Jan. 28, 2025 – As he takes the microphone for his confirmation hearing before the U.S. Senate Committee on Finance, you might notice something about Robert F. Kennedy Jr., the president’s nominee to lead the Department of Health and Human Services: He speaks with a shaky voice.
The cause: spasmodic dysphonia, a neurological condition that disrupts the brain’s ability to coordinate muscle movement during speech. Kennedy, 71, told the Los Angeles Times he first noticed his voice changing at age 42. “I feel sorry for the people who have to listen to me,” he told the Times.
Spasmodic dysphonia is just one of many conditions that can change the way someone talks. Anything that injures your vocal folds – or affects the tiny muscles around them – can alter your voice.
“Voice changes happen for many reasons,” said Christina Kang Rosow, MM, MS, CCC-SLP, a medical speech-language pathologist and voice teacher based in Florida. “There are anatomical or neurological reasons, or even just catching a virus that happens to go the wrong way.”
More and more people are finding this out. A study from Harvard Medical School found that 12.2% of Americans reported a voice problem in 2022 – an increase from 7.6% a decade prior.
You might notice temporary vocal changes for a week or so after a cold, or for a few days after screaming at a concert. Don’t ignore voice changes that last longer.
“If someone's been hoarse persistently for longer than two weeks without an obvious cause, like a recent cold, they need an examination of their throat by an ear, nose, and throat doctor to find out what's going on, and, most importantly, to possibly detect a cancer early on,” said Clark Rosen, MD, director of the Voice and Swallowing Center and chief of the Division of Laryngology at the University of California-San Francisco. Sometimes, hoarseness is the only sign of laryngeal cancer.
Here are some of the top reasons people have trouble speaking, how these problems are treated, and how to cope with a voice that doesn’t sound like yours.
Vocal Damage
What happens: When you speak, your vocal folds collide and vibrate 100 times or more per second to produce sound. When you talk too much (or yell), the collisions and vibrations can be too strong, causing damage to the tissues.
“The impact stress on the vocal folds can create small areas of swelling and cause little sores to form,” said Adam Lloyd, SLP-D, CCC-SLP, MM, PAVA-RV, deputy chief of speech pathology and assistant professor of otolaryngology at the University of Miami Miller School of Medicine. “We call that phonotrauma, meaning sound trauma.”
Phonotrauma is a common cause of voice problems in people who use their voice a lot in their work.
“The voice has become more and more important to our economy and our occupations over the last 20 to 50 years, because there are less people doing manual labor, and there are a lot more people who are working with their voice, be it a schoolteacher or someone who works in sales or technical support,” Rosen said.
How it’s treated: First, a laryngologist will perform a videostroboscopy, using a tiny camera to examine your vocal folds for lesions.
Your treatment plan will depend on what they see. Voice rest may be one step. Use text messaging and email when possible and be concise when you do speak.
“We may also recommend exercises that decrease the impact stress of how we're using our voice: speaking easier, speaking a little softer, and trying to have what we call better vocal hygiene,” Lloyd said.
Rosen often tells people to “walk before you talk.” For example, instead of yelling to your family member upstairs, walk up and say your message quietly.
Some generally healthy habits – like drinking plenty of water and getting adequate sleep – also protect your voice.
“If your vocal folds are dry, they don't vibrate well,” Rosow said. “And then people want to have a better voice, so they push themselves, and it's like a domino effect.”
When you are sick with a respiratory virus that inflames your vocal folds, consider skipping loud events and celebrations. If you go, don’t talk (or cheer) loudly. When your vocal folds are already swollen, you can easily injure their delicate lining, Rosen said.
“We see a lot of people develop very serious voice problems when they're sick and they still go out and use their voice extensively,” he said. Some people develop vocal fold calluses that require surgery.
For work, Rosow recommends wearing noise-canceling headphones. They help you overcome the Lombard effect – your brain’s reflex to push your voice to be louder than your environment.
Muscle Tension
What happens: Sometimes, the problem isn’t in your vocal folds – it’s around them.
“Probably 35% to 40% of the patients with symptoms that we see in our voice clinic for evaluation don't have an anatomical abnormality on their vocal folds, but that doesn't mean that they don't have a voice problem,” Lloyd said. “They may have a muscle function problem or a sensory problem.”
Your vocal folds don’t work alone. A network of muscles moves your larynx to help you produce sound, and muscles in your neck help, too. An imbalance between airflow through the vocal folds and muscle tension in the neck and larynx, known as muscle tension dysphonia, can cause a strained or hoarse quality.
“Just like we can develop muscle tension in other parts of our bodies and be sore from sitting a certain way or from holding our shoulders in a certain way, we can create muscle tension patterns in the neck, which can contribute to a strained feeling or feeling of increased effort during speaking,” Lloyd said.
Rosow sometimes sees vocal problems in people who work with poor posture and a crooked neck.
“Ever since the pandemic, I'm seeing increased incidence of muscular-based voice disorders, and some of them are even called Zoom voice disorders because by having a lot of Zoom meetings, some people adapted a hyperfunction, an overworking habit, and that gave them serious vocal fatigue,” she said.
