The performer's voice [Second edition.] 9781597568821, 1597568821

Table of contents :
Contents
Preface
Contributors
Part I Overview
Chapter 1 Introduction
Chapter 2 Music and the Brain
Chapter 3 History of Professional Voice Care
Chapter 4 Anatomy of the Vocal Mechanism:Structure of the Voice
Chapter 5 Physiology of Voice Production: How Does the Voice Work?
Chapter 6 Normal Voice Maturation:Hormones and Age
Chapter 7 The Pediatric Voice
Chapter 8 The Aging Voice
Chapter 9 Artistic Vocal Styles and Techniques
Part II Diagnostics
Chapter 10 Case History, Interview, and Voice Handicap Assessment
Chapter 11 Examination of the Singer
Chapter 12 Aerodynamic and Acoustic Voice Measurements
Chapter 13 Perceptual Attributes and Assessment of the Singer’s Voice
Chapter 14 Reflux and the Performer’s Voice
Chapter 15 Acute Assessment of Professional Singers
Part III Medical Treatments
Chapter 16 Medications: The Positive and Negative Impact on Voice
Chapter 17 Complementary and Alternative Medications and Techniques
Chapter 18 Vocal Emergencies
Chapter 19 Medical Problems in Performers
Part IV Behavioral Treatments
Chapter 20 Training and Teaching the Singer
Chapter 21 Voice Therapy for Benign Vocal Fold Lesions and Scarin Singers and Actors
Chapter 22 The Alexander Technique and Other Strategies for Dealing With Vocal Tension
Chapter 23 Treatment of Injured Singers and Professional Speakers: The Singer/Actor, Singer/Dancer,and Singer/Musician
Chapter 24 Performance Anxiety: Identification, Assessment, and Treatment
Part V When Surgical Treatment Is Necessary
Chapter 25 Surgical Anatomy, Planning, and Consent
Chapter 26 Microlaryngoscopic Procedures and Operations
Chapter 27 Office-Based Procedures in Performers and Other Vocal Professionals
Chapter 28 Surgery (Nonlaryngeal) for the Professional Vocalist
Chapter 29 Postoperative Voice Care of the Singer
Part VI Building a Professional Voice Practice
Chapter 30 The Professional Voice Practice
Chapter 31 Medical-Legal Implications of Professional Voice Care
Appendix A Vocal Hygiene
Glossary
Index

Citation preview

e

Pe r f or me r ' s Voi c e SECOND EDITION

Mi c ha e l S . Be nni ng e r oma sMur r y Mi c ha e l M. J ohnsI I I

T he P erformer’s Voice Second Edition

T he P erformer’s Voice Second Edition

Michael S. Benninger, MD, FACS Thomas Murry, PhD Michael M. Johns III, MD

5521 Ruffin Road San Diego, CA 92123 e-mail: [email protected] Website: http://www.pluralpublishing.com

Copyright © by Plural Publishing, Inc. 2016 Typeset in 10/13 Garamond by Flanagan’s Publishing Services, Inc. Printed in Korea by Four Colour Print Group. All rights, including that of translation, reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, recording, or otherwise, including photocopying, recording, taping, Web distribution, or information storage and retrieval systems without the prior written consent of the publisher. For permission to use material from this text, contact us by Telephone:  (866) 758-7251 Fax:  (888) 758-7255 e-mail: [email protected] Every attempt has been made to contact the copyright holders for material originally printed in another source. If any have been inadvertently overlooked, the publishers will gladly make the necessary arrangements at the first opportunity. NOTICE TO THE READER Care has been taken to confirm the accuracy of the indications, procedures, drug dosages, and diagnosis and remediation protocols presented in this book and to ensure that they conform to the practices of the general medical and health services communities. However, the authors, editors, and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, expressed or implied, with respect to the currency, completeness, or accuracy of the contents of the publication. The diagnostic and remediation protocols and the medications described do not necessarily have specific approval by the Food and Drug administration for use in the disorders and/or diseases and dosages for which they are recommended. Application of this information in a particular situation remains the professional responsibility of the practitioner. Because standards of practice and usage change, it is the responsibility of the practitioner to keep abreast of revised recommendations, dosages, and procedures. Library of Congress Cataloging-in-Publication Data The performer’s voice / [edited by] Michael S. Benninger, Thomas Murry, Michael M. Johns, III. -- Second edition. p. ; cm. Includes bibliographical references and index. ISBN 978-1-59756-543-1 (alk. paper) — ISBN 1-59756-543-1 (alk. paper) I. Benninger, Michael S., editor. II. Murry, Thomas, 1943- , editor. III. Johns, Michael M., III., editor. [DNLM: 1. Voice Disorders — therapy. 2. Voice — physiology. 3. Voice Disorders — diagnosis. 4. Voice Training. WV 500] RF511.S55 616.85'5 — dc23 2015008571

Contents Preface vii Contributors ix

Part I.  Overview

1

1. Introduction Michael S. Benninger and Thomas Murry

3

2. Music and the Brain Iva Fattorini, Neil Cherian, and Lisa M. Gallagher

7

3. History of Professional Voice Care Gayle E. Woodson

23

4. Anatomy of the Vocal Mechanism: Structure of the Voice Nicolas E. Maragos

31

5. Physiology of Voice Production: How Does the Voice Work? Jack Jiang

39

6. Normal Voice Maturation: Hormones and Age Jean Abitbol

53

7. The Pediatric Voice Gillian R. Diercks and Christopher J. Hartnick

73

8. The Aging Voice Chad Whited, Jarrod Keeler, Leda Scearce, and Seth Cohen

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9. Artistic Vocal Styles and Techniques Sharon L. Radionoff

Part II.  Diagnostics

103

123

10. Case History, Interview, and Voice Handicap Assessment Thomas Murry and Michael S. Benninger

125

11. Examination of the Singer Peak Woo

143

12. Aerodynamic and Acoustic Voice Measurements Philippe H. DeJonckere

165

13. Perceptual Attributes and Assessment of the Singer’s Voice Rahul Shrivastav and Judith M. Wingate

179

14. Reflux and the Performer’s Voice Albert L. Merati

193

15. Acute Assessment of Professional Singers Josef Schlömicher-Thier and Matthias Weikert

209

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vi The performer’s VOICE

Part III.  Medical Treatments 16. Medications:  The Positive and Negative Impact on Voice Kelsey Stamnes, Tanya K. Meyer, David M. Alessi, and Audrey Crummey 17. Complementary and Alternative Medications and Techniques Michael D. Seidman 18. Vocal Emergencies Joseph P. Bradley and Adam M. Klein 19. Medical Problems in Performers Laura H. Swibel Rosenthal

223 225 237 255 265

Part IV.  Behavioral Treatments

277

20. Training and Teaching the Singer William D. Riley and Linda M. Carroll

279

21. Voice Therapy for Benign Vocal Fold Lesions and Scar in Singers and Actors Mara Behlau and Thomas Murry 22. The Alexander Technique and Other Strategies for Dealing With Vocal Tension Janet Madelle Feindel 23. Treatment of Injured Singers and Professional Speakers:  The Singer/Actor, Singer/Dancer, and Singer/Musician Jeannette L. LoVetri 24. Performance Anxiety:  Identification, Assessment, and Treatment Philip J. Lanzisera

299

Part V. When Surgical Treatment Is Necessary 25. Surgical Anatomy, Planning, and Consent Michael S. Benninger 26. Microlaryngoscopic Procedures and Operations Seth H. Dailey and Charles N. Ford 27. Office-Based Procedures in Performers and Other Vocal Professionals Paul C. Bryson 28. Surgery (Nonlaryngeal) for the Professional Vocalist Glendon M. Gardner and William G. Young 29. Postoperative Voice Care of the Singer Robert H. Ossoff and Thomas F. Cleveland

Part VI.  Building a Professional Voice Practice 30. The Professional Voice Practice Robert T. Sataloff and Claudio F. Milstein 31. Medical-Legal Implications of Professional Voice Care Robert T. Sataloff and Michael S. Benninger

315 329

341

355 357 367 379 385 397

407 409 421

Appendix A.  Vocal Hygiene 427 Glossary 429 Index 441

P reface

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his second edition of The Performer’s Voice follows the highly successful first edition published 5 years ago. The original editors have added Dr Michael Johns, who brings a new perspective to this edition. The Performer’s Voice, Second Edition brings together dedicated professionals who treat performers, educate performers, and conduct groundbreaking research on the elite voices of performers. Otolaryngologists, speech-language pathologists, psychologists, singing voice specialists, singing teachers, and performers have contributed their knowledge and offered insights on the newest approaches to the management of the voice professional. In this book, the focus is primarily on the singer and actor; however, other performers are included  —  voiceover artists, dancer/singers, and instrumentalist/singers, to name a few. Each type of performer brings specific issues to the treatment team and requires special attention; specific team members have joined this edition to offer unique solutions to all those who perform, regardless of the types of performances. This book identifies these individuals, presents reports on cases with special needs, and offers myriad solutions designed to preserve the voice and prevent further damage. All of the contributors to this volume have shown a dedication to the care of the performer through their academic training, research interests and experience, and clinical and/or performance backgrounds. Most of the contributors have been on stage as a performer at some point in their lives and bring that performance history to their specialty. The contributors range from current-day performers to choral conductors to past rock and roll musicians. In this edition, we have also added a number of additional chapters to address the expansion of interest in professional voice care. The book is divided into 6 sections. Part I presents an overview of the world of performance artists — how music influences brain development, a

history of professional voice care, who are performing artists, and why they are important. In addition, this section presents short reviews of the vocal anatomy and physiology, as well as the effects of age and vocal styles. Identifying and diagnosing singers’ voice problems follows in Part II. Problems that require medical care, voice training, or adaptation to the performance world are described. Part III describes pharmacologic treatments for the performer. The information in this section is particularly important for singers as many medications may have negative side effects that alter the voice temporarily despite their beneficial effects. There is also a discussion of nonlaryngeal medical problems and how they may impact and influence the voice. Part IV considers behavioral and nonsurgical treatments for the performer. In this section, speech pathologists and singing voice specialists offer a broad range of treatment options for the performer, both for the acute and long-term care of the singer. Part V describes surgical considerations for the performer. These chapters are specific to the performer’s voice. Types of surgery, when to do it, and how to avoid damage to the vocal mechanism are all considered in these chapters. There is a discussion of the evolution of voice surgical care with the growth of office-based procedures. Part VI addresses the needs and training involved in building a professional voice practice. Professional singers are not the most common patients seen by the speech-language pathologist, the psychologist, or the otolaryngologist. Thus, in this section, important guidelines are provided to direct individual practitioners on how to build and develop their practices to accommodate performers and medical-legal implications of a vibrant performing voice practice. In summary, The Performer’s Voice, Second Edition is a comprehensive book for those who treat the

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performer and for those who perform. The information brought to this volume by those who have cared for performers during their careers is an invaluable reference for everyone who cares for singers and other performers. The updates and new chapters

expand the breadth of the discussion of performers’ voice care and introduce new innovations and technology that are integral to a contemporary performing voice practice.

Contributors Jean Abitbol, MD Chief Ear, Nose, & Throat (E.N.T.) Clinic Université Paris Diderot Paris, France Chapter 6 David M. Alessi, MD, FACS Assistant Clinical Professor University of California, Los Angeles Former Chief, Division of Otolaryngology Cedars Sinai Medical Center Los Angeles, California Chapter 16 Mara Behlau, PhD Professor Universidade Federal de São Paulo Director Centro de Estudos da Voz São Paulo, Brazil Chapter 21 Michael S. Benninger, MD, FACS Chairman Head and Neck Institute at The Cleveland Clinic Professor of Surgery Cleveland Clinic Lerner College of Medicine Case Western Reserve University Cleveland, Ohio Chapters 1, 10, 25, and 31 Joseph P. Bradley, MD Assistant Professor Washington University Voice & Airway Center Department of Otolaryngology-Head and Neck Surgery Washington University in St. Louis School of Medicine St. Louis, Missouri Chapter 18

Paul C. Bryson, MD Director Cleveland Clinic Voice Center Head Section of Laryngology Cleveland Clinic Head and Neck Institute Cleveland, Ohio Chapter 27 Linda M. Carroll, PhD, CCC-SLP Private Practice New York, New York Senior Voice Scientist, The Children’s Hospital of Philadelphia Philadelphia, Pennsylvania Voice Researcher, Montefiore Medical Center Bronx, New York Chapter 20 Neil Cherian, MD Staff Neurologist Cleveland Clinic–Neurological Center for Pain Cleveland, Ohio Chapter 2 Thomas F. Cleveland, PhD Director Singing, Arts and Sciences Department of Otolaryngology Vanderbilt University Medical Center Nashville, Tennessee Chapter 29 Seth Cohen, MD, MPH Associate Professor Duke Voice Care Center Duke Otolaryngology-Head and Neck Surgery Durham, North Carolina Chapter 8

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Audrey Crummey, BS Weill Medical College Cornell University New York, New York Chapter 16 Seth H. Dailey, MD Associate Professor of Surgery Laryngeal Fellowship Director University of Wisconsin School of Medicine and Public Health Madison, Wisconsin Chapter 26

Madison, Wisconsin Chapter 26 Lisa M. Gallagher, MA, MT-BC Music Therapy Program Manager Arts and Medicine Institute Cleveland Clinic Lyndhurst, Ohio Chapter 2

Philippe H. DeJonckere, MD, PhD Emeritus Professor Federal Institute for Occupational Diseases Brussels, Belgium Chapter 12

Glendon M. Gardner, MD Senior Staff Otolaryngologist Henry Ford Health System Clinical Professor of Otolaryngology-Head and Neck Surgery Wayne State University School of Medicine Detroit, Michigan Chapter 28

Gillian R. Diercks, MD Clinical Fellow in Pediatric Otolaryngology Massachusetts Eye and Ear Infirmary Harvard Medical School Boston, Massachusetts Chapter 7

Christopher J. Hartnick, MD Professor Department of Otology and Laryngology Harvard Medical School Boston, Massachusetts Chapter 7

Iva Fattorini, MD, MSc Chair Global Arts and Medicine Institute Cleveland Clinic Lyndhurst, Ohio Chapter 2

Jack Jiang, MD, PhD Professor Division of Otolaryngology University of Wisconsin School of Medicine and Public Health Madison, Wisconsin Chapter 5

Janet Madelle Feindel, MFA Professor Voice/Alexander Technique/Dialects School of Drama, Carnegie Mellon University Pittsburgh, Pennsylvania Chapter 22 Charles N. Ford, MD Emeritus Professor Department of Surgery Division of Otolaryngology-Head and Neck Surgery University of Wisconsin, School of Medicine and Public Health

Michael M. Johns III, MD Director, Emory Voice Center Associate Professor, Otolaryngology Emory University Atlanta, Georgia Jarrod Keeler, MD Department of Surgery Division of Otolaryngology Duke University Durham, North Carolina Chapter 8

Contributors xi

Adam M. Klein, MD, FACS Associate Professor Emory Voice Center Department of Otolaryngology-Head and Neck Surgery Emory University School of Medicine Atlanta, Georgia Chapter 18

Claudio F. Milstein, PhD, CCC-SLP Director, The Voice Center Head and Neck Institute, Cleveland Clinic Associate Professor of Otolaryngology Cleveland Clinic Lerner College of Medicine Cleveland, Ohio Chapter 30

Philip J. Lanzisera, PhD, ABPP Senior Bioscientific Staff Psychologist Director, Psychology Intern Program Henry Ford Behavioral Health Detroit, Michigan Chapter 24

Thomas Murry, PhD Professor, Otolaryngology-Head and Neck Surgery Co-Director, Loma Linda University Voice and Swallowing Center Loma Linda University Health Center Loma Linda, California Chapters 1, 10, and 21

Jeannette L. LoVetri Director, The Voice Workshop Artist in Residence, Shenandoah Conservatory Lecturer, Drexel University College of Medicine Secretary, The American Academy of Teachers of Singing Advisory Board, The Voice Foundation New York, New York Chapter 23

Robert H. Ossoff, DMD, MD Director Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences Guy M. Maness Professor and Chairman Department of Otolaryngology Vanderbilt University Medical Center Nashville, Tennessee Chapter 29

Nicolas E. Maragos, MD, FACS Emeritus Professor Mayo Clinic Department of Otorhinolaryngology-Head and Neck Surgery Rochester, Minnesota Chapter 4

Sharon L. Radionoff, PhD Director, Sound Singing Institute Singing Voice Specialist/Voice Technologist Team Member–Singing Voice Specialist Texas Voice Center Houston, Texas Chapter 9

Albert L. Merati, MD, FACS Professor and Chair–Laryngology Department of Otolaryngology-Head and Neck Surgery University of Washington School of Medicine Seattle, Washington Chapter 14 Tanya K. Meyer, MD Associate Professor University of Washington, Seattle Seattle, Washington Chapter 16

William D. Riley, MM Private Studio New York, New York Chapter 20 Laura H. Swibel Rosenthal, MD Assistant Professor Department of Otolaryngology-Head and Neck Surgery Department of Pediatrics Loyola University Chicago, Stritch School of Medicine Chicago, Illinois Chapter 19



xii The performer’s VOICE

Robert T. Sataloff, MD, DMA, FACS Professor and Chairman Department of Otolaryngology-Head and Neck Surgery Senior Associate Dean for Clinical Academic Specialties Drexel University College of Medicine Philadelphia, Pennsylvania Chapters 30 and 31 Leda Scearce, MM, MS, CCC-SLP Clinical Associate Faculty Duke University School of Medicine Raleigh, North Carolina Chapter 8 Josef Schlömicher-Thier, MD Consulting Physician to the Salzburg Festival Consulting ENT Surgeon Private, Clinic Wenle Salzburg Chairman, Austrian Voice Institute Salzburg, Austria Chapter 15 Michael D. Seidman, MD, FACS Henry Ford Health System Director, Division Otologic/Neurotologic Surgery Medical Director, Center for Integrative Medicine Medical Director, Wellness Henry Ford Hospital Director of Research, Department of Otolaryngology-Head and Neck Surgery Clinical Professor of Otolaryngology Wayne State University School of Medicine Detroit, Michigan Chapter 17 Rahul Shrivastav, PhD, CCC-SLP Professor University of Georgia Athens, Georgia Chapter 13 Kelsey Stamnes University of California, Berkeley Berkeley, California Chapter 16

Matthias Weikert, MD Specialist in ORL, Voice and Speech Disorders, and Pediatric Audiology Consultant ENT Surgeon Department of Head and Neck Surgery General Catholic Hospital Barmherzige Brüder Regensburg, Germany Chapter 15 Chad Whited, MD Laryngology Fellow Clinical Instructor Division of Otolaryngology University of Wisconsin, Madison Madison, Wisconsin Chapter 8 Judith M. Wingate, PhD, CCC-SLP Associate Professor Department of Communication Sciences and Disorders School of Applied Health Sciences College of Health Sciences Jacksonville University Jacksonville, Florida Chapter 13 Peak Woo, MD, FACS Clinical Professor Department of Otolaryngology Icahn School of Medicine at Mount Sinai New York, New York Chapter 11 Gayle E. Woodson, MD, FACS, FRCS(C) Adjunct Professor Drexel University Professor Emeritus Southern Illinois University Springfield, Illinois Chapter 3 William G. Young, MD Laryngology Fellow Department of Surgery Division of Otolaryngology-Head and Neck Surgery University of Wisconsin, Madison Madison, Wisconsin Chapter 28

This book is dedicated to our families; Kathy, Kaylin, Ryan, and Lindsey; Marie-Pierre and Nicholas; Michael, William, and Catrina.

They are the source of our inspiration and motivation.



Part I Overview



Chapter 1 Introduction Michael S. Benninger Thomas Murry Your voice is the mirror of your soul.

O

ur voices influence nearly every part of human interaction and culture. Until relatively recently in human history, the voice was the sole method of communication. Early human history and recording of events was exclusively through oral history. It is only in relatively recent history that communication has been both written and oral. Despite the information explosion in written, printed, and digitalized/ computerized recordings, most people still use their voices as their primary means of communication. Even when people are alone, they will use their voices, to sing or to “speak to themselves.” Voice communication begins at birth. The birth cry is the first sign of life. The cry soon becomes the communication link between baby and mother. The voice of the mother soothes the crying voice. As the child develops, his or her voice plays a pivotal role in satisfying the needs of hunger, pain, and play. Some children develop pleasurable sounds whereas others use their voices strenuously and develop hoarseness or harshness. Still others find that humming or singing brings pleasure and reinforcement from family and friends. And that is often how these children go on to bigger and more prominent acting and singing roles in primary school, high school, and beyond. For some adults, singing is an enjoyable hobby, while for others it becomes their passion

and finally their profession. Even for those who did not get the principal part in the high school musical, training and practice under watchful eyes and ears help to develop the voice for later success in a vocally demanding profession. Eventually, these individuals become the voice professionals. Words mean more than what is set down on paper. It takes the human voice to infuse them with deeper meaning.  — Maya Angelou Who are professional vocalists? Loosely defined, professional vocalists are individuals who rely on their voices to be the major part of their occupation. This includes teachers, salespeople, coaches, politicians, broadcasters, singers, orators, clergy, and numerous other professionals. The voice demands, the techniques and style of use, and the overall quantity of use may vary considerably among these groups. Similarly, the quality demands and the ability to maintain their professional value may differ. Newscasters must talk rapidly with clear articulation, teachers must talk for long periods of the day, and sports coaches must talk loudly. Ultimately, however,

3



4 The performer’s VOICE the need to maintain a strong, effective, and clear voice affects each of these professionals and contributes in some way to their success. Without their voices, these individuals can no longer perform the duties required. One unique group of professional voice users is professional singers. Of all the voice professionals, singers are perhaps the most affected by problems with their voices, even subtle ones. There is a general expectation that a singer will always perform at his or her best, with a strong, pure, and clear voice with a broad range and unique character. Minor changes in quality are immediately scrutinized, far more so than minor hoarseness in other voice professionals. Because of these voice expectations, singers tend to also spend the most time of any voice professionals developing their voices through practice and training. They demand a higher quality for their own voices than even their audiences do. They are driven to perfection and will work diligently to crystallize their quality and refine their vocal style whether it is opera, gospel, or cabaret. This perfectionistic drive and focus on hard work and repetition are not only what leads to excellence but may increase the risk of injury. Any injury to singers’ voices has dramatic implications not only on their voices but also on their psyche and sense of self-worth. First, I lost my voice, then I lost my figure and then I lost Onassis!  — Maria Callas What happens when singers are injured and cannot perform at a level that either they or their audiences expect? That depends on many factors, including the professional level of the singer, the magnitude of the injury, the importance of the performance, the experience of the singer, the type of music to be sung, and the expectations from the audience for the performance. It is a simplification to suggest that the expectations of the performance of an elite opera singer are greater than that of a rock singer. There are too many variables to think like this. The demands of the performance vary for each individual and for each performance. Even for the experienced, elite opera singer, there may be an important difference between a Metropolitan Opera

premiere and a light-hearted recital at a hometown outdoor venue. The audition for entrance into a school of music is usually more critical to a developing young singer than the third performance of the weekend in the school play. The greatest musical instrument given to a human being is the voice.  — Dayananda Saraswati For some singers and for some performances, “the show must go on.” But there is a danger in thinking like that. Singers usually injure their voices when they are sick, fatigued, or under strain. When the experienced singer feels that he or she cannot perform to a known level, he or she will cancel the rehearsal or the show. Canceling at the last minute, however, becomes more difficult for the lead singer at a small college in the Midwest where there is no one else to take over the role. The need to perform must always be balanced against the probability of vocal injury. When the singer cannot use his or her full voice, the decisions must be made with the singer’s long-term career in mind. For some, it is simply of matter of rest and hydration; for others, their show cannot go on unless they seek treatment from knowledgeable individuals who understand the ramifications of voice care and vocal injury. Madonna Cancels NJ Show:  A sore throat forced Madonna to cancel the final NY area date of her Drowned World tour last night at the Meadowlands Arena.  — New York Times, August 2001

Google CEO Larry Page has vocal cord paralysis: When Google CEO Larry Page stopped talking at events last summer, some company watchers feared the worst. But Page revealed on Tuesday that he’s perfectly healthy, and his raspy voice is due to vocal cord paralysis.  — CNN Money, May 14, 2013

Introduction 5

To treat singers, one has to be aware not only of the important principles of anatomy, physiology, and pathology of the voice but also the critical interfaces between the voice, the sound produced, and the unique aspects of each individual singer. A comprehensive understanding of the differences in individual voice production, between musical styles and the more complex relationships the singer has with teachers, audiences, agents, and promoters, is necessary to comprehensively address the singer’s voice needs. Each singer is different, and each needs to be considered individually. Although there are a number of variables in the assessment and treatment process, the best rule to approach an injured singer is that there are no rules. Knowledge, education, compassion, and a thoughtful, deliberate approach bolstered by appropriate tools and equipment for evaluation and treatment are needed each time a singer comes to the clinic or studio with a voice problem. One fortunate aspect of the treatment of singers is that the characteristics of hard work and drive that can lead to injury are usually also applied to assessment, treatment, and rehabilitation. Singers sing because they love it. They rehabilitate their injured voices to resume their profession. They respect a knowledgeable voice clinician and will often follow the advice and recommendations without hesitation. In a large sense, singers are vocal athletes. Their bodies are the source of their vocation, and like other athletes, they base their careers on a somewhat fragile machine that is prone to injury. And, like athletes, they will do what is necessary to return to performing. In doing so, they rely on the specialized voice practitioners, primarily otolaryngologists and speech-language pathologists who specialize in voice disorders, and colleagues in the music community to help them return to their careers at the same level as before their injury. Actors and actresses also require exacting standards for their speaking voice. Projection, articulation, and endurance in the speaking voice range require training and practice. Injuries may occur in actors’ voices that restrict use and therefore income. Medical care and rehabilitation of the injured actor’s voice also fall to the otolaryngologist, speech-language pathologist, vocal pedagogist, and singing teacher. The current approach to caring for the performer’s voice is to use an interdisciplinary team of cli-

nicians. The performer’s voice care team is usually under the direction of an otolaryngologist or laryngologist. Laryngologists are otolaryngologists who specialize in diseases and disorders of the larynx. However, the performer’s internist should always be kept apprised of changes in the performer’s health status and of the prescribed medications. Speech-language pathologists are an integral part of the performers’ voice care team. Speech pathology encompasses many subspecialties of communication disorders. Relatively few have special training or intimate knowledge of the anatomy and physiology of the vocal mechanism or even an interest in the performing population. Most speech pathologists who routinely treat performers are closely aligned with an otolaryngologist and work together with the injured performer to achieve rapid and safe recovery of vocal injuries. Phoniatrists, singing voice specialists, and vocal coaches are also involved in the care of the performer. Phoniatrists are specialists in European countries who are trained as physicians but not as surgeons. They may prescribe medicines and offer behavioral treatments. Singing voice specialists are usually singers who go on to study the medically related aspects of voice use. They are usually affiliated with voice care teams and offer special singingrelated information to the singer and the members of the voice care team. There is a wealth of information available to the singer with a voice problem since the advent of modern voice care. Singers should be educated by their voice care team, and team members owe it to the singers to share the most up-to-date practice methods that are available. It is important for the voice care team to communicate with the performer’s other health care specialists, voice teachers, and others in the performing industry so that conservative and appropriate care is given when there is a voice injury. This second edition of The Performer’s Voice is written to present the most current and comprehensive approach to the care of the singer’s voice. The important anatomic, physiologic, and pedagogic principles of voice production for the singer will serve as the foundation for the care of the singer. The authors represent a wide array of people who have dedicated their careers to the prevention of voice injury; the diagnosis, treatment, and rehabilitation of



6 The performer’s VOICE the injured singer; and the education of others who continue to advance the science and art of voice care through education, research, and clinical practice. The diversity of the authors supports the important principles of the multidisciplinary approach to the care of the vocalist, particularly the singer. All of the chapters have been updated to bring the most upto-date information related to performing voice care and injury prevention. A number of new chapters have been added to make the book more comprehensive and to address new and challenging areas in performing voices. This book serves as a concise reference for the otolaryngologist or speech-language (voice) pathol-

ogist who wishes to focus their practice on the evaluation and care of vocalists, particularly the professional singer. It also provides a strong foundation in the understanding of the singer’s voice for singers, teachers of singing, pedagogues, and those who contract and produce vocal performances, as well as others who have already developed a foundation in voice and wish to become more familiar with the intricate principles of the performing voice. Ultimately, we hope that this book will continue to strengthen the fundamental foundations of voice care and will expand the multidisciplinary interests in the care and preventive treatment of the singer’s voice.

Chapter 2 Music and the Brain Iva Fattorini Neil Cherian Lisa M. Gallagher

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our brain loves music. Listening to music lights many nooks on the neurological map. Not only the brain areas that control hearing. But the areas that make you walk, dance, smile, and salivate; the areas that make you love and cry; and the areas that allow you to daydream and imagine. Music can engage the highest intellectual faculties, or it can stimulate the most elemental reflexes. We associate it with both spiritual purity and prurient sensuality. Music can make us happy when we’re sad, and add sadness to the sunniest mood. All of this happens in the brain. So any study of music and its effect on the body and health has to begin with the brain. This chapter has an ambitious agenda. We offer a broad overview of music and the brain in the context of healing. The subject is immense, so we move quickly through examples and topics. The goal is to share our excitement for this vast topic and encourage you to take a deeper dive. So what is music? At the most basic level, it’s ordered sound. Music is part of nearly every culture on earth, and wherever you find music, you’re likely to find it associated with health and healing. Music and health run hand in hand through many of the world’s cultural and religious traditions. Apollo was the Greek god of both music and healing. Perhaps the Muses used melody to soothe Zeus, in much the same way that the Biblical David charmed the melancholy King Saul with his harp. Plato and Aristotle

analyzed the effects of music on the emotions. In many African traditions, music is believed to be connected to spiritual and physical well-being. Johann Sebastian Bach composed his famous Goldberg Variations to help a sick count cope with insomnia. As music became more sophisticated, so did its abilities to alter the mind, spirit, and health. With the advent of scientific medicine, scientists launched formal studies into the effects of music on the mind. Psychiatric hospitals in the 1930s deployed music to soothe patients and prevent destructive behavior.1 After World War II, Veterans Administration hospitals engaged musicians to play for the recovering wounded to apparent good effect.2 Today, most hospitals in America offer music at some time or another to patients and visitors. Cleveland Clinic provides live music each weekday and ambient music throughout the day. Music can affect the mind and emotions in ways that are relevant to healing. The challenge now is to get a fuller understanding of how music and the brain interact, and to shape that knowledge into testable treatments. Music therapy, for instance, is now a formal health care profession. Many medical centers include music therapists on the teams that treat serious conditions. Here’s an example: Bill was a 52-year-old man admitted to the hospital with a left hemispheric stroke. Before his stroke, Bill enjoyed teaching, painting, and playing

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8 The performer’s VOICE the guitar. But his stroke shattered the language center of his brain, and he was in a coma. One of his doctors put it plainly to Bill’s wife: “Bill is lost to us”; but Bill was far from lost. Although paralyzed, he could hear and understand what was being said around him. Later, he recalled pleading inwardly, “I’m in here. Please don’t give up on me.” Bill’s determination undoubtedly helped him survive and awake from his coma, but his recovery was slow. He had trouble walking and using his right arm and hand. He tried to speak and knew what he wanted to say, but the words came out all wrong. A team that included neurologists, occupational therapists, physical therapists, speech therapists — and a music therapist — worked with him. The music therapist used singing, melodic intonation therapy, and breathing exercises to help rewire Bill’s brain to aid his speech. He was urged to return to playing the keyboard and guitar (Figure 2–1). This improved his motor control, physical coordination, gross motor, and fine motor skills. Every step forward also improved his emotional well-being and self-esteem. Two years later, Bill was able to return to public speaking, and he started running marathons, improved at his instruments, and began to

draw and paint again. Bill’s wife specifically credits music therapy with many aspects of his recovery. She recalls that while she thought she’d never hear Bill’s voice again, she was thrilled when after only two music therapy sessions she was able to hear Bill’s voice and personality again.

Brain Development, Music Centers in the Brain, and Benefits of Music New methods of brain imaging and discoveries in genetics have inspired an explosion of interest in the neurological aspects of music on the part of scientists and the lay public. Neurologist Oliver Sacks’ 2008 bestselling Musicophilia: Tales of Music and the Brain was one of several books on the topic to become popular in recent years.3 Other leading researchers in music and the brain are Daniel Levitin,4,5 Aniruddh Patel,6 Robert Zatorre,7 Valorie Salimpoor,8,9 and David Huron.10 There is a thirst for knowledge about the effect of music on the brain in utero. Parents play music for babies in the crib.

Figure 2–1.  Music therapy can be part of a comprehensive treatment plan for patients recovering from stroke. Here, a music therapist works with a patient to improve fine motor skills. Reprinted with permission, Cleveland Clinic Center for Art and Photography © 2012–2014. All Rights Reserved.



“Tiger Moms” add rigorous music training to their children’s already ambitious study schedules. What role does music play in brain development? How does music training affect the mind?

Brain Development It is never too early to introduce music. In fact, unborn babies can feel the vibrations of the music, respond to the volume of the music, and begin to recognize both their mother’s voice and particular melodies.11,12 The whole birthing process can be choreographed to music. Music therapists play slow, soothing melodies to help the mother relax and breathe regularly during contractions. Then when it comes time to push and deliver, they turn up the tempo. Lullabies are nearly universal and distinctive to cultures around the world. Childhood songs and nursery rhymes are learned casually during play, but they are rarely forgotten. Many of us will be able to recall and repeat the songs and rhymes of childhood until our dying day.

In Utero Studies Many cases prove the power of music on a baby in utero. Marie, for instance, sang to her baby when she was pregnant. She even put headphones around her stomach and played music to the developing child. Once the baby girl was born, she displayed the usual crying and discomforts experienced by infants, but Marie found she could easily and immediately quiet the child by singing the familiar songs and playing the recorded music heard in the womb. Babies recognize and show a preference for their mother’s voice beginning at 2 days after birth.12 In one study mothers were asked to play a particular piece of music to their babies 5 times a week during the last trimester of pregnancy. Noninvasive studies of the infants’ brains showed that the resulting neural activity lasted in some cases for several months.11

Early Music Training and Learning Children learn new things in a variety of ways and by using different media. Experts have identified diverse learning styles or forms, often associated

Music and the Brain

with distinct parts of the brain. These include auditory and perceptual learning, and they involve the auditory cortex within the temporal lobes.13,14 In these forms of learning, new information may ride its way into the brain by way of songs, melodies, and chants. For example: learning the ABCs as a song. Some children who have trouble memorizing facts for school may be able to sing the lyrics of popular songs they have absorbed without conscious effort. Changing a list of boring facts into a fun melody or chant could help the children memorize them more quickly and easily. It is widely believed that the structure and selfdiscipline of music lessons give children an edge in testing and other scholastic pursuits (Figure 2–2). However, the research on this topic has had mixed results. One study demonstrated that music training during early childhood improved auditory and motor skills and created structural changes in the brain after only 15 months of training.15 Children often begin music lessons when they are young. This is a perfect time because their brains are sensitive to changes, and those who play musical instruments display greater plasticity throughout the brain ​ — meaning that their brains are better able to grow, change, and be rewired as they learn and encounter new experiences.15,16 Training in music involves a variety of skills and systems that are activated in the brain such as fine motor, preparation, execution, multiple senses, planning, perception, discrimination, cognition, vocabulary, counting, and understanding fractions.16,17 It is possible that these skills can transfer to math, verbal, nonverbal, and spatial skills, as well as IQ and other scores on standardized tests.17 One study found that children in elementary school who received training in music had higher English and math skills on standardized tests than those who had no training; however, the results of many other studies have been insignificant, mixed, or inconclusive.17,18 Other factors such as the quality of the music training, the child’s motivation, the child’s IQ level prior to music lessons, and the supportiveness of the parents also play a significant role in the child’s music training and subsequent abilities.16 While at this time there is no definitive answer as to whether or not early music training provides an edge in testing scores and abilities, this is a topic that will continue to be researched until the answers are found.

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10 The performer’s VOICE

Figure 2–2.  Early music training is believed to provide numerous benefits for children. Reprinted with permission from the Beck Center for the Arts.

Playing a musical instrument engages the entire neurological complement, including the motor, somatosensory perception, auditory, visual, memory, attention, and emotional systems.19 All this activity causes some areas of musicians’ brains to grow noticeably larger and have greater plasticity.19 Better understanding of these processes will eventually enable us to put them to work in neuro-rehabilitation for stroke patients and those with brain injuries.

Music Centers in the Brain As we said, music can activate nearly every part of the brain, but some parts of your brain get more involved than others. Figure 2–3 shows the anatomy of the brain and areas of function. Many parts of the brain contribute to helping us play musical instruments or enjoy musical performance. The discussion below uses a very broad brush as a comprehensive discussion of music centers of the brain would require a book unto itself.

The brainstem is like Grand Central Station — ​ connecting body and brain so you can breathe, move, sense, have a heartbeat, be conscious.13,20 Musicians need to integrate the information from their eyes, feet, skin, fingertips, and ears in performance. Regular breathing is critical to all performers and so is a steady heartbeat. Some classical musicians have been known to cheat in performances by taking a class of drugs known as beta-blockers, which prevent the heart from beating too quickly. The brainstem can be affected by listening to music, such as pulsing dance music, resulting in an immediate physical response. The cerebellum (see Figure 2–3) helps with coordination, balance, posture, and muscle tone and activity.20,21 This part of the brain allows a rock drummer to hold on to the sticks and coordinate the movements of fingers, hands, toes, and feet. It allows a violinist to stand and play without toppling over. It contributes poise to a concert pianist and helps a flashy guitar player jump around or duck-walk while fingering notes.

Figure 2–3.  Brain anatomy and areas of function. Reprinted with permission, Cleveland Clinic Center for Art and Photography © 2012–2014. All Rights Reserved.

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12 The performer’s VOICE The occipital lobe (see Figure 2–3) involves sight, image perception, and recognition.13,20 Sight reading is a prized skill among musicians. It is the ability to look at an unfamiliar piece of music and play it well the first time through. However, reading and playing music at any level is an incredibly complex interaction that links the activity of the occipital lobe with motor and sensory skills in a symphony of neurological signaling. The parietal lobe (see Figure 2–3) has a role in the identification and evaluation of objects and their properties.13,20 It recognizes the shape, texture, and weight of things. Imagine a violinist picking up his or her instrument, balancing it under the chin, placing the fingers just right, and gently lowering the bow to the strings before commencing play. This is the parietal lobe at work. The frontal lobe (see Figure 2–3) is responsible for movement, judgment, abstract thinking, personality, and memory.13,20 In the left frontal lobe is what is known as Broca’s area (see Figure 2–3), which is the center for speech production.13,20 Broca’s partner in speech is Wernicke’s area (see Figure 2–3), found in the left parietal lobe, which helps with speech and language comprehension.20 These areas are also activated when a patient is engaged in singing a song.13 The prefrontal cortex within the frontal lobe (see Figure 2–3) is responsible for higher mental function; it allows us to judge, plan, reason, emote, and create.13,20 It puts the sapience in homo sapiens. The prefrontal cortex gives us the ability to appreciate and be moved by the structural, historic, and spiritual aspects of music. It allows us to judge and compare pieces of music and their performers. It also allows us to compose music, to fit it to lyrics, and to invent new instruments and new styles of playing. It is the cultural crossroads of the brain, where music is enriched by visual arts, literature, and one’s life experiences. Then there’s the limbic system — the emotional core of the brain.13 This is where Pagliacci gets its passion, soul music goes deep, and flamenco finds its blazing temperament.

Benefits of Music Music needs no justification. For many, it is the chief joy of existence. (A famous New Yorker car-

toon depicts a barren landscape of dirt, weeds, and old tires, with a caption underneath that reads: Life without Mozart.) Music can help overcome the depressive effect of almost any environment such as hospitals, prisons, and slums; and it can provide an escape from harsh reality. In fact, some of the greatest music of all time has been composed under what seems like unbearable conditions. Impoverished environments from the favelas of Rio de Janeiro to the Mississippi delta have produced some of our most invigorating and life-enhancing musical traditions. Ludwig van Beethoven created a world of profound beauty despite the cruelty of his upbringing and the deafness and neurological problems that tormented his adulthood. Listening to music can integrate all the different parts of what we consider our self. While we listen to music, we may be exercising the body, performing some household task, recovering lost memories, forgetting current problems, relaxing, memorizing, or driving — all at the same time. Our folk instincts tell us that a life that is full of music might be a life where all the physiological, communication, attention, reasoning, behavioral, and psychological forces are in balance.1

Therapeutic Uses of Music At the end of World War II, American Veterans Administration hospital wards were crowded with young men having various degrees of injury and disability. It was in this environment that the therapeutic benefits of music became dramatically and meaningfully apparent; and as we mentioned earlier, that’s where music therapy arose as a professional treatment modality with a formal educational curriculum. Today, music therapists undertake extensive university training in both music and medicine and complete a national certification exam in order to practice. Over the years, interest in using music for therapeutic purposes has continued to grow. An emerging field of music and medicine embraces a wide array and intersection of disciplines and activities related to the use of music for medical treatment or in health care environments. Music and medicine includes therapeutic, scientific, and relaxing qualities. It’s also a quest for discovery of the science behind the art. The field expresses the wish to use



music to promote what some who heal using traditional African music might call “the science of being; the art of living with health.”22 Culture, geography, heritage, and resources govern the forms that music and medicine take around the world. In some places, it is simply a musician playing for patients in a hospital lobby. Ambient or overhead music may be offered. Academic medical centers may have clinical centers to treat vocalists or musicians. Cleveland Clinic is an example of a medical center that does all of these things, in addition to a professional in-house music therapy program. Figure 2–4 shows the lobby of Cleveland Clinic during a special performance. Cleveland Clinic founder George Crile, Sr., MD, was a notable music lover. Practicing surgery at the turn of the 20th century, he shocked his colleagues by bringing a gramophone into the operating room to play popular tunes while he worked. He was among the first to combine music with surgery; something we take for granted today. International discussions of music and medicine revolve around a wide range of goals. They hope to use the nonverbal healing power of music to

Music and the Brain

n Act upon the human mind, body, and soul

to bring about self-realization n Promote quality of life n Improve spiritual, communicative, social,

intellectual, emotional, and physical wellbeing and health n Provide healing of emotion, spirit, body, and mind n Enable communication with others, selfexpression, and connection with one’s inner self n Mirror patients’ physical and emotional states n Enable individuals to compensate for losses they have suffered n Restore function, skills, gross and fine motor movements, and gait n Assist in healing and personal growth n Address memory loss, cognitive issues, self-esteem, and speech, language, and communication issues n Decrease stress, pain, depression, anxiety, shortness of breath, distress, and nausea n Improve mood, self-esteem, and energy22–32

Figure 2–4.  Performances in lobbies at Cleveland Clinic improve the environment for patients and families. Reprinted with permission, Cleveland Clinic Center for Art and Photography © 2012–2014. All Rights Reserved.

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14 The performer’s VOICE The huge gap between these aims and the amount of scientific work that is still needed in this area should serve as an inspiration to government, institutions, and philanthropists to increase funding for research.

Impact of Music on Health and Wellness Physical Reactions to Music Patients are often asked by medical professionals to rate their pain on a scale of 1 to 10. A patient we’ll call Cathy returned from her medical procedure reporting her pain as an 8 to the music therapist. That is serious pain. The music therapist worked with the patient to learn what her musical preferences were. Cathy had some favorite hymns and asked the therapist to play them, and as she did so, Cathy sang along. At the end of one 30-minute session, she reported that her pain was gone. This was despite the fact that she had forgotten to take her prescribed pain medication. Music can be a positive distraction from pain, shutting the gate to negative sensations.33 This is known as the gate control theory, and it was created identified by Melzack and Wall in 1965. An updated version of this theory from 2001, the neuromatrix model of pain,34 suggests that pain not only involves the sensation itself but an array of cognitive-evaluative, sensory-discriminative, and motivational-affective inputs such as memories, emotions, attention, and expectations.35 The body’s response to pain also involves behavioral, perceptual, and homeostatic systems; sensory processes; subjective, affective, psychological, physiological, and emotional processes; and endorphins that decrease the awareness of pain by stimulating brain receptors.13,35,36 Music, especially preferred music, is able to connect individuals to their memories, emotions, expectations, and attention while distracting them from their sensation of pain. Patients in one study who utilized music and guided imagery required 50% less narcotic medication after elective colorectal surgery and had lower presurgical and postsurgical anxiety and pain than those who did not use music and imagery.37

Music also has other physiological effects such as decreasing blood pressure, heart rate, oxygen saturation, and respiratory rate.38 Music that is fast can increase the musician’s respiratory rate, and it can create tension, stress, and a sense of urgency while also increasing the listener’s heart rate, sympathetic nervous activity, anxiety, and levels of cortisol and endorphins.38 On the other hand, slow music can decrease agitation, heart rate, insomnia, and sleep disturbances while increasing melatonin levels.38 It has been shown that music therapy can decrease shortness of breath and increase relaxation in patients.24 This is how it works: the therapist plays a song the patient has indicated that he or she likes. Using an instrument, the therapist initially matches the tempo of the song to the rate of the patient’s breathing. Then the therapist slowly takes the tempo down. The patient’s breathing slows at the same rate, allowing symptoms to abate. This is called musical entrainment.

