Specialist article: voice
Hoarseness?When breath and larynx do not work together
Your voice becomes rough, breaks off or tires after a long day? Here you can find out how the vocal folds and the vocal tract shape the sound, where hoarseness comes from, when it should be seen by an ENT practice and why, in our view, breathing, head balance and laryngeal tension are the basis of a resilient voice.
Does this sound familiar?
Your voice gives out, even though you don’t have a cold?
What applies to you?
Tap whatever applies to you.
If several points apply, it is worth taking a look at how your voice is produced and what supports it. In our view, frequent hoarseness without an infection is usually related to how you breathe, how your head is balanced and how much tension your larynx has to hold. These patterns can be trained.
When you should see an ENT practiceWhat laryngeal tension doesThe key points at a glance
- The voice is produced in the vocal folds in the larynx. The exhaled air sets them vibrating, and the throat, mouth and nose, acting as the vocal tract, shape this into sounds and tone.
- Hoarseness after a cold or a loud evening usually subsides after a few days. If it lasts longer than three weeks, the larynx should be examined at an ENT practice.
- If hoarseness keeps returning without an infection, in our view the voice is usually working uneconomically. Breathing, head balance and laryngeal tension form its basis, and this basis can be trained.
Video
Hoarseness: what to do when your voice gives out?
Das Video lädt erst nach dem Klick. Dann werden Daten an YouTube (Google) übertragen.
Vocal folds
Vocal cords or vocal folds? How the sound is produced
Everyone talks about vocal cords. Strictly speaking, the vocal ligaments are only part of what vibrates in the larynx.
To speak, you need air. When you breathe out, it flows from the lungs through the windpipe into the larynx. There, two folds lie opposite each other, the vocal folds. The air sets them vibrating; many times a second they strike against each other and open again. This is how the sound is produced.
The principle is like a guitar string. The tighter it is stretched, the higher the note. The vocal folds are tensed, stretched and brought together by small muscles in the larynx. The nerves of these muscles are branches of the vagus nerve; more about it in the article Stimulating the vagus nerve. For the vibration to happen easily, the mucous membrane must not dry out.
The sound is produced in the larynx. It is carried by the breath.Without an even airflow, the vocal folds do not vibrate economically. That is why voice work begins with the breath.
Vocal tract
From sound to speech: the vocal tract
The sound from the larynx on its own sounds like a hum. It only becomes intelligible in the spaces above it.
These spaces are grouped together under the term vocal tract. This means the pharynx, oral cavity and nose. This is where the sound becomes an A or an I, an M or an L. The tongue, soft palate, lips and lower jaw change the shape of these spaces in fractions of a second, sound by sound and word by word.
Throat
It connects the larynx, mouth and nose. Its width helps determine how full the voice sounds.
Tongue
It forms all the vowels and most of the consonants, starting from the tongue reference position.
Soft palate
It opens the passage to the nose for M, N and NG and closes it for the other sounds.
Lips
They form B, P, M, F and W and round the vowels O and U.
The vocal tract is also a resonance chamber, similar to the body of a guitar. It amplifies certain parts of the sound and gives the voice its colour. The tongue, lower jaw and larynx are linked via the hyoid bone. In our view, a changed tongue reference position therefore has an effect all the way down to the larynx. Where the tongue belongs is explained in the article on the tongue reference position.
Causes
Hoarseness: acute, frequent or chronic
Almost everyone has been hoarse at some point, after a cold, a concert or an evening at the stadium. What matters is how long it lasts and how often it comes back.
With an infection, viruses irritate the mucous membrane of the throat and larynx. It swells, the vocal folds vibrate with more difficulty, and the voice becomes rough or disappears altogether. Such acute conditions usually subside after a few days. It is different when the voice repeatedly fades without an infection, after work, in the evening or after talking for a long time. Specialists then speak of a functional voice disorder.
has a voice disorder at some point in their life, according to the American ENT guideline1
of the teachers surveyed had had a voice disorder at some point; in the rest of the population the figure was 28.8 %. 2,531 people in Iowa and Utah were surveyed2
of the teachers had a voice disorder at the time of the survey, compared with 6.2 % of the other respondents2
Teachers and people working in sales, on the phone or on stage often talk for hours, against noise and without a break. If the voice is overloaded for years, thickenings can form on the vocal folds, known as vocal fold nodules. In children who shout a lot and loudly, they are called screamer’s nodules.
