad. He didn’t notice anything terribly unusual about my cords at first, but he did see some irritation in my throat that he attributed to long-term acid reflux (GERD). I’ve had it for years and take meds for it. He and his PA put me on big prescription antacids and then a REALLY LAME, NO FUN low-acid diet (no caffeine, no alcohol, no soda, no spicy foods, low fat, no chocolate, etc.). Several weeks of that diet reduced the irritation in my throat. It did nothing to fix my voice but plenty to reduce the joy of living!

Ruling out GERD as the cause, we then tried CT scans of my neck and chest to check for tumors. Clean. Definitely good news, but we still didn’t have an answer.

After another peek at my larynx, the doctor diagnosed me with a malfunctioning right vocal cord, technically called vocal cord paresis. Vocal cord paralysis means the cord doesn’t move at all. Vocal cord paresis means the cord moves some, but not properly. Both conditions are caused by a nerve problem. Sometimes the body can repair the nerve damage over time, but it’s often permanent.

How the Voice Works

Above your windpipe lie two bands of tissue called vocal cords or vocal folds. When you’re not speaking, they form a V shape and lie open to allow air to pass through. When you speak, the bands come together and vibrate as air passes over them to produce various types of sound.

There are two nerves that control the voice. The superior laryngeal nerve (SLN) is shorter and raises the pitch, with a branch for each vocal cord. If that nerve gets damaged, your voice becomes more monotone and fatigues easily. The recurrent laryngeal nerve (RLN) runs down the neck into the upper chest and then doubles back up (hence “recurrent”). It controls the movement of the vocal cords and splits into a right and left branch, one for each cord. Since I could still vary my pitch and sing to some degree, we knew I had an RLN problem.

Damage to either branch of the RLN can produce a hoarse/soft voice like I have. Damage to both branches or damage above the split can cause problems with both cords. In some cases, both cords can become fully paralyzed, making it very difficult to breathe and demanding immediate medical intervention. Sometimes this nerve damage is caused by an infection or accidental injury during neck surgery, but in my case we didn’t know the cause. Medical people call these situations “idiopathic”. The right branch of my RLN just quit working properly.

Here is a video of a patient with a paralyzed vocal cord. Note that one cord moves back and forth while the other remains in place.

Summer 2021 – Daily Life

By this point, my voice wasn’t really getting any better or worse. It was just weak and inconsistent. It varied from day to day, throughout the day, and even from moment to moment. Speaking a lot tended to wear my voice out, so I lost some volume on days when I trained a new dispatcher or attended a social event, especially one that was loud and forced me to raise my voice to be heard. On the phone, I sounded almost normal thanks to the microphone near my mouth. But my voice didn’t carry well across a room and was hard to hear in noisy environments. At Six Flags, I had to get Jenny to order lunch for me because the people behind the counter couldn’t hear me. At a sporting event, or with someone who’s hard of hearing, I often needed to talk straight into their ear. That was fine for my wife but a little awkward for general interaction, especially during a global pandemic.

Except for a stint in management, I’d served as an on-the-job desk trainer in my dispatch office since late 2008. After all the drama with my voice, I finally stepped down as a trainer in September 2021. I talked a lot when I trained, and it wasn’t good for my voice or fair to my trainees to continue in that role.

Since I’m naturally an introvert and generally not talkative, losing some of my voice made me even less eager to speak and isolated me from others. Imagine how you would feel if no one could hear what you said. It felt like having a disability, and in a sense, it was.

August 2021 – New Doctor and Voice Therapy

The first ENT doctor was out of ideas by now, and I was also ready to move on. We agreed that I would switch to the UT Southwestern Voice Center, which has MDs and speech therapists who specialize in the voice. They often work with singers, speakers, and actors who need vocal help. My new doc, Lesley Childs, sang professionally for a while, and she’s extremely nice and has a positive attitude. Looking back, I wish I had gone straight to her. Voice disorders are uncommon, so it would have saved me some time to go straight to a voice specialist like Dr. Childs.

She did the same laryngoscopy procedure as the first ENT specialist, but more thoroughly. She noticed, especially when I laughed, that my right vocal cord didn’t move in sync with the left. She described the right cord as sluggish or flaccid. I should have told her that wasn’t a very nice word to use to describe a middle-aged man!

As expected, she wanted to start with conservative treatment before jumping to surgery. In some cases, the damaged nerve heals on its own within a few months, so many doctors hesitate to jump straight to surgery right away. So I attended several voice therapy sessions with one of their speech pathologists, a really nice guy named Jacob.

Voice therapy was interesting. We tried various exercises to give my voice more resonance, which would increase its power and volume. One technique was called straw therapy, which involved blowing into a normal straw for a bit prior to speaking. Like magic (actually through temporarily pressurizing the chamber below my vocal cords), it almost restored my old voice! But the effect lasted less than a minute before wearing off. It was fun to try but wasn’t a long-term fix. We tried other techniques as well – various humming sounds on different vowels and consonants, moving up and down in pitch, using my diaphragm more. All good techniques, but nothing changed the basic fact that my right vocal cord simply didn’t work properly.

Fall 2021 – First Injection – Juvederm

By October, my voice problem had been going on for about 9 months, and the odds were slim that the cord would ever function properly again. It was time for plan B – compensating for the loss.