Emotional Reactions to Music Music penetrates directly to the emotional core of our being. Tough police officers tear up at the first notes of “Danny Boy.” Music revives real memories and provides aesthetic enjoyment.9 Music doesn’t do its emotional work alone. It has biochemical helpers. They’re the same team that is activated by chocolate: dopamine and serotonin.4,8,9,39 These famous neurotransmitters are intimately linked to our moods, pleasure, anticipation, and reward.4,9 When we hear music we like, the body releases serotonin and dopamine into the autonomic nervous system.8,39 This is why when we listen to our favorite music, we just feel good. A monumental symphony like Beethoven’s 9th can stimulate fear, joy, pleasure, and spiritual transcendence and mobilize the whole brain. Fear is processed by the amygdala, the hypothalamus delivers joy and transcendence, and the nucleus accumbens is associated with pleasure and may even be responsible for the chills we get during the Ode to Joy.7–10,40 In the hospital, patients waiting for surgery are anxious in ways that those who have never had surgery can barely imagine. Music can boost the moods of these patients — and the hospital personnel who are taking care of them.23,24,37,38,41



Music and the Brain

Patients in psychiatric hospitals with depression and anxiety are also helped by music; especially if listened to daily and accompanied by regular use of antidepressant medications. However, what kind of music works best?38 Music the patient likes.42 Familiar, preferred, vocal, and improvisational music have been shown to increase positive neural activity; whereas startling, dissonant, and complex music, as one would expect, does not.43 The music therapist’s toolbox is full of interventions — live music listening, instrument playing, singing, and songwriting, just to name a few. Music therapists help patients tap into, express, and regulate their emotions — joy and sadness, anger and fear, wonder and tension, nostalgia and transcendence.44 They are also uniquely positioned to verbally process the reactions that the music may elicit.40,43 Figure 2–5 shows a music therapist in session with a patient in the hospital. Possible implications for utilizing music to change neuronal activity and to treat psychiatric and neurological disorders through the use of music have yet to be explored.40

Using Music in Rehabilitation A patient who has had a debilitating stroke or brain damage can draw hope from the neuroplasticity of the brain. This capacity allows the brain to relearn its old capabilities in small increments by rerouting and repurposing neural structures.45 The brain rewires itself by strengthening existing neural pathways, building new neural pathways, and compensating for those that no longer function. Promoting and directing neuroplastic rehabilitation is one of the objects of music therapy. We know that it can help improve cognitive abilities, memory, and sensory perception. The patient, Bill, for instance, regained his speech capabilities through neuroplastic reconstruction promoted by music therapy.

Regaining Speech Our discussion so far has jumped from music and medicine, to music and the brain, to the use of music therapy to treat functional and mood disorders. And

Figure 2–5.  A music therapist treats a patient at bedside for symptoms such as pain and anxiety and to improve mood, speech, and quality of life. Reprinted with permission, Cleveland Clinic Center for Art and Photography © 2012–2014. All Rights Reserved.

the jumping will continue because there is nothing static or localized about the relationship of music and the brain. Music seems to have a global pass that gives it entry to every remote passageway and secret chamber of the neurological system. If one part of the system shuts down, music can easily use another. This space-shifting quality is something that music therapists try to take advantage of in their work. Here’s an example: A patient named Sophia had a stroke. It damaged speech centers on the left side of her brain. Two days out, she still couldn’t say her name. As the music therapist entered the room, she heard the nurse asking the patient again and again to say her name. Sophia couldn’t do it. She was trying. But

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16 The performer’s VOICE the word couldn’t emerge. With every attempt, her frustration grew. The music therapist then introduced herself to the patient and got to work. She decided to use a technique called melodic intonation therapy (MIT).46 MIT, like many therapies that take advantage of neuroplasticity, addresses left hemisphere damage in a marvelously counterintuitive way. It addresses the damage on the left by utilizing the right hemisphere to help retrain the brain for speech.47 In the example above, the music therapist began by making up a melody to the patient’s name. Then she began singing the patient’s name, tapping the patient’s hand with each syllable. After many repetitions, she asked the patient to sing along with her. Sophia had learned the melody and joined in. Finally, the patient was asked to sing her name by herself. She did so, weakly at first. But by the end of 10 minutes, her voice was gaining strength. Shortly after that, Sophia’s family arrived for a visit. The therapist introduced herself and then turned to Sophia. “Tell them your name,” the therapist said. “Sophia,” the patient answered by speaking, not singing, her name. Although language is mostly localized on the left side of the brain, and music has a stronger presence on the right side, music’s metaphorical global pass gives it access to both hemispheres and their functions.19,20,46–50 Music penetrates and activates dormant language areas of the brain.47 In Sophia’s case, the music therapist might have gone on to use some other techniques: singing familiar songs, rhythmical cueing of speech, vocal and oral motor exercises, and special breathing exercises.48 Among the goals of these techniques is to strengthen a vast neural pathway known as the arcuate fasciculus fiber tract, which connects widely separated parts of the brain.20,46,48–50 If these techniques are to have a lasting effect, they need to be started early and continued until the patient has achieved maximum recovery.49

Improving Motor Function In any discussion of music and the brain, and music therapy, one very important fact often gets lost: music is pleasurable. The listening to and playing of music are positive reinforcement in themselves and in any activity we associate with them.1 Listening to

music can make a dull task enjoyable; rousing songs persuade young people to buy things and go places; the prospect of hearing beautiful music can motivate us to put on nice clothes, get in the car, and drive down to the concert hall — even after a hard day of work. Many music therapy techniques take advantage of the positive reinforcement effect of music to improve the neurological, psychological, and physical condition of patients (Figure 2–6). The worldwide enthusiasm for aerobic exercise classes, for instance, has been driven by musical accompaniment that makes exercise as enjoyable as dancing. The neurological music therapy technique known as patterned sensory enhancement is similar as it uses the elements and patterns of music to encourage patients to lift, reach, and grasp in rhythm.46 Therapeutic instrumental music performance addresses movement issues by encouraging patients to play instruments such as wood blocks, hand drums, tone bars to exercise movements they need to relearn.46 Rhythmic auditory stimulation is used to treat gait disorders, using strongly accented beats to cue walking. Patients who have had a stroke, Parkinson’s disease, and multiple sclerosis can benefit greatly from this technique.46,51–55

Other Approaches to Music in Health Care What are all the approaches to music in health care? Since music is so enjoyable, has so many faces, and is simply fascinating to learn about, understand, and explore, there are numerous ways for people to use music in health care. Physicians and researchers want to study the use of music in medicine. Music therapists want to innovate in their treatment of patients. Musicians want performance opportunities. Even patients, visitors, caregivers, and the community are eager to get into the act. So it is that in addition to the recognized profession of music therapy, there are many other approaches to music in health care, including performing arts medicine, medical humanities, music neuroscience, medical ethnomusicology, integrative music medicine, drumming, and recreational music making (RMM).27,56 RMM is a relaxed music session



Music and the Brain

Figure 2–6.  Patients participate in music therapy by playing instruments, singing, or songwriting. Reprinted with permission, Cleveland Clinic Center for Art and Photography © 2012–2014. All Rights Reserved.

for recreation that helps prevent nursing burnout; alters moods of older adults, employees, and longterm care workers; and affects immune function on the cellular level.56 The profession of music therapy has many different approaches within its discipline as well: behavioral, developmental, biopsychosocial, music psychotherapy, neurological, analytical, and guided imagery, to name a few. Some of these approaches are highlighted below.

Music Psychotherapy Whereas the traditional psychotherapist encourages the patient to talk, the music psychotherapist encourages the patient to use music while expressing his or her feelings.57 Both types of psychotherapy hope to build a therapeutic relationship, access the patient’s inner life, and develop skills to make life changes.58 The approach has been used to address the physical and emotional effects of chronic pain, where it takes advantage of the brain’s plasticity to redirect neuronal activity.13 Skilled music psychotherapists use their techniques to address fear, anger, coping skills, and the ability to express emotion.45,57

Neurological Music Therapy Neurological music therapy (NMT) is serious science. It deploys a systematic group of standardized therapeutic techniques based on clinical and evidencebased practice.46 It incorporates the most reliable research in music therapy, brain sciences, neurology, medicine, rehabilitation, and biomedical sciences of music.46 To practice neurological music therapy, the music therapist requires additional training in brain pathologies, physiology, neuroanatomy, and language, speech, motor, and cognitive rehabilitation.46 Like other approaches, NMT uses singing, rhythm, and playing instruments, but it uses these activities to target specific portions of the brain that are associated with the deficit being addressed.46

Analytical Music Therapy Analytical music therapy integrates improvisation and psychotherapy in a holistic way.45 Patients and analytical music therapists improvise music together. They musically and verbally explore and process unconscious thoughts and feelings to promote selfknowledge and growth through creative expression.45

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18 The performer’s VOICE This is particularly effective in pain management, where it is used to help patients gain insight into their emotions, physical problems, spiritual distress, and psychological concerns, all of which can contribute to their symptoms of physical pain.45

The Bonny Method of Guided Imagery and Music Classical music is at the heart of the Bonny method of guided imagery and music (BMGIM), where pieces of music are carefully chosen to induce internal imaging that promotes healing.59–61 The therapist guides the patient into a relaxed state, encourages and supports the patient to connect with the imagery that is conjured by the music, and interprets the imageries with the patient.59 The tempo, simple musical structure, steady rhythm, and easy harmonies promote deep relaxation in the patient in order to promote spiritual, emotional, and physical healing.59

Summary Music is so much a part of what makes us human that it is hard to separate its therapeutic uses from the hundreds of other social, ritual, and entertainment functions it serves. In recent years; however, the intuitive connection between music and healing has undergone more and more rigorous investigation. When it comes to studying the healing effects of music, all roads inevitably lead to the brain. The brain is where music happens. The brain is where the composer composes and where the performer generates the movements that make the sounds. The brain is where the listener perceives these sounds, identifies them as being different from random environmental noise, and reacts to them with interest, revulsion, pleasure, or exaltation. Research has shown that music therapy can be effective for many conditions, but particularly in helping patients to manage pain. Should this be any surprise? We all self-medicate with music. We use it to relax, to cope with the discomfort of loneliness and boredom, and to reconcile us to the spiritual and existential anxieties of life in the universe.

As music affects every part of the brain, so it infuses every stitch in the fabric of society, from the cathedral to the nightclub, the schoolroom to the nursing home, the small town to the big city. In the same way, music inhabits all realms of the medical and therapeutic world. There are rigorously scientific music therapy programs, where board-certified music therapists conduct research and apply the results of randomized controlled studies. Then there are aspiring and loosely evidenced initiatives for easing the troubles of the mind and body. There is also music that is just music: a patient listening to music on a smartphone in the hospital bed or the strolling violinist in the lobby. Music therapy interventions and approaches used by trained and board-certified music therapists bring hope to ordinary patients with common problems and to many patients who would previously have been beyond hope. In the short time that it has been studied, music therapy has shown the potential to improve communication and motor skills after stroke or brain injury, as well as to improve mood, decrease chronic pain, and open the way to patients’ inner lives, connecting the mind, body, and spirit to promote healing and wholeness. Tempo, volume, melody, harmony, and rhythm in the hands of a trained music therapist seem to be able to promote brain plasticity and rehabilitation among the elderly, stroke patients, and those with neurological disorders. With more research, more funding, and institutional support, music therapy will unquestionably be able to perform these and other tasks more effectively in the future. One important and promising use of music therapy now and even more so in the years to come is in the treatment of Alzheimer’s disease.62 Therapists treating these patients have discovered that they can get a response from patients with severe dementia by playing songs from the patient’s childhood or hit songs from their teen and young adult years. They’re finding that even music that is unfamiliar to the patient may help calm agitation. Singing together promotes emotional closeness between these patients and those who love them. As our population rapidly ages, the number of cases of Alzheimer’s disease and other age-related dementias is increasing at an alarming rate. The shortage of any hopeful or effective treatments for these conditions may give



Music and the Brain

music therapy its greatest opportunity and challenge to affect millions of lives around the world. The human brain is the most complex object in the universe. It contains enough mysteries to keep researchers busy studying it until the end of time. Music — with its ability to cross thresholds, bypass barriers, and make friends across the whole range of neurological functions — will be part of that brain research. Music may contain the divine proportions that are the secret to communication among all living things. There is much to be learned — and the best way to begin may be with the original music instrument — the human voice.

References 1. Zimmerman E, Lahav A. The multisensory brain and its ability to learn music. Ann N Y Acad Sci. 2012;1252:179–184. 2. American Music Therapy Association. What is music therapy? 1998. http://www.musictherapy. org/. Accessed June 16, 2014. 3. Sacks O. Tales of Music and the Brain. New York, NY: Vintage Books; 2008. 4. Levitin DJ. This Is Your Brain on Music: The Science of a Human Obsession. New York, NY: Penguin Group; 2007. 5. Levitin DJ. The World in Six Songs: How the Musical Brain Created Human Nature. New York, NY: Penguin Group, Inc.; 2008. 6. Patel AD. Music, Language, and the Brain. New York, NY: Oxford University Press; 2008. 7. Zatorre RJ, Salimpoor VN. From perception to pleasure: music and its neural substrates. PNAS. 2013;110(suppl 2):10430–10437. 8. Salimpoor VN, Benovoy M, Larcher K, Dagher A, Zatorre RJ. Anatomically distinct dopamine release during anticipation and experience of peak emotion to music. Nat Neurosci. 2011;​ 14(2):257–264. 9. Salimpoor VN, Zatorre RJ. Complex cognitive functions underlie aesthetic emotions: comment on “From everyday emotions to aesthetic emotions: Towards a unified theory of musical emotions” by Patrik N. Juslin. Phys Life Rev. 2013;10:279–280. 10. Huron D, Marguilis EH. Musical expectancy and thrills. In Juslin PN, Sloboda JA, eds. Handbook

of Music and Emotion: Theory, Research, Applications. New York, NY: Oxford University Press; 2010:575–604. 11. Partanen E, Kujala T, Tervaniemi M, Huotilainen M. Prenatal music exposure induces long-term neural effects. PLoS ONE. 2013;8(10):e78946. 12. Fifer WP, Moon CM. The role of mother’s voice in the organization of brain function in the newborn. Acta Paediatr. 1994;83:86–93. 13. Taylor D. Biomedical Foundations of Music as Therapy. 2nd ed. Eau Claire, WI: Barton Publications; 2010. 14. Leopold L. Prewriting tasks for auditory, visual, and kinesthetic learners. TESL Canada J. 2012;​ 29(2):96–102. 15. Hyde KL, Lerch J, Norton A, et al. Musical training shapes structural brain development. J Neurosci. 2009;29(10):3019–3025. 16. Wan CY, Schlaug G. Music making as a tool for promoting brain plasticity across the life span. Neuroscientist. 2010;16(5):566–577. 17. Forgeard M, Winner E, Norton A, Schlaug G. Practicing a musical instrument in childhood is associated with enhanced verbal ability and nonverbal reasoning. PLoS ONE. 2008;3(10):e3566, 1–8. 18. Johnson CM, Memmott JE. Examination of relationships between participation in school music programs of differing quality and standardized test results. J Res Music Educ. 2006;54(4): 293–307. 19. Pantev C, Herholz SC. Plasticity of the human auditory cortex related to musical training. Neurosci Biobehav Rev. 2011;35:2140–2154. 20. Thaut M. Training Manual for Neurologic Music Therapy. Fort Collins, CO: Michael Thaut, Center for Biomedical Research in Music, Colorado State University; 1999. 21. Ropper AH, Samuels MA. Adams and Victor’s Principles of Neurology. 10th ed. New York, NY: McGraw-Hill; 2014. http://accessmedicine​ .mhmedical.com.library.ccf.org/content.aspx​ ?bookid+690&Sectionid=45424414. Accessed August 28, 2014. 22. Nzewi M. Backcloth to music and healing in traditional African society. Voices. 2002;2(2):1–4. https://normt.uib.no/index.php/voices/rt/print​ erFriendly/85/67. Accessed August 18, 2014. 23. Gallagher LM, Steele AL. Developing and using a computerized database for music therapy in palliative medicine. J Palliat Care. 2001;​17(3):​ 147–154.

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24. Gallagher LM, Lagman R, Walsh D, Davis MP, LeGrand SB. The clinical effects of music therapy in palliative medicine. Support Care Cancer. 2006;14:859–866. 25. Gray E. Music: a therapy for all? Perspect Public Heal. 2013;133(1):14. 26. World Federation of Music Therapy. What is music therapy? http://www.musictherapyworld​ .net/WFMT/About_WFMT.html. Accessed August 18, 2014. 27. International Association for Music & Medicine. http://www.iammonline.com. Accessed August 18, 2014. 28. British Association for Music Therapy. What is music therapy? http://www.bamt.org/musictherapy.html. Accessed August 18, 2014. 29. British Association for Music Therapy. Music therapy and neuro-disability. http://www.bamt​ .org/BAMT_Neuro-disability_Oct_12[1].pdf. Accessed August 18, 2014. 30. Music Therapy New Zealand. What is music therapy? http://www.musictherapy.org.nz/. Accessed August 18, 2014. 31. Tsiris G. Music therapy in Greece. Voices: A  World Forum for Music Therapy: Resources. https://voices.no/community/?=country-of-themonth/2011-music-therapy-greece. Accessed August 18, 2014. 32. India’s First. What is music therapy? http://www​ .indiasfirst.com/music-therapy-treatment-india/ index.htm/. Accessed August 19, 2014. 33. Melzack R, Wall PD. Pain mechanisms: a new theory. Science. 1965;150:971–979. 34. Melzack R. Pain and the neuromatrix in the brain. J Dent Educ. 2001;65(12):1378–1382. 35. Melzack R. Pain and stress: clues toward understanding chronic pain. In: Sabourin M, Craik F, Robert M, eds. Advances in Psychological Science, Vol. 2: Biological and Cognitive Aspects. Hove, England: Psychology Press/Erlbaum (UK) Taylor & Francis England; 1998:63–85. Psychology: IUPsyS Global Resource. 2009. http://ebook​ .lib.sjtu.edu.cn/iupsys/Proc/mont2/mpv2ch03​ .html. Accessed January 4, 2014. 36. Bernatzky G, Presch M, Anderson M, Panksepp J. Emotional foundations of music as a non-pharmacological pain management tool in modern medicine. Neurosci Biobehav Rev. 2011;​ 35:1989–1999. 37. Tusek D, Church JM, Fazio VW. Guided imagery as a coping strategy for perioperative patients. AORN J. 1997;66(4):644–649.

38. Lin S-T, Yang P, Lai C-Y, et al. Mental health implications of music: insight from neuroscientific and clinical studies. Harv Rev Psychiatry. 2011;19(1):34–46. 39. Groberman A. Depression. http://www.psyweb​ .com/articles/depression/depression-and-sero​ tonin. Accessed February 22, 2014. 40. Koelsch S. Brain correlates of music-evoked emotions. Nat Rev Neurosci. 2014;15:170–180. 41. DeMarco J. The benefit of music for the reduction of stress and anxiety in patients undergoing elective cosmetic surgery. Music Med. 2012;4(1):44–48. 42. Höller Y, Thomschewski A, Schmid EV, Höller P, Crone SP, Trinka E. Individual brain-frequency responses to self-selected music. Int J Psychophysiol. 2012;86:206–213. 43. Moore KS. A systematic review on the neural effects of music on emotion regulation: implications for music therapy practice. J Music Ther. 2013;50(3):198–242. 44. Trost W, Ethofer T, Zentner M, Vuilleumier P. Mapping aesthetic musical emotions in the brain. Cereb Cortex. 2012;22:2769-2783. 45. Scheiby BB. Analytical music therapy for pain management and reinforcement of self-directed neuroplasticity in patients recovering from medical trauma. In: Mondanaro JF, Sara GA, eds. Music and Medicine: Integrative Models in the Treatment of Pain. New York, NY: Satchnote Press; 2013:149–179. 46. Thaut, MH. Rhythm, Music and the Brain: Scientific Foundations and Clinical Applications. New York, NY: Routledge; 2005. 47. Saur D, Lange R, Baumgaertner A, et al. Dynamics of language reorganization after stroke. Brain. 2006;129:1371–1384. 48. Tomaino CM. Effective music therapy techniques in the treatment of nonfluent aphasia. Ann N Y Acad Sci. 2012;1252:312–317. 49. Conklyn D, Novak E, Boissy A, Bethoux F, Chemali K. The effects of modified melodic intonation therapy on nonfluent aphasia: a pilot study. J Speech Lang Hear Res. 2012;55:1463–1471. 50. Schlaug G, Marchina S, Norton A. Evidence for plasticity in white matter tracts of patients with chronic Broca’s aphasia undergoing intense intonation-based speech therapy. Ann N Y Acad Sci. 2009;1169:385–394. 51. Freedland RL, Festa C, Sealy M, et al. The effects of pulsed auditory stimulation on various gait measures in persons with Parkinson’s disease. NeuroRehabil. 2002;17:81–87.



52. Hausdorff JM, Lowenthal J, Herman T, Gruendlinger L, Peretz C, Giladi N. Rhythmic auditory stimulation modulates gait variability in Parkinson’s disease. Eur J Neurosci. 2007;26:2369–2375. 53. Thaut MH, Leins AK, Rice RR, et al. Rhythmic auditory stimulation improves gait more than NDT/Bobath training in near-ambulatory patients early poststroke: a single-blind, randomized trial. Neurorehabil Neural Repair. 2007;21:​ 455–459. 54. Bethoux F, Stough D, Conklyn D, Butler R. Impact of a home walking program utilizing rhythmic auditory stimulation. Int J MS Care. 2012;​14(2):10. 55. Conklyn D, Stough D, Novak E, Paczak S, Chemali K, Bethoux F. A home-based walking program using rhythmic auditory stimulation improves gait performance in patients with multiple sclerosis: a pilot study. Neurorehab Neural Repair. 2010;24:835–842. 56. Bittman B, Berk L, Shannon M, et al. Recreational music-making modulates the human stress response: a preliminary individualized gene expression strategy. Med Sci Monit. 2005;11(2):​ BR31–40. 57. Loewy J. The use of music psychotherapy in the treatment of pediatric pain. In: Dileo C, ed. Music Therapy & Medicine: Theoretical and Clinical

Music and the Brain

Applications. Silver Spring, MD: The American Music Therapy Association, Inc.; 1999:189–206. 58. Quentzel SJ. Music has charms to soothe a savage beast: an integrative medical-psychiatric perspective on pain and music. In: Mondanaro JF, Sara GA, eds. Music and Medicine: Integrative Models in the Treatment of Pain. New York, NY: Satchnote Press; 2013:11–27. 59. Jackson NA. Backed into a corner: the use of guided imagery and music in the care of a woman with chronic pain. In: Mondanaro JF, Sara GA, eds. Music and Medicine: Integrative Models in the Treatment of Pain. New York, NY: Satchnote Press; 2013:181–192. 60. Heiderscheit A. GIM: Deprivation and its contribution to pain in eating disorders. In: Mondanaro JF, Sara GA, eds. Music and Medicine: Integrative Models in the Treatment of Pain. New York, NY: Satchnote Press; 2013:347–371. 61. Justice RW, Kasayka RE. Guided imagery and music with medical patients. In: Dileo C, ed. Music Therapy and Medicine: Theoretical and Clinical Applications. Silver Spring, MD: The American Music Therapy Association, Inc.; 1999:​ 23–29. 62. Clair AA, Tomaino CM. Education and care: music. http://www.alzfdn.org/EducationandCare/music​ therapy_pr.html. Accessed August 28, 2014.

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Chapter 3 History of Professional Voice Care Gayle E. Woodson

I

t is generally considered that the specialty of laryngology was born when Manuel García, a singing teacher, introduced the technique of indirect laryngoscopy to the medical profession.1 Vocal performance is an ancient art, and performers have sought care for voice disorders throughout history. But the treatment of hoarseness was empirical and traditional until the larynx could be examined, to accurately identify pathology. There are still mysteries and some unsolvable problems in voice care, but in the past century and a half, we have made tremendous progress. There was essentially no scientific basis for the field of voice care prior to the use of indirect laryngoscopy. Over time, advances in voice care have continued to draw and developments in science and technology (Table 3–1). Table 3–1.  Developments That Have Advanced Knowledge in Laryngology Ability to examine the larynx Surgical technology Advances in knowledge of structure and function of the vocal tract Pharmacology Voice therapy Office-based surgical interventions

Laryngeal Examination García’s presentation to the Royal Society of Medicine in 1855 is regarded as a turning point in care of the voice, as it introduced a means of physically examining a living larynx. However, others have made significant contributions to the development of indirect laryngoscopy, both before and after García.2 In 1829, Babington presented a system of mirrors coupled to a tongue retractor that he had developed for examining the larynx, published in his report in The London Medical Gazette.3 This device was not widely accepted, because it was cumbersome and awkward to use. Lyons, in France in 1836, and Liston, in Scotland in 1840, reported using mirrors to examine the larynx. García’s report introduced the use of a common, simple, and ancient instrument, the dental mirror with reflected sunlight for illumination. After García’s report, Turk in Vienna and Czermak in Budapest began to work with mirror laryngoscopy, and Czermak developed a very user-friendly system that employed artificial light. The ability to view the larynx during phonation was fascinating and allowed physicians for the first time to appreciate how the normal voice was produced and how pathology supervened.4 Many types of laryngeal pathologies were beautifully illustrated by physicians who were also artists and skillfully

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24 The performer’s VOICE reproduced what they saw in their laryngeal mirrors. Figure 3–1 is a fanciful sketch by Dr F. J. Knight, one of the founders of the American Laryngological Society. Laryngeal photography was also occasionally accomplished via the laryngeal mirror. Figure 3–2 depicts one of the earliest laryngeal photographs, from a patient with laryngeal paralysis. Through the years, technological advances have improved our ability to examine the larynx. Table 3–2 chronicles the developments in this realm. Highspeed cinematography and stroboscopy were used in research in the early 20th century, but stroboscopy could not be applied clinically until the availability of improved optics in the latter 20th century.5

Rod-lens telescopes provided vastly improved and magnified views of the larynx, with detail comparable to that of operative microlaryngoscopy.6 Flexible laryngoscopy permits laryngeal examination even in patients with unfavorable anatomy or prohibitive gag reflex.7 Both mirror exam and telescopic exam are restricted to use in a narrow range of vocal behavior and sometimes only during phonation of the vowel “ee.” Flexible laryngoscopic examination can be performed throughout a wide spectrum of laryngeal behavior, including connected speech, breathing, cough, and Valsalva. The addition of a camera provided a magnified view and the ability to record the examination for a more detailed review

Figure 3–1.  Drawing by Dr F. J. Knight, circa 1885. Reprinted with permission from the Historical Documents Collection of the American Laryngological Society, http://www.alahns.org/Historical_CD/pages/74_jpg​ .php.

History of Professional Voice Care

Figure 3–2.  Photograph of the larynx in a patient with right recurrent laryngeal nerve paralysis. Photo taken by Dr J. R. French of Brooklyn and presented to Dr J. H. Hooper on June 4, 1885. Reprinted with permission from the Historical Documents Collection of the American Laryngological Association, http://www.alahns​ .org/Historical_CD/pages/3_22_jpg.php.

Table 3–2.  Development of Laryngeal Examination Transoral laryngeal surgery

1852

Mirror laryngoscopy

1854

Direct laryngoscopy

1896

Suspension laryngoscopy

1916

High-speed motion picture

1940

Operative microlaryngoscopy

1950s

Stroboscopy — research

1954

Telescopic laryngoscopy

1974

Fiberoptic laryngoscopy

1979

Videolaryngoscopy

1980+

Stroboscopy — clinical

1980+

Chip camera

2000+

High-speed video clinical use

2007

and a permanent record.8 In the 21st century, the distal chip camera has further enhanced clinical laryngeal examination, providing images that are far superior to any obtained with a fiberoptic laryngoscope. High-definition video produces larger and clearer images obtained by any means. And now high-speed video recording (HSV) has become clinically available. This is a significant advance, because in contrast to stroboscopy, HSV provides a true slowmotion record of vocal fold motion. Stroboscopy illuminates the larynx with bright flashes of light at or near the fundamental frequency of the voice, to produce either a slow-motion view or an image of the vocal fold frozen in one phase of vibration. Stroboscopy cannot be applied in patients with very irregular voices, since there is no regular fundamental frequency to determine the rate of light flashes. HSV captures images at rates of up to 1 000 000 frames per second and thereby records true slow motion, albeit for a very short interval of phonation. Thus, the vibration of the vocal folds can be studied even in patients with very hoarse voices.

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26 The performer’s VOICE

Surgical Technology Just as mirror laryngoscopy permitted the development of laryngeal diagnosis, direct laryngsocopy opened the doors to laryngeal surgery. Green 9 reported transoral removal of a laryngeal polyp in 1852. However, a formal system for operative laryngoscopy, termed autoscopy, was developed by Kirstein and first reported in American literature in 1896.10 Chevalier Jackson popularized operative laryngoscopy in this country and refined the instrumentation.11 The addition of a suspension arm stabilized the operative field and allowed the surgeons to use both hands. The operating microscope not only enhanced surgical precision but also allowed a more detailed examination of the larynx, with better identification of pathology. The concept was pioneered by Albrecht and refined and popularized by Kleinsasser.12,13 Geza Jako developed a laryngoscope that permitted binocular visualization.14 He also developed precision microsurgical instruments. Instrumentation is still evolving to provide precise and atraumatic tissue handling. The development of laser surgery allowed precision, no-touch surgery. This technology has also evolved, with various wavelengths, smaller spot size, and super pulse mode. In the 21st century, laryngologists have increasingly used office-based endoscopic approaches to treat voice disorders in awake patients. For example, atrophic vocal folds can be augmented by percutaneous or transoral injection under videoendoscopic control. Polyps and vascular lesions can be treated by fiberoptic delivery of laser. Such minimally invasive procedures avoid the need for general anesthesia.

Advances in Knowledge of Structure and Function of the Vocal Tract Both voice therapy and laryngeal surgery have benefited tremendously from improved understanding of physiology and anatomy. As mentioned above, the advent of mirror laryngoscopy profoundly stimulated interest in laryngeal diseases and in this country led to the establishment of the American Laryngological

Society (ALA). This provided a forum for laryngologists to present new knowledge and greatly fostered advances in the field. However, in that early era, laryngology was not greatly concerned with voice care because of preoccupation with infectious and neoplastic problems. In addition, there was little or no collaboration between laryngologists and other voice professionals, such as singing teachers. Frequently discussed topics at ALA meetings included diphtheria, syphilis, and tuberculosis. However, there were some discussions of professional voice issues. One paper presented at the fourth annual meeting was titled “On the Singing Voice, Its Physiology, Pathology, and Treatment”15 (Figure 3–3). In 1887, a major portion of the ninth annual meeting of the ALA was dedicated to professional voice care entitled “The Treatment of Laryngitis in Professionals.” Many treatments were recommended, including emetics; astringents; caustics; silver nitrate; perchloride of iron; wine; vaporized zinc, benzoin, turpentine, eucalyptol, and cocaine. Fortunately, the moderator of the session and ALA president, Dr DeBlois, ended the conference by stating, “I have had these professional vocalists under my care, and I have found that, no matter how much zinc is used, or how much turpentine is sprinkled upon the carpet, if they do not rest their vocal organs the hoarseness will continue” (Transactions of the American Laryngological Association, 1887). Despite some sporadic interest in professional voice care, there was little attention devoted to it in the American medical literature. Dr Hans Von Leden has noted that during the 1950s, the reputation of a laryngologist depended to a large degree on how many laryngectomies he had performed.16 Dr Van Lawrence, an otolaryngologist who became physician to the Houston Grand Opera in the 1960s, found little available information or guidance when he began caring for performers (V. Lawrence, personal communication). The field of American voice care benefited significantly from phoniatrists who immigrated from Europe in the mid-century. Hans Von Ledan has said, It is true that in the 1930s and 1940s a number of leading Phoniatricians including Froeschels, Brodnitz, Moses, Weiss and Arnold came to the United States as refugees. It is sad to report

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Figure 3–3.  A page from the Program of the Fourth Annual Congress of the American Laryngological Society, held in Boston, June 12–14, 1882, listing a presentation by Dr S. W. Langmaid, “On the Singing Voice: Its Physiology, Pathology and Treatment.” Reprinted with permission from the Historical Documents of the American Laryngological Association, http://www.alahns.org/Historical_CD/pages/36B3_jpg.php.



28 The performer’s VOICE that most of these distinguished foreign leaders encountered considerable prejudice in addition to difficulties with the English language and with adjusting to totally different academic standards. Over a period of years, only a very few were able to adapt successfully. Paul Moses became the leading voice specialist in California, and his book on the Voice and Neurosis is still a valuable text. Dr. Friedrich Brodnitz became an authority on voice in the city of New York and in the American Academy of Otolaryngology (he became one of my mentors); Arnold was eventually successful in becoming the chairman of a new Department of Otolaryngology in Jackson, Mississippi.16 One development that profoundly facilitated scientific advances in the field was the establishment of the Voice Foundation in 1969. This effort was spearheaded by Dr Wilbur J Gould, and the transactions of those meetings were for years faithfully edited by Dr Van Lawrence. The yearly symposia sponsored by this organization have provided a forum for interdisciplinary collaboration and sharing of knowledge between physicians, speech pathologists, singing teachers, and basic scientists. The rich and varied programs provided a much-needed stimulus to the field (http://www.voicefoundation.org). One particularly significant example of the impact of knowledge on voice care is Hirano’s description of the layered microarchitecture of the vibratory edge of the vocal fold.17 Understanding of the importance of the intricate structure of the lamina propria has driven the development of the microsurgical principles of mucosal preservation, minimal touch. It also explains the profound implications of vocal fold scar. Current research into the biology of the lamina propria will hopefully enable us to rehabilitate the scarred larynx by restoring the submucosal tissues.

Advances in Pharmacology Advances in pharmacology have profoundly benefited voice care. Until the early 20th century, the available treatments for laryngeal inflammation were

meager and lacked scientifically supported rationale. Various topical and inhaled therapies were recommended. Here is an example of a recommended therapy for acute laryngitis: The patient should then put a large bath-towel round his neck and shoulders and, taking hold of his tongue with one corner of the towel, pull well out whilst sitting so that the funnel of the spray is not more than two inches from his open mouth. He should then, while keeping the tongue well out, inhale the vapour deeply into his lungs for five or ten minutes at a time — including also the nose when there is catarrh of that organ — and then get back to bed and roll his head up in the shawl. This can be repeated three times a day.18 Another text recommends these measures for acute laryngitis: Correct the pathology in nose or pharynx, instruct patient in voice use, heroin or codeine for cough suppression, and strychnine as a general tonic and stimulant of vocal cords. It is stated that local treatment is of no avail, except for relief of pain.18 The value of rest and voice retraining was widely recognized as the best treatment for chronic laryngitis, but the details of voice retraining were often proprietary secrets held by recognized experts. One therapeutic textbook published in 1911 made this recommendation for the treatment of chronic laryngitis: “For those who can afford it — it is best to begin treatment by a course at Aix-les-Bains, Mont Dore Ems, or Salsomaggiore, where the local treatment is thoroughly carried out.”18 We currently take for granted the availability of powerful antibiotics, antihistamines, decongestants, and acid-suppressive medication. These drugs provide profound relief, and their efficacy has illuminated the pathogenesis of voice disorders, fueling further progress. For example, the efficacy of proton pump inhibitor therapy provided support for the use of fundoplication surgery in chronic laryngitis, which has proven to be quite effective.

History of Professional Voice Care

Voice Therapy Voice therapy has long been recognized as a vital component of voice care. A 1909 otolaryngology textbook notes that acute laryngitis is “usually met with in males who have been indulging too freely in alcohol and tobacco, or overusing the voice.”19 The best treatment for recurrent laryngitis was voice retraining. In a 1911 textbook, the following is recommended for chronic laryngitis: In the writer’s experience, the greatest good is obtained from skilful massage of the neck an larynx combined with vibration. . . . It is sometimes very difficult to get patients out of their old habits, which is so necessary in these cases before they can learn to produce their voice with a wide-open pharynx and, therefore, without “pinching” or “squeezing.”18 Despite the recognized importance of voice therapy and observed efficacy over many years, it is still not adequately reimbursed by third-party payers. This is difficult to comprehend, considering that one would not consider treatment of many orthopedic disorders without the inclusions of physical or occupational therapy. A major goal of clinical research should be the collection of data to identify and support the efficacy of the best approaches to voice therapy, so that the benefits of voice therapy are more available to those who need them.

Assessment of Voice Quantitative assessment of vocal function is vital for documenting response to treatment of voice disorders, so that we can make progress in improving therapy. Acoustic analysis, standardized perceptual scores, aerodynamic measures, and validated questionnaires have allowed us to answer some important questions, despite the fact that we still do not have voice measures that are as rigorous as the diagnostic audiometric assessment of hearing. Several factors limit our ability to quantitatively assess the voice: acoustic analysis, while objective, is not use-

able in very severe voice disorders. Second, it has not been possible to objectively or quantitatively identify the qualitative parameters that we perceive in voices. Aerodynamic measures hold promise in describing physiologic parameters of voice production, but clinical application lags and no standard parameters have been established.

Summary Advances in voice care have been sparked by breakthroughs in optical technology, fueled by curiosity about the vocal system, and ultimately driven by love and respect for the human voice. The greatest understanding of the voice and vocal disorders will result from continued interdisciplinary collaboration among all those who care for those who treasure their voices.

References 1. Garcia M. Observations on the human voice. Proc R S Med. 1855;7:399. 2. Bailey B: Laryngoscopy and laryngoscopes — ​ who’s first? The forefathers/four fathers of laryngology. Laryngoscope. 1996;106:939–943. 3. Wells WA. Benjamin Guy Babington — inventor of the laryngoscope. Laryngoscope. 1946;56:​ 443–454. 4. Mackenzie M. The Use of the Laryngoscope in Diseases of the Throat. Philadelphia, PA: Lindsay and Blakiston; 1865:9. 5. Moore GP. Vocal fold movement during vocalization. Speech Monogr. 1937;4:44–55. 6. Ward P, Berci GI, Calcaterra TC. Advances in endoscopic examination of the respiratory system. Ann Otol Rhinol Laryngol. 1974;83:754–760. 7. Sawashima M, Hiorse H. New laryngoscopic technique by use of fiberoptics. J Acoust Soc Am. 1968;43:168–170. 8. Yanigasawa E, Casuccia A Jr, Suzuki M. Videolarlyngoscopy using a rigid telescope and video home system color camera: a useful office procedure. Ann Otol Rhinol Laryngol. 1981;90:​ 346–350.

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9. Green H, ed. Morbid growths within the larynx. In: On the Surgical Treatment of Polypi of the Larynx, and Oedema of the Glottis. New York, NY: Putnam, 1852:56–65. 10. Scheppegrell W. A new communication upon autoscopy of the respiratory passages — examination of the larynx and trachea without a mirror. Laryngoscope. 1896;1:370. 11. Jackson C, Jackson CL. Disease and Injuries of the Larynx. New York, NY: Macmillan; 1942:330. 12. Albrecht R. Uber den Wert kolposkopischer Untershchungsmethoden bei Leukoplaken und Carcinomen des Mundes und Kehlkopfes. Arch Ohrenheilk. 1954;164:459–463. 13. Kleinsasser O. Mikrochirurgie im Kehlkopf. Arch Ohrenheilk. 1964;183:428–433. 14. Jako GJ. Laryngoscope for microscopic observation, surgery, and photography. Arch Otolaryngol. 1970;91:196–199. 15. Langmaid SW. On the singing voice, its physiol-

ogy, pathology, and treatment. Paper presented at: Transactions of the Fourth Annual Congress of the American Laryngological Association; June 14, 1882; Boston, MA. 16. von Leden H. 100 Years of German phoniatry and pediatric audiology: a tribute to Professor Herman Gutzmann, Sr. Paper presented at: XXIV Kongress der Union Eurpoaischen Phoniater; September 16–18, 2005; Berlin, Germany. http:// www.phoniatrie2005.com/gruss_leden.htm 17. Hirano M. Phonosurgical anatomy of the larynx. In: Ford CN, Bless DM, eds. Phonosurgery. New York, NY: Raven Press; 1991. 18. Hutchinson R, Collier H. An Index of Treatment by Various Writers. New York, NY: William Wood; 1925:539–542. 19. Packard FR. Inflammatory conditions of the larynx. In: Packard FR, ed. Diseases of the Nose, Throat, and Ear. Philadelphia, PA: Lippincott; 1909:223–233.

Chapter 4 Anatomy of the Vocal Mechanism: Structure of the Voice Nicolas E. Maragos

T

he mechanism that produces voice is, on the surface, a rather mundane structure that mostly is taken for granted. We know intuitively that everyone’s voice is a little bit different, but even though we use the sound of someone’s voice to figure out very quickly who is on the telephone, and whether or not they are sick or tired or worried or in a hurry, we still do not think much about it. For the singer, however, and for others who tend to stretch the vocal mechanism “to the limit,” the voice and its health take on added importance. To understand the conditions that may do harm to the voice, we must, therefore, understand what it is that produces the best sound over the course of a lifetime. Thus, the study of the anatomy of the vocal mechanism is paramount to understanding the basics of vocal health, hygiene, and preservation of our gift of voice.

Vocal Mechanism as a Whole Although the larynx (“voice box”) generates the vocal sound, it is neither the beginning nor the end of the vocal mechanism. Voice production involves 3 rather separate and yet intricately coupled physiologic systems: the sound power source (lower

respiratory system), the sound production system (larynx), and the sound-modifying system (all structures above the larynx). Before delving into the finer details of the larynx itself, we should spend some time understanding the anatomy of the remainder of the vocal mechanism and primarily the lower respiratory system since articulation and resonance are covered in a later chapter. Voice is produced when the lining tissue of the vocal folds, the mucosa, is put into oscillation and changes a steady stream of air into a rhythmically interrupted airstream.1 The air, of course, has to come from the lungs, and the power pushing the air out of the lungs comes from the contraction of the abdominal and chest muscles, relaxation and recoil of the diaphragm, and an intact neurologic system that coordinates and controls this movement. Since motor nerves must innervate motor muscles to cause them to move (contract), anything that blocks the nerves of inspiration and expiration either partially or completely will cause airflow problems. Normal exhalation takes place with a larger flow of air at the beginning of exhalation and a quickly decreasing flow thereafter. This pattern is fine for quiet breathing, but for a smooth, stable, and prolonged vocal output, the airstream needs to be modified for a steadier flow. Thus, anything that hampers the normal

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32 The performer’s VOICE action of the diaphragm, chest, or abdominal muscles may have a great impact on the voice. The action of diaphragmatic contraction is mediated through the phrenic nerves on both sides. The phrenic nerves are a mix of motor nerves from the third through fifth cervical roots (C3–C5) in the neck and come directly out of the spinal cord through spaces between the vertebral bodies (spinal column).2 Branches from roots C3 to C5 combine into a single nerve high in the neck on each side, travel downward in the neck to the posterior mediastinum between the lungs, and finally lie next to the heart before reaching the top surface of the diaphragm. Because the diaphragm is dome-shaped curving upward, contraction of the diaphragm through phrenic nerve stimulation leads to an increase in size of the chest cavity and inhalation.3 Thus, if one or both phrenic nerves are injured or weakened, the person is not able to breathe in to stay alive. The most recent well-known individual with this condition was actor Christopher Reeve, whose spinal cord was injured above C3, that is, above the formation of the phrenic nerves. He spent his last years on a portable respirator because of his total loss of diaphragmatic function. The intercostal muscles of the chest and the abdominal muscles also receive their motor nerve supply through the spinal nerve roots exiting the spinal column farther down. The intercostals span the distance between adjacent ribs and pull the ribs together when they contract. The abdominal muscles surround the abdominal contents and squeeze everything inward during contraction. The balance of tension between the abdominals and intercostals, on one hand (pushing air out), and the diaphragm, on the other (pulling air in), is what voice professionals and, especially, singers spend years mastering. A deficit in this part of the vocal mechanism will, therefore, lead to a decrease in peak performance and a less than optimal vocal output.