The mucous membrane suffers too. During long periods of speaking and with mouth breathing, the fine film of moisture on the vocal folds dries out. They vibrate with more difficulty, and the voice loses resonance.
Getting it checked
Hoarse for more than three weeks? Then see an ENT practice
The vocal folds cannot be seen from the outside. Only a look into the larynx shows whether they are healthy.
If the hoarseness lasts for more than three weeks, have your larynx examined at an ENT practice. There it is viewed with a mirror or a camera. Often nothing threatening is found, but the examination is still important, because nodules, polyps, a paralysis or, rarely, a tumour need their own treatment. The American ENT guideline recommends laryngoscopy after four weeks at the latest, and without waiting if there are warning signs1.
Shortness of breath
Wheezing or breathlessness together with the hoarseness
Lump in the neck
A palpable swelling in the neck that does not go down
After procedures
Hoarseness after an operation on the head, neck or chest, or after mechanical ventilation
Smoking
Anyone who smokes or has smoked for a long time should have hoarseness checked sooner
Voice as a profession
Anyone who depends on their voice professionally does not wait three weeks
If the ENT practice finds no pathological findings on the vocal folds, in our view the voice is usually working uneconomically. This is exactly where training the basic functions comes in. It can be combined with voice therapy. Do not stop prescribed treatments on your own; discuss any changes with your practice.
Functional voice disorder
Too weak or too pressed: the uneconomical voice
In a functional voice disorder, the vocal folds are healthy. What is disturbed is the way they are used.
For a sound to be produced effortlessly, the larynx needs a stable but not rigidly held starting position. Then little breath pressure is enough, and the vocal folds vibrate freely. If the interplay gets out of balance, the voice tips in one of two directions. Both cost effort and, with a lot of speaking, lead to hoarseness and vocal fatigue, and in extreme cases to loss of voice.
Too weak
- Quiet, little vocal pressure
- Hardly any variation between high and low
- Breathy, air audibly escapes
- You have to strain to be heard
Too pressed
- High pressure, the neck visibly works along
- Bright and strained, the voice feels tight
- Frequent throat clearing, a feeling of a lump in the throat
- Rough and tired after speaking for a long time
The economical voice lies in between. In voice work it is called the settled voice, full, carrying and without pressing. It arises when the airflow, laryngeal tension and body tension fit together. That is what the next sections are about.
Basic function: breathing
The voice needs a supporting breath
The sound is produced when you breathe out. How the air gets into the lungs and how it flows back out therefore shapes the sound.
The most important breathing muscle is the diaphragm, a flat sheet of muscle running across beneath the lungs. When you breathe in, it lowers and the abdominal wall bulges slightly forwards. When you breathe out, it rises again and the air flows evenly through the larynx. How the diaphragm and pelvic floor work together is described in the article Pelvic floor training.
When speaking, you quickly take a breath between two sentences, sometimes through the mouth, and during longer pauses calmly through the nose. If, on the other hand, you breathe high into the chest and raise your shoulders, in our view you shift the work onto the neck muscles, and the larynx comes under tension.
The route the air takes also counts. The nose warms and humidifies the air you breathe. If it flows through the open mouth, it dries out the surface of the vocal folds. A research group in the USA had healthy women breathe through the mouth or nose for a quarter of an hour and then measured how much air pressure the vocal folds needed to start vibrating.
of mouth breathing were enough for this phonation threshold pressure to rise in 20 healthy women. After nasal breathing it fell3
found speaking easier after nasal breathing. After mouth breathing, 6 out of 10 found it more strenuous3
took part in the follow-up study. In those prone to vocal fatigue, the phonation threshold pressure rose more after mouth breathing than in the others4
In our view, mouth breathing is an underestimated factor in frequent hoarseness, especially at night, when it continues for hours. How a dry mouth develops by the morning is explained in the article on dry mouth. Why a strip of tape over the lips changes little about the breathing pattern is covered in the article on mouth taping.
Basic function: head balance
The larynx depends on head balance
The larynx does not sit firmly on a bone. It hangs in a network of muscles that reaches from the skull to the breastbone.
