Voice and Upper Airway Book Reviews

BOOK REVIEWย ๐Ÿ“š

My five top texts:

Voice Work: Art and Science in Changing Voices By Christina Shewell. A perfect combination of art and science when it comes to voice and itโ€™s packed full of practical ideas on improving breath, voice, posture and vocal health.

Speech Pathology Management of Chronic Refractory Cough and related disorders. By Anne Vertigan & Peter Gibson. The chronic cough bible for speech therapists! It has helped me develop my skills and the service I run and really understand the evidence base and theory behind chronic unexplained cough. A must read!

Laryngeal Endoscopy and Voice Therapy. A Clinical Guide. By Sue Jones. This helped me achieve my voice clinic and laryngoscopy competencies but it remains a brilliant guide to return to when updating procedures and ensuring good practice. Itโ€™s also great for the developing voice therapist and students in voice placements.

Psychosocial Perspectives on the Management of Voice Disorders. By Janet Baker. Clinically helpful and evidenced based. The second section is particularly relevant for speech therapists learning how to incorporateย  counselling skills into their voice therapy approaches. Itโ€™s very clear and easy to read and follow. Inspiring for immediate use with patients as you read it. Includes some nice case studies and discussions.

Complete Guide to Respiratory Care in Athletes. Edited by John Dickinson & James Hull. A very detailed look at breathlessness in athletes. Most relevant to me are the excellent sections about exercise induced laryngeal obstruction, dysfunctional breathing patterns, allergic rhinitis in athletes and I learnt a lot more about respiratory system function during exercise. A very helpful read for me as I joined the airways MDT. Helped with MDT patient management and improved my knowledge.

How do speech therapists treat chronic refractory cough?

Speech and Language Therapy is evidence based, effective treatment for chronic refractory cough (medically unexplained persistent coughing for more than 8 weeks).โฃ
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๐๐ฎ๐ญ ๐ฐ๐ก๐š๐ญ ๐๐จ ๐ฐ๐ž ๐๐จ ๐ญ๐จ ๐ก๐ž๐ฅ๐ฉ ๐ฉ๐ž๐จ๐ฉ๐ฅ๐ž ๐ซ๐ž๐ฌ๐จ๐ฅ๐ฏ๐ž ๐ญ๐ก๐ž๐ฌ๐ž ๐ฌ๐จ๐ฆ๐ž๐ญ๐ข๐ฆ๐ž๐ฌ ๐๐ž๐›๐ข๐ฅ๐ข๐ญ๐š๐ญ๐ข๐ง๐  ๐œ๐จ๐ฎ๐ ๐ก ๐ฌ๐ฒ๐ฆ๐ฉ๐ญ๐จ๐ฆ๐ฌ??โฃ
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Initial assessment is very detailed and involves taking a medical, social and psychological history. Laryngoscopy is an examination of the voice box which rules out any laryngeal pathology and is often very reassuring for cough patients. Part of our role is to ensure all medical investigations for cough and medication checks are complete. Assessment will include patient rated outcome measures and symptom frequency and severity ratings. โฃ
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Education is key to improving awareness and motivation for effective treatment. Speech therapy helps facilitate patients to control their cough. โฃ
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Cough control strategies – various techniques for this. Teaching and modelling from SLT and lots of practice.โฃ
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Throat care is vital to optimise hydration and comfort in the upper airway. Advice about acid reflux management, hydration, good inhaler technique, diet, sleep, lifestyle, voice use, posture might be included here.โฃ
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Head and neck tension release – exercises and strategies for improving muscle tension balance in the neck and shoulders. This area of our bodies is prone to holding tension and its very muscular. Tension is common. โฃ
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Voice Therapy techniques for easy, relaxed, resonant voice and optimal use of our instrument, particularly important for the professional voice user who is also coughing.โฃ
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Taking a counselling approach to supporting patients. There is a link between anxiety and cough. Chronic cough can significantly impact on quality of life and cause distress, relationship problems and confidence issues. Even more so now during the Covid 19 pandemic. โฃ
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Taking a multidisciplinary approach to the treatment of chronic cough is gold standard. Physiotherapists are very often involved if there is a breathing pattern disorder or if the patient also has asthma, COPD or bronchiectasis. โฃHaving clinical psychology input is also helpful.