Vocal Mechanism at the Center “The living voice is that which sways the soul” (Pliny the Younger — Letters. Book ii. Letter iii.). Educators, writers, and philosophers from ancient civilizations

understood well the meaning and essence of voice. From Pliny the Younger’s quote from 103 ad to Henry Wadsworth Longfellow’s 19th-century quote that “the human voice is the organ of the soul,” people knew there was something special about good vocal production. At the center of euphonia (“good sound”) is the larynx, and it follows that a normal or near-normal laryngeal organ must be available for the voice user to produce the sounds that sway the soul of the listener. The larynx is a composite structure situated in the mid-neck, or rather suspended in the neck from the skull above. Muscles connected to the larynx from both above and below act upon it to change its position in the neck and help it carry out its 3 vital functions: airway closure during swallowing, airway opening during breathing, and airway modulation during voicing. These outside (extrinsic) muscles are often those that the voice teacher, either consciously or unconsciously, tries to manipulate to improve the student’s voice. Those muscles that raise the larynx in the neck are called elevators, and those that lower the larynx are named depressors. The hyoid bone at the top of the larynx is the primary point of attachment of these elevators and depressors. The names of these suprahyoid (above) and infrahyoid (below) muscles are not important to the student, but speech pathologists, voice therapists, and voice teachers need to be reminded of their existence and the great value (or harm) that may come to the student if these muscles are injured, too tense, or malfunctioning in any way.

Vocal Mechanism: External Support The larynx by definition includes those bony, cartilaginous, and internal soft tissue structures spanning from the top of the hyoid bone to the bottom of the cricoid cartilage (Figure 4–1). The rigid external skeleton from superior to inferior includes the hyoid bone, thyroid cartilage, and cricoid cartilage. These structures form a semirigid tube that normally can be bent forward and shortened in a superior/ inferior direction but cannot be bent from side to side. This tube is also rigid when rotated, making it



Anatomy of the Vocal Mechanism:  Structure of the Voice

Epiglottis Hyoid bone Superior horn of thyroid cartilage Thyrohyoid membrane

Superior thyroid notch Thyroid cartilage lamina

Cricothyroid ligament Inferior horn of thyroid cartilage Cricoid cartilage Trachea

Figure 4–1.  External structure of the larynx, anterior view.

possible to operate on the posterolateral larynx with this maneuver in the awake patient. All the internal cartilaginous and soft tissue structures are attached to the thyroid and cricoid cartilages or are supported by them through a system of muscles, ligaments, and membranous sheets of thicker fibrous tissue. The thyroid cartilage is the largest cartilage of the larynx and is formed by 2 relatively flat and broad plates of cartilage fused anteriorly at the midline of the neck. It connects posteriorly to the hyoid bone above and the cricoid cartilage below through 2 pairs of horn-shaped projections, the superior and inferior cornua, respectively. The superior cornu attaches to the hyoid bone above through a ligament on each side, the lateral thyrohyoid ligament, as part of the suspensory system of the larynx mentioned earlier. The inferior cornu forms a joint with the cricoid cartilage on either side, the cricothyroid joint, which allows the forward flexing of the thyroid cartilage on the cricoid cartilage but not sideways flexing. The anterior angle of the 2 lamina of the thyroid cartilage are different in men (90°) than in women (120°), hence the greater protrusion of the man’s thyroid cartilage, which prompts the term

Adam’s apple. The cricothyroid joints, as we learn in a later chapter, are important for the normal action of the cricothyroid muscles during vocal pitch modulation. Two of the most important structures of the larynx are the paired cricoarytenoid joints (Figure 4–2). As their name implies, these joints connect the cricoid cartilage to the arytenoid cartilages. Located posteriorly and just below the level of the vocal folds, these joints support arytenoid movement, including a gliding motion for adduction and abduction of the vocal folds, tilting forward and backward to put the vocal processes in better vertical alignment during phonation, and a rotation around a semivertical axis. The cricoarytenoid joint capsule and, in particular, the posterior cricoarytenoid ligament hold each arytenoid in place on top of the cricoid.4 Without this support, the arytenoid would fall into the larynx from its rather precarious perch atop the cricoid. Abnormalities of these joints (scarring, arthritis, etc) will impact laryngeal function by affecting vocal fold movement and position. Better treatment of these problems is one of the future directions in laryngeal surgery.

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Corniculate cartilage

Muscular process Vocal process

of arytenoid cartilage

Cricoid cartilage

Figure 4–2.  Cricoarytenoid joints, anterosuperior view.

Vocal Mechanism: Internal Support The study of medicine and human anatomy may be daunting and, at times, confusing, but the language of medicine is actually very simple once one understands a few rules of the system.5 Muscles, ligaments, and membranes connecting 2 rigid structures (cartilage or bone) are named using the names of the connected parts. Muscles have a beginning (origin) and an end (insertion), pull toward their origin, and are named using the roots of the structure of origin first and then the structure of insertion. Thus, the muscle that originates on the inside surface of the thyroid cartilage and inserts on the vocal process and anterior body of the arytenoid cartilage is named the thyroarytenoid muscle, not the arytenothyroid muscle. Ligaments and membranes follow the nomenclature of the muscles. The arytenoid cartilages are the heart of the larynx. The attachments to these paired cartilages include the muscles, ligaments, and fibrous tissue important in voice production. The arytenoid cartilages are mostly pyramidal in shape with 3 processes or points of attachment to other structures. These are the vocal process anteriorly, the muscular process laterally, and the superior process.6 The vocal process protrudes from the anterior portion of the arytenoid body and attaches to the medial thyroarytenoid muscle and ligament (vocalis mus-

cle and vocal ligament; Figure 4–3). Attached to the muscular processes are the lateral and posterior cricoarytenoid muscles, and spanning the distance between the arytenoid cartilages posteriorly is the interarytenoid muscle. These latter muscles position the arytenoid cartilages in the airstream to facilitate breathing, swallowing, and voicing. As mentioned above, the vocal folds are suspended between the thyroid cartilage anteriorly and the arytenoid cartilages posteriorly at the vocal processes of the arytenoids.7 The thyroarytenoid muscle constitutes most of the body of the vocal fold and acts to pull the arytenoid toward the thyroid cartilage to both shorten the length of the vocal fold and bulk it up isometrically. The lateral cricoarytenoid muscle arises from the anterior and lateral cricoid cartilage and inserts onto the laterally placed muscular process of the arytenoid, whereas the posterior cricoarytenoid muscle arises from the posterior surface of the cricoid cartilage and also inserts onto the muscular process (Figure 4–4). Contraction of these muscles moves the arytenoid into its various positions so that the larynx may complete its normal functions. Finally, contraction of the interarytenoid muscle will pull the arytenoids closer to each other and fill the interarytenoid space with folds of overlying soft tissue and mucosa, thus effectively obliterating any opening between these cartilages. All the above-mentioned muscles obtain their motor nerve supply from the recurrent laryngeal nerve on each side.6 The last intrinsic laryngeal

Arytenoid cartilage

Muscular process Vocal process

Cricoid cartilage

Posterior cricoarytenoid muscle Lateral cricoarytenoid muscle Transverse and oblique Interarytenoid muscles Cricoarytenoid muscles Thyroarytenoid muscle Vocalis muscle Vocal ligament

Thyroid cartilage Superior view

Figure 4–3.  Internal muscles of the larynx, superior view.

Thyroepiglotticus

Aryepiglotticus Transverse arytenoideus

Oblique arytenoideus

Posterior cricoarytenoideus

Lateral thyroarytenoideus Lateral cricoarytenoideus

Cricothyroideus (removed)

Figure 4–4.  Intrinsic muscles of the larynx, posterior oblique view. Reprinted with permission, Tucker HM. The Larynx. New York, NY: Thieme Medical Publishers; 1987:14. http://www.thieme.com.

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36 The performer’s VOICE muscle affecting the voice, the cricothyroid muscle, acts indirectly on the vocal fold. It is situated on both sides in the anterolateral space between the cricoid and thyroid cartilages. Its motor nerve supply is through the external branch of the superior laryngeal nerve. Cricothyroid muscle contraction raises the tension of the vocal fold by increasing the distance between the vocal process of the arytenoid and the anterior attachment of the vocal ligament and thyroarytenoid muscle to the thyroid cartilage. This is accomplished through the cricothyroid joint mentioned earlier, a joint that allows pivoting and anterior flexion of the thyroid cartilage upon the cricoid. Alterations in cricothyroid muscle strength or imbalance of strength between the right and left sides is probably the most overlooked deficit of the vocal mechanism but one that is extremely important to singers and other voice users alike. Some laryngeal structures are not directly responsible for vocal production. However, they do impact the resonating quality of the voice, especially if they “get in the way” of the outflow from the larynx. These structures are the epiglottic cartilage and the paired false cords (ventricular folds). The epiglottis sits anteriorly and above the vocal folds and is attached by its petiole to the inside of the thyroid cartilage, while the false cords reside above and lateral to the vocal folds. The primary purpose of these supraglottic (above the vocal folds) structures is to help protect the airway during swallowing. However, they may partially or totally obstruct the vocal output in those patients with, for example, muscle tension dysphonia or spasmodic dysphonia, and without an easy airflow out of the larynx, the voice will be impaired. The medial thyroarytenoid muscle and the vocal ligament make up the body of the vocal fold over which the flexible mucosa of the vocal fold moves. Ultrastructural studies have shown a division of the submucosal fibrous tissue in this area, also called the lamina propria, into 3 distinct parts: superficial, middle, and deep layers (Figure 4–5). The superficial layer of the lamina propria is the most important of these layers, for its sparse and pliable collagen binds this tissue loosely and allows the shearing force from the airstream out of the lungs to rhythmically open and close the airspace between the vocal

folds during normal phonation. Sound production without this movement leads to a dysphonic voice. The middle and deep layers of the lamina propria are important because of their increased ability to produce thicker fibrous tissue (scarring) after injury, thus having a negative impact on the voice.

Vocal Mechanism: Vascular and Physiologic Support The arterial blood supply to the larynx comes mostly from the inferior thyroid artery through its inferior laryngeal branch.6 After entering the larynx posterolaterally with the anterior branch of the recurrent laryngeal nerve just above the cricothyroid joint on both sides, this artery joins branches from both the cricothyroid artery anteriorly and the superior laryngeal artery superiorly to form a rich anastomosis inside the thyroid cartilage.8 As these vessels further divide into smaller and smaller vessels, they finally reach the submucosal tissue and, in the vocal fold, they run parallel to the edge. The capillary supply to the vocal folds and surrounding structures brings nutrients in and takes metabolic waste products away, but it also removes the heat generated in the mucosa from the energy expended during phonation (mechanical movement, muscle contraction). Increased capillary flow, however, is not the most efficient way to protect the vocal folds from harm. Mucous glands occupy the superior mucosa of the anterior vocal fold in the ventricle, and the mucus secreted there is used for cleaning, lubricating, and protecting the vocal folds. Thus, the anatomy of an area of the body and its physiologic function once again go hand in hand.

Vocal Mechanism: Neurologic Support The peripheral motor nerve supply to the larynx is well known and has been mentioned already. The internal laryngeal muscles are supplied by the vagus nerve, which gives off 2 branches to the larynx before



Anatomy of the Vocal Mechanism:  Structure of the Voice

Statified squamous eqithelium MUCOSA EPITHELIUM

LAMINA PROPRIA Superficial layer Intermediate layer Deep layer

VOCALIS MUSCLE

Ciliated columnar epithelium

Figure 4–5. Ultrastructure of the vocal fold. Reprinted with permission, Hirano M. Phonosurgery — Basic and Clinical Investigations. Fukuoka, Japan: Otologia; 1975:241.

it continues downward to supply the rest of the gastrointestinal (GI) tract.9–11 These are the superior and inferior (recurrent) laryngeal nerves. The superior laryngeal nerve (SLN) further divides into an internal sensory branch and an external motor branch. The internal branch enters the larynx between the hyoid bone and thyroid cartilage and pierces the thyrohyoid membrane 1 cm in front of the superior cornu of the thyroid cartilage (Figure 4–6). It carries information from touch-sensitive receptors, heatsensitive (thermal) receptors, and mucosal receptors sensitive to chemical changes back to the brainstem. In addition, it picks up information from the internal muscles and joints of the larynx as well. Meanwhile, the external branch of the SLN is dedicated to sup-

plying motor innervation to the cricothyroid muscle but also picking up sensory information from the anterior subglottic mucosa.12 The inferior or recurrent laryngeal nerve (RLN) takes its name from its course through the neck and into the upper chest and its subsequent looping around the aortic arch on the left and the subclavian artery on the right. It then “recurs” in the lower neck, running in the groove between the trachea and the esophagus and traveling upward to finally reach the posterolateral larynx.13 As the RLN reaches its target muscles, it sends motor fibers in succession to the posterior cricoarytenoid muscle, the interarytenoid muscle, the lateral cricoarytenoid muscle, and the thyroarytenoid muscle. It also has sensory branches

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38 The performer’s VOICE

Superior laryngeal nerve

Internal branch External branch

Inferior pharyngeal constrictor muscle Cricothyroid muscle Cricopharyngeus muscle (part of inferior pharyngeal constrictor) Recurrent laryngeal nerve

Figure 4–6.  Innervation of the larynx, right lateral view.

connecting to the subglottic mucosal sensory receptors and the internal laryngeal muscles. If the patient has a congenital anomaly of the right subclavian artery, a “nonrecurrent” RLN will be present.14 However, the RLN always enters the larynx just above the cricothyroid joint to gain access to the internal muscles that it must innervate.

Summary The vocal mechanism is an intricate system of balances between the abdomen, chest, neck, and head. It is no wonder that physicians and philosophers throughout recorded time have marveled at the human ability to communicate vocally with other people. The voice is part of our individual identity, and to protect that part of our identity, we must,

therefore, understand how the voice works and how to maintain it throughout our lives. Learning vocal anatomy is the fundamental step in preserving our gift of voice and one well worth taking.

References 1. Tucker HM. The Larynx. New York, NY: Thieme Medical Publishers; 1987:136–137. 2. Anson BJ, ed. Morris’ Human Anatomy. 12th ed. New York, NY: McGraw-Hill; 1966:1059. 3. Anson BJ, ed. Morris’ Human Anatomy. 12th ed. New York, NY: McGraw-Hill; 1966:30. 4. Sellars I, Sellars S. Cricoarytenoid joint structure and function. J Laryngol Otol. 1983;97:1027–1034. 5. International Anatomical Nomenclature Committee. Nomina Anatomica. 6th ed. Edinburgh, UK: Churchill Livingstone; 1989. 6. Anson BJ, ed. Morris’ Human Anatomy. 12th ed. New York, NY: McGraw-Hill; 1966:1409–1427. 7. Hirano M. Phonosurgery — basic and clinical investigations. Otologia (Fukuoka). 1975;21:​239–298. 8. Mihashi SK, Okada M, Kurita S, et al. Vascular network of the vocal cord. In: Stevens KN, Hirano M, eds. Vocal Fold Physiology. Tokyo, Japan: University of Tokyo Press; 1981:45–58. 9. Strong MS, Vaughan, CW. The morphology of the phonatory organs and their neural control. In: Stevens KN, Hirano M, eds. Vocal Fold Physiology. Tokyo, Japan: University of Tokyo Press; 1981:13–20. 10. Tyler HR. Neurology of the larynx. Otolaryngol Clin North Am. 1984;17:75–79. 11. Kambic V, Zargi M, Radsel Z. Topographic anatomy of the external branch of the superior laryngeal nerve: its importance in head and neck surgery. J Laryngol Otol. 1984;98:1121–1124. 12. Wallach JH, Rybicki KJ, Kaufman MP. Anatomical localization of the cells of origin of efferent fibers in the superior laryngeal and recurrent laryngeal nerves of dogs. Brain Res. 1983;261:307–311. 13. Caiot P, Bousquet V, Cabanie P, et al. The nerve loops crossing below the subclavian artery and their anatomical variations. Anat Clin. 1984;6:​ 209–213. 14. Saunders G, Uyeda RY, Karlan MS. Nonrecurrent inferior laryngeal nerves and their association with a recurrent branch. Am J Surg. 1983;146:​ 501–503.

Chapter 5 Physiology of Voice Production: How Does the Voice Work? Jack Jiang

T

he production of voice requires the interaction of many physiological processes whether one sings an aria or simply has a conversation. Most commonly, the word phonation conjures images of vibrating vocal folds. The vocal folds serve as an energy transducer; they are responsible for converting aerodynamic power into acoustic power. There are many other contributors to speech, however. The aerodynamic power necessary for voice production is generated subglottally by the chest, thorax, and abdomen. Then, above the vocal folds, resonators modulate the sound into a human voice. This chapter looks more in depth at how these physiological processes interact to create the voice and how singers can control and master their voices.

Theories of Phonation Theories and models of vocal fold vibration have undergone considerable development over the past 150 years. As early as 1741, the vocal folds were demonstrated to be the source of sound production.1 A model from the 1950s termed the neurochronaxic theory described each vibration as being controlled by individual nerve pulses.2 The neurochronaxic theory

has now been rejected in favor of more empirically validated models, namely, the myoelastic-arodynamic theory and the body-cover theory.

Myoelastic-Aerodynamic Theory Published in the late 1950s,1 the myoelasticaerodynamic theory is now one of the most widely accepted theories for how vocal fold vibration is initiated and maintained. This theory is most appropriately studied by breaking it into its two components. Myoelastic refers to the gross neuromuscular structure control of vocal fold tension and elasticity during phonation. Regulation of elasticity in turn influences the vibration characteristics of the vocal folds. Muscular control over how close the vocal folds are held is also important. During normal exhalation, the vocal folds are about 60% apart, or abducted.3 During phonation, the muscles are contracted to adduct (bring together) the vocal folds into the stream of airflow. By controlling the configuration of the glottal aperture (opening between the vocal folds), the body can influence pressure differences above and below the glottis. This helps drive the aerodynamic features of vocal fold vibration.

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The aerodynamic component of this theory emphasizes the role of fluid dynamics during phonation, specifically the continuity law and Bernoulli’s principle. The continuity law assumes an incompressible flow confined in a duct. At all points in the duct, flow must be equal; this is the proverbial “what goes in must come out.” Airflow is equal to the cross-sectional area multiplied by the particle velocity. Therefore, if the duct narrows, the velocity must increase proportionally to maintain contact flow (Figure 5–1). In algebraic form: v1A1 = v2 A2 = constant where v is the particle velocity and A is the crosssectional area at a given point.4 This leads to Bernoulli’s principle, which deals with the conservation of energy of a flow confined

in a pipe. At any point in the flow, the total energy of the fluid is composed of two components: the kinetic energy due to particle flow and the potential energy due to the pressure on the walls of the pipe. Total energy in the fluid must be conserved. Thus, when the particle velocity increases at a constriction and the kinetic energy of the fluid increases, the potential energy of the fluid must decrease. This is observed by a reduction in pressure on the walls of the pipe. This is especially relevant during the opening and closing of the glottis during phonation; as air passes through the narrowed glottis, it increases in velocity and decreases the pressure exerted on the glottal walls.4 At a simple level, Bernoulli’s forces are credited for maintaining vocal fold oscillation. As air passes through the narrowed glottis, the particle velocity increases (continuity law) and the pressure subse-

Figure 5–1. Bernoulli effect. As an incompressible flow enters a constriction, flow must remain constant. This is accomplished by increasing velocity, as represented by the dashed line, proportionally to the reduction in area. The high and low pressures and velocities are indicated with the changes in area. The gauges beneath the diagram indicate relative pressure at each point in the tube.



Physiology of Voice Production: How Does the Voice Work?

quently drops (Bernoulli’s law). This reduced pressure draws together and collapses the vocal folds. When the subglottal pressure builds up, it reportedly flows the vocal folds apart and allows the cycle to repeat. This repetitive process goes on hundreds of times each second of phonation. This explanation is inadequate, however. Bernoulli forces are present in the glottis without preference to whether it is opening or closing. Although these forces are effective for drawing the vocal folds together, they ultimately will lead to vocal fold damping. In other words, the Bernoulli forces are such that, instead of maintaining vibration, they will eventually lead the vocal folds to rest. The additional input necessary to maintain vibration comes from the supraglottal air column. The air column has a degree of inertance, or resistance to change. When air passes through the glottis, it collides with the stagnant air particles already in the supraglottal air space. This creates an area of high pressure (a compression) that aids in driving the vocal folds together. Similarly, when the vocal folds collide with each other, they cut off airflow, but the air above the glottis continues to move forward. This creates an area of low pressure (a rarefaction) that aids vocal fold reopening.4 These forces can all be incorporated into an explanation of how vocal fold vibration takes place (Figure 5–2). To initiate phonation, the vocal folds are adducted so there is only a narrow channel between them. As expiratory pressure builds up from the lungs at the glottis, the air pressure pushes against the elasticity of the vocal folds. Eventually, the pressure reaches the minimum pressure needed to begin vibration, the air pushes the vocal fold tissue aside, and air flows through the vocal folds. The difference between the subglottal and supraglottal pressures combined with the deflection of the vocal fold mass creates a positive pressure, which draws air up through the trachea. As described by Bernoulli’s law, the airflow increases in velocity as it flows through the narrowed glottis. As air escapes through the glottis from the subglottal reservoir, the subglottal pressure decreases, thus decreasing the force holding the vocal fold apart. The Bernoulli effect generates a negative force, which pulls the vocal folds medially together again. Also, closure is aided by the passive recoiling

(elasticity) of the vocal fold as they return to the position they were held in before being deformed by the transglottal pressure.5 When the vocal folds are drawn medially together, they once again obstruct the airflow, and the cycle repeats itself in what is termed the glottal cycle. The key point of the myoelastic-aerodynamic theory is that each glottal cycle is repeated without the need for repetitive muscular contraction after the vocal folds are initially brought together. Vibration is maintained through aerodynamic principles. The number of times the vocal folds open and close each second is referred to as the frequency. The average frequency is 110 Hz in males and 200 Hz in females, but the human voice has a tremendous range and depends on many complex interactions.5 The Bernoulli theory suggests that the effective mass and tension of the vocal folds, which are under neuromuscular control, are the most important factors for controlling frequency.

Body-Cover Theory The body-cover theory asserts that the 5 layers of the vocal folds can be classified into 2 groups to help account for vocal fold motion (Figure 5–3). The cover consists of the epithelium and the superficial and intermediate layers of the lamina propria. The cover is noted for being pliable and elastic but not muscular and therefore not contractile. The deep layer of the lamina propria and the thyroarytenoid muscle fibers comprise the body. Active contractile properties of the body allow for adjustments of stiffness and concentration of mass.6 The morphological structure of the vocal folds is important for controlling the tension of the vocal folds. The effective tension relies on the coupling of the vocal fold cover to the adjustable body. When the thyroarytenoid contracts, the body stiffens.7 This contraction causes the distance between the arytneoids and the thyroid to shorten, so the cover becomes lax and pliable. The influence of the thyroartytenoid contraction on the fundamental frequency depends on the depth of vocal fold movement. If vibration is occurring primarily at the cover level, contraction of the thyroarytenoid will make it more lax and thus lower the fundamental frequency. If vibration

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42 The performer’s VOICE

Figure 5–2.  Vocal fold movement during one complete cycle. Beginning at the left, the vocal folds are adducted, followed by opening of the lower margins, opening of the upper margins, closure of the lower margins, and finally, closure of the upper margins. Adapted from Vocal Parts Software. Blue Tree Publishing Web site. http://www.bluetreepublishing.com/Details.cfm?ProdID=65. Accessed April 3, 2015.

is deeper, however, and involves the body of the vocal folds, the increased tension for contraction of the thyroarytenoid will lead to an increase in fundamental frequency.8 The body-cover theory is used to account for the very large number of modes of vibration possible in the human vocal folds. Due to the loose coupling between the cover and the body, the cover can move independently of the body in an extremely variable

ripple of tissue deformation.6 This nonuniform tissue movement is characterized by normal modes of vibration, which detail the vibration patterns of the vocal folds. For instance, the lower margins of the vocal folds typically lead the upper margins in opening and closing of the vocal folds. This creates an alternation between convergent (closed at the top) and divergent (closed at the bottom) shapes in the vocal folds whose asymmetry helps to sustain the oscillations.4



Physiology of Voice Production: How Does the Voice Work?

Epithelium Cover

Body

Superficial lamina propria Intermediate lamina propria Deep lamina propria Thyroartenoid muscle

Figure 5–3.  Layers of the vocal folds. The epithelium and superficial and intermediate layers of the lamina propria comprise the cover while the deep layer of the lamina propria and the thyroarytenoid muscle comprise the vocal fold body.

The more flexible the vocal folds are, the more potential there is for self-oscillation, and consequently, the more difficult it is to describe their movement. Current study of the vocal folds lacks consensus on the contribution of nonlinear dynamics to the vibration; multiple variables likely interact as either linear interactions of nonlinear systems or nonlinear interactions of linear systems.5 Chaos theory (fractal analysis) has been employed to try to explain the complexity and redundancy of vibratory patterns.9

Mucosal Wave Movement In addition to the theories detailing how vibration is maintained, there is a clear model detailing how the vocal fold mucosa opens and closes in a wavelike pattern (Figure 5–4).10 It is a common misconception that the sound produced by the vocal folds is a direct result of their vibration, much like a vibrating guitar string. On the contrary, the sound produced by the vocal folds is the result of small bursts of air that escape while the vocal folds vibrate. The vibration consists of an alternating sequence of medial (clos-

ing) and lateral (opening) movements. The asymmetry of these movements, which begin at the lower margins and travel to the upper margins of the vocal folds, helps to maintain oscillation. This movement is termed the mucosal wave because of its similarity to how waves travel in a fluid media.5 Canine larynges have been studied with video­ stroboscopy and high-speed video to show how different variables affect the mucosal waveform. Mucosal wave velocity has been shown to increase with vocal fold lengthening,11,12 greater airflow,11 greater subglottal pressure,13 and laryngeal muscle contraction associated with higher fundamental frequency.13

Phonatory Inputs The vocal folds are often thought of as the source of voice. Although they are essential in the conversion of aerodynamic power to acoustic power, the vocal folds do not act alone. Voice production requires contributions from subglottal pressure, the vocal folds, and supraglottal resonators.

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Figure 5–4.  Measurement of the mucosal wave. The first panel is a superior view of the glottis on high-speed video. A single pixel line (red line) is then plotted over time in the second pane. Here we can visualize the movement of this point along the vocal folds. By fitting curves (as in pane 3), we can measurement movement of the upper and lower margins of each vocal fold.

Subglottal Pressure Vocal fold vibration is powered by subglottal aerodynamic inputs. When intrathoracic pressure exceeds atmospheric pressure, there is a positive subglottal pressure. This subglottal pressure is primarily controlled by the lower respiratory airway, particularly the elastic properties of the chest walls and the active muscular contraction of the chest, diaphragm, and abdominal muscles. However, changes in the larynx and upper airway can also influence subglottal pressure. These changes are dynamic and influence the phonation threshold pressure and glottal

resistance. To respond to these changes, there must be complex and rapid feedback systems. Although not fully understood, feedback systems may include a combination of pressure sensors, proprioreceptive sensors, muscle tension/stretch sensors, and auditory sensors.5 This feedback helps the body to regulate the amount of subglottal pressure required to start phonation. The phonation threshold pressure, the minimum subglottal pressure required to initiate and sustain vocal fold vibration, is very important in the study of phonation. A low phonation threshold pressure means that relatively little respiratory effort is required to drive vocal fold vibration. The phonation threshold pressure decreases when there is a decreased prephonatory glottal width (the vocal folds are closer together), the viscosity of the vocal folds is decreased,14 the thickness of vocal folds is increased, or when the pitch is lowered. Phonation threshold pressure is elevated in dehydrated vocal folds,15 patients with vocal polyps,16 and patients with Parkinson’s disease.17 This necessary subglottal pressure cannot be generated without glottal resistance, which is the ratio of transglottal pressure to transglottal airflow. This ratio was originally constructed in an effort to define something invariant about the glottal region of the airway. However, it has been difficult to tabulate due to the large number of geometric factors that affect the ratio, including glottal width and shape.4 A more useful number to characterize flow through a constricted area, such as the glottis, is a measure called the Reynold’s number. This number is defined as Re =

vd µ

where Re is Reynold’s number, v is air particle velocity, d is the effective diameter of the constriction, and μ is the kinematic viscosity. When Reynold’s number exceeds a certain critical value, the fluid exiting the constriction will exhibit turbulent flow, like raging whitewater. Below the critical value, fluid exiting the constriction will exhibit laminar or steady flow (Figure 5–5). Usually, the flow resistance increases with turbulent flow because of the increased energy dissipa-



Physiology of Voice Production: How Does the Voice Work?

Figure 5–5. Reynolds number. A. If the speed of air is slow enough and the glottis wide enough, air exiting the glottis will exhibit laminar flow in parallel sheets. B. If these factors combine to give a Reynold’s number above the threshold, turbulent flow will result.

tion. This can be useful for phonating certain sounds, like [h], but is not desirable for other sounds such as vowels.4 It should be noted that most singers attempt to maintain laminar flow throughout phases in the music.

Biomechanical Properties of Vocal Folds Vibration of the vocal folds is a complex process whose characteristics are modulated by the biomechanical properties of the vocal folds. Specifically, the mass, stiffness, and viscosity of the vocal folds are important to regulating their vibration. The fundamental frequency of vibration is inversely related to mass, defined as the amount of vocal fold material that is effectively vibrating. While the actual mass of the vocal folds is fairly constant except in cases of edema or growths, the mass per unit length is easily modifiable. Longitudinal stretching of the vocal folds, caused by contractions of the cricothyroid muscle, thins out the mass, modifies the cross-sectional shape of the vocal folds, and increases fundamental frequency. Contraction of other muscular fibers, namely, the thy-

roarytenoid, brings the arytenoid and thyroid closer together, thus increasing the concentration of mass and decreasing fundamental frequency (Figure 5–6). The second key biomechanical property of the vocal folds is stiffness, or the effective restoring force per unit of displacement. Stiffness is directly proportional to vocal fold tension and largely regulated by vocal fold length.4 Contraction of the crico­ thyroid muscle increases the physical length of the tissues and thus increases the stretch tension. This is a passive state of tension because it occurs as a result of the tissue being spread over a greater area, much like a rubber band’s tension increases as it is stretched. Contraction of the thryoarytenoid muscle fibers results in an active tensing of the vocal fold body. Although thyroartytenoid contraction increases the stiffness and tension in the muscular body, it reduces tension in the cover.4 Optimum phonation requires a balance between the tension of the muscular body and the cover; the more closely the tensions of the body and cover are matched, the more efficient the conversion of aerodynamic to acoustic energy. This balance is not determined by the absolute level of contraction of each muscle but rather the differential control between them.4

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biphasic tissue composed of a solid porous structure swelled with interstitial fluid. This biphasic structure impacts the way that the vocal folds experience stress and is responsible for the viscous behavior of the vocal folds (Figure 5–7).18 Higher viscosity, such as results from dehydration of the vocal folds, translates to greater internal friction, greater energy loss in the form of heat, and a higher phonation threshold pressure. Viscosity is not independent of mass and tension; longitudinal tension increases viscosity, whereas the greater vocal fold thickness that results from contraction of mass reduces viscosity.

Supraglottal Resonance

Figure 5–6.  Muscular tuning of fundamental frequency. A. Contraction of the cricothyroid will elongate the vocal folds, putting a passive stretch tension on the vocal fold cover. B. Contraction of the thyroarytenoid muscle results in an active tensing of the vocal folds.

Finally, viscosity is an important biomechanical property of the vocal folds. Viscosity is a measure of how resistant the vocal folds are to change in deformation.4 The vocal folds can be considered a

The sound exiting the glottis consists of the fundamental frequency plus many harmonics, or overtones. The supraglottal vocal tract helps to shape those sounds from raw noise into a human voice. The filtering effects of the supraglottal vocal tract modulate the acoustic output of the glottis and regulate the acoustic power. The higher frequencies are more susceptible to energy loss because of the damping characteristics of the source spectrum of glottal vibration.5 When the waveforms reflect off other structures, resonance occurs. To appreciate resonance, we turn to the analogy of a bottle with a narrow neck. When one blows across the top of the neck, the air in the bottle resonates at a certain frequency. The resonant frequency is a characteristic of the bottle, not of the air being blown across it. Pouring liquid into or out of the bottle will change its resonant frequency by changing the air column’s size and shape (Figure 5–8). Similarly, air will resonate at a certain frequency in the supraglottal vocal tract. Each resonance in the vocal tract is called a formant. Changing the size and shape of the airway by moving the tongue, jaw, lips, and any other structures in the upper airway will change the resonant frequency. Lengthening the airways causes a decrease in the formant frequencies, the energy regions of vowels. The resonance in the supraglottal air tract is responsible for the perceived differences in vowels. Each vowel is defined by the lowest 2 formants, which are characteristic of the supraglottal vocal tract.4 (See a more extensive discussion of formants in Chapter 12.)



Physiology of Voice Production: How Does the Voice Work?

Figure 5–7.  A stress-strain curve for tissue. Strain is the change in length divided by the original length. Stress is the force per unit area. At first, the tissue does not bear a load. As strain increases, the threshold is reached. At low strain levels, the tissue is elastic and the stress-strain curve is linear. After the yield point, the tissue experiences permanent change and energy loss. When the maximum strain is reached, the tissue will fail or break.

Phonatory Control Mechanisms Pitch As described by the myoelastic-aerodynamic theory, 2 main factors interact to control pitch: tension and mass. The tension involves both the passive tension on the vocal fold cover and the active stiffness of the vocal fold body. Lengthening the vocal folds increases stretch tension on the vocal fold cover, and increasing the length also decreases the mass per unit length, which leads to an increase in frequency. The average person can control these changes to have an overall pitch range of about 2 octaves. Raising the pitch primarily relies on contraction of the cricothyroid muscle. Contraction of the cricothyroid causes the vocal folds to lengthen and the medial edge to thin. Because the cricoarytenoid

muscle limits the movement of the arytenoid cartilages, contraction of the cricothyroid also causes an increase in vocal tension. All of these factors can be fine-tuned to elevate pitch. Breath pressure has also been shown to covary with pitch. This has been demonstrated in both excised larynges and computer models, but it is a complex relationship that is not yet completely understood.19 Current evidence shows that while pitch and pressure are related, they do not have a causal link. There are 2 mechanisms for lowering the pitch. From a higher pitch to a lower pitch, one simply relaxes the muscles in the larynx. Then natural elasticity of the vocal folds returns them to the tension required to produce their normal pitch. Further lowering of the pitch requires contractions of the thyroarytenoid muscle. This draws the arytenoid and the thyroid cartilages together, thus increasing the concentration of mass and decreasing the tension

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Figure 5–8.  A diagram of how resonant frequency changes. The resonant frequency depends on the volume of the jar, not the airflow. Increasing the airflow will result in the same frequency; however, reducing the volume of the jar will yield a different frequency.

in the cover.7 This rounds the medial edge of the vocal folds and allows for greater amplitude of vibration. Contraction of the thyroarytenoid can be used to lower the pitch below the normal pitch at high frequencies. Because there is little movement of the deep tissues, contraction of the thyroarytenoid is used to fine-tune the pitch.

Loudness Loudness of voice is a measure of how we perceive pressure or power differences. The largest determinant of loudness is the intensity of sound, which is the physical measure of power or pressure ratios. Increased intensity requires the vocal folds to open

and close with more vigor. Control of this is possible at the subglottal, glottal, and supraglottal levels. This control relies on the same basic mechanism that controls frequency, so it is difficult to vary them separately. There are 2 contributors to subglottal regulation of vocal intensity: subglottal pressure and tracheal airflow.20 At the level of glottal regulation, intensity is linked to the level of medial compression.21 When the vocal folds are more tightly compressed, more force is required to blow them apart. They then are drawn together more forcefully and close more rapidly. Tightly compressed vocal folds stay closed together longer and thus increase the intensity with which each burst of air escapes the vocal folds. This level of regulation is especially important at low pitches.22



Physiology of Voice Production: How Does the Voice Work?

Supraglottal factors can also affect vocal intensity. The size, shape, and placement of resonators are important. Trained speakers learn how to effectively control frequency and intensity independently. Trained singers can also increase vocal intensity with less respiratory and vocal effort by changing the shape and stiffness of the vocal tract to tune formants. It is well known that there is a major jump in the voice spectrum around 3000 Hz known as the singers’ formant that allows the singer’s voice to soar over the accompaniment.4

Voice Quality One of the main ways to evaluate vocal quality is through vocal registers, which are perceptually distinguishable modes of phonation. The ideal phonation register is modal, or chest. This register is present in the middle-frequency range. Because it is the most efficient mode of phonation, it is the mode used most commonly in daily conversation. Speechlanguage pathologists focus on teaching their clients to use this mode of phonation. Below modal phonation is the pulse or glottal fry register. This low-frequency phonation (30–90 Hz) is distinguishable by its crackly, Strohbass (straw bass) sound. It is important to note that it is not simply a lower frequency of phonation; it is a different mode of phonation that contains a secondary syncopated beat. During this syncopated vibration, 2 opening cycles occur in close succession followed by a prolonged closed phase that may last for up to 90% of the cycle. It requires only low subglottal pressure to maintain because the vibrating margin is flaccid and thick. The lack of tension allows air to slowly bubble through the vocal folds instead of pushing them into rapid vibration. To eliminate the crackly quality of this voice, one must increase the tension of the vocalis muscle.23 On the opposite end of the vocal spectrum is the high-frequency (300–600 Hz and above) loft or falsetto register. The falsetto register is defined by a very short, or completely absent, closed phase with the vocal folds making contact only briefly. During this type of phonation, the vocal folds are more thin and reedlike. The cricothyroid and thyroarytenoid

muscles both exhibit heightened activity.24 When the vocal folds reach the maximum possible contraction, they must use a different mode of increasing pitch. The posterior portion of the vocal fold is damped, and there is reduced degree of movement.23 Two common variations on these modes of vibration are breathy and pressed voice. Breathy voice results when the vocal folds remain slightly abducted during vibration. This mode is inefficient because it causes air wastage and vocal fatigue, but it is not damaging to the phonatory mechanism. However, breathy phonation may be an indication of an underlying pathology, like vocal polyps, that is preventing complete closure of the vocal folds. On the other side of the spectrum, pressed phonation results from full glottal adduction. This variation on the voice is often viewed as strong and commanding, but it is actually abusive to the vocal folds and can lead to damage.5 Nonregistered voice quality can be described based on its stability. Phonation with long-term modulation of intensity may be labeled as persistent, variable, or controlled; the terms traditionally given to these modulations in intensity are tremulous in pathological voices, nervous in emotional voices, and vibrato in singing voices. Involuntary variations in stability are labeled hoarse. Hoarseness may result from glottal incompetence in vocal fold paralysis, lesions that affect vocal fold mass, or vocal fold hyperfunction. For an objective evaluation of hoarseness, clinicians often refer to signal-to-noise ratio, or SNR.5 Overall voice quality, or timbre, is defined by the partial emphasis of different overtones. Essentially, it is an evaluation of the qualities that make each voice unique and humanlike. Timbre is influenced by selective amplification by the walls of a series of resonators in the pharynx or mouth. Timbre is closely related to the skewing of the glottal volume velocity. This refers to the fact that the flow maximum occurs after the maximum glottal area. Skewing is linked to the inertance, or resistance to change in airflow, of the airway. When phonation occurs, the stagnant air in the vocal tract must be pushed out. The resistance of the stagnant air increases supraglottal pressure and thus decreases translaryngeal pressure. Elongating the vocal tract with maneuvers

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such as lowering the larynx or protruding the lips can increase inertance. Greater inertance means greater skewing of the flow maximum, and the more the flow maximum is skewed, the more energy is in the higher harmonic frequencies of the voice.

Voice Range Voice output falls within a range of intensity and frequency. This is the voice range. The human voice range has minimal and maximal limits. When phonation is softer than the minimum limit, it switches to a whisper without vocal fold vibration. Phonation also has an upper limit of intensity and loudness. Beyond the upper limit, the voice becomes irregular and strained. The voice range profile (VRP), also called a phonetogram, can be used to describe the voice range (Figure 5–9).25 The VRP is a plot of the vocal intensity versus fundamental frequency, with the intensity range typically being smaller at the frequency range extremes. Different individuals can have different ranges. Additionally, training and pathology can change the range. A trained singer

has a larger voice range, which means the person can sing louder and at a higher pitch. The voice range is determined by vocal fold structure and control. The quantitative relationship has been studied using vocal fold models.26–28 Specifically, the biomechanical properties of vocal fold tension and vocal fold symmetry play very important roles in controlling the voice range. Good training can build a strong vocal fold muscle, optimize tension, and optimize the glottal shape. This improves the range of phonation. A localized lesion, such as a nodule, will significantly reduce the phonation range.4 The VRP can shrink to zero in the case where the larynx cannot sustain regular phonation. Because vocal fold vibration is generated by subglottal pressure, subglottal pressure can be used to characterize the upper and lower limits of the voice range. Phonation threshold pressure (PTP) indicates the lower limit since it is the minimum pressure required to initiate and sustain phonation. Phonation threshold flow (PTF) is the flow that corresponds with PTP. The pressure at which the voice becomes irregular is classified as phonation instability pressure (PIP). The corresponding flow at that point is the phonation instability flow (PIF).

Figure 5–9.  Voice range profile (VRP). This simulated plot represents the frequency and intensity ranges for a trained singer, normal patient, and a patient with a vocal fold lesion. While training can increase the VRP in a singer, a vocal fold lesion can reduce the VRP.



Physiology of Voice Production: How Does the Voice Work?

PIP and PIF can be used to indicate the upper limit of the voice range. It is important to note that phonation above the voice range is vocally abusive. An example of this type of voice use is shouting loudly with voice breaks, which causes phonotrauma. Additionally, above-range phonation may occur clinically in many pathological conditions, such as vocal fold lesions. In this above-range case, since the PTP has merged with PIP, the voice is always irregular and hoarse and tends to cause phonotrauma.29

Summary Overall, voice production involves the interaction of many physiological systems. It begins with the aerodynamic pressure generated by the chest, thorax, and abdomen. Muscles in the larynx can be used to control the width of glottal opening and the tension in the vocal folds, which, when combined with the pressure inputs, drive the vocal folds into a series of rhythmic vibrations. The results is a wave of air pressure changes sent to the upper vocal tract, where it can be modulated by resonators and filters to produce the instrument known as the human voice.

References 1. Van Den Berg J. Myoelastic-aerodynamic theory of voice production. J Speech Hear Res. 1958;1:​ 227–244. 2. Tucker HM. The Larynx. New York, NY: Thieme Medical Publishers; 1993. 3. Stemple JC, Glaze LE, Gerdeman BK. Clinical Voice Pathology: Theory and Management. San Diego, CA: Singular Publishing Group; 2000. 4. Titze IR. Principles of Voice Production. Englewood Cliffs, NJ: Prentice Hall; 1994. 5. Jiang J, Lin E, Hanson DG. Vocal fold physiology. Otolaryngol Clin North Am. 2000;33:699–718. 6. Hirano M. Morphological structure of the vocal cord as a vibrator and its variations. Folia Phoniatr (Basel). 1974;26:89–94. 7. Titze IR, Luschei ES, Hirano M. Role of the thyroarytenoid muscle in regulation of fundamental frequency. J Voice. 1989;3:213–244.

8. Titze IR, Jiang JJ, Drucker DG. Preliminaries to the body-cover theory of pitch-control. J Voice. 1988;1:314–319. 9. Baken RJ. Irregularity of vocal period and amplitude: a first approach to the fractal analysis of voice. J Voice. 1989;4:185–197. 10. Hertegard S, Gauffin J. Glottal area and vibratory patterns studied with simultaneous stroboscopy, flow glottography, and electroglottography. J Speech Hear Res. 1995;38:85–100. 11. Jiang JJ, Yumoto E, Lin SJ, Kadota Y, Kurokawa H, Hanson DG. Quantitative measurement of mucosal wave by high-speed photography in excised larynges. Ann Otol Rhinol Laryngol. 1998;​107:98–103. 12. Titze IR, Jiang JJ, Hsiao TY. Measurement of mucosal wave propagation and vertical phase difference in vocal fold vibration. Ann Otol Rhinol Laryngol. 1993;102:58–63. 13. Nasri S, Sercarz JA, Berke GS. Noninvasive measurement of traveling wave velocity in the canine larynx. Ann Otol Rhinol Laryngol. 1994;​ 103:758–766. 14. Finkelhor BK, Titze IR, Durham PL. The effect of viscosity changes in the vocal folds on the range of oscillation. J Voice. 1988;1:320–325. 15. Verdolini K, Titze IR, Fennell A. Dependence of phonatory effort on hydration level. J Speech Hear Res. 1994;37:1001–1007. 16. Jiang J, O’Mara T, Conley D, Hanson D. Phonation threshold pressure measurements during phonation by airflow interruption. Laryngoscope. 1999;109:425–432. 17. Jiang JOM, Chen HJ, Stern JI, Vlagos D, Hanson D. Aerodynamic measurement of patients with Parkinson’s disease. J Voice. 1991;13:583–591. 18. Zhang Y, Czerwonka L, Tao C, Jiang JJ. A biphasic theory for the viscoelastic behaviors of vocal fold lamina propria in stress relaxation. J Acoust Soc Am. 2008;123:1627–1636. 19. Shipp T, Doherty ET, Morrissey P. Predicting vocal frequency from selected physiologic measures. J Acoust Soc Am. 1979;66:678–684. 20. Holmberg EB, Hillman RE, Perkell JS. Glottal airflow and transglottal air pressure measurements for male and female speakers in soft, normal, and loud voice. J Acoust Soc Am. 1988;84:511–529. 21. Berke GS, Hanson DG, Gerratt BR, Trapp TK, Macagba C, Natividad M. The effect of air flow and medial adductory compression on vocal efficiency and glottal vibration. Otolaryngol Head Neck Surg. 1990;102:212–218.