What to do: A speech-language pathologist can teach you exercises to balance muscle tension and airflow. You might need to actively relax certain muscles.
“I'm a big fan of what's called laryngeal manual therapy, where we do massage techniques to the neck to try to elicit a relaxation response of the muscles,” Lloyd said. “We also do techniques like mindfulness and progressive relaxation.”
It’s like working out, just for your laryngeal muscles instead of your biceps.
“Sometimes it takes time and effort in order to solve the problem,” Lloyd said. “That might require multiple sessions of voice therapy and some lifestyle modifications.”
Reflux
What happens: This isn’t heartburn, or gastroesophageal reflux (GERD), which happens when stomach acid creeps up into your esophagus. With laryngopharyngeal reflux, acid reaches your vocal folds and back of the throat, causing irritation.
People with laryngopharyngeal reflux often have a hoarse voice along with swallowing problems and mucus in their throat.
“One of the reasons why this is such a commonly misdiagnosed and common problem is that not all patients that have laryngopharyngeal reflux disease have heartburn, which is kind of the classic feature of GERD,” Rosen said. “We don't know exactly why that is, but we do know it's very, very common.”
What to do: Many people with laryngopharyngeal reflux improve by changing their diet and lifestyle habits, he said.
He often recommends avoiding late-night meals and foods that aggravate reflux: alcohol, mint, chocolate, and anything spicy or tomato-based.
Some people find relief from alginate supplements like Reflux Gourmet Rescue, Rosen said. The theory is that this seaweed-based thickening agent forms a temporary barrier in the stomach to keep gastric acid from traveling up the throat.
Neurological Disorders
What happens: The spasmodic dysphonia that affects Kennedy, also known as laryngeal dystonia, is a neurologic condition specific to the voice. It affects the brain's ability to smoothly use the muscles of the voice box. Muscles spasm while the person is talking.
“The most common version is the vocal cords basically squeeze too tight, and so the voice is very strained and hard to get out,” Rosen said.
Other neurological disorders can also have vocal side effects. For example, the most common neurological disorder, essential tremor, is known for causing shaky hands, but it can also cause a shaky, weak voice.
Many people with Parkinson’s disease speak softly, slur words, or stutter. Sometimes, vocal changes are the first sign of the disease, Rosen said.
About a quarter of people who survive a stroke have impaired speech. Damage to the brain, nerves, and muscles can all make it hard to talk.
What to do: Spasmodic dysphonia can be improved with Botox shots in the muscles of the vocal folds every three to four months, Rosen said. Botox curbs nerve signals to the affected muscles.
When essential tremor causes vocal changes, speech therapy and Botox shots into affected muscles can help, Rosen said.
In Parkinson’s, medical treatment for the disease is important, along with voice therapy from a speech-language pathologist who specializes in helping people with voice disorders.
“These therapy techniques focus on reestablishing an effort level that one would need in order to sound clearer and louder,” Lloyd said. “It’s sort of like rebalancing how you perceive your own effort level and voice so that you can get back up to what people perceive as more of a normal level of loudness.”
After a stroke, speech therapy can help some people communicate again.
Paul Strikwerda, a Vermont-based voiceover artist, woke up from a stroke seven years ago and found that his voice, once expressive and clear, sounded flat and robotic. He also had a hard time with saying words correctly. With “facial gymnastics” exercises, breathing techniques, and lots of practice, his speech therapist helped him progress from speaking one-syllable words to full monologues.
“All in all, it took me a year of weekly therapy sessions (including lots of workouts for my brain) to get back to some semblance of my new self,” he said.
Still, he struggled with hoarseness. His ear, nose, and throat doctor discovered scarring on one of the muscular bands that make up the vocal folds, which might have been caused by a breathing tube inserted to save his life during his stroke.
He rested his voice by going multiple days without speaking and auditioning only for short-form voiceover work.
How to Cope With a Changing Voice
No matter the cause, a change in the voice can be a real pain. Sometimes, it can literally hurt to speak. Voice problems can also disrupt your life.
“When you have a problem with your voice, it slows everything down,” Lloyd said. “It makes the simplest task of communicating, ordering food, or doing a business transaction much more complicated.”
You might even feel judged.
“People will often say that people look at them differently or treat them differently when they have a voice that differs from what's considered to be normal,” Lloyd said.
These challenges can take an emotional toll.
“We routinely work with our mental health colleagues, because anybody who has a communication problem is at risk for having an emotional response as well,” Lloyd said.
For Strikwerda, losing his voice was frustrating, especially as a professional communicator.
“I felt like a soccer player who had lost the use of his legs,” he said. “I went through periods of despair, feeling worthless, and unsure of what the future would hold.”
Fortunately, that didn’t last forever. Now, Strikwerda focuses on gratitude for his recovery and his care team.
“Working with a neuropsychologist, I learned how to be soft on myself, be patient, and to celebrate progress, no matter how small,” he said. “I went through a period of mourning, saying goodbye to the old Paul, and inventing the new one, almost from scratch.”