At the top, the larynx hangs from the hyoid bone. It is the only bone in the body that does not touch any other bone. Muscles connect it to the lower jaw, the tongue and the base of the skull; others pull downwards to the breastbone and shoulder blade. The position of the larynx is set between these pulls.
When the head is balanced above the body, the pulls keep each other in equilibrium. If it moves forwards, for example at a screen or when looking at a phone, the lines of pull in the front of the neck change. In our view, this shifts the starting position of the hyoid bone and larynx, and the vocal folds work under altered tension. More on head balance can be found in the article on neck and back.
Measurements support this connection. In 25 female teachers with persistent voice complaints, a forward head posture, a high hyoid bone and tense muscles under the chin were among the strongest indicators of a weak voice5. A review of eight studies with 303 teachers consistently found a forward head posture together with increased tension in the laryngeal and hyoid muscles6.
Such data show a connection, not the direction.In our view, head balance is at the start of this chain.
Try it yourself: say “Good morning” out loud, once with your head pushed far forwards and once with your head upright. What do you notice?
Laryngeal tension
When the larynx moves upwards
When you speak, the larynx is constantly moving a little, guided by muscles above and below the hyoid bone. This mobility adjusts the vocal folds.
The animation leads from the floor of the mouth to the larynx. At the top it hangs from the hyoid bone, and below it long, flat muscles pull towards the breastbone. If both sides work in balance, the larynx stays mobile and the voice free.
In the voice disorder caused by muscle tension, technically called muscle tension dysphonia, this balance is shifted. The larynx is pulled upwards when speaking, and the surrounding muscles hold on instead of fine-tuning.
were X-rayed while producing a tone. In muscle tension dysphonia, the hyoid bone and larynx were clearly higher than in the comparison group without a voice disorder7
were examined by ultrasound. In muscle tension dysphonia, the hyoid bone and thyroid cartilage moved further when producing a tone, and the further the larynx moved, the more strenuous speaking was8
The pattern deviates
Mouth breathing, a low-lying tongue or a forward head posture change the starting position in the neck.
The body compensates
The neck muscles and the muscles at the hyoid bone take on holding work. The nervous system stores the compensation as a habitual pattern.
The larynx loses room to move
It sits higher, the vocal folds work under pressure, and the mucous membrane dries out faster.
The voice makes itself felt
Hoarseness in the evening, throat clearing, a feeling of a lump in the throat and vocal fatigue. When and how strongly depends on the extent, the duration and the load.
In our view, this chain is at the start of many voice problems without a medical finding. Muscles that are integrated into their function are used and keep a balanced tension. Muscles that constantly have to compensate become tense in one place and slack in another. If the function works properly again in everyday life, the work is redistributed.
Body tension
Upright, not pressed
In the video, Dr. Berndsen explains why he prefers to stand when speaking. When standing, the body finds a supporting basic tension more easily.
Body tension does not mean making yourself stiff. Pulling your shoulders back, as was once meant by “stand up straight”, tenses the neck and chest, and the throat works along. What is meant is a relaxed upright posture in which the head balances above the body.
Then the scalene muscles can do their job. They run from the cervical spine to the first and second ribs and lift the upper chest when you breathe in. If the head is pushed forwards, in our view they work mainly as postural muscles, and the breath lacks space.
Like a tent with guy ropes
A tent stands well when all the ropes pull evenly. If one pulls too hard, the canvas becomes distorted. We see the neck and larynx in a similar way. If the head tips forwards, individual muscles have to hold on, and the vocal folds feel the effect.
A carrying voice is not a feat of strength.It arises when breath, head balance and larynx work together. Then it needs little pressure and still carries.
Training
Voice therapy and training the basic functions
For functional voice disorders, voice therapy in speech therapy practices is one of the established approaches. It combines voice exercises with breathing work, posture and vocal hygiene. A Cochrane review found in three randomised trials that this combination improves vocal function compared with no treatment, in one trial over at least 14 weeks9.
Our approach starts one level deeper and trains the basic functions of breathing, swallowing and head balance in one shared sequence. Dr. Berndsen regularly uses the training for recurring hoarseness without an organic finding and describes patients whose voice changed more than they would have expected. This is experience from practice and not a promise. There are no studies on the FaceFormer for hoarseness. That means the connection has not been tested, not that it does not exist.