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52 The performer’s VOICE 22. Isshiki N. Regulatory mechanism of voice intensity variation. J Speech Hear Res. 1964;7:17–29. 23. Seikel JA, King DW, Drumright DG. Anatomy and Physiology for Speech, Language, and Hearing. Clifton Park, NY: Thomson Delmar Learning; 2005. 24. Zemlin WR. Speech and Hearing Science: Anatomy and Physiology. Boston, MA: Allyn & Bacon, 1998. 25. Titze IR. Acoustic interpretation of the voice range profile (phonetogram). J Speech Hear Res. 1992;35:21–34. 26. Herzel H, Berry D, Titze I, Steinecke I. Nonlinear

dynamics of the voice: signal analysis and biomechanical modeling. Chaos. 1995;5:30–34. 27. Wong D, Ito MR, Cox NB, Titze IR. Observation of perturbations in a lumped-element model of the vocal folds with application to some pathological cases. J Acoust Soc Am. 1991;89:383–394. 28. Zhang Y, Jiang JJ. Chaotic vibrations of a vocal fold model with a unilateral polyp. J Acoust Soc Am. 2004;115:1266–1269. 29. Zhang Y, Reynders WJ, Jiang JJ, Tateya I. Determination of phonation instability pressure and phonation pressure range in excised larynges. J Speech Lang Hear Res. 2007;50:611–620.

Chapter 6 Normal Voice Maturation: Hormones and Age Jean Abitbol

T

he life of the voice, its path, its challenges and limitations, and its emotional impact throughout the human existence, is a journey. It will challenge us to understand how the cycle of life can leave its scars on both the female and the male voice. The route is not the same. The voice matures primarily through its genetic inheritance, the DNA. There

are many secondary reasons for maturation and aging of voice. They are discussed in this chapter (Figure 6–1). We will come to understand how the alchemy between mind, body, and hormones creates the voice and how the passage of time impacts the voice. In the chaotic logic of the space and time

Causes of Aging → P rim a r y ° Genetic inheritance—cannot e— an notprevent pr e v e nt

→ S e c onda r y ° Accidents, infections, diet, lack of exercise, C-V diseases, diabetes, mental diabetes mental stress, pollution, alcohol, tobacco and drugs — preventable

DNA Figure 6–1.  Primary and secondary causes of aging.

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continuum, this precious gift that is the voice is an emotional amplifier that we must protect. The voice is extremely responsive to sex hormones1 as well as other hormones in the body.2

Hormones and Voice The Complex Story of an Internal Clock Why does puberty change the voice so much in men? Why a does a woman’s voice change during her menstrual cycle? How can the vibration changes at menopause result in breakings of the voice? How does a cyclic pathology appear on a vocal fold? Is the voice injured after the hormonal “earthquake” around age 50? So many questions, so many clues. If we are to solve this enquiry, we shall inevitably have to understand the hormones, their impact on the voice, and the scar of time. Between the cell and the larynx, the brain and language, hearing and vocalizing, the vocal landscape takes shape, but in all its forms, the voice is always a reflection of our personality. What separates the infant’s screams from that sexy female voice or from that male voice that charms us so? How does the hormonal revolution of adolescence transform the voice? How does our genetic mapping stamp the verbal expression of our thinking and our emotional universe? Voice and hormones: two words that clash, meet and harmonize. The voice is sexual. But is our voice’s sex the same as our genetic sex? Is it determined by our XY, XX chromosomes, or by estrogen and progesterone hormones in women and androgens in men? Our musical instrument, the larynx, is a hormonal target. At puberty, the larynx undergoes a host of changes. These transformations are determined by our genetic heritage but more so by our hormones. Indeed, the castrato retains a child’s voice, said to be feminine because he did not receive testosterone. This is proof enough of the unquestionable impact of male hormones on our vocal folds and of their determining influence on our male genetic print.

Does voice have a sex? If it does, is its character hormonal or chromosomal? Our voice changes over the years, it changes with our life story, with our appearance, and with our physique. It also changes as a function of our emotional environment. Our fingerprint identifies a physical part of our anatomy that is unique to us. It has no duplicate. Our voiceprint reveals our personality, our sensibility, as well as our sexuality. Let’s try to follow the trail of the sexual voice. Let’s retrace the steps of this miracle of life, from the embryo through to adulthood and the aged.

Voice Development: A Hormonal Target The infant’s cries have no gender traits. While mothers can usually recognize their child’s cry, infant voices are not identifiable as feminine or masculine by others. By the age 7 or 8, differences in the male and female pitch begin to occur. However, only at puberty will a sexual register impose itself on children’s voices. The larynx is hormonally dependent and evolves with time and the sexual life of each individual.1 When you hear people speaking on the radio or on the phone, you can identify their sex from their voices within a few tenths of a second. The voice is a secondary sexual characteristic. Of course, sex hormones influence it, but so do other hormones. The role of the thyroid gland cannot be minimized in the development of the voice. Time has an important influence on hormonal activity. This dimension plays a role not only in the evolution of life but also in our day-to-day life. Certain hormones must be secreted at precise moments of our life: during our fetal development, at birth, and at puberty. Before those exact moments, it is too soon, and afterward, it is too late. This remarkable internal clock of ours is not yet fully understood. Thyroid hormones are a case in point. If they do not do their work in the first years of our life, irreversible physical and intellectual anomalies are brought upon, and these may lead to cretinism. Should one later try to palliate this hormonal deficiency with artificial substitutes, it would be of little or no avail. Thyroid gland injury, espe-

Normal Voice Maturation: Hormones and Age

cially in children, often results in voice changes that compromise normal pitch, loudness, and voice quality.3 Nowadays, very early diagnoses enable appropriate treatment to be prescribed in good time.4 But if the impact of our hormones dictates the need for a precise timetable, if they are to efficiently influence the evolution of our life, nowhere is this more evident than in a woman’s menstrual cycle and our diurnal cycle. In our diurnal cycle, cortisone is naturally secreted by our body at the end of the day and in the early morning. These different secretions are controlled by an internal feedback system that avoids hormonal excess or insufficiencies through autoregulation. The thyroid gland’s role is to counter the aggressions of the outside world (the weather, cold, heat, stress). Thyroid hormones play a determining role in our vocal register. The thyroid gland at the base of our neck can become the seat of a goiter, basically a nodular increase in its volume, or conversely, it can become hyposecretive. The thyroid is indispensable to the evolution of the voice. It acts as do bellows on a fire, stimulating a majority of organs in our body and influencing our vocal timbre. In a serious case of hypothyroidism, the voice becomes harsh. The vocal folds present a slight edema and the vocal muscles become congested. This well-known pathology regresses as soon as thyroid extracts are administered. The voice recovers its normal register and its natural harmonics. However, the essential elements that modify the quality of our voice are our sex hormones: estrogen, progesterone, and androgen. The role of our sex hormones is to enable our sexuality to adapt. Of all mammals, man is the one with the greatest hormonal complexity — to such an extent that, if our hormonal secretion is upset, it can cause irreversible damage. If no substitutes are provided for certain glands when these are suppressed, the outcome can be fatal. Finally, the precarious balance between our hormones is what ensures the stability of the living being. Their action is the key to the evolution of our adolescence. Our endocrine glands, the main ones being the pituitary gland, the ovaries, the testicles, the thyroid, and the adrenals, produce a hormone inside the gland and secrete it through an excretory canal into our blood vessels. The hormone stimulates a specific receptor organ, the organ that can facilitate the desired out-

come: adrenaline accelerates the heart, testosterone increases our libido. Only the ovaries secrete estrogen and progesterone, the female hormones, and then only if the ovaries have previously been stimulated by follicular stimulating hormone (FSH) and lenticular hormone (LH), the pituitary hormones.1 Finally, estrogens and progesterone will, in turn, stimulate one of their main target organs, the genital organs, and bring on the menses in a woman, if she still has a uterus. If a woman has had a hysterectomy, she has no uterus, and therefore no menses; the target organ at the end of the line has been removed. The consequences of the menses are definitively gone but not the consequences of the sex hormones’ effects on her organism. Thus, other target organs like the vagina, the breasts, or the larynx retain their tonicity and their hormonal rhythm. In certain respects, the hormone is like a cordless remote control, but its operating method is molecular rather than infrared. An infinitesimal amount suffices for a significant impact. In the same way that vitamins are an indispensable element in our nutrition because the body does not produce them, hormones that are produced by our cells are just as indispensable to our survival. They accelerate, stabilize, or slow down their target organ.

The Larynx as a Target Organ for Multiple Hormones Hormones play an intermediary role between our brain and our various organs, notably the larynx. As a target organ, the larynx is warned by its specific receptors of the arrival of hormonal molecules. Our mighty hormonal factory gets into gear at puberty. The 3 masters that manage it are the brain, the hypothalamus, and the pituitary gland. Their orders trigger hormonal secretions. The first intervenes: our neurologic center and emotional world pass information in the form of electrical impulses on to the hypothalamus at the base of the encephalon. The second takes over to pass this information on to the pituitary gland. The third now secretes substances and expedites them to the glands concerned. The informed gland then secretes its hormones and releases them into the bloodstream, where they will

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migrate to the target organs and also inform the hypothalamus and the pituitary gland that all is well, that the secretion rate is satisfactory. This feedback is remarkably precise and maintains a harmonious hormonal balance. When hormonal secretions are excessive, the hypothalamus and pituitary glands jointly diminish the stimulation of the gland concerned.

Puberty, Vocal Metamorphosis: Male or Female, the Choice Is Made Adolescence takes us down the path leading to sexdetermined pitch characteristics. The adolescent male, now virile, slim, and athletic, is ill served by his shrill, unbearable falsetto voice. Meanwhile, the magic of evolution will have endowed others with the vocal vibration of a Caruso or a Callas, or simply that of the man-in-the-street, as much at home with his voice as he feels at home in his skin.

The Hormonal Revolution At puberty, the threshold between childhood and adulthood, our secondary sexual characteristics develop along with physical and psychological transformations specific to each sex.5 From the new-

born to the old adult, chin angle plays a role in vocal development and decline (Figure 6–2). In the Western world, the average age of puberty is between the age of 10 to 13 years, while in the East, it is between the age of 9 to 12. The appearance of our sex hormones — estrogens and progesterone in girls and androgens in boys — triggers the development of the third layer of epithelium cells on the vocal folds (prior to this time, like other mammals, we just have 2 layers). Thus, the harmonics of our voice become adult in part due to this third layer and in part due to the final development of the striated muscle of the vocal folds.6 As a girl matures, she develops higher harmonics, as well as some lower ones that she previously lacked. In boys, the action of testosterone on the muscular and mucosal structure of the vocal cords favors the appearance of new low harmonics and the loss of some of the child’s high harmonics. The hormonal revolution is more impressive in men. The shape and covering of the vocal cords changes, thickens, grows, and acquires more volume, but the thoracic cage, lungs, stature, and brain are also evolving. In the West, men’s left brain develops more than the right brain, whereas women maintain a certain equilibrium between the rational brain and the emotional brain. The consequences of puberty for the voice may be more

Chin-angle during the life of the individual Newborn 6 year old

Adult

Old age

Figure 6–2.  Changes in chin angle over a lifetime.

Normal Voice Maturation: Hormones and Age

obvious in boys than in girls, but they exist in both sexes. Adolescence triggers emotional changes that are usually congruent with the person’s physical appearance. In women, the vocal pitch drops by a third of an octave compared to girls’ voices. In men, the voice drops by an octave.

Puberty Can Take a Wrong Turn It can take 1 to 5 years for an adolescent boy to acquire his adult voice. But puberty can also take a wrong turn. A lack of harmony due to an imbalance between voicing and breathing produces a voice that “goes off the rails,” like a Tyrolean melody. Compared to women, men have greater lung capacity, a more developed cardiovascular system, a higher level of hemoglobin and red blood cells, and more striated muscle mass.7 In the boy turned young man, a falsetto voice that cannot stabilize itself must be treated. It produces an anachronism between the apparent youth of the voice and the young man’s physical appearance. A difficult harmonization between voice and physical appearance is one of puberty’s most delicate obstacles because the voice is seen to project its owner’s personality. Therefore, when necessary, one should definitely help adolescents successfully complete this metamorphosis. Voice therapy is the primary treatment to help an adolescent with this problem. Treatment for the adolescent male high voice consists of breathing exercises, thyrohyoid and laryngeal massage, and reduction of upper body tension. The clinician works from the existing voice quality and tries to gradually direct the voice to a lower pitch with less tension.8 Control of his exhalation during laryngeal voicing and adapting his behavior to his sociocultural environment will help him discover his adult voice.

The Bend Has Been Successfully Negotiated:  Male or Female, There Is No Ambiguity In male singers, a well-defined head voice and chest voice make their appearance after puberty. These 2 vocal techniques bring into play the ligaments and muscles located between the thyroid and the cricoid cartilages, which are more developed in men.

They allow the larynx to rock, a movement that is facilitated by the previous calcification of the Adam’s apple. The significant lengthening of the vocal folds in men also makes it easier for them to sing in both head and chest registers. In women, the process of puberty is less eventful. It flows more smoothly. The thyroid cartilage and the cricothyroid membrane hardly change. The vocal cords lengthen slightly and increase their muscle mass. Despite the formation of the third epithelium layer, the vocal fold remains very supple, with a fine mucous membrane. Small glandular cells as depicted in Figure 6–3 keep the vocal folds lubricated and depend on feminine hormones (estrogens and progesterone). The ovaries enter their active period of reproduction. The progesterone, a steroid hormone, is secreted by the corpus luteum in the ovary starting with the first cycle of the adolescent girl to the last cycle before menopause. The secretion of progesterone lasts only 2 weeks per cycle. Its role is to prepare the uterus for pregnancy (progesterone, gestation). It lasts only during the active period of reproduction. Its action can occur only if estrogens have prepared the hormonal receptors. If estrogens have not been secreted, progesterone has no impact on the hormonal target. When the first menstrual cycles appear, they are irregular. They become progressively regular if there is no cyst in the ovary or if there is no endometriosis. After a few months, the voice discovers new high-pitched and low-pitched harmonics. The periodicity of the female hormones’ secretions gives rhythm to the adolescent girl’s life cycles. The lunar cycle is orchestrated by the hypothalamopituitary axis due to the action of 2 hormones that act directly on the ovaries to stimulate the secretion of estrogens and progesterone. Note that the menstrual cycle presents 2 distinct phases: a follicular phase between the 1st and the 14th day of the cycle, in which only estrogens are present — there is no progesterone — and a luteal phase between the 15th and the 28th day of the cycle, during which both estrogens and progesterone are secreted. In this context, ovulation occurs on the 14th day. The similarity between the follicular changes in the ovaries and the vocal folds is quite similar, as shown in Figure 6–4.

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Glandular Epithelium

Figure 6–3.  Glandular cells depend on female hormones to keep the vocal folds lubricated.

SMEAR TEST The parallelism is amazing

- 1st – 14th day of the cycle

- 14th – 28th day of the cycle

Figure 6–4.  Comparison of cervical and vocal fold smears during 2 stages of the female ovarian cycle.

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Normal Voice Maturation: Hormones and Age

All Is Sweetness and Light Between the Lunar Cycle and the Solar Cycle In both men and women, the sex glands have 2 functions. The first is reproduction, through the formation of sperm in men and the preservation of the ovum in women. The second is synthesis of the sex hormones: androgens in men and estrogens, progesterone, and a hint of androgens in women. In girls, the number of ova is predetermined from birth. This is the number of follicles, which exist only in the ovaries. The ovum has 23 chromosomes, but they are all X chromosomes. Therefore, the sex of the baby will be determined by the spermatozoon, which can be X or Y. In men, the testicles ensure the regular production of sperms almost until death. The male climacteric is delayed in some men until their 80s. Whereas men renew their sperm daily according to the solar cycle, women ovulate in tune with the “lunar cycle.”

The Female Voice The Female Life Span: The Premenstrual Voice Syndrome A Woman’s Voice The reproductive system undergoes a regular cycle known as the menstrual cycle. Voice changes can be identified and usually fluctuate systematically with the menstrual cycle. The first menstrual cycle appears during adolescence. It is triggered by 2 hormones, FSH and LH, that launch the process of the life cycle. The lunar cycle harmonizes over the next 40 years. The active phase of the genitals has begun. Each cycle is punctuated by a physical, mechanical, and ovarian impact but equally by a molecular, hormonal, and chemical impact, with repercussions on the entire organism.9 In this first part of the cycle, there is no progesterone and only estrogens are secreted. During the second period of the cycle, both estrogens and progesterone are secreted. But, critically, the progesterone can only act if the estrogens have previously prepared the ground and informed the receptors of the target organs. Adolescents often undergo rapid and even daily changes in

their voices. The changes are difficult to measure but clearly noticeable perceptually.10 The sudden drop in estrogens and progesterone production brings on the menses is the first day of a new cycle.

Three Actors for Our Sex Life:  Androgens, Estrogens, and Progesterone Each molecule triggers a modification of the mucous membranes, muscles, and bony tissues; therefore, our laryngeal instrument, our voice, is also modified. It also influences the cerebral cortex, thereby influencing the brain.11 This influence is indispensable at puberty and persists for the rest of one’s life. The feminine voice has exerted its charms since millennia. In ancient Greece, Apollo and Orpheus discussed the merits of the athlete’s worship of the body and of the powers of a mermaid’s voice to soothe emotions. When estrogens are flowing, the vocal timbre is sharper.  The estrogens secreted by the ovaries have different implications for the larynx. They result in a slight thickening of the cordal mucous membrane, which creates greater vibratory amplitude. The voice acquires a good timbre. The desquamation of superficial cells is reduced, accompanied by a decrease in the need to clear one’s throat and in the amount of laryngeal mucous fluid. The lipid cells under the cordal mucous membrane are stimulated. The voice becomes more supple (in the menstrual cycle, this is called the maturation phase with a proliferate action). Genital cells and cordal mucous membrane cells: Are they different? In 1982, receptors for estrogen hormones were identified on the vocal folds and in the uterus. These separate findings were confirmed by Abitbol et al1 using comparative studies of smears taken from the vocal folds and the cervix of the uterus during the same day of the menstrual cycle. The results were amazing as in both cases, the cellular aspect was identical (see Figure 6–4). The smears taken from the cervix of the uterus and those taken from the vocal folds matched perfectly. This correspondence had long been suspected. Given that both anatomical structures have the same type of mucous membrane, it is only logical that they should have the same cyclical impact.

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But this scientific discovery provided an objective proof to what had long been suspected. This finding is consistent with the observation that the voice can change with the menstrual cycle. Estrogens also act on the mammary glands and their excretory canals to affect the growth of girls’ breasts at puberty. Their action on the metabolism of calcium influences the bony and cartilaginous structures of our larynx. These structures increase or maintain global bone mass. Estrogens also improve the permeability of blood vessels and capillaries, which are very numerous in the vocal folds, thereby increasing oxygenation. They have no effect on striated muscle. They diminish the risk of Alzheimer’s disease. They also have an antagonist effect with androgens. Finally, for progesterone, the second, strictly female hormone, to be effective, the tissues must first have been impregnated with estrogens. Progesterone appears almost exclusively in women (smaller amounts by the adrenal glands in both sexes). Progesterone causes a thickening of the vocal folds. As its name indicates, progesterone is a hormone that enables gestation to persist. It is secreted in the ovaries only during the active genital phase of a woman’s life, from the age of 15 to approximately 55. It prepares the mucous membrane of the uterus for the nesting of the ovum. That is its primary role. With respect to the vocal folds, progesterone causes cells on the surface of the mucous membrane to slough off (a process called desquamation). It thickens the secretions of the glands located below and above the vocal folds, causing dryness of the larynx, the need to clear one’s throat, less agility when singing, and a narrow register during the 4 days preceding the menses. If the voice is strained during this phase, nodules may form (these are small supple swellings of the vocal fold mucous membranes).12 Progesterone also brings on a slight decrease in the muscle tone of the vocal folds. The progesterone diminishes and may increase the permeability of capillaries. This causes the extravascular fluid, which is located outside the blood vessels, to stagnate in the tissues of the vocal folds, bringing on edema of the vocal folds, which remain swollen during the week prior menses. Generally speaking, progesterone can decrease the intensity of menstrual

cramps. Smooth muscle also lines blood vessel walls. Therefore, progesterone can relax blood vessels and decrease the blood pressure. Progesterone affects the bone metabolism. It stimulates a cell in the bone called the osteoblast, which is responsible for new bone formation. The osteoblast uses calcium to form new bone. Bone is constantly in a state of development. Osteoclasts, stimulated by estrogens, break down old bone, while new bone replaces the old bone under the direction of osteoblasts. This is another example of how estrogen and progesterone work together. When progesterone and estrogen are available in their proper relationship, they promote good health. In the absence of sufficient quantities of progesterone, the body begins to produce androgens to regulate the effect of estrogen. It is thanks to progesterone that the intravascular fluid is transferred to the extravascular spaces in the surrounding tissues but not the way back. Consequently, if the balance between the 2 hormones is satisfactory, the interstitial fluid will be well distributed. Vocal fold edema will be minimal. If this is not the case, the progesterone will stop the return of the interstitial fluid to the vessels, causing an edema to form. It is a one-way street with progesterone: from the capillaries to the interstitial tissue and to Reinke’s space. The progesterone in this instance closes the door of the capillaries and prevents them from draining the tissues. For women who experience premenstrual voice syndrome, voice quality and stability have been found to be better among those who use birth control pills. Lower values were found for all acoustic measures with the exception of the voice turbulence index. Results also provided preliminary indication for vocal changes associated with the days preceding ovulation.13 Progesterone acts on the envelope of neurons. Progesterone is secreted by the ovaries and was originally considered a hormone involved only in reproductive functions. But Gago4 has demonstrated that it can be synthesized within the nervous system by neurons and glial cells. The progesterone has promyelinating and neuroprotective effects. Moreover, it can be synthesized locally in the nervous system by neurons and glial cells and can therefore be considered a neurosteroid. It plays an astonish-

Normal Voice Maturation: Hormones and Age

ing role. It activates the synthesis of the protective sheath of the neuron, the myelin sheath. The myelin sheath, a sort of protective sleeve that shields the nerve from all traumatic aggression and from differences in temperature, enables nervous impulses to be transmitted at a constant speed between the brain and its target organ. Nerves that have this myelin sheath conduct nervous impulses better and faster. The impact of progesterone on the brain has led to a better understanding of therapeutic approaches to treating neurologic diseases and certain myopathies that alter the myelin sheath and, therefore, nerve conduction, such as in myotrophic lateral sclerosis or multiple sclerosis. It seems that progesterone significantly slows the evolution of these afflictions.

Imbalance Between Estrogens and Progesterone The imbalance between estrogens and progesterone causes a cyclical edema in the last week of the menstrual cycle, resulting from the accumulation of interstitial fluid in the vocal folds. A similar process causes some women to have swollen legs before their menses.

The Voice Injured by Hormones and Premenstrual Phase A violent pain, then no more voice! At around 5:00 pm on Friday in the fall, I received a phone call from the Opera Bastille informing me that the diva S.L., an international lyrical soprano with a remarkable track record and an outstanding vocal technique, could no longer sing. Her voice was injured. She arrived at my office at 6:30 pm: “I’m dying, doctor.” Her impresario explained to me what had happened: “During the rehearsal, Mrs. S.L. felt tired. She has been feeling tired for the past few days. We just arrived this morning from Germany. But she insisted on attending rehearsals, to practice and to get to know the orchestra. All was going well. Today, I took her to the Opera House. She sang in a normal voice for a few minutes, without straining. But at one point she had to sustain a high-pitched note and she felt a violent pain on the right side of her neck. I saw her grimace, but she carried on singing her lines. The tenor responded. During the forced rest of a

few dozen seconds imposed by the tenor’s verse, she was able to catch her breath. When she sang again, her voice had dropped, the high register was gone, and the B note and its pianissimo had evaporated. Impossible to do the vibrato! Her voice had gone! I asked if she could talk. ‘Yes,’ she answers, but softly. But she couldn’t sing. We interrupted the rehearsal, and here we are.” Worried, she bursts into tears and asks me, “Is my voice injured?” I examine her. But first, I would like to share with you a lesson I have learned from experience. Artists know their voice inside out. They know perfectly well if one fold is vibrating badly. Their knowledge of their laryngeal instrument is remarkable. When artists complain of a vocal problem, most of the time they are right. If I can’t detect pathology of the vocal cords, it doesn’t mean that there isn’t one; it simply means that I haven’t found it. Consequently, I have to keep searching, dig deeper, carry out more technical examinations, and remain on the lookout for pathology. Who is guilty? S.L. points to her larynx with her finger to indicate the exact place where she felt pain during her vocal effort. Her finger is indicating the right vocal fold. Palpation of her neck is normal. It reveals no particular sensitivity. The videoendoscopic examination shows a subepithelial hematoma on the right fold, but it vibrates. But it cannot lengthen or shorten. Its contour has changed. The precarious balance of this exceptional instrument has been damaged. What happened? How can a professional singer with perfect technical mastery and an irreproachable lifestyle be the victim of such a regrettable lesion? The diva, S.L., in her 40s, is not on birth control. Her menses are normal. However, she informs me that during those 4 to 5 days that precede her period, her breasts are sore, her legs feel a little heavy, her pelvis is sore, and her voice alters slightly. I ask her to be more precise regarding the changes to her voice. She answers with exemplary precision. “I lose 10% to 15% of my voice, in order to be heard above the orchestra, I have to control my breathing better and brace my pelvis more than usual on stage to counter the weakness of my vocal folds. My register is also affected. I lose a half-tone to a tone in the high notes, but my low tones are still great. My vocal control is also affected at this time. I often clear my throat and feel tired. By the end of the

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62 The performer’s VOICE performance, my larynx feels sore. I am used to it, and usually, it goes pretty well.” I ask her to explain what she means exactly by control: “By control, I mean sensing the timbre of my voice. In that phase of my cycle, prior to the menses, the color of my voice is a bit more metallic, the vibrato is a little harder to hold. But especially, I find it hard to do a pianissimo on certain frequencies. I have practically no problem in the forte. It’s changing from one harmonic to another that bothers me, that’s a problem. I find it hard to control my full voice.” I ask her, “Mrs. S.L., what phase of your menstrual cycle are you in now and in how many days you think you’ll get your period?” This was for me the crux of the matter. “In 2 or 3 days, doctor.” I add, “Did you have time to warm your voice up properly before the rehearsal?” She thinks about this, and then confirms my intuition: “No, I was already late, and on top of that the air was

dry because of the air conditioning, and I arrived this morning by plane.” To all intents and purposes, the guilty party that had caused the hemorrhage of the vocal fold had now been flushed out. This diva normally sings at 70% of her capabilities. In her premenstrual phase, just before her menses, she sings at 90% of her capabilities to produce a comparable timbre. But today, other elements perturbed her vocal musicality. The Opera House’s air conditioning had dried the atmosphere. She was feeling tired. She informs me that she had also slept badly the night before. She had flown to Paris this morning. On examination with videolaryngostroboscopy, a large hematoma is found (Figure 6–5). The reasons for the hematoma are getting clearer. The singer had premenstrual vocal syndrome. The examination has revealed not only the hematoma on the right vocal fold, easily diagnosed, but micro

Figure 6–5.  Vocal fold hemorrhage in the premenstrual phase of the female ovarian cycle.

Normal Voice Maturation: Hormones and Age

varicose veins on the left vocal fold, sign of venous fragility. The singer does not suffer from them. The fold vibrates normally. The danger they present stems from their fragility. Her vocal power damaged the right vocal fold. That brought on the hematoma. Indeed, 4 days before the menses, the vessels are more fragile due to hormonal influence. The lubrication of the vocal folds was perturbed by the dryness of the atmosphere. The micro varicose veins burst, but only under the submucosal layer. They burst under pressure during the very powerful vocalizations of this lyrical soprano in a high register, the result being the submucosal hemorrhage. Could she have avoided the misfortune, per chance?  There was no way of predicting this accident. It was the first of her career. The reasons for it are simple. For years now, she has made it her practice to warm up her voice, to loosen her vocal folds, to oxygenate her laryngeal muscles. But she did not have time to prepare her laryngeal instrument. It is just before her menses, and she is fragile. The reasons for the accident are now clear. To her fans’ immense disappointment, her performances have to be cancelled. Her treatment begins. It is simple: strict vocal rest combined with sprays, phlebotonics, minerals, and anti-inflammatory medicine. Two weeks later, all was back to normal. A cyclical treatment of 10 days each month, for a minimum of 2 years, and regular stroboscopic examinations, especially prior to her menses, were recommended. The fragility of her blood vessels and the impact of the progesterone at the end of her menstrual cycle were both partly responsible for her vocal predicament (Figure 6–6). This type of problem must have been known in earlier times, because since the 19th century, any female singer performing at the Scala Opera House in Milan could cancel her performance during the 5 days preceding her menses and during her menses and still receive her fee. Back then, the influence of the hormonal cycle on women’s voice was already known.

The Voice Changes During the Menstrual Cycle A premenstrual cycle is evident in all women. But only a third of adult females present a more notice-

Figure 6–6.  Edema and microvarices of the vocal fold.

able edema of the vocal folds and swollen breasts, symptomatic of the precarious balance of the sex hormones. Women on birth control can sometimes present these symptoms if the pill is biphasic (containing both estrogens and progesterone). What is going on? The case of Mrs. S.L., the diva, is a good illustration of the premenstrual vocal syndrome. However, she did not present all the symptoms. The usual syndrome is an altered voice. This can be accompanied by a bout or recurrence of gastric reflux. But you will recall that progesterone is already having a drying effect on the vocal folds. This causes a posterior laryngitis, as well as an edema of the cordal joint. But no pain will accompany these symptoms because neither the pharynx nor the larynx has been hurt. The dry environment in the Opera House and, before that, the dry recycled air in the airplane had increased the risk of hematoma of the vocal folds. The singer with a premenstrual vocal syndrome often complains of tiredness, of a loss of pianissimo, of an alteration in certain harmonics in the higher registers, of a deficit in the power of the voice, and of a veiled voice. In some patients, I have also observed pharyngitis and cyclical sore throats, as well as halitosis that required vaporization of the tonsils with the help of the laser in order to avoid a monthly intake of antibiotics and anti-inflammatories. During the premenstrual period, the formation of an edema can create or aggravate the formation of nodules on the vocal folds. This causes a hoarse

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voice during the 6 days that precede the menses and during the first 2 days of the menses. If this cyclical, episodic dysphonia recurs too often or gets worse, the nodules also get worse. At first, they are soft and do not prevent the vocal folds from vibrating correctly. From one cycle to another, this simple nodule, the size of a small, supple button in the central third of the vocal fold, hardens. As a result, the hoarseness is permanent. This problem always requires voice therapy to enable the singer to rebalance the axis between her breathing and the vocal fold vibration. Sometimes, these voice therapy sessions carried out by the “clock makers” of physiotherapy, namely speech language pathologists, are backed up by phonomicrosurgery. This intervention becomes necessary if the voice remains impaired between menses and seriously handicaps a singer’s career. However, it is then more judicious to operate on these pathological vocal cords well clear of the week preceding the menses, thus allowing the organism to spontaneously reabsorb the edema of the vocal cords, which normally disappears between the 3rd and the 20th day of the menstrual cycle.

The Voice and Pregnancy A professional singer can sing remarkably well while being 2 to 7 months pregnant. The vocal folds are then nicely plump and perfectly lubricated. The quality of the vibration is actually improved. The hormones that accompany pregnancy confer special warmth to the voice’s harmonics. The voice is rounder; it carries well. It seems that pregnancy does beautify the voice. After the seventh month, the breathing support is impaired, which is only normal. The sole ailment that needs to be treated during a pregnancy is gastric reflux.

Menopause: With or Without Hormones? Different Times, Different Problems During menopause, this cycle is progressively disrupted. But menopause, which today is of interest to us all, became topical only relatively recently.

In ancient Greece, 400 years bc, the menopausal woman did not exist or was an exception as the average life expectancy was 23 to 27 years. Menopause still rarely occurred in the Middle Ages because life expectancy was then 23 to 40 years. Only in the 20th century was menopause finally taken into consideration. Indeed, girls born in the 1980s can expect to live to the age of 92! Menopause now corresponds to practically half of a woman’s life. By the end of the 20th century, France accounted for nearly eight and a half million menopausal women. The importance of the voice, the development of verbal communication, and interpersonal relationships all point to the essential problem that voice and menopause are now beginning to pose. The key symptoms of menopause include hot flashes, loss of periods, and vaginal dryness, often aggravated by thyroid changes. Why do these changes occur in a woman’s voice around this period of her life? During perimenopause, progesterone levels collapse. Very few estrogens remain. Equally, the secretion of male hormones also drops off considerably. But their presence, now that they are no longer counterbalanced by feminine hormones and essentially by progesterone, can sometimes cause the voice to become more masculine. Thus, the ovary becomes a simple endocrine gland with no reproductive function. The menopausal phase normally lasts from the age of 47 to the age of 55. The impact that the sex hormones have on their various target organs disappears, but not without consequences. However, nowadays, the administration of substitute hormones enables the unpleasant consequences of this lack of sex hormones to be delayed to an increasingly later age, saving many women from a trying experience that is both mentally and physically hard to accept. In the 1950s, this perimenopause period was referred to as “the change of life,” implying that an entire chapter in a woman’s life was coming to a full stop. Our better understanding of the endocrinological world has given the menopausal woman greater quality of life on a daily basis. D’Haeseleer et al14 examined physiological characteristics in postmenopausal women taking hormone replacement and compared them to women not taking hormonal replacement. They found the postmenopausal women without hormone replace-

Normal Voice Maturation: Hormones and Age

ment showed a significant lower speaking fundamental frequency and improved their lower voice range compared to the hormone replacement groups. Hormonal substitutes may be contraindicated. They are not recommended in cases notably of breast cancer, a high-risk family background, cardiovascular pathologies, or cholesterol-related afflictions. For this reason, a medical checkup is a prerequisite for women in their 50s who are considering their options. Thereafter, a regular checkup should be performed. The ovary becomes just an endocrine gland of estrogens and androgens. The receptors of sex hormones receive more androgens and become more receptive to them. As a result, the vocal cord mucous membrane thickens. This is accompanied by a lack of tonicity and a deficiency of its contours. The voice becomes deeper and more masculine. Meanwhile, the 60-year-old woman may develop symptoms such as increased hairiness as an indirect consequence of androgens. A smear test of the cervix of the uterus indicates an atrophy of the epithelium. The same result is obtained from a smear test of the vocal folds. This parallelism is amazing.

Menopause and the Vagus Nerve The larynx is controlled by the vagus nerve. At menopause, the brutal drop in progesterone results in a progressive slowing of nerve conduction that is barely noticeable. This slowdown is due to a relative lack of myelinization of peripheral nerves and induces slower nervous conduction from the brain to the larynx. As a result, vocal response slows down slightly, which can hamper rapid changes of frequencies when singing. Later, the vibrato (7 vibrations per second) cannot be maintained. The voice gradually gears down to the tremolo (4 vibrations per second).

The Modigliani Woman and the Rubens Woman Observation of menopausal women has led us to categorize them into 2 vocal types that can be distinguished. Why is this? Put simply and to caricaturize it, one can distinguish the 2 types of menopausal women by their appearances. The first type, slim

with very few fat cells, we will call the Modigliani type (as in Modigliani’s paintings). The second, somewhat stouter, we will call the Rubens type (as in Rubens’s paintings). Estrogen synthesis happens on 3 levels: at the level of the ovaries, when these are functional; at the level of the brain (hypothalamus, tonsils, and hippocampus); and finally at the level of fat cells. The latter cells are the ones that interest us here. They are particularly active during menopause. For the past 30 years, we have known that, in both men and women, fat cells can turn androgens into estrogens. The relationship between obesity and a higher secretion of estrones (estrogen derivatives) is also age related. It is higher in menopausal women. This is the work of a specific gene in our DNA (cytochrome 19 associated with P450 aromatase) that facilitates the transformation of androgen into estrogen in our adipose cells. Thus, the lower need for hormone substitutes of our Rubens-type woman is due to the fact that her fat cells will transform her androgens into estrones. Meanwhile, our slim Modigliani woman is more likely to need hormone substitute therapy, prescribed, of course, with due respect to contraindications. Obese tenors have been found to have a higher level of estrogens and a slightly lower level of testosterone than those found in baritones and bass singers. Indeed, slim, deep bass singers with their bony figures have a higher level of androgens. They have no fat cells that could help the organism to metabolize testosterone into estrogens. With age, muscle mass diminishes, adipose mass increases, and cells are redistributed differently about the body.3,9,10 Corticosteroids boost the increase of fat cells. Therefore, menopausal women need to be cautious about consuming them. A carefully considered hormone substitute therapy program, associated with vitamins and minerals, can bring considerable benefits to most female voice professionals if their body can tolerate it, which is far from being a given. I have noted that women who receive such treatment are able to avoid developing a masculine voice as they age and also preserve a beautiful voice for a significantly longer time. I have been most impressed by certain sopranos who have kept the same tessitura until the age of 65.

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Male Hormones:  The Lower Frequencies Take the Voice Hostage Women secrete androgens, the male hormone “par excellence,” but in minute doses: on the one hand via the adrenal glands just above the kidneys, on the other hand via the internal theca, a very precise part of the ovaries themselves. Indeed, females require a touch of testosterone to ensure a satisfactory level of libido and enough low-pitched harmonics in their voice to distinguish it from a child’s voice. But the level of testosterone must be around 150 µg/dL. If it is too low, the libido disappears. If it is too high, masculinity sets in and excess pilosity or hirsutism can occur. This action is often irreversible and is also aggravated by steroids. The consumption of androgens leaves indelible marks in women. That is why voice professionals should check their medication carefully for the presence of androgenic anabolic derivatives. These elements may also be present in certain progesterone preparations and their molecular derivatives.

The Male Voice The androgens secreted by the testicles have a direct effect on the voice. They certainly act on the bony tissues but also on the brain. They increase aggressiveness. It is no accident that yelling is often an integral aspect of male expression in combat, both in men and in animals. This male hormone builds his laryngeal muscles and lends power to his call. The significant influence of androgens on his vocal print and on the power and frequencies of his call without a doubt triggered the appearance of secondary sexual attributes. Androgens increase blood flow in the organism and improve oxygenation and muscle performance. Note that cortisone can have an androgenic effect and psychiatric side effects, including euphoria. This induces some voice professionals to overdose on it, hoping to be at their best vocally. But this is dangerous because it can have a rebound effect. When you come off cortisone, muscle tone decreases abruptly, and tiredness, possibly even a light depression, may set in.

The Aging Voice: Does the Voice Age? Do Voices Wrinkle? We age. Aging is a progressive alteration of the body’s response in our life from maturity to death, a biological necessity for recycling of elements in nature. Our voice ages, as does our body.5 Aging is a natural biological evolution. It is a consequence of stress, of age, of maturity and it is reflected in the state of our tissues, vessels, and brain. Different theories have tried to explain aging. The free oxygen radical theory claims that aging weakens proteins. According to the genetic heritage theory, genes carry an innate blueprint of timetable for growth, repair, and death in every cell of our body. But we all have a gene for apoptosis located on chromosome 9. These genes are thought to be the “end-of-life” genes. They program our cellular death. Telomere length on the chromosome determines the life span. According to chromosomal research, the genetic heritage of Homo sapiens allows for a life expectancy of 100 to 150 years. Aging is caused by life’s vicissitudes. If we can’t prevent the genetic inheritance, we may be able to avoid or to decrease the impact of accidents, infections, cardiovascular diseases, diabetes, mental stress, pollution, alcohol, tobacco, and drugs.14,15 Lack of exercise is one of the factors, as is diet. In France, in 1980, 9% of the population was over 65. By the year 2000, nearly 15% was over 65. In 2030, close to 25% is expected to be over 65. These statistics may well be replicated for most developed countries.

The Voice Changes With the Passing Years: Why Does Presbyphonia Appear? Age, muscle atrophy, and the effects of other medical problems, including intubation for needed surgery, are factors that are associated with presbyphonia.16 Thirty years ago, very little was known about the aging of the voice, or presbyphonia, a medical condition that begins around the age of 80. A new medical field has opened up over the past few years. As

Normal Voice Maturation: Hormones and Age

time goes by, the vocal folds lose their suppleness. The vocal fold atrophies. There is a loss of hydration, a loss of collagen and elastin fibers. Remaining fibers are thicker. As a result, the laminar structure of the cordal tissue is less supple. Consequently, when you tighten your vocal cords, they arch and no longer make proper contact. They allow some air to slip through. If you speak for any length of time, you become breathless. Many clinical signs are well known: (1) intensity drops down due to vocal atrophy, (2) register narrows due to vocal elasticity, and (3) low pitch lowers due to vocal suppleness (fat cells substitute for muscular cells fibers). n First formant and second formant are low. n Loss of suppleness of the resonators n Lack of F0 stability n Vibrato becomes a tremolo. n Presbyacoustic: feedback and importance

of the audiophonatory loop weakens. n Videolaryngoscopy and stroboscopy

are very useful to study anatomical and physiological changes. The following were found in older individuals.1 1. Sulcus vocalis in 34% 2. Bilateral amyotrophy with bowing vocal folds in 55.6%

3. Arthrosis of the cricoarytenoid in 21.6% with hypomobility in 10% 4. Superior laryngeal nerve paresis in 7.2% 5. Lack of vibration in 71% (54 atrophy, 5 sulcus alone, and 10 bowing folds)

It May Be Mechanical The larynx, the resonators, the feedback, or the audiophonatory loop may be altered (Figure 6–7). In addition, the oxygenation of brain area such as Broca’s and Wernicke’s areas and the planum temporal will slow down the speaking and the singing voice. There are multiple reasons why our voice changes as we get older. The first alteration is mechanical and anatomical in nature: the thyroid, cricoid, and arytenoid cartilages progressively harden, lose their suppleness, ossify, and calcify. The anterior part of the arytenoid cartilage, point of insertion for the vocal fold, and the epiglottic cartilage do not ossify, but they lose elasticity. As for the vocal fold joints, like any other joint, they show signs of inflammation and arthritis. The cricothyroid joint also shows signs of arthritis, causing increased difficulty in the head voice and a decrease in the agility and speed of the vocal folds when practicing musical scales. Joint suppleness is affected by a loss of collagen

Lips Tongue Eardrum Vocal Folds Figure 6–7.  The audiophonatory loop.

67



68 The performer’s VOICE fibers and by a degeneration brought on by dehydration. Laryngophyaryngeal reflux is very common due to insufficiency of the cardia in elderly or obese people. This opens the road for arthritis of “the vocal folds” or more precisely of the cricoarytenoid joint.

Teeth and the Aging Voice Our vocal instrument, the larynx, cannot shoulder all the blame. The buccodental point of articulation is part of the vocal aging process, yet it is often ignored. Losing one’s teeth causes the upper and lower lips to collapse, forming pinched lips. Our jaw is oddly designed. It is shaped like a horseshoe, with a very specific angle between the horizontal part and the 2 vertical parts. On the left and right sides, it articulates with the base of the cranium. This bony part is very strong. When the teeth fall out, it calcifies. The closed angle that normally forms an almost 90-degree angle between the horizontal section and the vertical section in adults opens wider in the toothless person. With advancing age, the lack of teeth causes the jaw to decalcify and erode. Moreover, the angle between the horizontal and vertical parts becomes wider with an angle around 120° (usually, it is around 90–95°) while the horizontal part of the mandible becomes slimmer and the vertical part shorter, all factors contributing to a dramatic change in the profile of the face. The mandible seems squashed under the cranium and the nose droops to the level of the upper lip. Paradoxically, the absence of teeth means the mouth can no longer open fully. The mandible joint becomes less supple. This underscores the importance of maintaining an efficient set of teeth and resorting, when necessary, to dental implants, to ensure that the lips rest against a satisfactory surface, thereby avoiding bone degeneration of the mandible.