The Video Consultation Checklist

Check the following before you carryout a video consultation
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๐Ÿ”น Everything you will need during the session is within arms reach (water, pens, paper, diagrams, documents open for sharing, equipment, glasses, diary etc).โฃ
๐Ÿ”น Your space is quiet and the risk of disturbance is minimal.โฃ
๐Ÿ”น The WiFi is working.โฃ
๐Ÿ”น Equipment test complete.โฃ
๐Ÿ”น Headset and Mic available. โฃ
๐Ÿ”น Camera is eye level.โฃ
๐Ÿ”น The client has been prepped about video access and tips for optimising their set up and environment (refer to VoiceFit Infographic – download here)โฃ
๐Ÿ”น Your voice is strong and prepped. โฃ
๐Ÿ”น Lighting is adequate and will stay that way throughout. Consider the natural light changing if your consultation is in the evening as the sun sets. โฃ
๐Ÿ”น You are ready and start the video call or enter the waiting room at least five minutes before the start time so you are there when your clients joins you. โฃ

How the Normal Voice Works

 

I often suggest to students new to clinical voice placements to develop and practise a description of how the normal voice works. Itโ€™s an integral part of understanding voice production and empowering the voice patient with knowledge about their own instrument. So hereโ€™s a basic description

The voice box is located in the front of the neck. It is otherwise known as the larynx. We have two vocal cord muscles, just behind the Adamโ€™s apple, which are moved and controlled with the help of different muscles throughout the neck. The power source of voice is breath from the lungs. Think of the lungs being the fuel tank. At rest, your vocal cords are open to allow the air to move freely in and out of the lungs. When you want to speak, the vocal cord muscles are innervated by branches of the vagus cranial nerve; as air flows out from the lungs the vocal cords move, acting like a vibrating valve that chops up the airflow from the lungs into audible pulses that form the sound. The muscles of the larynx adjust the length and tension of the vocal cords to โ€˜fine tuneโ€™ the sound and alter the pitch and tone. The tone of voice may be modulated to indicate feeling and emotion. Varying the pitch of ones voice makes it sound interesting and pleasant to listen to. The articulators (the parts of the vocal tract above the larynx consisting of tongue, palate, cheek, lips, etc.) articulate and filter the sound emanating from the larynx to make speech. The male and female larynx differ in size. The male larynx grows larger and as a result of this the pitch of the voice drops and deepens as the vocal cords become longer and thicker and vibrate together slower. Male vocal cords vibrate an average of 110 cycles per second; female vocal cords 180-220 cycles per second but this will vary greatly between individuals and the type of speech or singing task.

A voice quality will sound โ€œnormalโ€ if the power source, the sound source and the articulators work in balance and efficiently. If one or other or all are disrupted voice may sound abnormal. A clinical case history and visual examination of the voice box is integral for diagnosis and to understand why a voice is not working normally.

Check out this Video and watch how the vocal cords vibrate as you speak and which muscles are involved.

 

How does voice change through the ages?

Letโ€™s think about why voice quality changes as we grow and as we get older.

The larynx and phonatory system changes hugely over the course of a lifetime.โฃ
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At birth the vocal cords are 3mm long and the mucosal covering of the folds is thick and loose. The vocalis muscle fibres are incomplete.โฃ
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In early childhood the layers of vocalis muscle become more differentiated and the histology develops. The whole larynx descends from C1-C4. The complexity of sound a child can produce becomes more sophisticated. Between 5 and 8 years old pitch can extend to a two and a half octave range. Vocal differences between the sexes will begin to occur. โฃ
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In adolescence, the male larynx changes dramaticallyย  due to body growth and hormonal influence. The vocal folds double in length reaching an adult size of 17mm or more. The thyroid cartilage tips forward at an angle creating the Adamโ€™s Apple. Modal pitch drops.โฃ
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The female voice will also deepen from childhood through adolescence due to general body growth.โฃ
The adult larynx reaches mature final histological make up and differentiation of the structural layers at around 16 years old and will sit at a level between C3 and C6.โฃ
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Towards the end of middle age in women, hormonal changes can cause the vocal folds to thicken and stiffen and pitch might be lower. Men are more likely to notice an increase in pitch after middle age as the vocal folds loose some bulk becoming thinner. โฃ
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Into old age as the layers thin and the vocalis muscle can atrophy and thin out, the vocal cords can bow and vibrate differently. Presbylarynx leads to higher, often unstable pitch and a weaker, breather voice. Laryngeal cartilages can also calcify with age and the cricoarytenoid joints can stiffen making it harder to close the vocal cords.โฃ
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For the most part ageing voice changes are gradual and are not seen or heard as abnormal. If it changes someoneโ€™s voice and affects quality of life impacting on every day responsibilities or hobbies then help can be sought from a voice specialist speech therapist. If youโ€™re worried about your voice, first step speak to you GP. Xxโฃ