In the basic exercise, the FaceFormer sits in the oral vestibule, behind the lips and in front of the teeth. The tip of the tongue rests at the reference point behind the upper incisors, and the head is upright. You press the lip wedge together, bite down briefly and swallow. How the hyoid bone and larynx work together in this process is described in the article on swallowing.
From around week 6, the breathing exercise is added. You breathe in through your nose for six seconds, pause briefly, bite down and swallow, then breathe out for six seconds. You extend the breathing pause in small steps.
- From day 1
Basic exercise
Three times a day for a few minutes with the FaceFormer ZERO.
- From around week 3
Pull exercise and night
The pull exercise is added, and at night you wear the ZERO.
- After a few weeks
Switching to the ONE
During the day you use the ONE. It is the same size as the ZERO, just made of firmer material.
- From around week 6
Breathing exercise
Calm nasal breathing with increasing breathing pauses.
- For advanced users
Head balance rotation with breathing
Breathing and head balance in one sequence, ideally in consultation with a practice.
- Over months
The pattern runs by itself
The exercise manual allows six to twelve months.
The free FaceFormer app guides you through the basic exercises, and you will find all modules on the exercise pages, including the head balance rotation with breathing. If you have an acute inflammation in the mouth, throat or larynx, pause until it has subsided. The training can be combined with voice therapy.
Everyday life
Easing the strain on your voice in everyday life
If your voice is strained after an infection or a long day, rest helps above all. With recurring hoarseness, in our view rest alone is not enough. One common piece of advice should be treated with caution: whispering. In a study of 100 people with voice complaints, the larynx was observed with a camera during normal speaking and during whispering.
tensed the area above the vocal folds more when whispering than when speaking normally. In 18 % nothing changed, and in 13 % the tension was lower10
Quiet rather than whispering
Speak little and with a calm, normal voice. Whispering does not relieve the larynx in everyone; in many people it strains it more.
Drink enough
Water keeps the mucous membrane moist. A review found better voice values after drinking and worse ones with a lack of fluids11.
Breathe through your nose
Lips loosely together, the tongue in the tongue reference position. During speaking pauses, the air flows back in through the nose.
Plan breaks
If you talk a lot, give your voice some rest in between, especially on long days of teaching or phone calls.
Clear your throat sparingly
Frequent throat clearing puts strain on the vocal folds. A sip of water or a deliberate swallow often eases the feeling more gently.
Head over the body
Set up your screen, desk and seat so that your head is balanced and does not drift forwards.
Questions
Frequently asked
What helps with hoarseness?
With an infection, above all rest your voice. Speak little and with a calm, normal voice, drink enough and breathe through your nose. Whispering is not rest; in many people it tenses the larynx more. If hoarseness returns repeatedly without an infection, in our view rest is not enough, because then the voice is usually working uneconomically. Voice therapy has evidence for this; training the basic functions of breathing, swallowing and head balance starts one level deeper.
When should I see a doctor about hoarseness?
If it lasts longer than three weeks. It should be checked without waiting if you have shortness of breath or wheezing, a lump in the neck, after an operation or ventilation, if you smoke or have smoked, and if you depend on your voice professionally.
What is a functional voice disorder?
A voice disorder in which the vocal folds themselves are healthy. What is disturbed is how they are used. The voice is then too weak and breathy or too pressed, it tires quickly and becomes hoarse with a lot of speaking. In our view, breathing, head balance and the tension around the larynx play the decisive role here.
Vocal cords or vocal folds: which is right?
Both exist. The vocal fold is the entire vibrating fold in the larynx, with a muscle at its core. The vocal ligament is the elastic layer of collagen above it, and the mucous membrane lies over everything. In everyday language, people say vocal cords and mean the vocal folds.
Why am I often hoarse without having a cold?
If the ENT practice has found no pathological finding, in our view the voice is usually working uneconomically. Common reasons are a lot of speaking without breaks, mouth breathing that dries out the mucous membrane, a head pushed forwards and a larynx that is held rigid while speaking. These patterns can be trained.
Can mouth breathing make you hoarse?