Muscles and Neurons Must Keep Fit The problem is simpler with regard to muscles and ligaments. It is not only our vocal tract that may be impaired. Superficial and deep muscles of the head and neck are also important as are facial muscles.

With age, but especially in case of insufficient physical exercise, the myofibrils of the striated muscles degenerate and turn into fibrosis and, secondarily, fat cells.15,17,18 We know of exceptional singers who are 75 years old. We also know of teachers who, once retired, spend considerably less time speaking, resulting in vocal cord muscular atrophy. The internal biomechanical properties of the vocal fold are no longer stimulated. The neuromuscular junction is also normally solicited by phonatory activity. If it is not, muscle activity decreases. Even our nerves undergo a reduction of the myelin sheath, which affects the speed at which messages are transmitted between the brain and the muscles. As a result, these patients’ elocution slows down. This combination of muscles and ligaments receives energy from the arteries and laryngeal capillaries feeding it. A decrease in physical and sports activity reduces the suppleness of the vessels, here and in the entire organism, and accelerates the onset of arteriosclerosis. It affects oxygenation and weakens the musculature, triggering a vicious circle. The return to sports and voice activities should be very progressive and regular. The elderly need to be very patient in their renewed quest for fitness.

The Vocal Fold By the age of 70, nearly 72% of patients who have stopped being vocally active present with atrophy of the vocal folds and epithelium that they did not have prior to their 50s. The synovial joints in the larynx and in the middle ear as well as the temporomandibular joint are affected by aging, as shown in Figure 6–8. Gray19 has observed that the extracellular matrix sees its enzymes diminished, causing the fibers with collagen IV and VII to decline. The interstitial matrix has less water and hyaluronic acid. There is a loss of elastic fibers in the proteoglycans webbing. The lamina propria, an indispensable element under the cordal epithelium, becomes rigid and stiff. Triggering a vibration becomes more difficult. The viscosity increases and the gliding effect diminishes. This suite of alterations, aggravated by deficient lubrication of the epithelium, often justifies supplementing the diet with substitute vitamins and with minerals that have a role to play in vocal activity.

Normal Voice Maturation: Hormones and Age

Middle ear

Larynx TM joint

Figure 6–8.  The synovial joints play an important role in the aging voice in the middle ear (left ), cricoarytenoid joint in the larynx (middle), and temporomandibular joint in the jaw (right ).

n Before 50 years old:  we do not observe

atrophy (0%) of the vocal fold muscle. But there is 0.7% bowing vocal folds and 7% sulcus vocalis. n After 70 years old:  there is 72% atrophy, 8% bowing of the vocal folds, and 64% sulcus vocalis. n After 80 years of age:  there is 81% fat with keratosis in the vocal muscle and ligament. There is an atrophy of the lamina propria. In males, the vocal ligaments shorten, and the intermediate layer of the lamina propria (LP) is thinner (loss of the elastic fibers, atrophy of the deep layer of the LP, and loss of collagen fibers which leads to fibrosis). In females, the mucosal covering of the vocal fold becomes thicker and there is also loss of elastic fibers. Besides the vocal fold structure, the glandular cells located on the superior and subglottic epithelium atrophy as previously shown in Figure 6–3. Accordingly, the lack of lubrication also disturbs the vibratory pattern.

The Breath:  Power of the Voice The energy of the voice is intimately connected with our breathing. Our lungs progressively weaken with age. In people who do not engage in physical activity, bronchial efficiency diminishes by almost 40%

between the ages of 40 and 80. That is a significant drop. Our lung capacity is affected by atrophy of the peribronchial muscles, a reduction in the number of alveoli in the lungs and in their elasticity. The thoracic cage loses its suppleness and therefore its amplitude. Asthma and asthma-like conditions are more frequent as are cardiopulmonary diseases. The stiffness of the thoracic vertebrae perturbs the elasticity of the thoracic cage. Physical activity is the antidote for this.18

Thyroid Hormones Besides these mechanical elements, the decrease in sex hormones plays a major role. With age, there is also a frequent drop in the secretion of thyroid hormones, hormones that generate energy for the muscles and that hydrate the organism. Hypothyroidism changes can be observed in 33% of menopausal women. Women are more subject to thyroid disease than men, and it is particularly prevalent in menopausal women. Menopausal women should be routinely screened for thyroid disease as part of their annual examination. For those who are taking estrogen or changing the dose of the estrogen, the more estrogen they take, the more thyroid hormone their body needs and vice versa. This is because estrogen increases a protein in the blood called thyroid binding globulin (TBG). The higher the TBG levels are, the lower the free thyroid hormone levels is. Both hypothyroidism and perimenopause are associated

69



70 The performer’s VOICE with weight gain. The reason for this weight gain is that the basal metabolic rate (BMR) is the rate of energy expenditure. The thyroid gland controls partially the BMR. With too little thyroid secretion, our food is burned at a lower rate of energy and, if the calorie intake remains the same, weight gain occurs. Hot flashes and vaginal dryness may be worse due to thyroid changes. Thyroid hormones should be controlled systematically in presbyphonia after menopause or andropause. Patients with a sluggish thyroid often require appropriate therapeutic treatment to get them out of their lethargy and feeling energetic again. A daily dose of a synthetic thyroid hormone therapy is typically prescribed and followup tests are done every 6 to 8 weeks. The dosage is adjusted until the right level is found, usually within 3 to 4 months of T3.

Man and Andropause At the age of 70, andropause may appear. The blood analysis will diagnose the lack of androgens. If there is no contraindication such as cancer of the prostate, androgen treatment may be useful to recover the vocal folds’ shape, the tonicity of the resonators, and consequently a powerful voice with a satisfactory register.

The Paradox of the Aging Voice In Women As the menopausal woman advances in age, her new hormonal balance, with its absence of estrogens and its very mild secretion of testosterone due to the atrophy of her ovaries, is no longer able to sustain the tonicity and strength of the vocal fold muscles. As a result, both vocal folds atrophy progressively and the mucous membrane covering them becomes thinner and dehydrates. Initially, the voice displays a narrower register, the higher harmonics are lost, and the voice is less powerful and tires faster. But a paradoxical effect sets in. Because the vocal cord has diminished in thickness and becomes finer, the voice, which had become a little deeper, now becomes higher, more

delicate, and sometimes even shrill. You often hear 80-year-olds speaking with a very high-pitched voice. One can thicken the vocal folds again by injecting a substance into them that will ensure reasonable timbre and vocal endurance.

In Men After the age of 70, men can present these same vocal symptoms in the male climacteric. Yet, the vocal structure in this case behaves like an athlete in all respects. As with women, hormone therapy is indicated in conjunction with specific nutrition hygiene, but vocalizations are indispensable. Androgenic hormonal therapy is rarely advisable because of its danger for an altered prostate. For men, vocal training is the best guarantee of keeping a young voice. An example I like to quote concerns a professor of French at the Lycée Henri-IV in Paris, who also lectured at the Sorbonne and who was in the habit of speaking over 4 hours a day. I had known him for over 10 years. When he stopped his academic activities, he started writing his memoirs and barely said a word for the next 6 months. He used to have an athlete’s larynx. But when I saw him again a year later, I detected an impressive atrophy of his vocal folds. He was only 65 years old, yet he had the voice of an old man. The right treatment combined with intensive speech therapy enabled him to practically recover his normal voice. I advised him to carry on lecturing for a minimum of 3 hours a week. Our voice ages only if we isolate ourselves from others. Regular practice and communication with others stimulates the voice and preserves its timbre.

Rejuvenating the Voice This atrophy of the vocal folds can be corrected through voice and speech therapy and, on rare occasions, through phonosurgery (surgery of the voice). This phonosurgery consists of injecting a product into the shrunken cordal muscle to increase its volume to its previous state. The voice regains satisfactory power and tonality. The voice of these dysphonic, breathless patients once again becomes dynamic. This type of surgery is only practiced if the standard medical and speech therapy treatment

Normal Voice Maturation: Hormones and Age

has failed. This “voice lift” is often very successful. The key to preserving a youthful voice is to be serious about physical exercise, hydration, lubrication of the vocal folds, dental hygiene, muscular activity, nutrition, vitamin and mineral supplements, and possibly appropriate hormone therapy. Often, antireflux medication (to treat the acidity coming from the stomach to the larynx) is necessary.14,20 If you take good care of the health of your voice, you can most certainly retain an efficient vocal tessitura and timbre. Hormonal treatment may be used. A complete exploration of the thyroid gland often discovers a deficiency in thyroid hormones, which has to be treated. This appears more often in females.

A Multifactor Treatment More than 80% of patients undergo voice therapy for approximately 6 to 8 sessions. Some prefer to add singing lessons and join a choir, which is an excellent decision. They feel that they can improve their voice if they belong to a team and practice using it instead of being lonely and quiet. Some may require an acute treatment for arthrosis (anti-inflammatory medicine or injection of steroid in the cricoarytenoid joint), reflux treatment (proton pump inhibitor [PPI]), or injection of material in the bowing vocal fold. Alternative medicine with vitamins, minerals, and antioxidants such as omega-3 are now being added to the treatment regimen. An important point has to be made: we must not forget the lubrication of the vocal tract and eventually prescribe molecules such as acetyl-cysteine. Dental care is critical. Implants may be necessary and respiratory physical therapy is sometimes indispensable. If you try to talk as if you have no teeth by turning your lips inside, your voice is a very old voice: the door of your voice is your lips.

Prevention Is Possible If you do not take proper care of yourself, the voice will age. Vocal registers will narrow, the voice will weaken, and the timbre will lose color and become metallic. This can be avoided by adopting a regular and constant healthy lifestyle; by taking antioxidants, vitamin C and vitamin E, and minerals such as

magnesium; and by keeping up physical and intellectual activities. Unfortunately, the impact of passing years is sometimes less forgiving with regards to our hearing. We have seen that listening and audiophonatory feedback are essential to the quality of the voice. All voice professionals should have their hearing checked regularly to test for auditory acuity. If necessary, one should not hesitate to correct a hearing deficiency with a hearing aid. Nowadays, hearing aids are very well tolerated and, in most cases, will help voice professionals to reestablish a correct balance between their vocal and auditory functions. A hearing aid keeps one in touch with the outside world. It is a safeguard against isolation. It stimulates the audiophonatory loop and contributes to a precise control of the voice while speaking and singing (see Figure 6–7). One last anecdotal story: recently, a very famous 82-year-old French pop singer called me at 11:30 pm after his concert. He said, “Doctor, I have a voice problem, my first show this evening was a disaster. I could not sing. I have no pain. I don’t understand. I may have lost my harmonics. Could you see me now?” As you may guess, I did. I looked at his vocal folds. They did not show any problem and were perfect like those of a young singer. His ears did not have any wax. After talking to him, I asked, “How is your feedback of the sound on stage? The orchestra and your own voice?” He answered, “The orchestra was also as bad as my voice.” I did an audiogram. He did have a hearing loss. He did not know about it. The next day, he was fitted with hearing aids and he did sing fabulously well. This electroacoustic device, which is designed to amplify sound, gave him the crucial key for a singer: the harmonics. It was not the voice but the master of the voice: the hearing process. The human voice is not immune to the effects of aging. Vocal quality and strength can be affected by a number of different conditions that increase in prevalence with age. The memory and the activity of the brain are indispensable to keeping a good voice.21 Fortunately, with appropriate diagnosis, environmental and hygienic interventions, specific medical treatments, and voice therapy, most people can maintain a functional, quality voice through all of their lives.15,20

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72 The performer’s VOICE

Summary Like a ship on the waves of the ocean, the voice travels through the ever-changing weatherscape of hormones and emotions. It changes through the voyage of the hormonal storm of our being. Your voice is the vibrations of life. If your larynx is the harp, your voice is its soul.

References 1. Abitbol J, Abitbol P, Abitbol B. Sex hormones and the female voice. J Voice. 1999;13(3):424–446. 2. Kadakia S, Carlson D, Sataloff RT. The effect of hormones on the voice. J Singing. 2013;​69(5):​ 571–574. 3. Orbelo D, Eckborg DC, Thompson DM. Dysphagia associated with lingual thyroid gland and hypothyroidism: improvement after lingual thyroidectomy. Ann Otol Rhinol Laryngol. 2011;​120:775–779. 4. Gago N, Akwa I, Sananes N, et al. Progesterone and the oligodendroglial lineage: stagedependent biosynthesis and metabolism. Glia. 2001;36(3):295–308. 5. Von Leden H, Alessi DM. The aging voice. In: Benninger MS, Jacobson BJ, Johnson AF, eds. Vocal Arts Medicine: The Care and Prevention of Professional Voice Disorders. New York, NY: Thieme Medical Publishers; 1994:269–280. 6. Hammond TH, Gray SD, Butler JE. Ageand gender-related collagen distribution in human vocal folds. Ann Otol Rhinol Laryngol. 2000;109:913–920. 7. Scherer RC, Rubin JS. Laryngeal physiology: normal and disordered. In: Benninger MS, ed. Benign Disorders of Voice. Alexandria, VA: American Academy of Otolaryngology-Head and Neck Surgery; 2002:29–44.

8. Sapienza C, Hoffman-Ruddy B. Voice Disorders. San Diego, CA: Plural Publishing; 2009:248–249. 9. Lee R, Hopkins V. What Your Doctor May Not Tell You About Menopause. Boston, MA: Warner Books; 1996. 10. Celic O, Celik, A, Atespare A, et al. Voice and speech changes in various phases of menstrual cycle. J Voice. 2013;27(5):622–626. 11. Kansaku K, Yamuara A, Kitazawa S. Sex differences in lateralization revealed in the posterior language areas. Cereb Cortex. 2000;10(9):​ 866–872. 12. Benninger MS. Dysphonias secondary to neurologic disorders. J Singing. 1996;52:29–32. 13. Amir O, Kishon-Rabin L. Association between birth control pills and voice quality. Laryngoscope. 2004;114(6):1021–1026. 14. D’haeseleer E, Depypere, H, Claeys S, Baudonck N, Van Lierde K. The impact of hormone therapy on vocal quality in postmenopausal women. J Voice. 2012;26(5):671–675. 15. Mueller PB. Senescence of the voice: morphology of excised male larynges. Folia Phoniatr. 1985;37:134–138. 16. Hirano M. Aging of the vibratory tissue. Acta Otolaryngol. 1989;107:428–433. 17. Peres G. Nutrition des Sportifs, Abrégé de Médecine du Sport. 8th ed. Paris, France: Masson; 2002. 18. Malmgren LT, Jones CE, Bookman LM. Muscle fiber and satellite cell apoptosis in the aging human thyroarytenoid muscle: a stereological study with confocal laser scanning microscopy. Otolaryngol Head Neck Surg. 2001;125:34–39. 19. Gray SD, Tritle N, Li W. The effect of mitomycin on extracellular matrix proteins in a rat wound model. Laryngoscope. 2003;113(2):237–242. 20. Kaufman JA, Amin MR, Aviv JE, et al. Laryngopharyngeal reflux (LPR). Ear Nose Throat. 2002;​ 81(9):1–32. 21. Abitbol J. Odyssey of the Voice. San Diego, CA: Plural Publishing; 2006.

Chapter 7 The Pediatric Voice Gillian R. Diercks Christopher J. Hartnick

T

he development of speech and voice in the pediatric population is important for social interaction and learning. Thus, abnormalities may have a profound impact on the well-being of children and their families.1 Voice disorders are prevalent, affecting 6% to 9% — or approximately 5 million — of school-aged children.2 Dysphonia is more common in male children, affecting 7.5% of boys and 4.6% of girls.3 While vocal fold nodules are the most common pathology responsible for dysphonia in school-aged children, a wide variety of other congenital and acquired lesions should be considered in the pediatric population. Because symptoms may be present from birth, dysphonia may be difficult detect and thus be undertreated, placing children at risk for speech delay, reduced self-esteem, and diminished educational opportunities.2,4,5 Untreated voice disorders are associated with inferior quality of life, including decreased class and extracurricular activity participation, reduced interactions with peers, and the development of maladaptive behaviors.2 Voice abnormalities may also be present along with other more global speech, language, and developmental issues, which may complicate assessment and treatment. Pediatric laryngology is a relatively new field of study; therefore, guidelines and treatment protocols for children with dysphonia are limited. This chapter is intended to highlight the unique anatomical, diagnostic, and treatment considerations in children with voice disorders.

Anatomy An understanding of laryngeal development is critical in evaluation of the pediatric voice. The pediatric larynx is structurally different from the adult and adolescent larynx, which has important implications for laryngeal function and surgical interventions in children. The larynx is composed of cartilage, bone, and associated intrinsic and extrinsic musculature. The larynx forms from the fourth and sixth branchial arches and ventral foregut during the first 8 weeks of gestation. During development, the primitive laryngopharynx becomes obliterated by an epithelial lamina, then recanalizes in a dorsocephalic to ventrocaudal direction. Failure of the lumen to recanalize completely may result in supraglottic, glottic, and subglottic webs and atresias (Figures 7–1 and 7–2), which may lead to dysphonia and airway obstruction after birth. During the fetal period, neurologic differentiation begins and the ventricles and cartilaginous structures of the larynx develop. By the second trimester, movement of the larynx can be detected, and the coordination needed for complex swallowing and respiratory functions is present.6 The structure and position of the larynx also change after birth. In infants, the thyroid cartilage is telescoped beneath the hyoid bone, which narrows the thyrohyoid membrane. Additionally, the infantile

73

A

B

Figure 7–1.  Congenital anterior glottic webs. A. Thin glottic web with a subglottic component in a 3-year-old boy with dysphonia. Vocal fold distractors are placed in the ventricle. B. Thick anterior glottic and subglottic web resulting in subglottic stenosis and airway obstruction requiring tracheotomy.

A

B

Figure 7–2.  Congenital subglottic stenosis with lateral shelves. A. Grade 1 (99% o f funding & Tx

Mind

Spirit

CURRENT PARAD IGM Figure 17–2.  Illustration of the current paradigm of Western medicine regarding the disease process. Courtesy of Robert Levine, PhD.

239

240

The performer’s VOICE

Holistic/Integrative Medicine Paradigm - Hypotheses:

•The domains of B-M-S are inseparable and out of balance in disease

•Optimal treatment involves addressing all domains TOGETHER STRUC TURAL

MOVEMENT PATTERNS

BEHAVIORAL PATTERNS

Body

Mind

STRESS

HORMONA L EMOTIONAL NUTRITIONA L

Spirit DEPRESSION

GENETIC

PERSONAL PAST

SECURITY

SUPPORT

FAITH

Figure 17–3.  Illustration of the holistic/integrative medical paradigm of the disease process. Courtesy of Robert Levine, PhD.

Nutraceuticals, Vitamins, and Herbs Many herbs can be used for medicinal purposes, and many of them are extremely relevant to the singer. Some of the more commonly used herbs are listed in Table 17–2, where we have provided details, such as claims information, specific actions when known, contraindications, potential side effects, interactions, and dosages, when available.

There is always concern about whether a specific supplement contains precisely what the manufacturer claims. Unfortunately, there have been many examples suggesting that this is not always the case. However, herbal remedies are increasingly being sold with standardization information included on the labels. For the time being, we must take the manufacturers at their word, because this area is not regulated by the Food and Drug Administration (FDA).

241

APHA class: 2da

Kava Kava

Goldenseal

APHA class: 1

Echinacea

Herbal Supplement/APHA Class if Known

Insomnia

Mild to moderate anxiety

Mouth sores and sore throats

Topical antibiotic for wounds that are not healing well

Treatment and prevention of the common cold and flu

Indications

Anticonvulsant

Muscle relaxant

Mild analgesic

Antianxiety

Strong activity against a wide variety of bacteria and fungi

Endogenous Depression

Nursing mothers

Pregnancy

Pregnancy

Allergy to flowers of the daisy family

Autoimmune or chronic illness

Immunostimulant Enhances phagocytosis

Contraindications

Actions

Table 17–2. Herbs Used for Medicinal Purposes

Enlargement of pupils

Skin rash

Yellowish skin discoloration, Balance disturbance

Drowsiness

Mild gastrointestinal irritation

Antipsychotics

Antidepressants

Barbiturates

Alcohol

Buspirone

Benzodiazepine

continues

Standardized extract: 140–240 mg in 2–3 divided doses (30%– 70% kava-lactones)

Tea: .5–1 g in a cup of water

Tincture: swished or gargled

Increased nervousness

Whole dried root: 102 g TID As cream, cover entire surface of the wound

Methotreaxate

Imuran

Juice: 203 mL TID

Alcohol tincture (1:5): 3–4 mL TID

ie, Neoral Prednisone

As powder extract: 300 mg cap/TID

Dosage

Immune suppressants

Interactions

Gastrointestinal distress

Mild allergic reactions

Increased urination

Minor gastrointestinal irritation

Side Effects

242 Tonic Stimulant

Ginseng

APHA class: 2d

Improve cognitive, sexual, and GI functions

APHA class: 1

Guaranab

Pygeum Africanum

↑ Urinary flow

APHA class: 1

↑ Energy

Stimulant headache

↓ cholesterol

Diuretic,

Anti-inflammatory

Symptoms of BPH

↓ symptoms of BPH

Anti-inflammatory

Saw Palmetto

Dizziness/tinnitus

Dementia

Gingko Biloba

Diabetic impotence

Diuretic

Indications

Herbal Supplement/APHA Class if Known

Table 17–2.  continued

Caffeine-like activities

Sympathomimetic

Antiproliferative effect on fibroblast

Antiandrogenic

Diuretic

Inhibits dihydro­ testosterone

↓ capillary fragility

Free radical

Neuroprotective

HTN or hyperthyroidism

Renal disease

Cardiac problems

None reported

Do not take while on prescription BPH treatment

Arrhythmias

Anxiety

HTN

↑ Heart rate

Nausea and abdominal pain

None

Spontaneous bleeding

Avoid other stimulants

None known

Caution with diuretics

Anticoagulant properties may induce seizures, infertility

Thiazide diuretics

MAO inhibitors

SSRIs

Cyclosporine

Anticoagulants

↑ CNS blood flow If the patient is on anticoagulants

Caffeine

Coumadin

Hypertension

MAO inhibitors

Diabetes

Psychosis

Medications for:

Interactions

Stimulants

Insomnia

Hypoglycemia

Hypotension

Bleeding

Side Effects

Cardiac disease

Schizophrenia

Insomnia

Diabetes

Coagulopathy

Contraindications

Stimulates immune system

Depress CNS activity

Lower blood pressure

Physiologic effects

Actions

2 times as strong as caffeine

50–200 mg stand ext/d

160 mg BID

120–480 mg/d in 2–3 divided doses

Asian (Panax): .6–3 g 1–3 times daily

American: Root: .25–.5 po BID

Dosage

243 Rheumatoid arthritis Atherosclerosis

APHA class: 2b

Hawthorne

APHA class: 2c

Garlic

Black Cohosh

Migraine

Feverfew

↓ Cholesterol 10%–12%

Prevents agedependent vascular changes

Reduces levels of lipids in blood

Tinnitus

Vertigo

Expectorant

Diuretic

Emmenagogue

Astringent

Menopause

Arrhythmia

Indications

Herbal Supplement/APHA Class if Known

Enhances fibrinolytic activity

Prolongation of bleed and clotting time

Inhibition of platelet aggregation

Lipid lowering

Antimitotic

Antibacterial

Binds to estrogen receptors

Luteinizing hormone suppression

Estrogen-like action, oxytocic

Improves cardiac output and coronary blood flow

Inhibits serotonin release

Actions

None known

None known

Do not use with other inotropes

Avoid during pregnancies

Aster family allergies

Contraindications

Odor may pervade breath and skin

Allergic reactions

GI upset

Nausea, headache, and dizziness in high doses

Occasional GI upset

Mildly sedative

GI upset 6%–15% first week of use

Side Effects

Hypoglycemic

Anticoagulants

None known

Fox Glove

Digitalis

(inhibit cyclooxygenase)

Anticoagulants

Interactions

continues

(minced bulb and prep is taken orally)

4 g fresh garlic

Galenical prep for oral intake

40%–60% (v/v) corresponds to 40 mg drug

Extracts w/alcohol:

160–900 mg/d

equivalent to 0.2–0.6 units

50 mg–1.2 g/d

Dosage

244 Stimulant

(weight loss — not an approved use)

Bronchial edema

Asthma

Wound healing Sympathomimeticbronchodilator

SSRI and DA agonist

Weak MAOI

Antidepressant

Increases circulation

Antispasmodic

Actions

Thyrotoxicant

Pheochromo­ cytoma

Angle closure glaucoma

Hypertension

Anxiety

Cardiac problems

Avoid in pregnancy

Avoid during pregnancy

Contraindications

Death

HTN, neurosis, insomnia, palpitations, hyperglycemia

Photosensitivity

Side Effects

Oxytosh

Quanethedine

MAOI

Cardiac glycosides

Halothone

Antiseizure medications

MAOI

Antidepressants

Interactions

or herb/d

15–30 mg total alkaloid

300 mg TID

Dosage

b 

a 

Kava Kava has concerns for the potential of liver failure; do not use without physician or herbalist guidance. Guarana is an herb that has ~2.5 times the caffeine content of a typical cup of coffee; use with caution in caffeine-sensitive individuals. c  Ma Huang is a sympathomimetic and has been attributed to rapid heart rate and myocardial infarction on rare occasion; do not use without physician or herbalist guidance.

Ma Haungc

Mild to moderate depression Viral infections

Dizziness, tinnitus

APHA class: 2d

Fluid in the ears

Sedative, headaches

Indications

St John’s Wort

Pulsatilla

Herbal Supplement/APHA Class if Known

Table 17–2.  continued



Complementary and Alternative Medications and Techniques

The Dietary Supplement Health and Education Act of 1994 (DSHEA) was established to meet the concerns of consumers and manufacturers that safe and appropriately labeled products would remain available to all who would like to use them. The provisions of DSHEA are provided as n defining dietary supplements and dietary

ingredients; n placing the safety of the product

responsibility on the manufacturer; n creating guidelines for literature used in

connection with sales; n specifying how labeling can be used in

support of health benefit claims; n specifying labeling requirements; n governing regulations of good

manufacturing practices. DSHEA does not require FDA authorization for over-the-counter (OTC) herbal product labeling, but the Federal Trade Commission (FTC) typically requires claims about the efficacy or safety of dietary supplements be supported by competent and reliable scientific evidence. To include botanical drug substances in an OTC monograph, there must be published data establishing general recognition of safety and effectiveness, including results of adequate and well-controlled clinical studies. Numerous considerations are given to guide a supplier in assessing the adequacy of the scientific support for a specific advertising claim, which is meant to aid in the assurance of product content purity, safety, and efficacy. Scientific validity for a health claim includes 2 components: (1) that the totality of the publicly available evidence supports the substance/disease relationship that is the subject of the claim, and (2) that there is significant scientific agreement among qualified experts that the relationship is valid. Herbal products are classified by the American Herbal Products Association (AHPA) as follows: Class 1: No restrictions to its use Class 2a: External use only Class 2b: Not to be used during pregnancy Class 2c: Not to be used during lactation

Class 2d: Other specific contraindications Class 3: Use only under expert supervision Class 4: Unsafe One of the most reputable references with regard to the medicinal use of herbs is the Complete German Commission E. This commission provides monographs on hundreds of herbs, rating them as either positive or negative. Typically, an herb that is rated positively has reasonable scientific support and data to validate its use. An herb with a negative rating may be ineffective, unsafe, or simply not studied to the extent that sufficient information is available. The herb Echinacea provides us with a good example of some of the issues involved in herbal remedies. Echinacea is a very popular herb with a reputation for combating the common cold and flulike illnesses. It is a commonly used herb by professional singers at the first sign of a sniffle, cough, or general malaise. What most people do not realize is that there are 9 different subtypes of echinacea, including Echinacea purpurea, Echinacea pallida, and Echinacea angustafolia. Not only does each subtype have different health benefits, but those benefits vary depending on the part of the plant used. The leaf of E purpurea, for example, has been shown to enhance T- and B-cell functions, whereas the root of that same plant does not. Conversely, E pallida root has been shown to enhance T- and B-cell function, but the leaf of that same plant does not. Meanwhile, E angustafolia is rated as a negative herb by the German Commission E. Yet while visiting numerous health food stores, there were more than 100 bottles of echinacea on the shelves, and 95% of them contained E angustafolia!6 Why would the market be filled with E angustafolia if it is a negatively rated herb? One explanation is that manufacturers are not doing their homework. Another possibility is that it is a much less expensive or more available herb. Nutritional products that contain E purpurea leaf and pallida root are to be considered, both of which have been clearly shown in scientific studies to enhance and activate T- and B-cell functions, to encourage phagocytosis, and to have antibacterial and antiviral properties. Unfortunately, if a study is conducted with a product made

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from E angustafolia, the results are likely to indicate that it does not work in treating cold or flu symptoms. Studies like this cast doubt on all herbal remedies. Drug-herb interactions pose another reason for concern. Echinacea, for example, may interfere with Neoral, prednisone, Imuran, and methotrexate. Furthermore, consumers and physicians should understand that immunostimulants, like Echinacea and the herb goldenseal, should not be used for prolonged periods of time. There are also contraindications for patients who have immune disorders or severe infections, such as tuberculosis. St John’s wort is a commonly used herb for mild to moderate depression, yet it can interfere with commonly used anesthetics, and the results can be deadly. Thus, it is critical to learn about the potential for interactions. The professional singer needs to be aware of the potential benefit of other supplements as well. When singers get an upper respiratory tract infection (URTI), anxiety and fear set in, particularly when a show is scheduled later that day or in the next couple of days. Many professional singers turn to specific supplements. Given the plethora of choices, this chapter briefly discusses only a few of the more commonly used supplements. Ionized zinc has been demonstrated to have direct antiviral activity. In order to achieve this antiviral activity, the concentration required is 0.1 mmol/L to suppress rhinovirus activity. Zinc lozenges provide approximately 4.4 mmol/L. Zinc has been shown to protect cells from damage by viral toxins and inhibit the rhinovirus’s ability to attach, enter, and infect human nasal cells. Interestingly, studies have shown both efficacy and lack of efficacy. Some of this discrepancy can be accounted for by the compounds coupled with the zinc. These additives, specifically citric and tartaric acid, mannitol, and sorbitol, are used to enhance the flavor. However, these compounds can chelate the zinc and make it ineffective.7–13 There is a product called Zicam that is a homeopathic gel consisting of zinc gluconate. The mechanism of action is that the zinc gel binds to viral intercellular adhesion molecule (ICAM) attachment sites, stops the spread, and inhibits viral replication. However, in some cases, it may cause burning, and there have been some reports of anosmia, but it is suspected that the anosmia is more than likely

secondary to the upper respiratory tract infection itself (Hensley et al, unpublished data)14; intranasal Zicam has since been pulled from the market, but oral forms still exist. Another product that has been noted to be extremely helpful at rapidly eradicating the common cold and flu is a proprietary formula developed by the author and marketed by Body Language Vitamin Co (http://www.bodylanguagevitamins.com). This product utilizes the synergistic activity of multiple herbs and supplements, including E purpurea leaf, pallida root, goldenseal, zinc, quercetin, citrus bioflavanoids, and so on. It has been shown to reduce the duration of cold and flu by 70% to 85% in 85% of users, provided it is started at the onset of symptoms (Seidman, unpublished data). The ingredients have been shown to enhance T- and B-cell function and phagocytosis. It, like other herbals, should not be used in patients with active autoimmune processes or patients on immunosuppressant drugs. Uncaria tomentosa has been shown to increase T- and B-cell lymphocytes, and phagocyte and lymphoblast function. Its effects appear to be mediated by the activity of the constituent pentacyclic oxindole alkaloids (POAs). It has also been shown to contain quinovic acid, which reduces inflammation. There are no specific contraindications, side effects, or interactions.15,16 Pulsatilla (Anemone pulsatilla) acts as a sedative and an antispasmodic and can be used to treat headache, neuralgia, laryngitis, mild dizziness, and tinnitus. The herb has been demonstrated to have relaxation properties and to enhance circulation. Pulsatilla is not recommended for use during pregnancy. There are no known interactions, although a fresh pulsatilla plant can cause blistering or a rash. Aconite (Aconitum napellus) can be beneficial in the treatment of upper respiratory tract infections, influenza, facial neuralgia, arthritis, and gout. The alkaloids activate sodium channels, which have been shown to affect neural function. Aconite should not be used in conjunction with any other alkaloids such as quinine or morphine, or tryptophan. The side effects can include nausea, vomiting, dizziness, paresthesia, and palpitations. Cordyceps sinensis enhances immunity and reduces coughing by increasing lung “chi.” It acts as a bronchodilator increasing the function of natural



Complementary and Alternative Medications and Techniques

killer and B cells. There are no specific contraindications, interactions, or side effects.17 Astragalus membranaceus has been known to enhance energy, by increasing resistance to disease while increasing “chi” and circulation. Additionally, it has anti-inflammatory properties. It has been demonstrated to enhance the body’s ability to adapt to stress; stimulates proliferation of stem cells, macrophages, and lymphocyte cells; and increases the production of interferon. Although its use is to be questioned in the presence of active autoimmune diseases, there are no significant known contraindications, side effects, or interactions.18,19 Ginseng (Panax ginseng) has been useful in the treatment of fatigue, depression, stress, sexual energy, and digestion and promotes general wellbeing. It is an adaptogenic stimulant that promotes secretion of adrenocorticotrophic hormone, causing a release of endorphins and enkephalins. It should not be taken during pregnancy and may interfere with anticoagulant therapy. In high doses, it may cause insomnia, anxiety, and gastrointestinal upset. It should not be taken with other anticoagulants, stimulants (such as caffeine), monoamine oxidase inhibitors (MAOIs), or antipsychotics. Goldenseal (Hydrastis canadensis) has been shown to be beneficial for mucosal inflammation, diarrhea and gastritis, wound healing, immune function, URTI, and the flu. It is believed to act as an adaptogen (enhances body defenses) and may increase circulation. The herb should not be used during pregnancy. In high doses, it may cause nausea, vomiting, diarrhea, central nervous system (CNS) stimulation, and respiratory failure. There are no known significant interactions. There are many more herbs that can be considered, but this should provide the reader with a great start. Additionally, Table 17–2 lists additional commonly used herbs. It is critical for health care providers to question patients specifically about the use of nutraceuticals and herbs. Proven therapeutic options should be discussed. If a viable alternative exists, it can be considered, bearing in mind, of course, that natural does not necessarily mean safe. As always, one needs to be diligent about quality control and standardization, and realize that herbal/pharmaceutical interactions do occur with some frequency. Health care professionals should also consider nutraceuti-

cal safety issues and keep an objective perspective. According to one study, the average annual mortality rates over the past 12 years show that deaths related to vitamin use occur at approximately 1 death per year and herbs cause 2 deaths per year, whereas smoking is responsible for more than 400,000 deaths per year, poor diet is linked to 300,000 deaths per year, and pharmaceutical errors contribute to more than 100,000 deaths per year.20 Thus, it is not very likely that anyone will be harmed with nutritional or herbal therapies. Vitamins and minerals are crucial for many different bodily functions. A number of multivitamins provide the standard vitamins and minerals, but there is really no such thing as one pill that can provide everything the body needs. Typically, it takes 4 to 10 pills a day to obtain the necessary nutrients. It is always best if the ingredients are natural and minerals are chelated. Chelating a mineral means an amino acid is bound to the mineral. Thus, when physicians recommend Tums as a good source of calcium, this is a fallacy. Tums is calcium carbonate, the same chemical formula as stone. The absorption of calcium carbonate is approximately 2% to 4%. Thus, for my patients, I always recommended the use of a chelated calcium such as calcium glycinate, gluconate, or citrate. Furthermore, it is an added benefit if the supplement is produced in an FDA-inspected laboratory. In addition, antioxidants should have powerful molecular and cellular antioxidants that are well absorbed. Obtaining sufficient antioxidant protection could require an additional 2 to 4 pills a day. Many nutrition experts believe that our current vitamin and mineral guidelines are too low. The recommended dietary allowances (RDA), or dietary reference intakes (DRI), were established by the Food and Nutrition Board in 1941. They are considered the best scientific judgment on nutritional allowances and are designed to meet the nutrient needs of practically all healthy people. Although the RDAs are safe and adequate nutrient levels, they are neither minimal requirements nor optimal levels. This then raises the question of whether or not we need to take supplements. There is a considerable body of evidence suggesting that the answer to this question is yes. Although conflicting results can be confusing for the general public, health care practitioners

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should be aware of the important role played by vitamins, minerals, and other supplements in overall health. Although the public is encouraged to adopt a healthy lifestyle, engage in stress reduction, eat a nutritious diet, and obtain adequate exercise, few people actually follow those guidelines. As a result, vitamin, mineral, and antioxidant supplements are not only necessary but recommended by an increasing number of health authorities. They play a very important role in the health and maintenance of all people, and certainly professional voice users should consider some of these strategies. Aside from nutraceuticals, many other CIM therapies warrant further discussion. Traditional Chinese medicine (TCM) encompasses both acupuncture therapy and Chinese herbal therapy. It is a system of medicine that also looks at how diet, lifestyle choices, and emotions affect a person’s overall health.

Acupuncture and Chinese Herbal Therapy Our TCM is based on the concept that a vital life force, or energy (called “qi,” which is pronounced “chee”), is what fuels all of the functions of our bodies, including respiration, digestion, elimination, and reproduction. Symptoms and chronic disease patterns reflect an imbalance in this energetic system. Traditional Chinese medicine strives to alleviate or eliminate the symptom (also called the branch manifestation) while at the same time balancing the underlying cause (called the root). This allows the body to change the course of any underlying imbalance, thus giving way to alleviating chronic health issues. The energy, or qi, moves through the body along pathways known as meridians. These meridians have names that are similar to our Western organs such as the lung, spleen, and heart meridian. Each meridian relates to certain functions and processes within the body as well as to different emotions. Each meridian also connects and relates to other meridians, creating a unified system of energy within the body. One example of this is the lung meridian being closely related to respiration, health of the skin, perspiration, protection against colds and flu, and voice quality and strength. Symptoms that may reflect an

imbalance in the lung meridian might include cough, hoarse voice, or laryngitis, asthma, allergies, sore throat, and the common cold, to name a few. Specific acupuncture points and herbal formulas can be used to resolve the symptoms and restore balance. Acupuncture needles are very fine, thin needles that are gently tapped into the surface of the skin. Typically, they are about 10 times thinner than conventional needles and are not considered painful when inserted. Their insertion stimulates a physiologic healing response in which endorphins and enkephalins are released into the bloodstream. The patient often senses a feeling of extreme relaxation. Performers who need to strengthen their voice quality may find acupuncture and herbal therapies extremely effective. Chinese medicine can provide a strong foundation to support performers by protecting their voices during times when they may be more vulnerable. This may be when they are asked to perform multiples shows in a short period of time or during the cold and flu seasons. Acupuncture and herbal therapy may also be used to speed up recovery time for patients suffering from the common cold or just from the rigors of frequent voice use. When a performer feels a sore throat or some slight fatigue signaling the onset of an URTI, he or she can use TCM to help prevent the progression of the illness. Chinese herbals are classically plant, mineral, or animal based and are prescribed specifically for the individual and what his or her needs are. No 2 patients are identical, so their acupuncture and herbal therapies are tailored to their specific needs. Acupuncture has been demonstrated to relax and release muscle tension. It is the ease of movement by expansion and contraction of the diaphragm and surrounding external intercostal muscles that allows the lungs to inflate to capacity. In addition, it is especially beneficial to relax the muscles in the jaw, neck, shoulders, back, and abdomen. The technique of cupping is quite effective for relaxing muscles and increases circulation to these areas. Even the base of the tongue can tense, causing surrounding structures to contract, distorting voice clarity, pitch, and timbre. Last, acupuncture is calming and centering for the emotions. Sometimes unconscious thoughts or past emotional trauma create habitual holding patterns inside the body. Not only can this



Complementary and Alternative Medications and Techniques

affect mental state but could negatively affect the skeletal alignment, breathing, muscle performance, and the healthy functioning of the organ systems.

Hypnotherapy and Neuroimmunopsychology Mind-body therapies such as hypnotherapy or neurolinguistic programming (NLP) are helpful adjuncts to the professional singer. Hypnotherapy has been used for many years to facilitate relaxation and to envision a perfect performance. Many professional singers use this form of therapy. Initially, they experience several sessions with a professional hypnotherapist and then can learn to do this on their own. It is clear that our beliefs and perceptions strongly influence behavior. You are much less likely to succeed if you are not convinced that you will. A classic example is the following: before Roger Bannister ran 1 mile in less than 4 minutes, it was believed to be impossible. Within the same year of Roger’s landmark record, other athletes also ran the mile in less than 4 minutes because they now believed it to be possible. Similarly, Paula Radcliffe recently set a new world record by running the marathon in just under 2 hours and 16 minutes. These successes set the stage for further accomplishments. Beliefs are so powerful that they can affect our neuroimmunopsychology, and they are an invaluable asset to assist a person in achieving his o her goals. NLP is essentially the science of how to run your brain in an optimal way to produce the result you want. An example of the power of NLP is depicted in the book Unlimited Power by Anthony Robbins. There is a story of one of the great musicians of the 20th century, Pablo Casals, the cellist, told by Norman Cousins, author of Anatomy of an Illness.21 At 90 he was frail, arthritic, with emphysema and swollen clenched fingers. He walked with a shuffle, stooped over, his head pitched forward. Yet when he sat himself on the piano bench to play each morning, something quite miraculous happened. Casals suddenly transformed himself and went into a resourceful state, and as he did, his physiology changed to such a degree that he began to move and play producing both in his body and on the piano results

that should have been possible only for a healthy, strong, flexible pianist. The story goes on to say that his fingers seemed to race above the keyboard and his entire body seemed fused with the music. “By the time he walked away from the piano, he seemed entirely different from the person who sat down to play. He stood straighter and taller and he walked without a trace of a shuffle to the breakfast table and then went out for a stroll along the beach.” As Anton Chekhov said, “Man is what he believes.” NLP addresses the mind and allows the individual to form positive images that are the foothold for success. These strategies include success strategies, modeling excellence, utilizing past successes and resources, anchoring for success, and structure and physiology body posture, breathing, facial, expression, gestures, and others. A brief example of what a vocalist might do to harness the power of NLP is as follows: it is critical that singers envision a past performance when they had the perfect delivery of their tonal aspects and their ability to work the crowd. It is then necessary to elicit that resourceful state of being by discovering their success strategy. What did they see, hear, say to themselves? How did they use their physiology (stand, breathe, etc)? An anchor for success could then be established and utilized for the future. By being able to put themselves in the resourceful state through anchoring, they can again achieve excellent results. These powerful techniques can also be used to assist patients with a variety of disorders, including overcoming fears and phobias, anxiety, depression, and limiting beliefs. A hypnotherapist can also utilize the above strategies by incorporating them into a hypnosis script and using the techniques with the client during hypnosis. The power of the mind is a grossly untapped area of holistic health that has real opportunity to enhance the overall outcome.

Neuromuscular Therapy It is important to have a brief understanding of skeletal and muscular situations that can facilitate the voice or lead to its downfall. St John neuromuscular therapy (NMT) is a form of therapy that releases

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joints and ligaments and promotes improved circulation. There are several methods to support the vocalist by maximizing voice quality and endurance and by addressing vocal dysfunctions. Many of the same muscles will be treated for both wellness care and to correct abnormal or suboptimal function. Maximizing voice quality in the well person will usually involve treating all the muscles of phonation and air exchange. Vocal dysfunctions are treated by assessing the individual’s particular problem and, in addition to the muscles treated in wellness care, will more specifically and thoroughly treat the muscles involved with that problem. Voice quality, range, texture, resonance, and endurance are all affected by the tone of the associated musculature. Areas of hypertonicity are generally considered to be hypoperfused or even ischemic; ischemic areas have diminished range of motion and are believed to create trigger points. Trigger point referral sites may also develop reduced circulation, and this may manifest as pain, paresthesia, numbness, itching, and/or diminished range of motion.22,23 Hypertonicity of the muscles that affect the voice can occur as a result of direct trauma, such as sudden deceleration injuries, manual strangulation, and so forth; indirect trauma, such as injuries to other parts of the body that result in uneven muscle tone of the neck and shoulders; or microtrauma from repetitive use or poor posture. Practicing or performing in areas with exceedingly dry air, the presence of smoke, and so forth can also cause excessive and uneven muscle contraction. Vocal dysfunctions are often related to muscles of the larynx, the lips, and the tongue. Movement of the tongue, resonance, and clear articulation are directly affected by the condition of the muscles of the oropharynx, nasopharynx, and laryngopharynx. The hyoglossus, palatoglossus, genioglossuss, styloglossus, the pharyngeal constrictors, palatopharyngeus, palatines, levator labii, zygomaticus, risoris, obicularis oris, buccinator, and platysma, as well as many other superficial and internal muscles, often require treatment. Endurance and air volume are also issues and are related to muscles of the thorax, such as the intercostals, pectoralis major and minor, the rhomboids, serratus anterior and posterior musculature, and the diaphragm. Mandibular

range of motion is most profoundly affected by the temporalis, masseter, and medial and lateral pterygoid muscles. Treatment strategies are developed after assessing for imbalances of muscle tone. Therapy applied to the hypertonic areas will improve circulation and allow muscles to return to normal resting length and so allow the muscles to flex and extend freely for full expression of the voice. St John neuromuscular therapy uses several techniques such as friction, static pressure of 8 to 12 seconds’ duration, and trigger point therapy to externally and internally treat the bodies, origins, and insertions of all affected muscles where those muscles are entirely accessible, and treats as much as possible of those muscles to which access may be limited. Only the upper 2 to 3 inches of the pharyngeal constrictors, for example, can be treated internally in most individuals. St John neuromuscular therapy is a low-cost, noninvasive method to correct vocal dysfunction related to soft tissue problems and should be considered for therapy before more invasive solutions are attempted. In addition to effectively treating soft tissue pathology, this therapy will maintain good vocal health in the healthy individual as well as help perfect the voice of the vocal professional. This leads us to a brief discussion of massage therapy. Massage therapy has been demonstrated to have strong beneficial physiologic effects, including the ability to enhance immune system function24–27 and provide a sense of relaxation and well-being. Many professional performers find benefit to the healing properties of massage.