Professional Voice User Series #5 The Hairdresser

๐˜๐˜ฐ๐˜ค๐˜ข๐˜ญ ๐˜ฅ๐˜ฆ๐˜ฎ๐˜ข๐˜ฏ๐˜ฅ ๐˜ง๐˜ฐ๐˜ณ ๐˜ฉ๐˜ข๐˜ช๐˜ณ๐˜ฅ๐˜ณ๐˜ฆ๐˜ด๐˜ด๐˜ฆ๐˜ณ๐˜ด, ๐˜ฃ๐˜ข๐˜ณ๐˜ฃ๐˜ฆ๐˜ณ๐˜ด, ๐˜ฉ๐˜ข๐˜ช๐˜ณ๐˜ด๐˜ต๐˜บ๐˜ญ๐˜ช๐˜ด๐˜ต๐˜ด, ๐˜ธ๐˜ช๐˜ญ๐˜ญ ๐˜ท๐˜ข๐˜ณ๐˜บ ๐˜ฅ๐˜ฆ๐˜ฑ๐˜ฆ๐˜ฏ๐˜ฅ๐˜ช๐˜ฏ๐˜จ ๐˜ฐ๐˜ฏ ๐˜ง๐˜ข๐˜ค๐˜ต๐˜ฐ๐˜ณ๐˜ด ๐˜ด๐˜ถ๐˜ค๐˜ฉ ๐˜ข๐˜ด ๐˜ธ๐˜ฐ๐˜ณ๐˜ฌ ๐˜ฑ๐˜ญ๐˜ข๐˜ค๐˜ฆ, ๐˜ฑ๐˜ฆ๐˜ณ๐˜ด๐˜ฐ๐˜ฏ๐˜ข๐˜ญ๐˜ช๐˜ต๐˜บ ๐˜ข๐˜ฏ๐˜ฅ ๐˜ต๐˜ฉ๐˜ฆ ๐˜ค๐˜ญ๐˜ช๐˜ฆ๐˜ฏ๐˜ต ๐˜บ๐˜ฐ๐˜ถ ๐˜ข๐˜ณ๐˜ฆ ๐˜ธ๐˜ฐ๐˜ณ๐˜ฌ๐˜ช๐˜ฏ๐˜จ ๐˜ธ๐˜ช๐˜ต๐˜ฉ ๐˜ฉ๐˜ฐ๐˜ธ๐˜ฆ๐˜ท๐˜ฆ๐˜ณ ๐˜ต๐˜ฉ๐˜ฆ๐˜ณ๐˜ฆ ๐˜ข๐˜ณ๐˜ฆ ๐˜ด๐˜ฐ๐˜ฎ๐˜ฆ ๐˜ท๐˜ฆ๐˜ณ๐˜บ ๐˜ด๐˜ฑ๐˜ฆ๐˜ค๐˜ช๐˜ง๐˜ช๐˜ค ๐˜ค๐˜ฉ๐˜ข๐˜ญ๐˜ญ๐˜ฆ๐˜ฏ๐˜จ๐˜ฆ๐˜ด ๐˜ข๐˜ฏ๐˜ฅ ๐˜ ๐˜ฉ๐˜ข๐˜ท๐˜ฆ ๐˜ฉ๐˜ข๐˜ฅ ๐˜ต๐˜ฐ๐˜ฐ ๐˜ฎ๐˜ข๐˜ฏ๐˜บ ๐˜ท๐˜ฐ๐˜ช๐˜ค๐˜ฆ ๐˜ฅ๐˜ช๐˜ด๐˜ฐ๐˜ณ๐˜ฅ๐˜ฆ๐˜ณ๐˜ฆ๐˜ฅ ๐˜ฑ๐˜ข๐˜ต๐˜ช๐˜ฆ๐˜ฏ๐˜ต๐˜ด ๐˜ช๐˜ฏ ๐˜ต๐˜ฉ๐˜ช๐˜ด ๐˜ญ๐˜ช๐˜ฏ๐˜ฆ ๐˜ฐ๐˜ง ๐˜ธ๐˜ฐ๐˜ณ๐˜ฌ ๐˜ต๐˜ฐ ๐˜ช๐˜จ๐˜ฏ๐˜ฐ๐˜ณ๐˜ฆ. ๐˜ˆ๐˜ฏ๐˜ฅ ๐˜ฏ๐˜ฐ๐˜ธ ๐˜ง๐˜ข๐˜ค๐˜ฆ ๐˜ฎ๐˜ข๐˜ด๐˜ฌ๐˜ด ๐˜ข๐˜ฏ๐˜ฅ ๐˜ด๐˜ฉ๐˜ช๐˜ฆ๐˜ญ๐˜ฅ๐˜ด ๐˜ข๐˜ณ๐˜ฆ ๐˜ข๐˜ฅ๐˜ฅ๐˜ช๐˜ฏ๐˜จ ๐˜ข ๐˜ง๐˜ถ๐˜ณ๐˜ต๐˜ฉ๐˜ฆ๐˜ณ ๐˜ค๐˜ฉ๐˜ข๐˜ญ๐˜ญ๐˜ฆ๐˜ฏ๐˜จ๐˜ฆ. โฃ
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Here are my top voice tips:โฃ
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1. Itโ€™s always lovely to chat away to a client and itโ€™s important, however..! Sometimes allow the client to take the lead with conversation. You canโ€™t control how much they want to chat but you can reduce your vocal initiations. You donโ€™t have to stop asking any questions but limit it slightly to avoid vocal fatigue especially if youโ€™re prone to it. โฃ
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2. Allow yourself some voice naps e.g during break times, whilst washing or drying hair.โฃ
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3. Avoid talking at all over the noise of a hairdryer or loud music. โฃ
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4. As often as possible look up and into the mirror or directly at a client when talking to them.โฃ
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5. Try not to raise your volume or strain to talk. Speak slowly and clearly instead. Slightly over articulate. This will help your clients who arenโ€™t looking at you to hear you. If they ask you to repeat use your normal volume again. โฃ
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6. Drink 300mls of water based fluid between each client. Xx