My doctor recommended Juvederm injections into the vocal cord (injection laryngoplasty, in medical-speak). Juvederm (a brand of hyaluronic acid) is more commonly used to reduce wrinkles and plump lips, but it can also plump up a damaged vocal cord. The goal was to position the injured cord closer to the good cord so they could meet properly and allow more normal speaking volume. Juvederm is temporary in this situation, lasting maybe 4-6 months. She told me that afterward, my throat might be sore and my voice strained and tight for a few days, but once the swelling goes down, I should have a stronger voice.

If we were happy with the results, the next step would be a more complex operation next year to add a permanent implant behind my injured cord to push it toward the middle (medialization laryngoplasty). That way I won’t have to keep returning for injections every few months.

Voice Sample Nov 2 Before First Injection:

We did this in her office on November 2 with LOTS of numbing meds. It was a really quick procedure involving a fiber-optic camera up my nose plus a special needle down my throat for the injection. Once she started, it took maybe 5 minutes.

Immediately afterward, I discovered that I couldn’t really talk with my normal voice. Hmm. The only voice I could produce was a goofy falsetto that sounded like a combination of Mickey Mouse and Mr. Hankey from South Park. It cracked me up, so I made a video.

Nov 2, Just After Injection:

November 2021 – Recovery and Panic

I tried working one shift nine days post-surgery and sounded absolutely awful – still very hoarse, and the lower part of my voice simply wasn’t there. I sounded like a guy who was trying to sound female AND who’d been smoking for 50 years. Think Marge Simpson.

I started getting nervous. As a flight dispatcher, part of my job involves talking to pilots, operations agents, air traffic controllers, crew schedulers, and other coworkers within our operations center. Among other duties, I try to convince my pilots that I’ve given them a flight plan that they can trust, a plan that’s safe, legal, smart, and highly likely to have a good outcome. The route is solid. The fuel load is sufficient. If they call to discuss the plan, I use my voice to convince them I know my stuff and am confident in what I’ve given them. If I sound like I have the flu and ought to be in bed, it doesn’t give them a good impression.

I started wondering whether something had gone wrong, whether my voice was truly and permanently fried, whether I’d made a horrible mistake by getting this injection. Would I ever dispatch again? Did I need to start looking for a new job? Could my department find something for me that wouldn’t requiring talking to crews on live flights? As the primary income for a family of four, this was NOT a good feeling.

Voice Sample Nov 15 – 13 Days After First Injection:

Starting to panic, I went back to see the doctor two weeks post-surgery and got another scope done. She said my injected vocal cord was still REALLY swollen for some reason, which was why my voice hadn’t gone back to normal. She assured me that it would stabilize in time. I did my best to trust her expertise. By three weeks post-surgery, I was starting to sound closer to normal, although still not great. It was probably close to four weeks before I really sounded better than my pre-injection voice.

Voice Sample Dec 27 – 8 Weeks After First Injection:

It’s hard to tell from an iPhone recording, but my voice had more power and range at this point. People could hear me better in person. December and January were good months. I finally felt that the injection truly had done my voice some good and was worth the time, money, and drama. I didn’t feel disabled anymore. Friends would happily tell me, “Your voice sounds good!” But by the end of January, my voice began to slowly degrade as the Juvederm was absorbed by my body. It took a while for others to notice, but I could tell a difference.

March 2022 – Deciding the Next Step

In March, I saw Dr. Childs for a four-month checkup, expecting to schedule my implant surgery. She thought I still sounded pretty good, better than I thought I sounded. She scoped me again and saw that my right vocal cord still had a decent amount of filler left. She also noticed that I didn’t have a large gap between my good cord and my bad one. As a result, she didn’t recommend adding the implant yet. Instead, if I wanted any further intervention, she wanted to do another injection in May. But this time, instead of Juvederm, she wanted to knock me out, pull some fat from my belly (lipo!), and inject the processed fat into my cord. This approach would last a lot longer, possibly a year or more, and should be tolerated better by my body since it’s my own tissue instead of a foreign substance. After thinking about it for a while, I scheduled the surgery for May 19.

May 2022 – Second Injection (Fat)

We did the surgery my May 19 as scheduled at Clements Hospital in Dallas under general anesthesia. This process was much more involved (and more expensive!) due to the anesthesia and lipo, but still outpatient. Everything went well. I got a two-inch incision in my belly that stayed sore for a few days. My throat was a touch sore for about a day. However, this time my voice started out even worse than before. I could not speak above a whisper for a few days, not even in my goofy falsetto. After a few days, I could force out a bit of sound, but it strained my voice and sounded terrible. Now I’m waiting for my voice to stabilize so I can return to work.

Dr. Childs took some nice before-and-after pictures of my vocal cords during the surgery.

• Top Left: Pre-surgery resting state. Bad cord on right. Bit of leftover Juvederm from last surgery.
• Top Right: Pre-surgery while making sound, so cords are together. Bit of a gap between them, hence the soft voice.
• Bottom Left: Post-surgery while making sound. Less gap. Should produce more sound once I heal.
• Bottom Right: Pumped-up cord on right. It will shrink a bit as swelling goes down and a bit of the fat is absorbed, but it should remain bigger than the left cord for a while. That’s what we want!

To those of you who have supported, tolerated, understood, and encouraged me on this journey, I offer my deepest thanks. This is a weird problem to have, and your support has helped me greatly.