Summary In summary, although many CIM remedies have been in existence for thousands of years, there is a general lack of randomized, double-blind, placebocontrolled studies supporting their efficacy. As a result, many health care professionals are skeptical and hesitant to recommend CIM modalities. The care of the professional voice clearly involves utilizing strategies categorized as CIM. There is tremendous public interest in alternative therapies, particularly



Complementary and Alternative Medications and Techniques

in areas that are difficult to treat with conventional medicine. Statistics show that the amount of money being spent on CIM by the public is increasing rapidly each year. And, with increased funding now available from the National Institutes of Health, preliminary research is showing that certain CIM remedies are appropriate for treating a number of acute and chronic health conditions. In view of this, it is imperative that medical professionals familiarize themselves with these options. In addition, we should be aware that modalities we may consider to be “alternative” are mainstream and accepted practices elsewhere in the world (Table 17–3). Throughout the text and the tables, there are appropriate warnings related to some of the more common herbal supplements. It is always best to consult with a physician who understands herbal/ alternative therapies or a qualified herbalist before embarking on the use of these alternatives. One of the more common issues facing the professional singer is the need to remain healthy in the face of exposure to pathogens on the road or during long tours. The importance of rest, eating healthy, and supplementing wisely cannot be overstressed. Considering the use of individual herbs such as echinacea or goldenseal is also reasonable for the professional singer; as noted in the text, the Body Language Vitamin Co cold and flu remedy includes the right types of herbs in the correct combinations to potentially

prevent an upper respiratory tract infection or perhaps expedite the recovery. Another significant issue facing the professional voice is overuse or stress, and thus healthful and energizing herbs like garlic and ginseng may also be useful. In addition to herbs like Pulsatilla or Astragalus, acupuncture can also be a relatively efficient means to reduce vocal fold swelling if the singer prefers to avoid steroids in a more urgent situation. Because anecdotal evidence outweighs proof from clinical trials in the area of CIM, it is not always easy to determine what works and what does not. This results in products and therapies of varying quality and effectiveness. Hospitals and medical centers around the country are increasingly adding CIM to their repertoire; for readers who are passionate about using integrative medicine in their system, they are referred to an article that details the process.28 Above all, as health care professionals, we need to remove our blinders and consider the options, without jeopardizing our patients’ health. With both public interest and scientific research in CIM on the rise, our profession is certain to experience a further increase in the use of CIM therapies. For the sake of both our patients and our profession, it is essential that health care practitioners remain current in this increasingly evolving field.

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*Dr. Seidman discloses that he is the founder of Body Language Vitamin Co.

Cognitive Behavioral Therapy

No real negative side effects reported

None

Works on the mindfulness and subconscious areas of the mind, to unlock “selfinduced” roadblocks and inhibitions

This can benefit those with performance anxiety, and can help mentally prepare the vocalist for the performance of their life

Hypnotherapy, Neurolinguistic Programming

It is a deep tissue therapy and it can be uncomfortable Frailty. In the elderly with osteoporotic bones, there can be some risk. However, well-trained SJ NMT will adapt the pressure used and the range-of-motion exercises

This is a form of NMT that works on “releasing” or relaxing ligaments and muscles and may help with voice issues, projection and performance

Patients with tight muscles and ligaments in and around the neck, chest, and abdomen. Issues in these areas can affect projection and overall performance

St John’s Neuromuscular Therapy

Each specific herbal formula or individual herb or nutrient may have potential side effects

Each specific herbal formula or individual herb or nutrient may have potential contraindications

There are thousands of herbal and nutritional supplements available and their actions are quite diverse

Most medical disorders can be affected/ managed by healthy diet, appropriate lifestyle choices, and supplementation (we recommend Body Language Vitamin Co supplements*)

Holistic nutrition and herbal therapies

Rare, although minor irritation at skin site reported

Aversion to needles, but note these are very smallbore needles and the overwhelming majority of patients do not find it painful

Affects energy flow/ balance within the body, can promote wound healing, reduce inflammation, improve energy and sense of wellbeing and more

Most medical issues can be affected by the use of this therapy

Acupuncture and Traditional Chinese Medicine (TCM)

Side Effects

Actions

Contraindications

Indications

Form of Therapy

Table 17–3.  Integrative Medicine Therapies Commonly Used for Vocal Performers



Complementary and Alternative Medications and Techniques

References 1. Weil Lifestyle LLC. About Dr. Weil. http://www​ .drweil.com/u/Page/About/. Accessed December 2005. 2. Surow JB, Lovetri J. Alternative medical therapy use among singers: prevalence and implications for the medical care of the singer. J Voice. 2000;​ 14(3):398–409. 3. Asher BF. Complementary and integrative treatments: the voice. Otolaryngol Clin North Am. 2013;​46:437–445. 4. Barnes P, Powell-Griner E, McFann K, et al. Complementary and Alternative Medicine Use Among Adults: United States, 2002. CDC Advance Data Report #343. Atlanta, GA: CDC; 2004. 5. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA. 1998;280:1569–1575. 6. Blumenthal M, Busse W, Goldberg A, et al. The Complete German Commission Monographs: Therapeutic Guide to Herbal Medicine. Austin, TX: American Botanical Council; 1998. 7. Korant BD, Kauer JC, Butterworth BE. Zinc ions inhibit replication of rhinoviruses. Nature. 1974;​ 12:248(449):588–590. 8. Korant BD, Butterworth BF. Inhibition by zinc of rhinovirus protein cleavage: interaction of zinc with capsid polypeptides. J Virol. 1976;​18(1):​ 298–306. 9. Kelly RW, Able MH. Copper and zinc inhibit the metabolism of prostaglandin by the human uterus. Biol Reprod. 1983;28:883–889. 10. Novick SG, Godfrey JC, Godfrey NJ, et al. How does zinc modify the common cold? Clinical observations and implications regarding mechanisms of action. Med Hypotheses. 1996;46(3):​ 295–302. 11. Mossad SB, Macknin ML, Medendorp SV, et al. Zinc gluconate lozenges for treating the common cold: a randomized, double-blind, placebocontrolled study. Ann Intern Med. 1996;15;​ 125(2):81–88. 12. Jackson JL, Peterson C, Lesho E. A meta-analysis of zinc salts lozenges and the common cold. Arch Intern Med. 1997;10;157(20):2373–2376. 13. Jackson JL, Lesho E, Peterson C. Zinc and common cold: a meta-analysis revisited. J Nutr. 2000;​ 103(suppl S5):1512S–1515S.

14. Hirt M, Nobel S, Barron E. Zinc nasal gel for the treatment of common cold symptoms: a doubleblind placebo-controlled trial. Ear Nose Throat J. 2000;79(10):778–780, 782. 15. Reinhard KH. Uncaria tomentosa (Willd.) DC: cat’s claw, una de gato, or saventaro. J Altern Complement Med. 1999;5(2):143–151. 16. Keplinger K, Laus G, Wurm M, et al. Uncaria tomentosa (Willd.) DC. — ethnomedicinal use and new pharmacological, toxicological and botanical results. J Ethnopharmacol. 1999;64(1):23–34. 17. Li Y, Chen GZ, Jiang DZ. Effect of Cordyceps sinensis on erythropoiesis in mouse bone marrow. Chin Med J (Engl). 1993;106(4):313–316. 18. Chu DT, Wong WL, Mavligit GM. Immunotherapy with Chinese medicinal herbs, II. Reversal of cyclophosphamide-induced immune suppression by administration of fractionated Astragalus membranaceus in vivo. J Clin Lab Immunol. 1988;25(3):125–129. 19. Zhao KS, Mancini C, Doria G. Enhancement of the immune response in mice by Astragalus membranaceus extracts. Immunopharmacology. 1990;​20(3):225–233. 20. Seidman M. Nutrition and health: fact or fantasy? Paper presented at: Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery; September 20, 2004; Los Angeles, CA. 21. Robbins A. Unlimited Power. New York, NY: Simon and Schuster; 1986. 22. Alvarez DJ, Rockwell PG. Trigger points: diagnosis and management. Am Fam Physician. 2002;​ 65(4):653–660. 23. Simons DG, Travell JG, Simons LS. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol 1. 2nd ed. Baltimore, MD: Williams & Wilkins; 1999. 24. Zeitlin D, Keller SE, Shiflett SC, et al. Immunological effects of massage therapy during academic stress. Psychosom Med. 2000;62(1): 83–84. 25. Birk TJ, McGrady A, MacArthur RD, et al. The effects of massage therapy alone and in combination with other complementary therapies on immune system measures and quality of life in human immunodeficiency virus. J Altern Complem Med. 2000;6(5):405–414. 26. Von Adrian UH. A massage for the journey: keeping leukocytes soft and silent. Proc Natl Acad Sci USA. 1997;13(94):4825–4827.

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27. Hernandez-Reif M, Ironson G, Field T, et al. Breast cancer patients have improved immune and neuroendocrine function following massage therapy. J Psychosom Res. 2004;57(1):45–52.

28. Seidman MD, van Grinsven G. Complementary and integrative treatments: integrative care centers and hospitals: one center’s perspective. Otolaryngol Clin North Am. 2013;46:485–497.

Chapter 18 Vocal Emergencies Joseph P. Bradley Adam M. Klein

A

lthough the diagnosis and treatment of vocal disorders has evolved into a highly specialized, multidisciplinary practice over the course of the past century, a significant portion of voice care is still managed by the general otolaryngologist. Many of these practitioners do not have sophisticated video­ stroboscopic or speech pathologist assistance. Nonetheless, the improved portability, and increasing affordability of endoscopic technology continues to allow for better access, and thus visualization, in the office and in the field. Moreover, an increased awareness and focus on laryngology education within our residency training programs is closing the experiential gap between general otolaryngologists and subspecialists. Ideally, the diagnosis and treatment of the professional voice user presenting with a vocal emergency would occur in a setting where a full clinical and laryngologic examination can be performed.

History Is Essential The descriptor most commonly given by the vocal performer to describe a change in his or her voice ​ — ​hoarse — is also the most nonspecific word that could be chosen. This word does nothing to qualify the change in quality or express the vocal limitations imposed by the change. The onus is on the examiner to extract more useful information. Two similarly

worded questions that get to different ideas should be considered: (1) What is your voice doing that it should not do? and (2) What is your voice not doing that it should do? Details regarding the onset of the vocal disorder should emerge from questioning the patient. Vocal changes with a sudden onset, particularly in the middle of phonation, are very suggestive of a vocal fold hemorrhage or mucosal tear. Loss of range or loss of vocal control also provides insight into etiology. During soft singing, loss in the high range is a very sensitive indicator of vocal fold edema. Delays in vocal attack and increased effort in singing are manifestations of vocal fold lesions or edema. Other clues to vocal pathology include changes in vocal quality, increased effort, decreased endurance, or limitations in dynamic range. The patient’s level of vocal training and vocal awareness are also important to both the diagnosis and treatment of the disorder. Not only that, but knowing the patient’s vocal warm-up routines, time spent in rehearsal, length and frequency of performances, and vocal obligations between performances can help the clinician understand the degree of vocal demand and help to determine what can or cannot be done to minimize further phonotrauma. Associated conditions such as asthma, laryngopharyngeal reflux (LPR), and acute or chronic rhinosinusitis may present with throat clearing, cough, or rhinorrhea and need concomitant treatment.

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The events of acute vocal problems do not happen within a vacuum and there can be a number of factors to consider when planning treatment. There are significant differences in management options based on whether the patient is being evaluated days before a show, hours before, or during intermission. A patient needs to be aware of his or her own short, medium, and long-term career goals so that there is appropriate insight into how to adjust for the possibility of missing upcoming events. Moreover, the financial implications of missing any event are often vital, particularly when the performer has already been paid in advance.

Differential Diagnosis of Vocal Emergencies Vocal Fold Hemorrhage Vocal fold hemorrhages are the result of an acute phonotraumatic event (Figure 18–1) where the microvasculature in the superficial lamina propria (SLP) is subjected to shearing forces. The extent of hemorrhage is dependent on the size of the vessel, fluid pressure within the vessel, and whether scar tissue within Reinke’s space may limit extravasation. Most commonly, patients report a sudden voice change during a strenuous vocal task that leads to a stiff, coarse quality to their voice. Anticoagulants (aspirin, clopidogrel, warfarin, nonsteroidal antiinflammatory drugs [NSAIDs]), along with the perimenstrual period in women, can predispose patients to the development of a vocal fold hemorrhage.1 Identification of a vocal fold hemorrhage via laryngeal imaging is of utmost importance during assessment of the patient. Absolute voice rest should be maintained until resolution has occurred, either via resorption or with migration of blood away from the vibratory margin of the vocal fold. This will likely include cancellation of scheduled performances, so the otolaryngologist must be prepared to support the patient in his or her actions with management. All patients need to be advised of the risk of serious voice changes via scarring or development of a lesion if they choose to perform despite the hemorrhage.

Figure 18–1.  A hemorrhage involving the left true vocal fold in the adducted position.

Vocal Fold Mucosal Tear Mucosal tears typically develop as a result of harmful singing, yelling, or severe coughing. The shearing forces applied to the epithelial cover and the SLP literally cause a separation in the tissues (Figure 18–2).2 The most typical presenting symptoms include immediate coarse vocal quality, loss of range, and perilaryngeal discomfort. Laryngeal imaging will often demonstrate a concomitant hemorrhage, edema, and erythema. Videostrobolaryngoscopy will show a stiffened vocal fold. Visualizing the actual laceration can be rather challenging in the acute setting given the concomitant edema, so clinicians should have a low threshold for placing the patient on absolute voice rest if a tear is suspected and follow with serial observations. If complete voice rest is maintained, patients typically heal without harmful sequelae. If phonation or further coughing continues in the presence of a tear, the epithelium has the potential to heal down to the underlying ligament, leading to sulcus/scar, or curl up on itself, causing an epithelial bridge. Either one of the scenarios will lead to an adynamic vibratory segment on that portion of the vocal fold, permanently affecting the voice.

Acute Laryngitis The etiology of acute, infectious laryngitis, just as with an acute upper respiratory tract infection, can



Vocal Emergencies

A

B Figure 18–2.  A. An epithelial tear in the left true vocal fold with exposure of the underlying SLP. B. The same tear with a subepithelial saline infusion to better highlight the presence of the exposed SLP.

be viral, bacterial, or fungal. Fungal laryngitis, while less common, should be suspected in patients who are immunocompromised or on systemic/inhaled corticosteroids. Despite the specific etiology, the

effect on the vocal fold is the same. The superficial lamina propria becomes engorged with a mixture of inflammatory cells, leading to increased mass (Figure 18–3). This increased mass leads to a raspy tone

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over, patients need to be counseled that although their voice may feel better while on steroids, they are still at increased risk of vocal fold hemorrhage, tear, scarring, or permanent voice change if they choose to perform. Patients ought to be counseled on the risks of steroids in general — mood swings, psychomotor agitation, appetite change, sleep disturbances, osteopenia, gastric ulcers, and avascular necrosis of the hip. The clinician should also be aware of the performer who is “living shot to shot” and using the medication to mask their vocal overuse or misuse. Identifying those patients and diverting them to vocal rehabilitation via therapy may help free them from their chronic steroid use.

Acute Edema on Chronic Fibrovascular Change

Figure 18–3.  Effect of acute laryngitis on the vocal fold.

with an inability to reach higher frequencies. Higher pitches are dependent on the vocal fold being able to oscillate more quickly, which it is unable to do in the setting of increased mass.3 Depending on the severity of the edema, relative versus absolute voice rest may be indicated. Mild or moderate edema can often be treated with relative voice rest (ie, limiting vocal use to those things that are absolutely necessary). Absolute voice rest is required to manage severe edema. If there is suspicion for a bacterial etiology, then appropriate antibiotic coverage should be given, and an awake culture considered, if necessary.4 For mild to moderate edema, corticosteroids can serve as a useful adjunctive therapy, particularly when performance must still be facilitated. Intramuscular steroids, such as dexamethasone or cortisone, have a 1-hour onset of action. Oral steroids, such as prednisone or methylprednisolone, will produce the same effect within one day. For severe edema, systemic steroids have a much more limited effect. More-

Patients with underlying chronic fibrovascular change who experience acute phonotrauma will manifest vocal symptoms similar to acute edema. This is due to the increased vocal effort needed to overcome the reduced pliability of the affected regions of the vocal folds. These areas of the vocal folds become convex, and, during phonation, achieve early contact. This, in turn, leads to an hourglass-shaped glottal closure pattern with subsequent air escape anterior and posterior to the lesions, creating a leaky valve and producing increased vocal fatigue and decreased vocal endurance. Moreover, the lesions are stiffer than the surrounding SLP, which leads to a differential pliability between vocal folds and within each vocal fold. The diagnosis is most easily made on videostroboscopy and treated similarly to acute laryngitis.

Upper Respiratory Tract Infection Upper respiratory tract infections, regardless of etiology, may have a profound effect on the vocal performer, even if not strictly laryngitis. Secretions, throat clearing, localized edema, cough, dehydration, and malaise can all lead to acute vocal changes. A careful history focusing on onset and location of symptoms, along with physical examination, can lead to the diagnosis. For a suspected bacterial etiology, the practitioner may use empiric antibiotics, mindful



of the need to be judicious with antibiotic use in this growing era of resistance. Short-term use of topical nasal decongestants (eg, oxymetazoline or neosynephrine) is helpful in reducing nasal congestion and drainage. Oral decongestants (eg, pseudoephedrine or phenylephrine) can be too drying of the larynx, which can lead to increased shearing forces along the vocal folds and predispose the patient to acute phonotrauma. The use of pharyngeal anesthetics should be cautioned because of the potential loss in vocal control. Modified voice use, humidification, and vigorous hydration are highly encouraged during this infectious period. Patients ought to be discouraged from performing during this time.

Allergic Rhinitis Nasal congestion, rhinorrhea, and postnasal drainage can all be taxing to the vocal performer, although rarely does a show need to be cancelled. Short-term relief is often achieved with the use of oral antihistamines; however, the anticholinergic side effects can lead drowsiness, but also drying, which may predispose to increased shearing and phonotrauma. Newer antihistamines do have less anticholinergic effects. Longer term treatment is often necessary and includes regimens of nasal steroids, leukotriene inhibitors, and immunotherapy.5

Laryngopharyngeal Reflux Performers have a propensity for developing symptoms of laryngopharyngeal reflux (LPR). The rapid changes in diaphragmatic movement needed during singing have a tendency to increase intra-abdominal pressure, making reflux more likely.6 Add erratic eating habits and the stress of high-level vocal performance, and vocal performers become more prone to, and, therefore, susceptible to the effects of, reflux. The symptoms of LPR (throat clearing, globus, cough, and postnasal drip) and the symptoms of gastroesophageal reflux (heartburn, regurgitation) should be asked of patients. Treating reflux aggressively with the daily use of proton pump inhibitors, while adding H2-blockers as needed, should be considered along with dietary and behavioral modifications.

Vocal Emergencies

Acute Asthma Exacerbation An acute asthma exacerbation weakens the actuator of the voice, leading to diminished vocal strength and endurance. Inhaled corticosteroids, along with albuterol rescue inhalers, are the mainstay of treatment for persistent asthma. However, the patient and physician need to be aware of the impacts that corticosteroids can have on the larynx, including decreased muscle bulk and the development of fungal laryngitis.7

Functional Dysphonia As an event or performance nears, vocal performers can experience increased stress and anxiety. Poor vocal behaviors, especially muscle tension dysphonia, can create singing and speaking difficulties that may need to be urgently addressed with voice therapy before a performance. Major anxiety before a performance can lead to excessive laryngeal muscle tension and reduced breath support, leading to impaired vocal performance. Intervention strategies are encouraged to optimize respiratory support and maximize resonance and phonatory control. Maintaining good health and hydration are also important adjuncts. In general, performers should be counseled to avoid β-blockers and anxiolytics, which blunt mental and physical sharpness important during a performance.8 Having an established relationship with a trained voice/singing pathologist is essential to addressing these problems.

Site of the Evaluation Phone Triage While vocal emergencies do not exhibit a threat to the patient’s overall health and well-being, they still command a sense of urgency because of the urgent threat to one’s upcoming vocal obligations. Whether it’s the actor rehearsing her lines, a lawyer preparing for an important trial, or the Broadway singer whose range is reduced, all of these voice professionals will phone their physician expecting him or her to understand their troubles and to assist them. Not

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uncommonly, the call will come from the performer’s manager, attempting to convey his or her symptoms in a limited fashion. The ideal situation would be for the patient to come to the physician’s office, or for the physician to drive to the performance venue. Of course, if the venue is out of the area, this is not always possible, and medical decisions will have to be made over the phone on the basis of the history and by listening to the voice. When triaging a vocal emergency on the phone, trust in the patient is required of the physician. The pressures of an upcoming performance can exert a significant influence on a vocal performer, which may cloud judgment. The physician is responsible for gathering enough history about the event, the importance of the performance, and the gut feeling of the patient in order to provide appropriate guidance. The physician ought to have a low threshold for requesting that the patient be seen personally, either by himself or another colleague, in order to ensure vocal safety. However, the decision of whether or not to perform is ultimately up to the patient.

On-Site Evaluation The ideal location for evaluating an ill performer is the same as for any patient — the physician’s office. In this setting, the full diagnostic workup can be performed. The ability to use high-resolution laryngeal imaging and videostroboscopy is essential to an accurate diagnosis. However, circumstances may occur in which the clinician must go to the site of the performance in lieu of an office visit. If a performer is due to go on stage in minutes to hours, it is far better to evaluate the patient at the venue than risk a performance that the patient should cancel. An on-site evaluation of the performance venue also allows the physician to assess the environmental and acoustic features. The drawback to an on-site evaluation is the decrease in image quality when compared with in-office imaging.

Office Evaluation The most ideal location for evaluating the vocal performer is the clinician’s office. Not only does this allow for the use of videostroboscopic and highresolution laryngeal imaging, but it also separates

the patient from his or her stressful setting. Videostroboscopy provides the most sensitive information for assessing subtle vocal fold edema, lesions, glottal closure, and vocal fold pliability.

The Black Bag On-Site Evaluation The black doctor’s bag remains the mainstay of the rare home visit that a clinician may need to make. This is a bag that should contain a number of items at a minimum. Essential items include a charged otoscope, 4 × 4 gauze pads, tongue depressors, dental mirror, nasal specula, various syringes and needle sizes, nonlatex gloves, injectable steroids and vitamin B12, ear curettes, alcohol swabs, topical nasal decongestants and anesthetics, and antibiotic samples. Flexible fiberoptic laryngoscopes with portable light sources are easily purchased and carried. Improvements in technology have led to the development of portable stroboscopy and imaging equipment, with handheld strobe lights in further development. Rigid laryngoscopes are easily carried and will usually attach to the same portable light source that can be used on a flexible laryngoscope. Without the ability to perform laryngeal imaging, the provider should be discouraged from visiting the patient on-site and providing substandard care.

Office Location While there are some pathologies that are easily identifiable on indirect mirror or flexible fiberoptic examination, these limited imaging studies provide little useful information about laryngeal biomechanics and vocal fold oscillation. Moreover, the resolution of a flexible fiberoptic laryngoscope may not be enough to show subtle chronic fibrovascular changes. While a videostroboscopic unit is more expensive, any provider who routinely treats patients with voice disorders should be able to justify the cost. Other than having appropriate laryngeal imaging equipment, one must be prepared to treat acutely ill patients. Having a stock of injectable steroids or other commonly available medications used in treat-



Vocal Emergencies

ment is paramount to preventing further delays in treatment if the performer or production staff wait to go to the pharmacy until a more convenient time.

Management of the Acutely Ill Performer Minutes to Hours Before Showtime In these last moments before a show, the pressure is no longer on the performer but the treating physician. The need for an accurate diagnosis and appropriate decision making is essential, given that a significant amount of time, money, and effort have gone into preparing for the event. The otolaryngologist needs to determine if the performance needs to be cancelled in the event of a voice-threating pathology (vocal fold hemorrhage, vocal fold tear, or other significant injury). In the absence of one of these pathologies, a frank discussion between the physician, patient, and management, if the patient desires, needs to focus on whether the patient feels that he or she can adequately perform. If the patient feels that this is not possible, it is the responsibility of the physician to advocate for the patient.

Days Until Showtime When there are days leading up to showtime, patients and providers have the luxury of time. Patients have the time to be seen in the office with the optimal equipment. Providers have the time to watch for improvement or resolution of pathology. The ability to add voice rest is opened. There is also time to administer a wide variety of supportive medications, with time to take effect. There is also time to work with a speech therapist with singing expertise, in order to improve techniques and set vocal limitations and prevent further trauma.

Weeks or Month to Showtime Extended time before the next performance allows for more planned management. The role of voice therapy becomes essential to combating maladaptive

behaviors. More chronic disorders such as allergic rhinitis, LPR, and chronic sinusitis can be better controlled, and acute changes can be sorted out from chronic ones, hopefully allowing the performer to return to baseline.

Adjunctive Therapy Humidification and Hydration Humidification and hydration have a significant impact on maintaining a moist laryngopharyngeal complex, which aids both articulation and vocal fold oscillation. Particularly given that many adjunctive therapies have a drying effect, the importance of hydration cannot be overstated.

Corticosteroids There are a wide variety of steroids that can be used in the adjunctive treatment of the vocal performer. Patients must be counseled that steroids are a shortterm solution to an acute problem, and judicious use is necessary until a period of vocal rest is available. Longer term use of steroids can be fraught with side effects. Those performers who develop phonotrauma from repeated use and misuse of their voice are at most risk for abuse of corticosteroids. Steroids are often seen as the quick fix with relatively low risk. The authors’ choice for intramuscular steroids in the acute setting is a mixture of both a fast-acting and a long-acting steroid: dexamethasone 5 mg (4 mg/mL = 1.25 mL) and methylprednisolone acetate (Depomedrol) 100 mg (80 mg/mL = 1.25 mL). Dexamethasone begins working in the first hour and lasts approximately 24 hours, whereas Depomedrol begins working after 24 hours and lasts up to 5 days. When time allows for a course of oral corticosteroids, the authors prefer a burst of taper of methylprednisolone (Medrol dosepak).

Nonsteroidal Anti-Inflammatory Drugs Performers and nonperformers commonly use ibuprofen or other NSAIDs as an over-the-counter pain

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medication alike in order to treat sore throat. While the anti-inflammatory effect is highly beneficial, the increased risk of vocal fold hemorrhage ought to preclude their use.

and some of them can be quite drying. The authors also recommend avoiding lozenges or sprays that give a tingling feeling in the throat because the numb sensation can loosen tight control of the voice and potentially predispose the patient to phonotrauma.

Decongestants Oral decongestants such as pseudoephedrine or phenylephrine have an excellent effect on limiting nasal decongestion, but they come with increased dryness throughout the laryngopharyngeal complex. This, in turn, can have an impact on vocal effort.9 A short course of a topical nasal decongestant (oxymetazoline or neosynephrine) is effective with fewer side effects. If the course is limited for 3 to 5 days, the risk of rhinitis medicamentosa is lessened.

Antihistamines Antihistamines, commonly found in cold remedies with decongestants, also have a similar drying effect on the larynx and pharynx, albeit less. Secondgeneration, less sedating, antihistamines such as loratidine or cetirizine should be favored, particularly closer to performance time to avoid the sedating effects seen with first-generation drugs such as diphenhydramine.

Mucolytics Medications such as guaifenesin provide symptomatic relief by thinning secretions and easing expectoration. Both short- and long-acting formulations are found. The side effect profile is minimal and is very helpful for controlling the sensation of excess mucous.

Other Medications Some performing artists report improvement in their overall well-being with use of intramuscular vitamin B12, although the efficacy of this is not well known. Herbal remedies are often favored; however, many of them have their own risks, despite being natural,

When to Cancel the Performance Even when the provider and performer know that a show ought to be cancelled, making the decision not to perform is not easy, and the pressure to perform can be extreme. Cancelling an event has financial implications for the patient, the crew, and the venue, but artists also have loyal fan bases that they do not want to disappoint. As mentioned previously, the presence of a vocal fold hemorrhage or tear is an absolute indication for cancelling a performance. Complete voice rest is necessary in these cases and performers should be counseled extensively on the risks of vocal fold scar if they choose to perform anyway. Outside of these 2 pathologies, the decision to cancel must arise from a discussion between patient and provider. The patient must decide if he or she feels well enough to perform acceptably. As mentioned previously, if the patient decides that he or she is incapable of performing acceptably, then it is the responsibility of the provider to help advocate for the patient. In a previous review of 40 singers by Mishra et al,10 only 2 patients needed cancellation before a show when having an acute illness. Figure  18–4 shows a simple algorithm for how to manage the acutely ill performer.8

Summary The diagnosis and acute management of vocal emergencies can be a challenging and often stressful enterprise. A thorough history and appropriate laryngeal imaging is the key to treating the acutely ill performer. Having an in-depth understanding of the key etiologies behind acute dysphonia, along with awareness of the different pressures being placed on the professional performer, is critical for assisting otolaryngologists in the treatment of these patients.

Figure 18–4. How to manage the acutely ill performer. Reprinted with permission from Elsevier. Klein AM, Johns MM. Vocal emergencies. Otolaryngol Clin North Am. 2007;40(5):1063–1080.

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References 1. Neely JL, Rosen C. Vocal fold hemorrhage associated with coumadin therapy in an opera singer. J Voice. 2000;14(2):272–277. 2. Sataloff RT, Spiegel JR, Hawkshaw M. Acute mucosal tear and vocal fold hemorrhage. Ear Nose Throat J. 1994;73(9):633. 3. Sataloff RT, Shaw A, Markiewicz A. Acute laryngitis in a professional singer. Ear Nose Throat J. 2001;80(7):436. 4. Shah MD, Klein AM. Methicillin-resistant and methicillin-sensitive Staphylococcus aureus laryngitis. Laryngoscope. 2012;122(11):2497–2502. 5. McGrath KG, Patterson R. Allergic rhinitis jeopar-

dizing the careers of professional singers, justifies intense therapy. Allergy Proc. 1988;9(6):665–667. 6. Cammarota G, Elia F, Cianci R, et al. Worsening of gastroesophageal reflux symptoms in professional singers during performances. J Clin Gastroenterol. 2003;36(5):403–404. 7. Gallivan GJ, Gallivan KH, Gallivan HK. Inhaled corticosteroids: hazardous effects on voice-an update. J Voice. 2007;21(1):101–111. 8. Klein AM, Johns MM. Vocal emergencies. Otolaryngol Clin North Am. 2007;40(5):1063–1080. 9. Verdolini K, Titze IR, Fennell A. Dependence of phonatory effort on hydration level. J Speech Hear Res. 1994;37(5):1001–1007. 10. Mishra S, Rosen CA, Murry T. 24 Hours prior to curtain. J Voice. 2000;14(1):92–98.

Chapter 19 Medical Problems in Performers Laura H. Swibel Rosenthal

M

ulti Grammy Award-winning Adele is an extraordinary example of a brilliant vocal performer whose singing was suddenly and severely impacted in her early 20s by a laryngeal problem, which was treated successfully. While laryngeal health is critical to a vocal performer, other medical problems can impact performance as well, whether those medical problems directly affect the larynx, other areas of the airway such as the sinuses or lungs, or are caused by systemic medical issues (Table 19–1). Understanding a performer’s medical problems may be critically important in treating dysphonia. Common medical problems, such as upper respiratory infections and medical conditions requiring surgery, are examined with the performer in mind. Treatments, whether medical or surgical, may need to be tailored to the individual. Furthermore, performers may be more susceptible to certain medical conditions.

Medical Problems That Affect the Larynx The larynx is susceptible to systemic disease, infectious disease, iatrogenic disease, inhaled or other toxins, and trauma. Some problems intrinsic to the larynx, such as acute viral laryngitis or reflux are fairly common. Other problems such as malignancy are rare.

Parkinson’s and Other Neuromuscular Disease Michael J. Fox (accomplished Emmy Award- and Golden Globe Award-winning actor) and Maurice White (leader of the band Earth, Wind & Fire) raised awareness of Parkinson’s disease. The disease also ended the vocal careers of Grammy Award winner Linda Ronstadt1 and Golden Globe winner Bob Hoskins.2 Parkinson’s disease is a progressive movement disorder of unknown etiology in which there is reduced dopamine production. Classic signs include tremors, bradykinesia, and rigidity. There are many potential treatments, including levodopa, dopamine agonists, anticholinergics, and monoamine oxidase inhibitors (MAOIs). More than one-third of patients with Parkinson’s disease report dysphonia.3 Classically, the voice of a Parkinson’s patient is monopitch with a harsh and breathy vocal quality and articulatory imprecision. They usually have bowed vocal folds, similar to presbylarynges (or long-standing neuromuscular disease in which there is atrophy of the vocal folds), which describes general atrophy of the vocal folds secondary to aging. Other neuromuscular diseases can impact the voice as well, including multiple sclerosis, amyotrophic lateral sclerosis (ALS), myasthenia gravis,4 and spinal muscular atrophy. Multiple sclerosis is an autoimmune demyelinating disease that usually presents between ages 20 and 50 with episodes of

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Table 19–1.  Medical Problems That Affect the Larynx Neuromuscular disorders Parkinson’s disease Multiple sclerosis Amyotrophic lateral sclerosis (ALS) Myasthenia gravis Spinal muscular atrophy Inflammatory disorders Acute infection (sinusitis, laryngitis, pharyngitis, tonsillitis) Allergic disease (rhinitis, laryngitis)

a variety of physical and mental problems. Similar to Parkinson’s disease, although there is no cure, medications such as steroids can reduce symptoms. Fifty percent of patients with multiple sclerosis (MS) have dysphonia as a result of damage to the myelin sheaths in multiple motor and sensory pathways in the central nervous system. Even when MS does not directly affect the voice, it can negatively impact a performer’s career5 by the weakness, spasticity, and fatigue the disease may cause. Despite this, with healthy lifestyle, training, and medications, many singers can continue to perform with MS. Walter Williams from the O’Jays is one such performer, still active at 70.

Reflux laryngitis Smoking Autoimmune disorders Rheumatoid arthritis Sarcoidosis Scleroderma Systemic lupus erythematosus Pemphigus Sjögren’s syndrome Churg-Strauss syndrome Relapsing polychondritis Diabetes Asthma Trauma Iatrogenic Medication side effects Intubation Surgical injury Cerebrovascular accident Malignancy Laryngeal Pulmonary Central nervous system Skull base Esophageal

Inflammatory Disorders of the Larynx A mild inflammation of the vocal folds can cause significant dysphonia. Inflammation can be from a variety of sources, but can include allergies, reflux, smoking, or autoimmune disorders such as rheumatoid arthritis, sarcoidosis, scleroderma, systemic lupus erythematosus, pemphigus, Sjögren’s syndrome, Churg-Strauss syndrome, and relapsing polychondritis. Rheumatoid arthritis classically affects the cricoarytenoid and/or cricothyroid joints and can cause dysphonia (including changes in pitch and tone), but it is also associated with symptoms of cough, foreign body sensation, stridor, and snoring. In a study of 36 patients with rheumatoid arthritis undergoing videostroboscopy, 67% of patients had some abnormal findings, including bamboo nodules, muscle tension dysphonia, or pharyngeal-laryngeal reflux.6 Postmortem histopathological diagnosis is estimated in about 90% of patients with findings ranging from cricoarytenoid joint fixation and neuropathy of the recurrent laryngeal nerve, to myositis and presence of laryngeal nodules.7 Sarcoidosis is an inflammatory disorder that can cause granulomas in multiple organs. Sarcoidosis presents with laryngeal involvement in 0.5% to 1.4% of patients with sarcoidosis. It may be asymptomatic (8%–18%) or can present with hoarseness (70%–85%), dysphonia (10%–40%), dyspnea (47%– 60%), stridor (8%–10%), or cough (10%–13%).



Medical Problems in Performers

Diabetes One in 7 patients with diabetes has phonatory symptoms that impact their quality of life.8 Diabetic patients with poor glycemic control are more likely to have grading and straining.9 In professional voice users, diabetes can limit treatment options for vocal disorders. Providers should avoid steroids/glucocorticoids in the treatment of diabetic patients with dysphonia, as the medication may cause elevated glucose levels.

ness is estimated to cost approximately $2.5 billion in lost wages.15 Among the general population, office visits for hoarseness are diagnosed as acute laryngitis (42% of the time), nonspecific dysphonia (31%), benign vocal fold pathology such as nodules and polyps (11%), chronic laryngitis (10%), laryngeal cancer (2%), other speech disorder (1.5%), unilateral vocal fold paresis (0.7%), and bilateral vocal fold paralysis (0.1%).16 Other causes of chronic cough include postnasal drip, gastroesophageal reflux disease, and laryngopharyngeal reflux disease.

Hormones

Allergic Rhinitis and Sinusitis

At times, alterations in the voice that result from hormone changes are normal. Just as children experience changes in their voice from the growth of the larynx and an increase in androgens results in a lower pitch voice, adult performers can expect a change in their voice over time, simply associated with age and changes in their hormones. Postmenopausal women have a lower fundamental frequency (even after controlling for age),10 which can be postponed with hormone therapy.11 The overall prevalence of hoarseness is 50% in elderly patients, with a point prevalence of 29%. It is chronic (lasting more than 4 weeks) in nearly one-third of the 29%. Reduced volume of the vocal folds may limit their approximation, as in patients with presbylarynges.

Allergies can be from anything from molds and trees to pets and food. Atopy (or hypersensitivity) can present in the skin, the upper airway, or the lower airway, depending on the person, the allergen, and the type of sensitivity. Environmental allergies commonly cause symptoms such as nasal obstruction, rhinorrhea (runny nose), sneezing, and itchy and watery eyes. Symptoms can present in the throat with a chronic cough, postnasal drip, and potentially dysphonia, especially in patients with allergic laryngitis. Patients with allergies are more susceptible to nasal polyps and sinusitis. Acute or chronic sinusitis may present with nasal obstruction, rhinorrhea, purulent drainage, facial pain or pressure, headache, or other symptoms. Although nasal obstruction may interfere with resonance of the voice, the typical over-the-counter or prescription medications used to treat this may cause unwanted side effects that could impact performance as well.17 Certain antihistamines such as diphenhydramine or fexofenadine may cause sleepiness. Other antihistamines, such as loratadine, may cause agitation or anxiety. Decongestants, such as pseudoephedrine, may be stimulating. Furthermore, while these medications may help dry up the nose, they may dry the oral mucous membranes and larynx as well, especially when used in combination. Multiple medical treatment options exist for allergic disease and its manifestations. Oral or intramuscular corticosteroid treatments may be beneficial to a performer with acute dysphonia or other problems secondary to allergic disease. Chronic rhinitis

Upper Airway Problems That Affect Performance Cough and Hoarseness Performer or not, cough is the most common presenting complaint among adults seeking medical treatment in an ambulatory setting,12 and it is one of the most common chief complaints, overall, responsible for 30 million clinician visits annually in the United States.13 Over-the-counter self-medication estimated expenses for acute and chronic cough are in excess of $3.6 billion annually in the United States.14 Hoarse-

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and sinusitis are commonly treated with intranasal steroids. One treatment option for patients with environmental allergies may be immunotherapy, commonly referred to as allergy shots. This typically requires an injection administered once weekly in the physician’s office under observation in case of an adverse reaction. However, this may be an unrealistic option for patients who travel or cannot make an office visit weekly. For performers, especially those on the road, sublingual immunotherapy may be a better option. A dose of allergen is placed under the tongue at home or on the road. This has potential to be used for food allergies as well.

Tonsillitis Acute episodes of throat discomfort are most commonly infectious in nature. They may be viral or

bacterial (Figure 19–1). If episodes are recurrent or discomfort is chronic, infection is still a concern but reflux disease should also be considered. Less commonly, throat discomfort may be secondary to allergies or malignancy. Tonsil infection can coexist with or progress to an acute or chronic laryngitis, which can cause dysphonia. Tonsillitis can also cause a temporary or permanent hyponasal quality to the speech as a result of inflammation or swelling of the tonsil tissue. This change in resonance and nasal emission is commonly described as a hot potato voice. The etiology of the discomfort must be accurately diagnosed and treated. Again, over-the-counter remedies should be evaluated for their potential side effects, including pain medications such as ibuprofen or other nonsteroidal anti-inflammatory agents, which can exacerbate reflux symptoms. Tonsillectomy may be considered in patients with recurrent or chronic infections or peritonsillar abscesses. Another com-

Figure 19–1. Acute tonsillitis demonstrating erythema, edema, and purulent exudate in a patient with mononucleosis. Mono is caused by the Epstein-Barr virus.



mon indication for tonsillectomy, in both children and adults, is obstructive sleep apnea. Obstructive sleep apnea is a sleep-related breathing disorder characterized by pauses and/or shallow breathing while sleeping. In adults, it typically presents with snoring and excessive daytime sleepiness. If untreated, it can lead to cardiovascular problems or impairment of cognitive function. Continuous positive airway pressure (CPAP) machines are one treatment alternative and often a first line of treatment for adults. For many patients, weight loss may also improve sleep apnea.

Velopharyngeal Insufficiency Velopharyngeal insufficiency is characterized by the inability to separate the nasal and oral airway when desired. Essentially, the velum or palate does not meet the posterior pharyngeal wall. This results in hypernasal speech and nasal emissions. Speech can be very difficult to understand as this affects articulation of nearly all consonants. Velopharyngeal insufficiency is usually congenital, as in cleft palate. However, a short palate, submucous cleft, or simply a palate that does not move well can cause velopharyngeal insufficiency as well. Resonance disorders, whether they result in hypernasal speech or hyponasal speech, are common in the cleft and craniofacial population. As velopharyngeal insufficiency is usually a congenital problem, presumed limitations may discourage patients from entering into professional performance fields. However, this issue can be acquired and can be a serious problem when it occurs, for both vocal performers and those who play wind instruments. Acquired causes include degenerative neuromuscular conditions and central nervous system disorders, as above. There may be iatrogenic causes, as a result of any tissue loss from surgery, such as a unusual healing or scarring from an anterior approach to the spine, removal of a tumor, or loss of tissue or function from radiation therapy. One of the more common iatrogenic causes of velopharyngeal insufficiency is with an adenoidectomy, although this is performed only in children. Vocal performers should be aware that tonsillectomy and/

Medical Problems in Performers

or uvuloplasty (typically for obstructive sleep apnea) or sinus surgery could change the way the voice resonates, which may impact the sound of the voice.

Lower Airway and Common Systemic Medical Problems That Affect Performance Medical problems associated with other areas of the airway, apart from the larynx, may impact vocal performance as well. The connection between systemic diseases that affect joints or neuromuscular activity and vocal performance is understandable. However, providers must also be aware that other medical problems such as diabetes, hypertension, heart disease, pulmonary disease, and psychiatric disorders may affect vocal performance or the options for workup and treatment of dysphonia.

Pulmonary Disease and Asthma Pulmonary disease, including asthma, is common in the population and common among performers as well. Most performers are able to overcome asthma without significant impact on their career, but good lung function is imperative for a vocal performance. An acute attack of any kind of reactive airway disease can cause problems with a performance. Asthma or its treatment could directly affect the larynx as well. Chronic problems can impact phonation by means of harshness, hoarseness, normalized noise energy (NNE, which estimates energy of noise versus the voice in decibels), S/Z ratio (ratio of the length of ability to sustain an “s” sound to “z” sound in which higher ratios are indicative of pathology), and breathiness.18 Research suggests that some vocal problems could be a result of reactive airway disease or at least improve with treatment for reactive airway disease.19 Another theory is that these voice problems may be a result of treatment for asthma. Inhaled corticosteroids, which are commonly used to treat asthma, cause a voice problem in over half of patients. Such problems may include hoarseness, throat clearing, globus sensation, loss of voice, and,

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less frequently, throat pain. These side effects are more prevalent among professional voice users.20 Gastroesophageal reflux (and laryngopharyngeal reflux), which is associated with many of these symptoms, is a well-known side effect of steroids as well as many other medications. There is also a risk of laryngeal candidiasis (or oropharyngeal candidiasis) with use of inhaled steroids (Figure 19–2).