Top tips for improving your motivation to stay hydrated

๐—ช๐ข๐ญ๐ก ๐›๐ฎ๐ฌ๐ฒ ๐ฅ๐ข๐ฏ๐ž๐ฌ ๐ก๐จ๐ฐ ๐œ๐š๐ง ๐ฐ๐ž ๐ซ๐ž๐ฆ๐ž๐ฆ๐›๐ž๐ซ ๐ญ๐จ ๐๐ซ๐ข๐ง๐ค ๐ž๐ง๐จ๐ฎ๐ ๐ก ๐ฐ๐š๐ญ๐ž๐ซ ๐ญ๐จ ๐ค๐ž๐ž๐ฉ ๐จ๐ฎ๐ซ ๐›๐จ๐๐ข๐ž๐ฌ ๐š๐ง๐ ๐ญ๐ก๐ซ๐จ๐š๐ญ๐ฌ ๐ฐ๐ž๐ฅ๐ฅ ๐ก๐ฒ๐๐ซ๐š๐ญ๐ž๐ ๐š๐ง๐ ๐ญ๐ก๐จ๐ฌ๐ž ๐ญ๐ž๐ž๐ง๐ฒ ๐ญ๐ข๐ง๐ฒ ๐ฏ๐จ๐œ๐š๐ฅ ๐Ÿ๐จ๐ฅ๐๐ฌ ๐ฅ๐ฎ๐›๐ซ๐ข๐œ๐š๐ญ๐ž๐? โฃ
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My top tips for improving your motivation to drink more water are:โฃ
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๐Ÿ’งย You may have to trial a few but find the best water bottle that suits you, should be light and easy to carry around, allow you to drink quickly and efficiently, regularly throughout the day. My favourite is the @hydratem8 tracker bottle. โฃ
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๐Ÿ’งVisual reminders are very helpful. A good old post-itย note in a strategic place should do the job but for a higher tech reminder I LOVE the @thirstyulla reminder device – one size fits all water bottles. โฃ
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๐Ÿ’งย If youโ€™re on your phone or a tablet regularly set alarm reminders to take a drink of water. Or I LOVE the @plantnanny_us app. Itโ€™s very child friendly too if you want to involve the family or if you are supporting a child to drink more. โฃ