It can contribute. In a study of 20 healthy women, the air pressure the vocal folds need to start vibrating rose after 15 minutes of mouth breathing and fell after nasal breathing. At night, when mouth breathing continues for hours, this is particularly significant in our view.
What role does head balance play for the voice?
The larynx hangs from the hyoid bone, which is suspended in lines of muscle between the skull, lower jaw and breastbone. If the head drifts forwards, these lines of pull change. In teachers with voice complaints, a head pushed forwards was among the characteristics associated with a weaker voice.
Can I train with the FaceFormer if I am hoarse?
With frequent hoarseness without a pathological finding, you use the FaceFormer to train the basic functions of breathing, swallowing and head balance on which the voice is built. With acute inflammation in the mouth, throat or larynx, you pause until it has subsided. There are no studies on the FaceFormer in voice disorders. Voice therapy can be combined with the training.
More articles from the knowledge section
Where to go next
Sources
- Stachler RJ, Francis DO, Schwartz SR et al. (2018). Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngology Head and Neck Surgery 158(1_suppl):S1-S42. PMID 29494321. Source
- Roy N, Merrill RM, Thibeault S, Parsa RA, Gray SD, Smith EM (2004). Prevalence of voice disorders in teachers and the general population. Journal of Speech, Language, and Hearing Research 47(2):281-293. PMID 15157130. Source
- Sivasankar M, Fisher KV (2002). Oral breathing increases Pth and vocal effort by superficial drying of vocal fold mucosa. Journal of Voice 16(2):172-181. PMID 12150370. Source
- Sivasankar M, Fisher KV (2003). Oral breathing challenge in participants with vocal attrition. Journal of Speech, Language, and Hearing Research 46(6):1416-1427. PMID 14700365. Source
- Kooijman PG, de Jong FI, Oudes MJ, Huinck W, van Acht H, Graamans K (2005). Muscular tension and body posture in relation to voice handicap and voice quality in teachers with persistent voice complaints. Folia Phoniatrica et Logopaedica 57(3):134-147. PMID 15914997. Source
- Franzone R, Petrigna L, Signorelli D, Musumeci G (2024). The Relationship between Posture and Muscle Tensive Dysphonia in Teachers: A Systematic Scoping Review. Journal of Functional Morphology and Kinesiology 9(2):60. PMID 38651418. Source
- Lowell SY, Kelley RT, Colton RH, Smith PB, Portnoy JE (2012). Position of the hyoid and larynx in people with muscle tension dysphonia. The Laryngoscope 122(2):370-377. PMID 22252849. Source
- Freedman-Doan A, Pereyra Maldonado L, Lowell SY (2024). Hyolaryngeal Kinematics in Primary Muscle Tension Dysphonia Determined by Ultrasound. Journal of Voice, published online ahead of print. PMID 39232880. Source
- Ruotsalainen JH, Sellman J, Lehto L, Jauhiainen M, Verbeek JH (2007). Interventions for treating functional dysphonia in adults. Cochrane Database of Systematic Reviews (3):CD006373. PMID 17636842. Source
- Rubin AD, Praneetvatakul V, Gherson S, Moyer CA, Sataloff RT (2006). Laryngeal hyperfunction during whispering: reality or myth? Journal of Voice 20(1):121-127. PMID 16503476. Source
- Alves M, Krüger E, Pillay B, van Lierde K, van der Linde J (2019). The Effect of Hydration on Voice Quality in Adults: A Systematic Review. Journal of Voice 33(1):125.e13-125.e28. PMID 29122414. Source
Get started
Ready for the training?
The free FaceFormer app guides you through the basic exercises, counts along and reminds you of your sessions. If you wish, a practice from the practitioner directory can support you.
FaceFormer ZERO + ONE
Both material hardnesses for getting started, day and night. The set for adults.
FaceFormer ZERO
The softer FaceFormer for getting started, for children and for the night.
FaceFormer ZERO Children’s Set
ZERO with hygiene box, plush bag and success book with stamp.
FaceFormer training aims to restore the physiological setting of the basic functions of breathing, swallowing and head balance, with lip closure and the tongue reference position, thereby creating the conditions under which symptoms can improve. It does not replace a medical assessment. You can find practitioners near you in the practitioner directory.