Hypertension and Cardiovascular Disease and Stroke Overall, hypertension as well as other medical problems can lead to arteriosclerosis, which affects blood flow nearly anywhere in the body, including the heart, kidneys, brain, and extremities. Hypertension can lead to as cardiovascular disease and cerebrovascular accidents (or stroke). As with pulmonary disease, any problem affecting breath support, endurance, or that limits physical activity may impact performance. Although unusual, stroke can cause direct paralysis of the vocal folds, occurring

in about 20% of stroke patients. Recovery time of vocal fold motion is similar to other areas of motor recovery in stroke patients. Most stroke patients with vocal cord paralysis had involvement at the level of the brainstem, lateral medullary syndrome (Wallenberg syndrome), or Bernard-Horner syndrome affecting the recurrent laryngeal nerve.21 Although there is no evidence for hypertension directly affecting the voice, additional considerations may need to be made for treating a dysphonic patient with a history of hypertension. Medications should be carefully reviewed in any patient with a history of hypertension who presents with dysphonia, especially if associated with a cough or difficulty breathing. Angiotensin-converting enzyme inhibitors (ACE inhibitors) may cause angioedema, including edema of the lips and oral cavity down to the larynx. Betablockers limit cardiac responsiveness, which may be problematic for singers who also perform intensive physical activity, like dancing, during a performance. Many otolaryngologists commonly use topical vasoconstrictors in office procedures and/or in the operating room to help decongest the nose or control

Figure 19–2.  Candida laryngitis in a patient using an inhaled corticosteroid. The patient presented with dysphonia for 5 months. It resolved after treatment with fluconazole. Courtesy of Glendon M. Gardner, MD.



Medical Problems in Performers

bleeding. For patients with hypertension, especially if poorly controlled, one may want to consider limiting or avoiding a vasoconstrictor.22

gitis or nasal obstruction, which can both impact a performance significantly, even without significant findings on a physical examination.

Obesity

Public Health

Just as some performers with vocal fold nodules may rely on their nodules for their unique sound, weight change can alter the bulk (and sound) of the vocal folds. Obese patients may have an increase in hoarseness, murmuring and phonation, instability, and a decrease in maximum phonation time.23 Minor differences in strain, pitch, loudness, and phonation threshold pressure were found in patients after undergoing bariatric surgery.24 Obesity, however, is a more serious problem, as it increases risk for coronary artery disease, type 2 diabetes, hypertension, pulmonary disease, sleep disorders, stroke, liver and gallbladder disease, osteoarthritis, and some common malignancies.25 Obesity can lead to problems with posture and support of the voice. A common byproduct of obesity is an increased risk of laryngopharyngeal reflux, which can have a direct effect on inflammation of the vocal folds. In this era of multimedia recitals and performances, an attractive figure may make the difference in one person getting the role over another when there are not notable differences in voice quality.

As with the general population, several public health measures can help protect performers. While good hygiene and hand-washing have been most successful for preventing infectious diseases, in general, several vaccination programs have had remarkable impact on the larynx. Vaccinations that have a profound effect directly on the voice include those for diphtheria (can cause devastating laryngeal disease), Haemophilus influenzae (common cause of epiglottitis), annual flu shots (upper respiratory infection), and human papillomavirus (HPV can cause respiratory papilloma and laryngeal malignancy). Toxins that affect the general health of the larynx include tobacco and alcohol. These affect the larynx directly and indirectly by causing inflammation, but also increase risk for laryngeal malignancy. Of course, smoking tobacco can cause pulmonary disease and pulmonary malignancy, as well.

Performers May Be Susceptible to Certain Medical Problems Work Environment The Wall Street Journal ran an article, “A Sickening Season on Broadway,” in February 2014, when a lead performer in one show was out with the stomach flu, 4 performers in another show were out with illness, and during the performance additional actors got sick.26 Similar to a teacher and children in a classroom, there may be reasons that performers are at high risk for infection. They work together in small groups and small spaces, in potentially poorly ventilated areas. A common cold can cause laryn-

Calling in Sick There may be a stigma associated with calling in sick as a performer. An audience member getting to a seat who opens the playbill to find an insert reading, “Tonight’s performance of Frankie Valli will now be played by . . . ” is likely to think that the performer had some sort of medical problem. However, the casual theatergoers are unlikely to think of many of the problems above, such as a vocal fold hemorrhage, asthma exacerbation, or a neuromuscular disease. Issues that are more common and more commonly publicized that performers are potentially at higher risk for than the general population include the common cold, an injury, or even psychological problems. These are problems that may very well be in the audience’s differential. The drive to perform even when ill and not call in sick will increase the risk of transmission of viruses or bacteria to other performers. Performing with damaged vocal folds

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may cause further vocal fold injury. Performers may be less likely than others to seek medical treatment for a vocal problem or another medical problem. Among a group of contemporary commercial music performers surveyed in the United States, this was in part due to lack of medical coverage (for 39% of respondents). Males were less likely to seek care than females.27

Break a Leg This well-known ironic phrase is commonly used to wish performers well. It is used because it is considered bad luck to say good luck. Unfortunately, performers can succumb to injury whether in the larynx or elsewhere, and these can affect their performance. Sets can be dangerous places, especially when lifting heavy props or performing stunts. In addition, physical injuries that can be sustained outside of work should not be forgotten. Harvey Fierstein, who is well known for rarely missing a show, has been reported to perform for an entire year with a hernia acquired on set.26

psychiatric disorders such as bipolar disorder, mood swings, insomnia, and personality changes, as steroids have been associated with inducing psychiatric syndromes or exacerbating preexisting ones.

Hearing Loss There is perhaps no one with a medical problem that so ironically and directly impacted his musical performance better known than Beethoven. Known around the world with the popularity of his music spanning centuries, Beethoven had a progressive and eventually profound hearing loss, which eventually affected his ability to perform. Although Beethoven’s hearing loss was not noise induced, hearing loss is a known problem in orchestra performers,30 as well as other professional musicians, including rock/ pop or classical instrumental musicians, conductors, composers, and singers, who have 4-fold higher adjusted hazard ratio for noise-induced hearing loss compared to other professionals.31

Surgery for Performers Psychological Problems and Substance Abuse in Performers By nature of being on stage, one may expect that more attention is given to a performer’s untimely death than the general populations, which contributes to the perception of this association. One study found that successful American and European pop stars experience 1.7 times higher mortality than the matched population, with a disproportionate amount of mortality related to alcohol and drug use. Professional musicians, even those who do not reach stardom, have elevated levels of stress, depression, and substance abuse.28 Among Broadway performers, 91% report regular alcohol consumption, 10% report tobacco use, and 23% report illicit drug use. (In that study, 25% of respondents had been diagnosed with a vocal injury, and 1.7–4.7 days missed per year due to voice problems.29) A careful psychiatric history can be important to identify in performers. Steroids as treatment for dysphonia may need to be avoided in patients with a history of certain

Performers may be intimidated by surgery, even when undergoing surgery unrelated to a laryngeal problem. The recurrent laryngeal and superior laryngeal nerves may be susceptible to injury during surgery. Both are at risk during neck surgery, and the recurrent laryngeal nerve, specifically, is at risk in other surgeries as well. Surgery of the thyroid, parathyroid, cervical spine (with anterior approach), cervical esophagus, carotid artery, aorta, other cardiac surgeries, lung, aorta, heart, or skull base have all caused injury.32 Surgery under general anesthesia, which usually requires intubation, can result in hoarseness as the endotracheal tube sits between the vocal folds. Usually, postoperative dysphonia is temporary and a result of minor edema. For a more severe medical problem that could require prolonged intubation, the risk of laryngeal injury increases. In those intubated for more than 48 hours, 97% of patients will have some form of laryngeal injury, which can include vocal fold granulomas or granulation tissue (44%–52%), immobility (20%–



Medical Problems in Performers

39%), subglottic edema or narrowing (13%), vocal process ulceration (34%), or other problems. Duration of intubation and endotracheal tube and size did not correlate with immobility or degree of laryngeal injury.33 Vocal fold scarring can occur from intubation, caustic or thermal burns, after radiation, or vocal fold surgery. Injury to the cords, which would require multiple surgeries and/or healing by secondary intention (as in cases of recurrent leukoplakia or papilloma), can be expected to heal with poorer results. Anterior commissure surgery, vocal ligament injury, and bilateral injury increase the risk of scar development. Patients with chronic inflammation of the larynx are also at increased risk.34

rial cause, such as paradoxical vocal fold motion or muscle tension dysphonia, or a neuromuscular paralysis secondary to infection, malignancy, or surgical injury. If imaging of the larynx or recurrent laryngeal nerve is warranted in children, magnetic resonance imaging (MRI) is preferable to computed tomography (CT), to reduce radiation exposure. There are many congenital laryngeal malformations (including cysts or webs) that can cause dysphonia but are unlikely to be found in vocal performers as a result of the profound impact these lesions may have on the voice.

Summary Child Performers The prevalence of voice disorders in the general pediatric population reaches 25% and is likely higher in children who are vocal performers given the increased use of their voice. Voice disorders in otherwise healthy, developmentally appropriate children are usually due to overuse and less likely to be from one of the neuromuscular disorders or systemic disorders above. Vocal fold nodules are highly prevalent (approximately 75%), and treatment should always include voice therapy. Other commonly found pathologies include vocal fold cysts and papilloma. However, the prevalence of infectious causes, such as recurrent croup, allergic rhinitis, and asthma may be quite high. As a result, pediatricians often perform a trial of antibiotics, allergy, or reflux medications prior to otolaryngology referral.35 There is little evidence that antihistamines or proton pump inhibitors will improve dysphonia, especially without other evidence of allergic or reflux disease (aside from the dysphonia). Corticosteroids are indicated for hoarseness in pediatric patients with recurrent croup and allergic laryngitis. A careful examination is important. As with adults, reflux medication is not recommended in the general patient population, unless there are signs or symptoms of reflux or inflammation.36 As always, a careful examination is important to discern the etiology of a patient’s hoarseness. Children can have problems with vocal fold motion, as do adults, whether from a supratento-

Any medical problem that affects the size or movement of the vocal folds or breath support can, as expected, alter the voice. Providers treating patients for dysphonia must be aware of the patient’s medical history, as there may be laryngeal or extralaryngeal etiologies for the dysphonia. It is important to keep in mind that dysphonia could be a presenting symptom of a larger systemic inflammatory or neuromuscular disorder. In addition, the medical history may dictate which medications or treatments can be used or, more significantly, which may be contraindicated. In particular, while steroids can help certain medical problems such as asthma and inflammatory disease, they may be contraindicated in many other patients. There are few epidemiologic or other studies of medical problems in performers. It is an area of medicine that could use additional research. Acknowledgments. Collette Williams, MS3, Loyola University Chicago Stritch School of Medicine, for her research assistance.

References 1. Nash A. Heart-to-heart with Linda Ronstadt. AARP. August 26, 2013. http://www.aarp.org/ entertainment/books/info-08-2013/linda-ronstadt-discusses-parkinsons-memoir-simpledreams.3.html. Accessed October 15, 2014.

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2. Singh A. Bob Hoskins suffering from Parkinson’s disease. The Telegraph. August 9, 2012. http://www​ .telegraph.co.uk/culture/film/film-news/9462697/ Bob-Hoskins-suffering-from-Parkinsons-disease​ .html. Accessed October 14, 2014. 3. Hartelius L, Svensson P. Speech and swallowing symptoms associated with Parkinson’s disease and multiple sclerosis: a survey. Folia Phoniatrica Logopedica. 1994;46:9–17. 4. Mao VH, Abaza M, Spiegel JR, et al. Laryngeal myasthenia gravis: report of 40 cases. J Voice. 2001;15(1):122–130. 5. Reilly S. C&W’s “happiest girl” Donna Fargo, courageously battles multiple sclerosis. People. 1978;10(21). http://www.people.com/people/ archive/article/0,,20072241,00.html. Accessed October 14, 2014. 6. Gomez-Puerta JA, Cisternas A, Hernandez MV, Ruiz-Esquide V, Vilaseca I, Sanmarti R. Laryngeal assessment by videolaryngostroboscopy in patients with rheumatoid arthritis. Rheumatol Clin. 2014;10(1):32–36. 7. Hamdan AL, Sarieddine D. Laryngeal manifestations of rheumatoid arthritis, Autoimmune Dis. 2013, Article ID 103081, 6 pages. 8. Hamdan AL, Kurban Z, Azar A. Prevalence of phonatory symptoms in patients with type 2 diabetes mellitus. Acta Diabetol. 2013;50:731–736. 9. Hamdan AL, Jabbour J, Nassar J, Dahouk I, Azar ST. Vocal characteristics in patients with diabetes mellitus 2. Eur Arch Otorhinolaryngol. 2012;269(5):1489–1495. 10. D’haeseleer E, Depypere H, Claeys S, Wuyts FL, De Ley S, Van Lierde KM. The impact of menopause on vocal quality, Menopause. 2011;18(3):​ 267–272. 11. D’haeseleer E, Depypere H, Claeys S, Baudonck N, Van Lierde K. The impact of hormone therapy on vocal quality in postmenopausal women. J Voice. 2012;26(5):671.e1–7. 12. Simpson CB, Amin MR. Chronic cough: stateof-the-art review. Otolaryngol Head Neck Surg. 2006;134(4):693–700. 13. Irwin RS, Baumann MH, Bolser DC, et al; American College of Chest Physicians (ACCP). Diagnosis and management of cough executive summary: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1)(suppl):1S. 14. Altman KW, Irwin RS. Cough: a new frontier in otolaryngology. Otolaryngol Head Neck Surg. 2011;144(3):348–352.

15. Chang JI, Bevans SE, Scharts SR. Management of hoarseness/dysphonia. Otolaryngol Clin North Am. 2012;45(5):1109–1126. 16. Cohe SM, Kim J, Roy N, Asche C, Courey M. Prevalence and causes of dysphonia in a large treatment-seeking population. Laryngoscope. 2012;122:343–348. 17. Abaza MM, Levy S, Hawksaw MJ, Sataloff RT. Effects of medications on the voice. Otolaryngol Clin North Am. 2007:40(5):1081–1090. 18. Asnaashari AM, Rezaei S, Babaeian M, et al. The effect of asthma on phonation: a controlled study of 34 patients. Ear Nose Throat J. 2012;91(4):​ 165–171. 19. Cohn JR, Sataloff RT, Spiegel JR, Cohn JB. Airway reactivity induced reversible voice dysfunction in singers. Allergy Asthma Proc. 1997;18(1):1–5. 20. Ihre E, Zetterstrom O, Ihre E, Hammarberg B. Voice problems as side effects of inhaled corticosteroids in asthma patients — a prevalence study. J Voice. 2004;18(3):403–414. 21. Rigueiro-Veloso MT, Pego-Reigosa R, BranasFernandez F, et al. Wallenberg syndrome: a review of 25 cases. Rev Neurol. 1997;25(146):1561–1564. 22. Sunkaraneni VS, Jones SE. Topical anaesthetic or vasoconstrictor preparations for flexible fibreoptic nasal pharyngoscopy and laryngoscopy. Cochrane Database Syst Rev. 2011;(3):CD005606. 23. Bernardo da Cunha MG, Passerotti GH, Weber R, Zilberstein B, Cecconello I. Voice feature characteristic in morbid obese population. Obes Surg. 2011;21(3):340–344. 24. Solomon NP, Helou LB, Dietrich-Burns K, Stojadinovic A. Do obesity and weight loss affect vocal function? Semin Speech Lang. 2011;32(1): 31–42. 25. http://www.cdc.gov/obesity/adult/causes/ index.html. Overweight and Obesity. Accessed November 10, 2014. 26. Cohen S. A sickening season on Broadway. The Wall Street Journal. February 27, 2014. http:// online.wsj.com. Accessed September 30, 2014. 27. Gilman M, Merati AL, Klein AM, Hapner ER, Johns MM. Performer’s attitudes towards seeking health care for voice issues: understanding the barriers. J Voice. 2009;23(2):225–228. 28. Bellis MA, Hennell T, Lushey C, Hughes K, Tocque K, Ashton JR. Elvis to Eminem: quantifying the price of fame through early mortality of European and North American rock and pop stars. J Epidemiol Community Health. 2007;61:896–901.



29. Gehling D, Sridharan S, Fritz M, et al. Backstage at Broadway: a demographic study. J Voice. 2014;​ 28(3):311–315. 30. Emmerich E, Rudel L, Richter F. Is the audiologic status of professional musicians a reflection of the noise exposure in classical orchestral music? Eur Arch Otorhinolaryngol. 2008;265(7):753–758. 31. Schink T, Kreutz G, Busch V, Pigeot I, Ahrens W. Incidence and relative risk of hearing disorders in professional musicians. Occup Environ Med. 2014;71(7):472–476. 32. Swibel Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope. 2007;​ 117(10):1864–1870.

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33. House JC, Noordzij JP, Murgia B, Langmore S. Laryngeal injury from prolonged intubation: a prospective analysis of contributing factors. Laryngoscope. 2011;121(3):596–600. 34. Benninger MS, Alessi D, Archer S, et al. Vocal fold scarring: Current concepts and management, Otolaryngol Head Neck Surg. 1996;115:474–482. 35. Saljisevi M, Cohen S, Raynor E. Pediatrician approach to dysphonia. Int J Pediatr Otorhinolaryngol. 2014;78(8):1365–1367. 36. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dypshonia). Otolaryngol Head Neck Surg. 2009;141(3)(suppl 2): S1–S31.

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Part IV Behavioral Treatments



Chapter 20 Training and Teaching the Singer William D. Riley Linda M. Carroll

C

an anyone be taught to sing? Likely. Can any voice be taught to perform at a high level and in a consistent manner? That answer depends on many factors. Some accomplished singers do not explore their singing voice until their adult years, while others pursue the art and craft of singing from childhood by singing in choirs and taking music lessons. Musical awareness during the formative years is valuable, and often shapes the vocal pursuits of the individual. However, limitations in vocal capacity remain due to organic factors. A high soprano rarely becomes a contralto, and a low bass rarely becomes a Heldentenor. However some great singers have transitioned to a neighboring Fach due to vocal development/ training, aging, or systemic change due to illness or injury.

Singing Voice Development: Physiological Singing voice development is limited by physiology and influenced by environment, genetics, voice use, and overall health. Vocal and physical conditioning changes throughout the lifespan and impacts on voice function.1,2 While both can be affected by disorders, use of appropriate voice exercises can yield

improved voice function and efficiency regardless of age. The singing voice develops during the first few decades of life, stabilizes during the late teenage years, and then follows a decline with advanced age. Loss of voice quality with aging can be mitigated however with the use of voice exercises, and even aged adults can improve their voice quality and voice capacity with voice and physical conditioning.2,3 Among developing singers, significant improvement in glottal efficiency can be found after only 1 month of voice exercise.4 Even an untrained ear can often recognize a singer’s distinctive timbre through their speaking voice quality. There are many factors influencing a perception of a trained, or skilled, voice. Singers have longer vocalic segments in their speaking voice than nonsingers,5 and generally employ improved resonance quality in speaking mode compared to nonsingers. Whether professional or amateur, singers have younger sounding speaking voices as they age compared to nonsingers.6 Goals for voice training must consider chronological age as well as overall voice use demands. From childhood to puberty, the larynx continues to evolve with the gradual descent of the larynx from C2–3 to C7, vocal folds lengthening (lowering the speaking fundamental frequency), the layers of the

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lamina propria differentiating to the mature 3 layers (superficial, intermediate, deep), and the vocal ligament completing its attachment. Chodzko-Zajko and Ringel7 reported calcification of the arytenoid cartilages by age 25, finalizing the strength of the membranous and cartilaginous portions of the vocal folds. This stability of the arytenoid cartilages permits the singer to “anchor” in the posterior glottis and “flop” the vibrating, membranous portion. When coupled with efficient breath management and effective coupling to filter (resonance, articulation) function, the resultant voice can be of very high quality. Research by Kosla8 suggests 2 types of vortices that contribute to voice quality. The first vortices form just above the vocal folds (epilaryngeal space) during glottal closing and is formed by flow separation in the glottis. These flow separation vortices significantly contribute to rapid closing of the glottis, and hence, to producing loudness and high frequency harmonics in the acoustic spectrum. The second is a group of highly 3-dimensional and coherent supraglottal vortices, which can produce sound by interaction with structures in the vocal tract. The importance of glottic-supraglottic manipulation (source-filter interaction) has been examined in depth by Titze,9 with additional studies confirming the role of airflow in the epilaryngeal area (glottic to supraglottic) on vocal effort.10,11

Rationale for Training Benefits from training of the voice include respiratory health, psychological well-being through socialization, vocal stability through longevity, and maintenance of cognitive function. Singers are known to have improved skill for their respiratory capacity,12 which is impacted by overall improved posture. Postural control affects function on many levels, can be a significant indicator of overall health, and may influence the singer’s sense of well-being. The dictum “Posture dictates breathing” is valid and forms the premise of many training programs. Respiratory control, which includes the ability to establish a steady pressure head of airflow for the production of sound, remains a key skill for singers and actors alike. Inefficient posture leads to clavicu-

lar breath patterns, which then increase imbalance of breath management in sound production, leading to increased vocal fatigue, and poor voice quality. Athletic posture and balanced breath management are keys to quality voice production. While it has been known for decades that resonance (adjustments in the filter subsystem) influences laryngeal function (source subsystem), recent studies on semioccluded vocal tract exercises have found significant benefits of improved vocal economy and voice quality.13,14 Singing voice exercises often target clarity and efficiency of resonance to yield vocal power. This coupling between the source subsystem and filter subsystem is similar to acting voice training goals.15 Posture has a significant impact on voice and plays a focal role in breath management.16 Gould recognized the “importance of posture in maintaining respiratory and vocal efficiency” and defined voice production in man “as a secondary function of the general postural mechanism that includes respiratory activity.” The training programs of Alexander, Feldenkrais, and Yoga are based on transfer of efficient body posture and core strength to achieve efficient vocal production. The demands on posture are not insignificant for the singer who may be faced with performance on a raked (slanted) stage. Sagittal spine alignment and postural stability both significantly affect severity of dysphonia.17,18 Cervical spine alignment impacts on extrinsic-intrinsic laryngeal muscle balance and may affect access to pharyngeal airway space (resonance) as well as influence pitch control.19,20 Efficient posture is based on skeletal orientation and balance and not muscular holding. Inability to access balanced alignment, either through performance constraints or disease states (such as scoliosis), may interfere with vocal skill. Voice fatigue, often a precursor to vocal injury, has been found to be variable among trained singers and may be related to past voice history as well as repertoire factors.21 Vocal warm-up is recognized to be important for healthy singing voice use, but the tasks and length of warm-up appear to have high intersubject variability.22 Well-trained voice users can sustain extended voice use without deterioration of voice function23 and use a vocal cool-down after exercise. Both training and awareness of risk for injury may impact on vocal fatigue. Prolonged sing-



Training and Teaching the Singer

ing activities, such as karaoke singing, have been found to be less fatiguing with use of hydration and periodic vocal rest periods.24 This evidence harkens back to the famous Punt quote “It is remarkable how much punishment a well-lubricated larynx will stand, whilst a dry throat is a constant trial to the performer.”25 When trauma exceeds the capacity of the tissue to heal, or when aging (or disease) reduces the speed/success of healing, access to the singing voice can be impaired. Singing voice function can be used as an indicator of overall voice function, and gentle singing of “Happy Birthday” as a common diagnostic probe of voice capacity and vocal health is common among members of the voice team (laryngologist, speech pathologist, voice teacher).

Singing Voice Development: Artistic Young people who exhibit a desire to sing may express it at an early age, often as early as 4 to 8 years of age. In some communities there are numerous outlets for this, but in other communities there are none. Children’s voices vary in complexity from the simple medium voice treble instrument to the more complex preprofessional and professional performers who are active in the professional opera chorus, symphonic choirs, Broadway theaters, and pop professional venues. The mind of the young artist matures much more rapidly than the body. Because of this phenomenon, it becomes both convenient and important to educate these young vocalists with excellent musical skills, and training in parallel artist forms (musical instruments, theater, and dance training). It is no accident that many of these youngsters are very athletic, which can contribute to conflict in how to balance their various interests. The physiology of the young singer is best served by a moderate pace of development rather than an accelerated study program. Musical prodigies, whether pianists, violinists, or other instrumentalists, find performance opportunities in major venues by age 8 or 10. In the case of a concert violinist or a concert pianist, the career must be in full swing by age 16. In contrast, the vocalist is just

beginning to function physically as an adult by age 15 or 16, sometimes earlier in females. Consequently, the intensive training we give to Olympic athletes should not be used as a model for young singers until they reach this age. By age 15 or 16, girls are eager and willing to practice hours per day whereas young men may not be able (or willing) to do this until age 18 or 19. In the world of popular music, choruses of children’s voices are professionally employed in the Broadway theaters and on the sound stages of the film companies earning a handsome living for themselves and their families, long before the performer develops maturity in their vocal abilities. It is because of this professional need that teachers are encouraged to adopt a strategy for a calm step-bystep development of these tender voices rather than the aggressive accelerated training models employed by gymnastics, soccer and football. Young performers have eagerness to perform and willingness to attempt challenging vocal tasks. They may sustain vocal injury, either acutely or chronically, during the process of their youngest attempts for professional or social recognition. The teacher needs to encourage them to perform safely, especially during the pubertal period, and must teach restraint from phonotrauma at the same time. In the case of young adults and older adults, the typical assessment strategy is to use a balance sheet of assets versus deficits in the evaluation of the voice and the planning for remediation of vocal problems in order to create a strong, athletic, and musical performance. Vocal techniques should be taught from a basis of science with a strong emphasis on anatomy and physiology, and the mysteries of the performing arts should be explored long after the technical abilities of the vocalist are well established. Mature singers must balance the development of resonance, articulation, breath management, the avoidance of unnecessary tensions, and while strengthening the vocal mechanism, learn the boundaries of safe performance. Some health care providers have long thought the act of singing as inherently harmful to the voice, simply because they see injured voices far more often than they see healthy ones. The vast majority of singers with a serious career ambition are healthy in their voice use and are interested in remaining healthy. There are, however, numerous

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influences on the young performers to produce vocal qualities that border on dangerous behaviors, including, but not limited to, the imitation of aggressive or self-destructive vocal performers of the past. Many seemingly aggressive performers knew their limits and seldom exceeded their abilities. However, many singers that have been injured along the journey have abandoned sensible behaviors or been told by advisors that they must be prepared to sacrifice their voices in the process. This is simply not true.

Singing Voice Assessment: Why Is It Important? Assessment of singing voice capacity and function involves multiple system examination. Posture (walking, standing, sitting), manner and coordination of breath management, stability of breath support, control of voicing onset, ability to execute loudness changes, quality of resonance, clarity of vowel and consonant production, effort to elicit quality voice, coordination of nonverbal gestures to aid with communication of sung text, and ability to modify voice use are all the role of the voice teacher. In a typical singing voice assessment, the teacher needs to establish a sense of rapport with the singer, assessing whether the singer is fluent with social and communication skills necessary to be a performer. It is also important to determine whether the singer has had formal music theory training and whether they read music. One of the first technical areas to be evaluated is the singing voice range. The singer’s self-perception of vocal range may be very different from the reality of their physical range of phonation. The use of terms is important and in this respect, the singer may have been taught that the word range may be an indicator of voice type as well as physical capabilities of range. If a singer is having difficulty with their voice, it is important to know the prior vocal range of the singer. Pitch range is commonly communicated by giving the note name and the octave number. Middle C on the piano keyboard is C4 — the fourth time the note C appears from the lowest keyboard note to the highest keyboard note. The tenor voice “high C” is

C5, while the soprano voice “high C” is C6. Although some well-known singers do not read music, it is in the best interest for the singer to be knowledgeable in reading and writing music. The singer needs to understand dynamic markings of crescendo, diminuendo (decrescendo), staccato, marcato, accent, and tenuto to allow rapid communication of vocal flexibility and musical gestures. Lack of vocal flexibility contributes to voice fatigue and impacts on the musical message. In the initial voice lesson or training session, the singer’s vocal abilities should be tested with simple scale passages, leading the singer gradually to the lowest tones of the voice and then testing the highest tones. As the singer approaches higher tones there is often a process of self-editing in which the singer is uncomfortable or unwilling to sing higher. For a determination of the true range of phonation, however, we need to go beyond concert acceptability and test the alternate technical possibilities, including the squeakiest falsetto of a timid male voice or the unnervingly high range of the whistle register for a teenage soprano. It is also prudent to test whether a singer can sing rapid passages and contrastive long, slow passages during the initial evaluation. Once the range of phonation is established, it is important to determine the dynamic range (volume) of the voice. Simple crescendo/diminuendo tasks (soft-loud-soft volume without changing the pitch) on target notes and subsequently in simple scale passages will determine whether the singer is dynamically flexible or single-mindedly inflexible with their dynamic variety. Inability to alter the loudness of the voice on a given note can lead to voice fatigue, as well as limited musical approach to a vocal line (even in a simple scale passage). It is not unusual for a highly experienced performer to have a narrowly defined self-image of the voice that may include prohibition of softest singing or loudest singing. Many singers may define themselves as “loud only,” “soft only,” “breathy only,” or “ragged only” in their pursuit of a sense of vocal style, but this is a signal of voice limitation. As the evaluation proceeds, the trainer needs to keep an expert ear open to speaking voice use as well as cultural or slang propensities in communication. There may come a time in the training process where a discussion of speech habits, language hab-



Training and Teaching the Singer

its, and the perceptions of class, style, and commercial viability enter into the discussion of speech and voice behaviors. If the singer’s voice quality or vocal control leads the teacher to suspect prior vocal injuries, they need to be discussed at this time. The ongoing nature of healing, reinjury, and return to normalcy must include a discussion of referrals and treatment options that are outside the specialty of the singing voice trainer. Referrals to qualified physicians, speech-language pathologists, massage therapists, nutritionists, and psychotherapists may need to be encouraged after the evaluation is complete. If there is a reduction in vocal quality or control during the course of training, the singer should also be referred to a qualified voice team to determine etiology and assist with a management plan. Throughout the assessment, attention should be paid to breath management. Breathing patterns that are clavicular or thoracic should be reoriented to lower abdominal-diaphragmatic. Breath inhalation should not be noisy or have stridor, and should be paced comfortably for the vocal task (speaking or singing). Comfortable breathing should be present for nasal inhalation and or oral inhalation. Noisy or effortful breath inhalation can affect voice quality and vocal control.

Singing Voice Training For centuries, speakers have used singing voice exercises to enhance speaking voice quality. Singing requires improved attention and skill to all phonatory subsystems (power, source, filter) and incorporates both left and right hemisphere function. In addition, individuals are more likely to self-monitor voice use and technique when singing compared to conversational speaking. For over 2 centuries, the use of messa di voce (soft-loud-soft) exercises have been touted as important skills for quality of singing. Advances in voice science have confirmed the importance of mucosal wave propagation and phonation threshold pressure (softest phonation pressure) for access to quality vocal production, including the ability to change vocal loudness. Singing voice training is not isolated to laryngeal function, however.

The conversion of airflow to sound waves to amplification is essential for voicing. Impaired breath management, or breath control, can undermine initiation and maintenance of voice. Impaired adductory force or faulty mucosal wave propagation can undermine initiation and maintenance of voice. Impaired access to filter function (resonance, articulation) can undermine initiation and maintenance of voice. For this reason, singing voice training must address all these functional aspects of voice production as well as the artistic communication of voice. Breath management training includes awareness of posture and its effect on breath inhalation and breath support. Many teachers will begin breath training with physical stretching designed to enable the singer to breathe easily accessing abdominaldiaphragmatic breathing as the dominant mode. Breath management is individual, however, and highly influenced by the physical characteristics of the singer, as well as general posture. Hixon26 identified 3 main body types: endomorph, ectomorph, and mesomorph. Amount of rib cage versus abdominal excursion appears to be influenced by body type, and breath support strategies may differ between body types. Regardless of body type, breathing should be centered in the lower portion of the rib cage to permit steady control of a pressure head toward the vocal folds. A steady pressure head is more easily achieved using coordinated support muscles in the lower rib cage and abdominal region rather than upper thoracic musculature. Singers who are faced with voice use following strenuous physical exercise (dancing, running up stairs) need precise skills to reestablish lower breath patterns. Similarly, singers who must perform in unusual physical postures (lying on a flat surface, draped over props, such as Gilda in Rigoletto or Tristan in Wagner’s opera of the same name) need strategies to optimize ease of breath inhalation and breath support, avoiding compensatory laryngeal tension and compromise of voice quality. There are many exercises to improve the functional technique of voice production. Titze and Laukkanen10 have advocated use of SOVT (semioccluded vocal tract) straw phonation to improve vocal economy, using the straw to increase the inertive reactance of the vocal tract in the 200 to 1000 Hz range and thereby reinforce vocal fold vibration. Research on

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SOVT found significant improvement with mucosal wave propagation, reduction in muscle tension patterns, improved subglottal pressure, normalization of transglottal flow, narrowing of acoustic bandwidth, improved awareness of tonal placement, and improved quality of voice following 10 minutes of SOVT straw phonation. Benefits remained present after 90 minutes. SOVT utilizes a straw the approximate length of the individual’s vocal tract (larynx–lips) and uses a 5-mm or narrower diameter straw. Vocalizing through the straw then requires double the amount of breath support but does not permit an increase in airflow. Narrowing of the sound into the straw enhanced forward tonal placement. The straw reduces the volume of sound heard, yet allows the singer to fully practice voice. Although SOVT does not work with all singers, it can be beneficial for many singers. Vibration therapy (flutters) is an exercise program that has similar features to SOVT. Vibration therapy utilizes a dual oscillator (larynx + lips or larynx + tongue), thereby reducing the workload away from the vocal folds. Singers with excessive laryngeal tension or a unique anatomy may have difficulty executing performing vibration therapy. Therefore, the singer’s ability to maintain dual oscil-

lation throughout the range is a technical probe of the singer’s skill. Skilled singers should be able to change pitch and volume independently, as well as slowly engage phonation with vibration therapy. Regardless of the exercise program, the vocal skill and vocal instincts should be addressed by the voice teacher. Vowel exercises are very important for all genres of singers. The use of slow and rapid scales, stepwise and contrasting intervals, in both major and minor keys, is necessary to develop a fully functional vocal instrument. It is important to use the front vowels (/i,e/) first, using their forward ring resonance to transfer focus (forward tonal placement) to the mid /ɑ/, and then the back vowels /o,u/), which have greater loft resonance. Therefore, the order of the vowels during exercise /i/, /e/, /ɑ/, /o/, /u/ is important. It is prudent to begin with a simple five note exercise regardless of the language of the singer or the vocal style of the singer. To communicate precision of both vowels and consonants, it is advantageous to use the International Phonetic Alphabet (IPA). IPA has established symbols for all the phonemes (speech sounds) in all languages (Figure 20–1). In this manner, IPA is a shortcut to target phoneme production.

Figure 20–1.  International Phonetic Alphabet symbols for American English vowels, corresponding to placement within oral cavity. Front vowels /i, I, e, E, / involve tongue height as a primary articulator, while back vowels /u, U, o, O/ involve lip rounding as a primary articulator.



Training and Teaching the Singer

Consonants are easily described by their manner of production and place of primary articulatory contact (Table 20–1). Articulatory contact can be adjusted to improve consonant-vowel transitions and can also be adjusted to meet vocal line demands. Use of contrasting vowels in repeated ascending-descending scales can reveal baseline pitch control as well as consistency of voice quality across cardinal vowels /i,e,a,o,u/ (Figure 20–2). Once the singer has executed the 5 cardinal vowels with dynamic variations and nonforceful voicing onset, the singer should be encouraged to increase the intensity of the onset by utilizing the y-buzz15 before each vowel. This strategy improves focus of voice with voicing onset and establishes focus in the resonance (filter) subsystem. Range development can be explored through a number of scale or arpeggio patterns, some small and some large (Figures 20–3, 20–4, and 20–5). For the beginning singer, it is prudent to use a moderate range of a third or a fifth, and in later sessions

expanding the exercise to an octave or more. Leaping intervals are important, but leaps should not be phonotraumatic. During singing, it is important to monitor breath management. There should not be a sudden increase or decrease of breath flow for higher or louder voice. Breath flow should be relatively stable throughout singing. Singers at all levels have a tendency to push breath when feeling insecure. Matching of airflow through interval studies is a vital part of the training of the voice to avoid pushing, yelling, or pressed phonation. Flexibility in the singer’s voice is necessary to negotiate scales, intervals, and register transitions with a sense of smoothness, matching quality of the various parts of the voice, as is required by many specific musical styles (classical, jazz, choral, etc). In the classical world, choral singers are often introduced to Handel’s Messiah or similar virtuoso flexibility experiences. This kind of ornamental or scale passage work can be adopted by other musical

Table 20–1.  International Phonetic Alphabet Symbols for American English Consonants, by Manner and Place of Articulation PLACE Manner

Bilabial

Plosive

p b

Fricative



LabioDental

LingualDental

LingualAlveolar

LingualPalatal

t d f v

T D

Velar

Glottal

k g ʃ Z

h

tS dZ

Affricate

Nasal

m

n

Glide

w

l

ŋ ɹ

j

Figure 20–2.  Simple 5-note ascending-descending scale with messa di voce on final note.

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Figure 20–3.  Ascending-descending vocal warmup, on lip flutter, with gradual coordination of voicing. The simple 5-note ascending scale is also executed on vowels throughout the vocal range.

Figure 20–4. Sliding third vocal warm-up, often begun on /u/ (“oo”) and then expanded to all vowels in midrange.

Figure 20–5.  Descending 5-note scale with messa di voce on first and last note.

genres with very good outcomes. The teacher needs to identify the singer’s deficits with respect to vocal flexibility and devise meaningful exercises that will motivate the singer to adapt the technical strategies into their vocal style (Figures 20–6, 20–7, and 20–8). During vocal exercise probes, it is important to assess presence of unnecessary tensions as well as baseline postural reflexes. Phonation does require active muscle involvement, as well as muscle loading. When loading leads to excessive tension, the singer must recognize that moment and revise the task to avoid overloading. For this reason, singers must self-monitor their voice use, preferably through sensation rather than dependence on audition. Similarly, the teacher must have skills to visually and

auditorily assess risk for overloading that could lead to misuse, abuse, or injury. Artistic personalities often want to isolate and hold to examine a new construct while developing a new skill. It is important for the teacher to look for holding patterns and redirect the singer to avoid excessive tension (neck, jaws, shoulders, etc). Strategies to avoid or reduce tension include (1) touch the offending muscle, (2) move the offending muscle, or (3) think relaxation of the offending muscle. Most of the tensions throughout the body can be redirected by the strategies of touching or moving the overtensed muscle. Physical tension is a muscular process and needs to be addressed on an anatomical and physiological basis.



Training and Teaching the Singer

Figure 20–6.  Descending flexibility scale with change of vowels.

Figure 20–7.  Vocal flexibility exercise, beginning on ascending thirds and finishing with descending triplets, with change of vowel between ascending and descending segments.

Figure 20–8.  Flexibility panting exercise (from DEVT27), coordinating phonation with panting, and change of vowel.

It must be stressed that the singing voice is not limited to the interior of the larynx. Both physical tension and lack of body strength affect voice function. Therefore, the entire physiology of the body should be trained in symphony with vocal training to achieve good vocal function and a musical experience. Vocalists are athletes and must adhere to similar training values. To that end, the concept of work, stress, and rest is central. Exercising the voice is an absolute requirement and should be planned as clearly and concisely as an Olympic gymnast’s regimen. In the context of training a serious performer, the discussion of exercise physiology needs to be a central construct. The vocal instrument should be treated in an athletic context; because of this, it is prudent to adopt many of the strategies of sports medicine. There is a vast literature on exercise physiology and its impact on physical training of the body. Physical training should focus on core muscle strength to facilitate easy access to abdominal-

diaphragmatic support, as well as physical flexibility to perform the physical demands on stage as a performer. Singers may choose Pilates, Yoga, Alexander, or a cross-training principle for body conditioning. Exercise physiology principles of warm-up and cooldown are also essential. Vocal exercise and physical exercise condition the voice while good nutrition provides fuel for voice. Recently, there has been greater attention to healthy nutrition in the general population, enabling singers to gain further information on best nutrition for their bodies. For this reason, there is an advantage for serious singers to consider evaluation by a nutritionist, rather than seeking the latest fad in foods. Finding the balance of exercise, nutrition, and stress is the first step toward healthy voice use. With this foundation, detailed training for clarity of voice and communication of text can be undertaken. The singer should be skilled with communication of text, and have an understanding of the message to be conveyed. The clarity of the text is

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important but should not sacrifice vocal health. Many voice teachers focus on vowels alone, leaving the singer to be fearful of consonants. Oren Brown, noted vocal pedagogue, stated, “Vowels are the rooms in which singers live. Consonants are the doorways that propel you from room to room” (personal communication 1994). Some consonants and vowels are difficult to produce clearly in certain ranges of the voice, but work very well in a more comfortable singing range. The singer is not always permitted to change the pitch or approach of the target syllable but is sometimes able to change the “color” of the vowel, permitting the formants (from resonance) to better align with the harmonics from the source (larynx). Lighter articulatory contact for higher pitches may reduce possible damping effects and thereby improve projection. These strategies may be necessary to permit adequate text clarity without contributing to vocal strain or poor voice quality. Most singers have well-developed auditory skills prior to formal voice training but have reduced awareness of resonance. Resonance is a result of coordinated breath support during phonation. The changing acoustics of rooms impair the ability to scan for true voice production and inhibit planning of vocal placement. Resonance sensations are more dependable across rehearsal and performance spaces. These resonance sensations remain constant under any acoustic environmental. The singer can feel the vibrations in the skull or the sense of space inside the pharynx, regardless of the auditory conditions in the performance space. Vibrations of the bones of the skull are easy to discover during sustained humming on /m/, /n/, or /ŋ/. These sympathetic vibrations of bony structures are the vocalist’s equivalent to the spruce soundboard of a Stradivarius violin or a Bösendorfer grand piano. These sensations will eventually develop the

ring resonance of the singing voice, a basic element of power in the vocal spectrum. It is important to attain consistent resonance independent of vocal loudness. Presence of ring resonance improves ease of vocal projection and contributes to bright vocal timbre. The other important resonance sensation is loft resonance, or the sense of height of space during the sound production. Loft resonance is more dominant for lip rounded vowels that have heightened pharyngeal space, such as /o/ and /u/, and increased intraoral space. Loft resonance contributes to timbre of warm and rich, offering a balance to the resonance aspects of ring resonance. When source (laryngeal) function is smoothly coordinated with filter function (resonance/articulation) and maintained with appropriate support, the singer is able to negotiate through the register transitions without abrupt auditory compromise of voice quality or control. Register transitions may be amplified for some vocal styles (country) or used as a strategy to change the perception of the voice. Nevertheless, all singers should have adequate control in the register transitions to avoid sudden loss of vocal power or sudden change in voice quality. Vocal registration exercises generally involve loudness variability in the specific region of the register transition (passagio), as well as pitch and loudness flexibility exercises between the surrounding notes of the passagio (Figure 20–9).

Special Considerations for Performance Style It is uncommon for a singer to be equally skilled for contrasting performance styles. However, it is becoming increasingly common for audiences (or casting agents) to request a performance outside the

Figure 20–9.  “ng-sniff exercise” (from DEVT27) to improve registration control.



typical for a given singer. Technique is technique, and style is the application of technique to a particular performance medium. Some singers are more skilled with crossover between styles. Successful crossover may depend on the performer’s natural intuitions and overall vocal signature. Some performers seek alternative performance venues to expand their audience exposure, to enlarge their overall target base, or as a financial incentive. Still, there are many considerations for the myriad of performance demands currently within the genre of available (and viable) careers in the field of singing. Performance styles include opera, recital, concert, Broadway, pop, rock, jazz, country and western, folk, blues, soul, rap, hip-hop, sacred, cantorial, baroque, choral, praise team, gospel, club singer, and studio musician. Each performance venue has unique demands each with risks and benefits.