๐Ÿ’ง Finally, make water visible so that youโ€™ll see it and be naturally reminded to take regular sips. At the start of the day fill enough glasses or bottles to cover your desired daily intake – a target helps with motivationย โฃand place them around the house or office where youโ€™ll see them.
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There is abundant evidence that good hydration improves vocal stamina and endurance and reduces the risk of vocal injury. Forgive yourself if you have a โ€˜badโ€™ water day but plan for how to improve the next day. Xx

Professional Voice User Series #4 The Gym Instructor

๐˜Ž๐˜บ๐˜ฎ ๐˜ข๐˜ฏ๐˜ฅ ๐˜๐˜ช๐˜ต๐˜ฏ๐˜ฆ๐˜ด๐˜ด ๐˜๐˜ฏ๐˜ด๐˜ต๐˜ณ๐˜ถ๐˜ค๐˜ต๐˜ฐ๐˜ณ๐˜ด ๐˜ข๐˜ณ๐˜ฆ ๐˜ฑ๐˜ณ๐˜ฐ๐˜ง๐˜ฆ๐˜ด๐˜ด๐˜ช๐˜ฐ๐˜ฏ๐˜ข๐˜ญ ๐˜ท๐˜ฐ๐˜ช๐˜ค๐˜ฆ ๐˜ถ๐˜ด๐˜ฆ๐˜ณ๐˜ด. โฃ
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Recent research indicates that most instructors think of themselves as occupational voice users but the majority do not have any previous voice training. Dehydration and hoarse voice seem to be common problems in the industry. โฃ
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It is of upmost importance, to effectively carry out their job and teach and empower clients, that fitness instructors follow some voice care and training guidance as part of self care. They are vocal athletes and without their voices could not effectively do their job. โฃ
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My ๐ญ๐จ๐ฉ ๐Ÿ‘ ๐ฏ๐จ๐ข๐œ๐ž ๐ญ๐ข๐ฉ๐ฌ for fitness class instructors are:โฃ
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1. ๐Ž๐ฉ๐ญ๐ข๐ฆ๐ข๐ฌ๐ž ๐ก๐ฒ๐๐ซ๐š๐ญ๐ข๐จ๐ง. Consider your age, weight and level of physical and vocal activity and make sure you achieve overall good systemic hydration and also surface hydration for your voice. Have your own familiar and distinctive water bottle for motivation. Invest in a water tracker. Iโ€™d recommend a Thirtsy Ulla.
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2. ๐”๐ฌ๐ž ๐ ๐จ๐จ๐ ๐ช๐ฎ๐š๐ฅ๐ข๐ญ๐ฒ ๐š๐ฆ๐ฉ๐ฅ๐ข๐Ÿ๐ข๐œ๐š๐ญ๐ข๐จ๐ง when teaching classes. Do your research for the best option of headset for you. And practice helps too. The main reason for having a mic is to reduce vocal strain so speaking at a normal volume and slowing your speech rate is vital, but this can feel strange at first. โฃ
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3. Consider your voice like any other muscle in the bode. Before, during and after a work out you need to ๐ฐ๐š๐ซ๐ฆ ๐ฎ๐ฉ, ๐ฆ๐จ๐ง๐ข๐ญ๐จ๐ซ ๐ฆ๐ฎ๐ฌ๐œ๐ฅ๐ž ๐ฉ๐ž๐ซ๐Ÿ๐จ๐ซ๐ฆ๐š๐ง๐œ๐ž ๐š๐ง๐ ๐ญ๐ก๐ž๐ง ๐œ๐จ๐จ๐ฅ ๐๐จ๐ฐ๐ง. Have a voice routine just like you do and your teach during your classes for other muscles. It will only take a few minutes out of your day and will make all the difference to your voice.โฃ

Here’s an extra tip that wasn’t in my original blog post…follow Sara Davis @voxfit_ on Instagram and check out her podcast episode as a guest on ‘Off the Bike’ with Crystal Bonham Episode # 4. Both are packed full of useful voice care tips. Sara is a voice specialist speech therapist, passionate advocate for the professional voice and a gym class instructor. She has done research on the need for voice training for fitness instructors.

What is Exercise Induced Laryngeal Obstruction (EILO)?

โฃExercise Induced Laryngeal Obstruction is a breathing problem that affects people during peak exercise. โฃ
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It is inappropriate narrowing of the upper airway at the level of the vocal cords and/or supraglottis (above the vocal cords). โฃ
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This makes it difficult to get air into the lungs and can cause noisy laboured inhalation breathing, tightness in the throat, a feeling of suffocation. Onset is rapid and recovery is usually rapid once exercise is ceased. โฃ
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It can be miss-diagnosed as exercise induced asthma and unsuccessfully treated with inhaled medication. It can co-exist with asthma. It can feel very frightening but unlike asthma it is not dangerous. It is not reflective of a personโ€™s fitness level and can occur in the most highly trained athletes. It often occurs in adolescent or young adult athletes who are highly competitive or driven to perfection or might have underlying performance anxieties. โฃ
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It is diagnosed by examining a personโ€™s larynx during continuous exercise. Using a laryngoscope through the nose that is attached to a camera and then to a helmet to stay in place as you exercise. The movements of the vocal cords can then be examined. In EILO they will be seen to move closer together during inhalation instead of opening widely to let air in.โฃ
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Part 2 of this EILO series will focus on treatments.โฃ Donโ€™t hesitate to ask me ANY questions x

Professional Voice User Series. #3 The Recruitment Consultant

The ๐‘๐ž๐œ๐ซ๐ฎ๐ข๐ญ๐ฆ๐ž๐ง๐ญ ๐‚๐จ๐ง๐ฌ๐ฎ๐ฅ๐ญ๐š๐ง๐ญโ€™s voice is in high demand. โฃ

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This is the 3rd post in my professional voice user series. I have an amazing friend at the top of her game in recruitment. Iโ€™ve witnessed her in action and her vocal load is high. A lot of phone calls and meetings. The professional relationships she builds all rely on her voice for communication. Both with clients and individual job applicants. She is supporting candidates and managing stressful situations and her own team. โฃ
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My 5 top voice tips for anyone working in recruitment are:
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1. Use a good quality ๐ก๐ž๐š๐๐ฌ๐ž๐ญ and ๐ฆ๐ข๐œ๐ซ๐จ๐ฉ๐ก๐จ๐ง๐ž for optimal communication and minimal distractions.

2. ๐Œ๐ข๐ง๐ข๐ฆ๐ข๐ฌ๐ž ๐›๐š๐œ๐ค๐ ๐ซ๐จ๐ฎ๐ง๐ ๐ง๐จ๐ข๐ฌ๐ž in your office or wherever youโ€™re working so you arenโ€™t tempted to use too much volume. Speak at a quiet volume. โฃ

3. Take regular short breaks just to move around and have a good ๐ฌ๐ญ๐ซ๐ž๐ญ๐œ๐ก, wander round the office, do a few minutes of yoga at lunchtime. If you have wireless headphones you can stand up or move whilst on calls. โฃ
4. ๐’๐ฉ๐ž๐š๐ค ๐ฌ๐ฅ๐จ๐ฐ๐ฅ๐ฒ and ๐ฉ๐š๐ฎ๐ฌ๐ž for emphasis. Pause before each verbal response to train yourself not to speak too quickly. Itโ€™s important you use optimal breath so take a top up breath in each time you pause to avoid vocal strain.โฃ
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5. Drink at least 2 litres of ๐ฐ๐š๐ญ๐ž๐ซ during the working day. Get yourself a fancy reusable bottle that youโ€™d like to have out on your desk and sip regularly. Itโ€™s got to be in your sight or you might forget. Pop a ๐ƒ๐‘๐ˆ๐๐Š post it note on your computer as a reminder.โฃ