The Opera Singer Opera singers require solid vocal technique because of the repertoire demands and because performance venues may range from a smaller house (250 seats) to quite large performances spaces (greater than 38,000 seats), usually without amplification. These singers must project the voice without strain, while managing a raked (angled) stage, heavy costumes (including wigs and headpieces), and foreign language demands. Depending on the role, they may be required to have additional skills in dance, fencing, or gymnastics. The opera singer must have artistic vocal technique, drama/theater training, and comfort with languages. Opera audiences are often well versed in the vocal demands for the singers and have high expectations. Although the singer may alter a specific cadenza (vocal embellishment), they cannot typically alter the performance key and cannot change the order of vocal demands during the performance. “There is no coddling in the opera business, and the rehearsal demeanor of the singer will often be one of the determining factors in whether the singer is retained for subsequent seasons.”28 Rehearsal period with other members of the cast may be brief (2–3 rehearsals) or extended (6 weeks or more). Opera companies may have a repertory

Training and Teaching the Singer

season, with several opera productions during the week. Opera companies are assigned a level (G, P, A, B, C, D, E), depending on overall operating budget. The highest level is Class G (such as The Metropolitan Opera House, Chicago Lyric, San Francisco Opera, Covent Garden, La Scala), have an operating budget of >$10 million, and have a larger performance space and management team. The lowest level is Class E (such as small regional companies or festival companies) and have an operating budget of 50 years old, intubation longer than 15 hours, and a medical history of diabetes or hypertension.12 Voice changes associated with intubation have been characterized acoustically but are not conclusive. The fundamental frequency has been noted to either increase,13,14 decrease,15 or not change at all.16–20 Studies have noted that the fundamental frequency perturbation quotient (jitter) did not change at all20 or that jitter increased within the first few hours19 but then resolved to normal baseline measures within 24 hours.16,21,22 The sound pressure level perturbation quotient (shimmer) was also observed to not change at all16,20,21 or be increased17 and resolved within 24 hours.22 Maximum phonation time decreased within the first few hours but then resolved to normal baseline measures within 24 hours.16,18 Noise to harmonic ratios were either noted to not change at all16,20 or increase within the first few hours and then resolve to normal baseline measures within 24 hours.18,22 Prior to surgery, the patient should always advise the surgeon and the anesthesiologist that he or she is a vocalist. The anesthesiologist will then take even more care to avoid a traumatic intubation. A smaller tube (6.0 for women, 7.0 for men) is preferred unless the patient is very large or has poor pulmonary reserve and requires maximum ventilation.23,24 Even after a completely normal atraumatic intubation, development of a vocal process granuloma is pos-

sible. This manifests itself with globus sensation, the urge to clear the throat and sometimes voice changes weeks after the intubation. Gastroesophageal reflux is thought to be the factor that causes granulomas to form in a small number of patients. Preoperative antireflux/antiacid prophylaxis with proton pump inhibitors or H2 antagonists might be considered, whether the patient has a history of gastroesophageal reflux disease or not.24 Other interventions that have shown promise in decreasing postoperative hoarseness includes a preoperative injection of corticosteroids,23,25 coating the endotracheal tube with water-based steroid cream,26–28 and taking a preoperative over-the-counter antiseptic lozenge.29 Loucks et al30 propose a protocol for “vocal athletes” who will be undergoing endotracheal intubation. This includes preoperative counseling by a speech-language pathologist (SLP) regarding the importance of vocal hygiene both before and after intubation. Next is a thorough discussion with the anesthesiologist concerning alternatives for intubation (regional anesthesia, laryngeal mask airway), use of a small tube, attention to humidification and cuff pressures, tube positioning, and exceptional care during the actual intubation. Both the SLP and otolaryngologist carry out a complete voice assessment preoperatively, and any medical conditions (allergies, reflux) and maladaptive vocal behaviors are identified and treated prior to the intubation. After extubation, maintaining vocal hygiene is stressed. Important factors include voice rest for 24 hours, maintaining adequate hydration either intravenously or orally, humidification of inspired air, treatment of reflux, and avoidance of nausea and vomiting with appropriate medications. Assessment of the larynx immediately after extubation and again within 1 month of extubation allows for early identification and treatment of any injuries that may have occurred and any maladaptive vocal behaviors that may have developed.30 Another option for airway management during surgery is the laryngeal mask airway (LMA). This device has a cuff that seals off the airway at the level of the supraglottis rather than passing a tube between the vocal folds. The airway is not quite as secure as with an ET tube.31 The voice changes associated with LMA use appear to be similar to that seen with standard ET intubation but may be less



Surgery (Nonlaryngeal) for the Professional Vocalist

severe.21,22,32 Rarely, there have been cases of injury to the larynx reported with the LMA.33,34 Chipped teeth are an unlikely but well-known complication of endotracheal intubation. This is a concern for all patients, but especially for those performers whose appearance is a factor in obtaining employment. Making the anesthesiologist aware of any cosmetic dental work (caps, bridges, crowns) and wearing a protective tooth guard are helpful in avoiding dental injury.

Resumption of Singing After Endotracheal Intubation Although significant injury to the larynx is unlikely after a general anesthetic, the entire experience is likely to affect normal function at least minimally. These minor effects include mild sore throat, dry throat, decreased level of alertness (sedation), mild vocal fold edema, decreased sensation, susceptibility to nausea, decreased muscle strength, poor respiration and overall fatigue. Additionally, many patients will be treated with narcotic analgesics that sedate, decrease motor function, and cause nausea. Any combination of these factors may adversely affect singing technique. It is therefore advisable that the singer abstain from singing of any sort until these various symptoms have completely resolved. If the speaking voice is affected in any way, the singer should seek an otolaryngologic evaluation immediately. If the speaking voice is normal, the singer can resume singing with typical warm-up exercises. Should there be any abnormalities with the singing voice again, otolaryngologic evaluation is indicated immediately. Assuming that all is well with both speaking and singing voice, the singer can carefully resume full activity. Any problems discovered in the postoperative period will alter this plan, of course. Most singers will be able to resume singing without medical or SLP intervention after a routine endotracheal intubation. The most conservative approach is that described by Loucks and discussed above.30 Also, the various surgeries discussed in the remainder of this chapter add other factors that influence when a vocalist can resume full activity. These issues are described below.

Surgery of the Head, Neck, and Upper Chest Surgery of the head, neck, and upper chest encompasses many different types of surgery to address conditions such as thyroid cancer, carotid artery stenosis, cervical spine arthritis, and lung cancer. The majority of the risk associated with surgery in this region is due to the many nerves located in this vicinity, providing sensation and muscular control of the entire vocal tract. Injury to these nerves, referred to as the cranial nerves (CNs) due to their exit directly from the brainstem, can manifest in changes of voice quality, articulation, as well as swallowing. For a vocalist, an injury in one of these structures could be a potentially career-ending event. Although a frank discussion of the surgeon’s own experience and the likelihood of this problem may frighten the patient, it may also reassure that it is unlikely to occur. One of the most important cranial nerves for the vocalist is the vagus nerve (CN X). This nerve supplies both sensation and motor movement for the larynx via 2 nerve branches, the superior laryngeal nerve (SLN) and the recurrent laryngeal nerve (RLN). Injury to these 2 nerve branches at any point along their path to the larynx will result in either sensation changes in the throat or paralysis of the muscles of the larynx. While an injury to the SLN will impair high pitch vocalization, an injury to the RLN will result in a paralyzed vocal fold with resultant breathy weak voice and possible aspiration.35 An injury to the vagus nerve prior to the branching point will cause the loss of function to both nerve branches, resulting in sensory and muscular deficits not only in the larynx but also the pharynx and soft palate with velopharyngeal incompetence (hypernasal voice and nasal regurgitation of liquids). Paralysis of one or both of the vocal folds from RLN injury can result from a variety of surgical procedures in the neck and chest due to the long course of the nerve that traverses these 2 structures to travel to the larynx. Rarely, surgical resection of the nerve can be necessary depending on the pathology present at the time of surgery. More commonly, unintentional injury occurs, ranging from stretch or compression injury, partial transection, or full

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transection. The most common surgeries responsible for RLN injury are thyroid and parathyroid surgeries, anterior approach to the cervical vertebrae, and carotid endarterectomy.36 The likelihood of a permanent paralysis after thyroid surgery is less than 5%.37 For carotid endarterectomy, this number is less than 0.5%.38 Anterior approach to the cervical vertebrae has been reported by Jung to have as high as a 24% incidence of vocal fold paralysis immediately after surgery and 11.3% at 3 months, whereas others have reported only a 1.4% rate.39,40 Suggested interventions to reduce the likelihood of the RLN injury have included using the left side for the surgical approach as well as a reduction of the ET tube cuff pressure after the retractors have been placed.41,42 Use of an ET tube with electromyography (EMG) capabilities may also be helpful in avoiding injury to the vagus or recurrent laryngeal nerves.37,43,44 During thyroid or parathyroid surgery, the strap muscles are retracted and sometimes cut. These muscles control the position of the larynx in the neck during phonation and swallowing. Care should be taken to avoid cutting these muscles or denervating them, as this may adversely affect pitch control.23,45 Surgery in the mediastinum (mediastinoscopy with biopsy, thymectomy) can also result in injury to the RLN, as can any surgery of the upper chest.46 The left RLN is at greater risk than the right, due to its longer course. Surgery of the aortic arch, which is usually emergent, will often result in injury to the left RLN. Surgery for lung cancer has become a more common cause of surgically caused unilateral vocal fold paralysis in several series.47,48 Unfortunately, in these cases, preservation of life often supersedes preservation of the normal voice. Skull base surgery puts at risk a number of cranial nerves (CN) including numbers V, VII, VIII, IX, X, XI, and XII. The other cranial nerves can also be damaged, but these listed are those most prone to injury that could adversely affect voice and articulation. Skull base surgery is usually performed for removal of tumors, both benign and malignant as well as vascular anomalies. The need to preserve life in these cases often takes precedence over maintaining function, but the professional voice user must be made aware of the potential injuries and sequelae before surgery is undertaken. As discussed above, injury of the vagus nerve (CN X) at the skull base

will result in a high vagal injury, causing effects in the larynx from the loss of the RLN and SLN function, but the injury will also affect the function of the soft palate and pharynx. The pharynx and tongue base receive sensory and motor innervation from the glossopharyngeal nerve (CN IX). Injury to this nerve affects swallowing and articulation. Likewise, injury to the hypoglossal nerve (CN XII) causes paralysis of the ipsilateral anterior two-thirds of the tongue and a resultant problem with articulation, although people compensate surprisingly well from this injury even without recovery of nerve function, at least with regard to speaking and swallowing. Whether an isolated CN XII paralysis would make it impossible to sing well is not known. Unfortunately, large skull base resections often result in injury to several of these nerves at once, which results in patients with severe dysphagia and dysarthria. Rhytidectomy (facelift) and salivary gland surgery puts the facial nerve (CN VII) at risk. Permanent injury with rhytidectomy is rare (0.1%) and temporary injuries only 3%.49 An injury to that nerve causes paralysis of different parts of the face and may include the orbicularis oris muscle, which controls the lips. This would impair articulation. Injury to other branches of the facial nerve causes a cosmetic deformity and may lead to ocular problems. The amount of tightness of the facial structures after rhytidectomy may adversely influence a singer’s technique and should be taken into account by the surgeon and the patient when she resumes singing.23,50 Injury to acoustic and vestibular nerves (CN VIII) will cause unilateral sensorineural hearing loss and imbalance and/or vertigo, respectively. These injuries are most likely during surgery of the temporal bone for chronic ear disease or tumors that arise from CN VIII itself, most commonly the acoustic neuroma. Hearing loss is obviously a problem for a vocalist, although the other ear is usually fully functional and adequate. The dysfunction of the vestibular system, however, can be disabling for an extended period of time, interfering with balance. Surgery for chronic ear disease (mastoidectomy) also puts the entire facial nerve at risk. Injury results in paralysis of the entire side of the face with possible damage to the eye and an obvious cosmetic problem as discussed above.



Surgery (Nonlaryngeal) for the Professional Vocalist

Surgery of the Vocal Tract The vocal tract includes all of the spaces above the vocal folds, including all of the pharynx, the oral cavity and lips, nasal cavities, and paranasal sinuses. The vocal tract is the resonating chamber for the voice and is as important as the vocal folds are, and it may account more for the individual quality of one’s voice than the vocal folds. Commonly performed surgeries that can affect the vocal tract include tonsillectomy, adenoidectomy, septoplasty, rhinoplasty, inferior turbinate surgery, sinus surgery, and a variety of procedures for snoring and sleep apnea that involve the palate, oropharynx, and tongue base. Adenoid surgery is uncommon in adults and is usually performed in children. The adenoids are usually removed due to chronic infection or due to their large size resulting in obstruction of the nasopharynx. With obstruction of the nasopharynx, the voice develops a hyponasal resonance, which may not be present with those experiencing only chronic infection.51 Efforts to quantify differences between these 2 conditions have only shown different acoustic and nasal resistance measures, but no difference in perceptual voice characteristics such as hyponasality.52 Removal almost always results in a better voice with better balance between oral and nasal resonance, as the person is able to control this with the soft palate. This ratio of nasal and oral acoustic energy changes

significantly with the surgery, but the amount of this change decreases between 3 and 6 months postoperatively, likely due to the gradual development of a more posterior tongue position following surgery.52 Problems can arise when the soft palate is not normal, either weak or too short, and unable to effectively close off the nasopharynx when needed.53,54 This leads to velopharyngeal insufficiency with a hypernasal voice and nasal regurgitation of liquids similar to when the palate is paralyzed. A portion of patients who experience this directly after surgery will have resolution with time, but some may require surgical repair.55 Like adenoid surgery, tonsillectomy is performed because of chronic infections or for obstructive symptoms, such as obstructive sleep apnea. If the tonsils are quite large, they can cause a muffled or “hot potato” voice with either hyponasality or hypernasality based on what direction the tonsil growth occurs and how the tonsil tissue interacts with the velopharyngeal valvular complex56,57 (Figure 28–1). They have also been noted to alter articulation by affecting tongue positioning.58 Removal of the tonsil tissue via tonsillectomy improves these voices changes. Quantification of the voice changes are inconsistent between studies.59–63 Changes that have been noted in the speech spectrum include changes in the fundamental frequency of the voice59 or changes in the higher formant frequencies.58,61,62,64 These formant frequencies are the resonance characteristics of the vocal tract and determined by the

Figure 28–1.  Size 4+ tonsils in a patient with loud snoring. Tonsils of this size will also cause a muffled voice and are likely to cause obstructive sleep apnea.

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vocal tract shape.65 The first formant (F1) has been shown to vary with the volume of the oropharyngeal and hypopharyngeal space. The second formant (F2) varies in some vowels with the volume of the oral cavity.66 In general, these acoustic changes have been very mild, often are beneficial, and frequently return to preoperative status or a more normative state.63,67 The risk of removing tonsils as it relates to the singer is that scarring may occur as the tonsillar fossae heal that could affect the vocal tract. Fortunately, this rarely occurs. The surgeon must take care to avoid damaging the fascia surrounding the tonsillar capsule and the pharyngeal constrictor muscles deep to that fascia. A careful dissection in the appropriate plane should avoid that complication.23 Scarring could affect the singer’s ability to easily change the shape of the vocal tract and may affect the resultant sound or increase the effort required to achieve a certain sound. The decision to undergo tonsillectomy at all must be based on the reason it is being done. If a person is experiencing frequent and/or prolonged bouts of tonsillitis, he or she is likely to be feeling poorly often and is likely to miss much work. This will affect both her singing and ability to progress with her career. Singers who are always sick do not succeed. After surgery, the singer should not resume singing until the pharynx is completely healed, which often takes a month. While the pharynx is healing, pain with swallowing and phonation is common. This negative feedback may cause the singer to alter what is otherwise excellent singing technique to avoid the pain. This could lead to an undesirable change in technique. The singer should wait until she is comfortable with the changes in sensation and resonance before arranging an important engagement. The time that it takes to return to performing may vary, and it is important to inform the singer of this.68 Overall, vocalists who do decide to proceed with tonsillectomy or adenoidectomy for appropriate reasons will likely find short-term improvement in vocal resonance and reliability and long-term improvements in vocal sound, resonance, reliability, stamina, and overall general health.69 Obstructive sleep apnea (OSA) is a condition in which the airway collapses during sleep, resulting in a blockage in the flow of air through the throat. The person must wake up slightly to restore muscle tone in the throat, which opens the throat.

Once the throat is open, the breathing resumes, the person falls back asleep, snores, obstructs, and the cycle repeats. This condition results in a less than restful sleep and daytime sleepiness, and it is also associated with an increase in overall mortality.70 In children, obstructive sleep apnea is often due to adenoid and tonsil hypertrophy, whereas in adults, obesity plays a significant role as well as male gender, increased age, and craniofacial/upper airway abnormalities such as a long soft palate or a posterior tongue displacement from a short mandible.71–73 Surgery for sleep apnea aims to increase the diameter of the airway through the throat. With many people having airway obstruction at multiple levels, surgical treatment for OSA can involve the soft palate, pharyngeal walls, tonsils, tongue base, and often the nasal cavities; in other words, surgery can involve the entire vocal tract.74,75 Uvulopalatopharyngoplasty (UPPP), a surgery to rearrange the soft palate, is often completed for surgical treatment of obstructive sleep apnea and can be combined with other procedures to address different areas of obstruction in the upper airway during sleep (Figure 28–2). There have even been recent efforts to use robotic surgery to help address areas of obstruction that have been more difficult to access surgically

Figure 28–2.  View of the oral cavity and oropharynx post uvulopharyngoplasty (UPPP). The uvula is absent and the soft palate is shorter and stiffer than it was prior to surgery.



Surgery (Nonlaryngeal) for the Professional Vocalist

in the past. As discussed above for adenoidectomy, soft palate paralysis, and tonsillectomy, alteration of these structures may have an effect on the quality of or effort required to produce a particular sound.23 Acoustic changes noted in patients undergoing UPPP with tonsillectomy have shown no large perceptual changes in voice quality or nasality, but there were changes noted in the first 2 formant frequencies depending on the vowels measured.76–80 Acoustic changes following robotic surgery for sleep have not been reported, but there have been reports of acoustic changes following robotic oncologic surgery of the hypopharynx showing increases in fundamental frequency variation and jitter. In these patients, harmonic to noise ratio and shimmer maintain a close to normal range.81 Robotic oncologic surgery addressing the oropharynx demonstrated even less acoustic changes.82 Sleep apnea is a serious condition that can lead to hypertension, heart disease, stroke, and auto accidents (from falling asleep while driving). It is a condition that warrants treatment, either with continuous positive airway pressure (CPAP) or surgery. If CPAP is chosen, humidification should be added to the machine so that it will not dry the vocal tract. Weight loss is usually an important component of treatment as well. The risks of the treatment must be weighed against the potential complications of untreated sleep apnea when deciding on how to proceed.68 In most cases, there are no complications following such surgery and no excessive scarring. As above for tonsillectomy, the patient should be counseled not to resume singing for at least 1 month after the surgery. Surgery of the nose is done for obstruction, cosmetics, or both. When the indication is obstruction, improving the patency of the nasal cavities can only have a positive effect on the voice. This surgery is usually a septoplasty as well as a procedure to decrease the size of the inferior nasal turbinates.67 A cosmetic rhinoplasty is done to improve the appearance of the nose and can result in a narrower internal nasal airway and nasal obstruction.83 A hyponasal (less than normal nasal resonance) voice and difficulty with nasal breathing may be the outcome.84 This hyponasality can be very difficult to repair. The singer must make it clear to the surgeon that no compromise of nasal airflow can occur as a result of the

rhinoplasty.50 Augmentation of the nose to change its shape, rather than aggressive reduction, is less likely to cause a smaller nasal airway. Nasal sepal perforation, a complication of septal surgery, can cause crusting and whistling, especially during deep inspiration. This would be particularly troublesome for a vocalist.50 Fortunately, these complications are rare, particularly if the surgery is performed by an otolaryngologist. In general, cosmetic surgery can safely be performed on singers with little to no risk. Like all surgeries, the potential benefits of cosmetic surgery should be weighed against the risks.23 Surgery to remove nasal polyps or remove chronically inflamed sinus tissue is another commonly performed procedure, especially since the advent of telescopes/endoscopes that allow an excellent magnified view of the inside of the nose and sinuses. This type of surgery will also usually help with nasal resonance and is associated with some formant changes in a majority of the vowel sounds.85–87 Acoustic changes have also been noted with sinus augmentation surgery for dental issues.88 Despite being less invasive and painful, the postoperative period is still an uncomfortable time, with the need for frequent nasal irrigation and debridement. It is wise to avoid making any significant performance commitments for the first month after surgery, but it is safe to continue singing.

Surgery of the Chest Wall and Abdomen The chest wall, diaphragm, and abdominal muscles are all structures that generate the power that drives the voice. While surgery is rarely aimed directly at these structures, they are frequently traversed en route to other organs that are the target of the surgeon. In the past, large incisions were always necessary to access the intrathoracic or intra-abdominal cavities. These approaches involved cutting through many layers of muscle and sometimes cutting or separating ribs. This resulted in very painful, often slowhealing wounds that made every breath or cough an unpleasant experience. Needless to say, providing proper breath support to the voice is difficult, if not impossible, in this situation. After healing, that

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function should be restored, likely in full. Overexertion or premature resumption of physical activities could also lead to development of incisional hernias that can continue to impair proper breathing and support and may require further surgery to repair.23 Currently, many abdominal surgeries are accomplished with a laparoscopic approach in which several small incisions are made through the abdominal wall to allow the passage of a telescope and several instruments. The resultant wounds are much less painful and heal much faster. This allows the singer to be able to resume singing with proper technique much earlier. The operations frequently performed with this approach include cholecystectomy, appendectomy, gastric fundoplication, and many gynecological procedures. Within the chest, thoracoscopy allows biopsies without causing severe damage to the chest wall. The smaller wounds that result will still cause significant pain with respiration but should heal much faster than traditional thoracotomy incisions. Unfortunately, many medical conditions, most notably cancer, still require the more traditional open approach to both the chest and abdomen. The surgeon is expected to use the approach that will provide adequate exposure while causing minimal morbidity afterward, but the patient should always discuss the approach that will be used as well as the activity limitations after the surgery, keeping in mind that the severity of the patient’s medical condition may supersede concerns about singing. Since abdominal support is very important in the production of voice, the singer should make sure that abdominal strength has returned prior to a performance or aggressive rehearsing or practice. With large chest and abdominal incisions, this may take months.

Surgery of the Musculoskeletal System Proper posture and stance contribute to efficient vocalization. Injuries to the extremities or back may affect this aspect of a singer’s technique. Likewise, surgery to repair such an injury can have the same effect on technique as the original injury.

If singers are experiencing musculoskeletal pain, they must be cognizant of how they might change their stance and how they might tense muscles that would ordinarily be relaxed while singing. Excess tension anywhere above the waist can lead to strain in the cervical musculature, the strap muscles, and finally vocal fatigue and pain when singing. Should surgery for a musculoskeletal problem be considered, it is wise for the surgeon and patient to understand thoroughly how the resultant wound will affect the simplest of activities, such as standing. The patient should have a clear understanding of how long the recuperative period is likely to be, in order to plan for upcoming performances.23 This will vary dramatically, depending on the type of surgery (eg, back vs hip vs foot surgery). Some surgery of the extremities can be done with regional anesthesia blocks or a spinal anesthetic. This type of anesthesia avoids the need for endotracheal intubation and potential injury to the vocal folds. This should be discussed with the surgeon and anesthesiologist prior to surgery, as mentioned at the beginning of this chapter.

References 1. Jones MW, Catling S, Evans E, Green DH, Green JR. Hoarseness after tracheal intubation. Anaesthesia. 1992;47(3):213–216. 2. Peppard SB, Dickens JH. Laryngeal injury following short-term intubation. Ann Otol Rhinol Laryngol. 1983;92(4, pt 1):327–330. 3. Domino KB, Posner KL, Caplan RA, Cheney FW. Airway injury during anesthesia: a closed claims analysis. Anesthesiology. 1999;91(6):1703–1711. 4. Gallivan GJ, Dawson JA, Robbins LD. Critical care perspective: videolaryngoscopy after endotracheal intubation: implications for voice. J Voice. 1989;3(1):76–80. 5. Kambic V, Radsel Z. Intubation lesions of the larynx. Br J Anaesth. 1978;50(6):587–590. 6. Pröschel U, Eysholdt U. Kurzzeit-Veränderungen an Kehlkopf und Stimme nach Intubation. Laryngo-Rhino-Otologie. 1993;72(2):93–97. 7. Mendels EJ, Brunings JW, Hamaekers AE, Stokroos RJ, Kremer B, Baijens LW. Adverse laryngeal effects following short-term general anesthesia:



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a systematic review. Arch Otolaryngol Head Neck Surg. 2012;138(3):257–264. 8. Colice GL. Resolution of laryngeal injury following translaryngeal intubation. Am Rev Respir Dis. 1992;145(2, pt 1):361–364. 9. Mencke T, Echternach M, Kleinschmidt S, et al. Laryngeal morbidity and quality of tracheal intubation: a randomized controlled trial. Anesthesiology. 2003;98(5):1049–1056. 10. Colice GL, Stukel TA, Dain B. Laryngeal complications of prolonged intubation. Chest. 1989;​ 96(4):877–884. 11. Stout DM, Bishop MJ, Dwersteg JF, Cullen BF. Correlation of endotracheal tube size with sore throat and hoarseness following general anesthesia. Anesthesiology. 1987;67(3):419–421. 12. Kikura M, Suzuki K, Itagaki T, Takada T, Sato S. Age and comorbidity as risk factors for vocal cord paralysis associated with tracheal intubation. Br J Anaesth. 2007;98(4):524–530. 13. Gleeson MJ, Fourcin AJ. Clinical analysis of laryngeal trauma secondary to intubation. J R Soc Med. 1983;76(11):928–932. 14. Lesser T, Williams G. Laryngographic investigation of postoperative hoarseness. Clin Otolaryngol Allied Sci. 1988;13(1):37–42. 15. Horii Y, Fuller BF. Selected acoustic characteristics of voices before intubation and after extubation. J Speech Hear Res. 1990;33(3):505–510. 16. Paulauskiene I, Lesinskas E, Petrulionis M. The temporary effect of short-term endotracheal intubation on vocal function. Eur Arch Otorhinolaryngol. 2013;270(1):205–210. 17. Yonick TA, Reich AR, Minifie FD, Fink BR. Acoustical effects of endotracheal intubation. J Speech Hear Disord. 1990;55(3):427–433. 18. Hamdan AL, Sibai A, Rameh C, Kanazeh G. Shortterm effects of endotracheal intubation on voice. J Voice. 2007;21(6):762–768. 19. Beckford NS, Mayo R, Wilkinson A III, Tierney M. Effects of short-term endotracheal intubation on vocal function. Laryngoscope. 1990;100(4):​ 331–336. 20. Toran KC, Lal BK. Does short-term endotracheal intubation affects the acoustic characteristics? Kathmandu Univ Med J. 2010;8(29):35–39. 21. Hamdan AL, Kanazi G, Rameh C, Rifai H, Sibai A. Immediate post-operative vocal changes in patients using laryngeal mask airway versus endotracheal tube. J Laryngol Otol. 2008;​122(8):​829–835. 22. Lee SK, Hong KH, Choe H, Song HS. Comparison of the effects of the laryngeal mask airway and

endotracheal intubation on vocal function. Br J Anaesth. 1993;71(5):648–650. 23. Benninger MS. Medical disorders in the vocal artist. In: Benninger M, Jacobson B, Johnson A, eds. Vocal Arts Medicine: The Care and Prevention of Professional Voice Disorders. New York, NY: Thieme Medical Publishers, Inc; 1994. 24. Powner DJ. Airway considerations for professional singers — a survey of expert opinion. J Voice. 2002;16(4):488–494. 25. Park SH, Han SH, Do SH, Kim JW, Rhee KY, Kim JH. Prophylactic dexamethasone decreases the incidence of sore throat and hoarseness after tracheal extubation with a double-lumen endobronchial tube. Anesth Analg. 2008;107(6):1814–1818. 26. Ayoub CM, Ghobashy A, Koch ME, et al. Widespread application of topical steroids to decrease sore throat, hoarseness, and cough after tracheal intubation. Anesth Analg. 1998;87(3):714–716. 27. Shaaban AR, Kamal SM. Comparison between betamethasone gel applied over endotracheal tube and ketamine gargle for attenuating postoperative sore throat, cough and hoarseness of voice. Middle East J Anesthesiol. 2012;​21(4):​ 513–519. 28. Sumathi PA, Shenoy T, Ambareesha M, Krishna HM. Controlled comparison between betamethasone gel and lidocaine jelly applied over tracheal tube to reduce postoperative sore throat, cough, and hoarseness of voice. Br J Anaesth. 2008;100(2):215–218. 29. Ebneshahidi A, Mohseni M. Strepsils(R) tablets reduce sore throat and hoarseness after tracheal intubation. Anesth Analg. 2010;111(4):892–894. 30. Loucks TM, Duff D, Wong JH, Finley-Detweiler R. The vocal athlete and endotracheal intubation: a management protocol. J Voice. 1998;​12(3):​ 349–359. 31. Harris TM, Johnston DF, Collins SRC, Heath ML. A new general anaesthetic technique for use in singers: the brain laryngeal mask airway versus endotracheal intubation. J Voice. 1990;4(1):81–85. 32. Zimmert M, Zwirner P, Kruse E, Braun U. Effects on vocal function and incidence of laryngeal disorder when using a laryngeal mask airway in comparison with an endotracheal tube. Eur J Anaesthesiol. 1999;16(8):511–515. 33. Inomata S, Nishikawa T, Suga A, Yamashita S. Transient bilateral vocal cord paralysis after insertion of a laryngeal mask airway. Anesthesiology. 1995;82(3):787–788.

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34. Bruce IA, Ellis R, Kay NJ. Nerve injury and the laryngeal mask airway. J Laryngol Otol. 2004;​ 118(11):899–901. 35. Dursun G, Sataloff RT, Spiegel JR, Mandel S, Heuer RJ, Rosen DC. Superior laryngeal nerve paresis and paralysis. J Voice. 1996;10(2):206–211. 36. Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope. 2007;117(10):​ 1864–1870. 37. Hermann M, Hellebart C, Freissmuth M. Neuromonitoring in thyroid surgery: prospective evaluation of intraoperative electrophysiological responses for the prediction of recurrent laryngeal nerve injury. Ann Surg. 2004;240(1):9–17. 38. Sannella NA, Tober RL, Cipro RP, Pedicino JF, Donovan E, Gabriel N. Vocal cord paralysis following carotid endarterectomy: the paradox of return of function. Ann Vasc Surg. 1990;4(1):42–45. 39. Baron EM, Soliman AM, Gaughan JP, Simpson L, Young WF. Dysphagia, hoarseness, and unilateral true vocal fold motion impairment following anterior cervical diskectomy and fusion. Ann Otol Rhinol Laryngol. 2003;112(11):921–926. 40. Jung A, Schramm J, Lehnerdt K, Herberhold C. Recurrent laryngeal nerve palsy during anterior cervical spine surgery: a prospective study. J Neurosurg Spine. 2005;2(2):123–127. 41. Apfelbaum RI, Kriskovich MD, Haller JR. On the incidence, cause, and prevention of recurrent laryngeal nerve palsies during anterior cervical spine surgery. Spine. 2000;25(22):2906–2912. 42. Jung A, Schramm J. How to reduce recurrent laryngeal nerve palsy in anterior cervical spine surgery: a prospective observational study. Neurosurgery. 2010;67(1):10–15; discussion 15. 43. Tan TP, Govindarajulu AP, Massicotte EM, Venkatraghavan L. Vocal cord palsy after anterior cervical spine surgery: a qualitative systematic review. Spine J. 2014;14(7):1332–1342. 44. Chandrasekhar SS, Randolph GW, Seidman MD, et al. Clinical practice guideline: improving voice outcomes after thyroid surgery. Otolaryngol Head Neck Surg. 2013;148(6)(suppl):S1–37. 45. Rubin J, Korovin G, Epstein R. Special considerations for the professional voice user. In: Rubin J, Sataloff R, Korovin G, eds. Diagnosis and Treatment of Voice Disorders. 2nd ed. Clifton Park, NY: Thomson Delmar Learning; 2003:583–595. 46. Widstrom A. Palsy of the recurrent nerve following mediastinoscopy. Chest. 1975;67(3):365–366.

47. Benninger MS, Gillen JB, Altman JS. Changing etiology of vocal fold immobility. Laryngoscope. 1998;108(9):1346–1350. 48. Gardner GM, Shaari CM, Parnes SM. Long-term morbidity and mortality in patients undergoing surgery for unilateral vocal cord paralysis. Laryngoscope. 1992;102(5):501–508. 49. Sullivan CA, Masin J, Maniglia AJ, Stepnick DW. Complications of rhytidectomy in an otolaryngology training program. Laryngoscope. 1999;​ 109​(2, pt 1):198–203. 50. Spiegel JR, Sataloff RT, Hawkshaw M. Plastic surgery in professional voice users: Special considerations. J Voice. 1990;4(1):86–90. 51. Grundfast KM, Wittich DJ Jr. Adenotonsillar hypertrophy and upper airway obstruction in evolutionary perspective. Laryngoscope. 1982;92​ (6, pt 1):650–656. 52. Andreassen ML, Leeper HA, MacRae DL, Nicholson IR. Aerodynamic, acoustic, and perceptual changes following adenoidectomy. Cleft Palate Craniofac J. 1994;31(4):263–270. 53. Witzel MA, Rich RH, Margar-Bacal F, Cox C. Velopharyngeal insufficiency after adenoidectomy: an 8-year review. Int J Pediatr Otorhinolaryngol. 1986;11(1):15–20. 54. Schmaman L, Jordaan H, Jammine GH. Risk factors for permanent hypernasality after adenoidectomy. South African Med J. 1998;88(3):266–269. 55. Stewart KJ, Ahmad T, Razzell RE, Watson AC. Altered speech following adenoidectomy: a 20 year experience. Br J Plast Surg. 2002;55(6):​ 469–473. 56. Finkelstein Y, Nachmani A, Ophir D. The functional role of the tonsils in speech. Arch Otolaryngol Head Neck Surg. 1994;120(8):846–851. 57. Kummer AW, Billmire DA, Myer CM III. Hypertrophic tonsils: the effect on resonance and velopharyngeal closure. Plast Reconstruct Surg. 1993;​91(4):608–611. 58. Hori Y, Koike Y, Ohyama G, Otsu SY, Abe K. Effects of tonsillectomy on articulation. Acta Otolaryngol Suppl. 1996;523:248–251. 59. Heffernan CB, Rafferty MA. Effect of tonsillectomy on the adult voice. J Voice. 2011;25(4):e207–210. 60. Mora R, Jankowska B, Mora F, Crippa B, Dellepiane M, Salami A. Effects of tonsillectomy on speech and voice. J Voice. 2009;23(5):614–618. 61. Chuma AV, Cacace AT, Rosen R, Feustel P, Koltaii PJ. Effects of tonsillectomy and/or adenoidectomy on vocal function: laryngeal, supralaryn-



Surgery (Nonlaryngeal) for the Professional Vocalist

geal and perceptual characteristics. Int J Pediatr Otorhinolaryngol. 25 1999;47(1):1–9. 62. Saida H, Hirose H. Acoustic changes in voice after tonsillectomy. Acta Otolaryngol Suppl. 1996;523:239–241. 63. Ilk HG, Erogul O, Satar B, Ozkaptan Y. Effects of tonsillectomy on speech spectrum. J Voice. 2002;16(4):580–586. 64. Svancara P, Horacek J, Vokral J, Cerny L. Computational modelling of effect of tonsillectomy on voice production. Logopedics Phoniatrics Vocol. 2006;31(3):117–125. 65. Raphael LJ, Borden GJ, Harris KS. Speech Science Primer: Physiology, Acoustics, and Perception of Speech. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. 66. Fant G. A study of vowels. In: Acoustic Theory of Speech Production. 2nd ed. Paris, France: Mouton De Gruyter; 1970:107–138. 67. Behrman A, Shikowitz MJ, Dailey S. The effect of upper airway surgery on voice. Otolaryngol Head Neck Surg. 2002;127(1):36–42. 68. Gardner G, Benninger M. Sleep disorders and the vocalist. J Singing. 1997;53(5):45–48. 69. Jarboe JK, Zeitels SM, Elias B. Tonsillectomy and adenoidectomy in singers. J Voice. 2001;​15(4):​ 561–564. 70. Marshall NS, Wong KK, Cullen SR, Knuiman MW, Grunstein RR. Sleep apnea and 20-year follow-up for all-cause mortality, stroke, and cancer incidence and mortality in the busselton health study cohort. J Clin Sleep Med. 2014;10(4):355–362. 71. Finkelstein Y, Wolf L, Nachmani A, et al. Velopharyngeal anatomy in patients with obstructive sleep apnea versus normal subjects. J Oral Maxillofac Surg. 2014;72(7):1350–1372. 72. Kohler M. Risk factors and treatment for obstructive sleep apnea amongst obese children and adults. Curr Opin Allergy Clin Immunol. 2009;​ 9(1):4–9. 73. Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004;​ 291(16):2013–2016. 74. Bachar G, Feinmesser R, Shpitzer T, Yaniv E, Nageris B, Eidelman L. Laryngeal and hypopharyngeal obstruction in sleep disordered breathing patients, evaluated by sleep endoscopy. Eur Arch Otorhinolaryngol. 2008;265(11):1397–1402. 75. Koo SK, Choi JW, Myung NS, Lee HJ, Kim YJ, Kim YJ. Analysis of obstruction site in obstructive sleep apnea syndrome patients by drug

induced sleep endoscopy. Am J Otolaryngol. 2013;​34(6):626–630. 76. Brosch S, Matthes C, Pirsig W, Verse T. Uvulopalatopharyngoplasty changes fundamental frequency of the voice — a prospective study. J Laryngol Otol. 2000;114(2):113–118. 77. Coleman RF, Sly DE. Preoperative and postoperative voice analysis of uvulopalatopharyngoplasty patients. Arch Otolaryngol Head Neck Surg. 1991;117(12):1345–1349. 78. Murry T, Bone RC. Acoustic characteristics of speech following uvulopalatopharyngoplasty. Laryngoscope. 1989;99(12):1217–1219. 79. Nakai K, Sakakura A, Takahashi H, Sadaoka T, Kakitsuba N. Articulation after uvulopalatopharyngoplasty. Eur Arch Otorhinolaryngol. 1996;​ 253(7):417–420. 80. Rihkanen H, Soini I. Changes in voice characteristics after uvulopalatopharyngoplasty. Eur Arch Otorhinolaryngol. 1992;249(6):322–324. 81. Park YM, Kim WS, De Virgilio A, Lee SY, Seol JH, Kim SH. Transoral robotic surgery for hypopharyngeal squamous cell carcinoma: 3-year oncologic and functional analysis. Oral Oncol. 2012;​ 48(6):560–566. 82. Park YM, Kim WS, Byeon HK, Lee SY, Kim SH. Oncological and functional outcomes of transoral robotic surgery for oropharyngeal cancer. Br J Oral Maxillofac Surg. 2013;51(5):408–412. 83. Guyuron B. Nasal osteotomy and airway changes. Plast Reconstruct Surg. 1998;102(3):856–860; discussion 861–853. 84. Foroughian M, Khazaeni K, Haghi MR, Jahangiri N, Mashhadi L, Bakhshaee M. The potential effects of rhinoplasty on voice. Plast Reconstruct Surg. 2014;133(2):109e–113e. 85. Chen MY, Metson R. Effects of sinus surgery on speech. Arch Otolaryngol Head Neck Surg. 1997;​ 123(8):845–852. 86. Hosemann W, Gode U, Dunker JE, Eysholdt U. Influence of endoscopic sinus surgery on voice quality. Eur Arch Otorhinolaryngol. 1998;​255(10):499–503. 87. Hong KH, Kwon SH, Jung SS. The assessment of nasality with a nasometer and sound spectrography in patients with nasal polyposis. Otolaryngol Head Neck Surg. 1997;117(4):343–348. 88. Ungor C, Saridogan C, Yilmaz M, Tosun E, Senel FC, Icten O. An acoustical analysis of the effects of maxillary sinus augmentation on voice quality. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;115(2):175–184.

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Chapter 29 Postoperative Voice Care of the Singer Robert H. Ossoff Thomas F. Cleveland

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ostoperative care of singers is important to the long-term success of surgery. Although the approach may vary with the practitioner, a multidisciplinary approach, including the surgeon, speech-language pathologist (SLP), and singing voice specialist (SVS), provides the thorough care necessary for postsurgery treatment. Whatever the postsurgery strategy, the goal must be to rehabilitate and equip the singer with the tools necessary to return to optimal voice use as soon as possible. This chapter presents concepts and strategies for the rehabilitation of singers postsurgery. The chapter includes postsurgery and medical protocols, as well as strategies and techniques necessary for equipping the patient with skills that will help the singer minimize the opportunity for reinjury.1

Treatment Strategies Postsurgery outcome depends on excellent presurgery advice, screening, and treatment. The screening and treatment received by the patient presurgery can, in some cases, obviate the need for surgery, but in all cases, it can jumpstart the postsurgery intervention by making singers familiar with the treatment protocols. Once the patient has completed surgery,

and aside from those noted in the section on exceptions, the postoperative protocol is the same for all benign vocal fold lesions, including vascular lesions that have been addressed via laser.

The Postoperative Protocol The following protocol is followed by the authors of this chapter. It is one that we have found to be successful over many years of caring for such patients. However, it is a guide and there are other approaches that have been used in successful practices. Because it is delivered in a 4-stage process over a 3-month period, measured postoperative care can accomplish several important goals. First, it can prevent the misuse/abuse of the voice that caused the problem initially and thereby give the patient downtime for healing. Second, it can give the voice care team time to effect changes in voice production that will help the singer minimize the chances for recurrence. Third, programmed visits for ongoing evaluation can help detect problems early and solve them before they really get started. In the following protocol, postsurgery visits occur at 2 weeks, 4 weeks, 8 weeks, and 12 weeks and coincide with the treatment stages given below.

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Stage 1 During the first stage, the patient is placed on voice rest for a period of 2 weeks immediately after surgery. The 2 weeks are the standard that we have used, although the amount of voice rest needed has been debated, and excellent surgeons and voice teams have had success with shorter periods of postoperative voice rest.2,3 This stage can be a welcome event for a busy patient who needs rest and recuperation, but it can severely test the resolve of a performer to be completely quiet for 2 weeks. To assist the patient with those who would interrupt the singer’s silence, the patient receives a button informing an observer that the patient is on voice rest and unable to communicate orally. The phrasing on the button is important because nonverbal behavior typically evokes a similar behavior from the person with whom the patient is seeking to communicate. The button should read as follows: “I am on voice rest and therefore cannot speak, but I can hear so please speak to me in a normal fashion.” The interested reader can find in Table 29–1 reactions one patient

received to her voiceless behavior. It is important for the physician to realize the responses patients receive on voice rest to help them be prepared for any eventuality. Nonetheless, this time of no voice use is crucial to the healing process, if for no other reason than keeping the patient from employing the abusive behaviors that may have caused the initial problem.

Stage 2 At the end of the voice rest period, the patient returns to the clinic for a stroboscopic evaluation and physician examination.4 At this time, provided the patient has healed sufficiently, the patient is taken off voice rest by a speech-language pathologist and given instructions as to how the voice is to be used over the coming 2 weeks. The written directions that accompany any verbal instructions by the SLP are given in Table 29–2. Essentially, when the patient is taken off voice rest, the protocol needs to be simple and easy for the patient to follow. Although this is also somewhat subjective to differences in practice

Table 29–1.  Twelve Things I Learned While Being Mute The following list was composed by a singer after being on voice rest for 2 weeks. 1.

Sales clerks yell at you, thinking you are deaf.

2.

Even the cat doesn’t “meow” to you anymore.

3.

Cashiers don’t ever count out your change to you.

4.

It takes two sandwich crème cookies to rid your voice of the medicine you take. (The patient is probably referring to the oral steroids she was taking at the time.)

5.

Friends think they are supposed to write notes back to you instead of answering audibly.

6.

A ringing phone can exasperate you or teach you patience.

7.

Store employees think you are “dumb” (in more ways than one) and doubt you.

8.

You become a more accomplished planner and writer.

9.

People think you know sign language, when all you know is motions.

10.

The reason deaf people use such exaggerated facial and hand gestures is to express feeling.

11.

You are still the same person on the inside — most people just treat you differently.

12.

How fortunate I have been for 43 years to have had the blessing of good health.



Postoperative Voice Care of the Singer

Stage 3

type, we recommend that the first day should have only 10 minutes of voice use, 5 in the morning and 5 in the afternoon. The next day, the voice use is doubled, and the use continues to double each day thereafter until the patient reaches normal voice use, which occurs by the end of the first week. The patient is precluded from telephone use until the end of the third week and is cautioned not to use the singing voice until the end of the fourth week. Further directives encourage the patient’s avoidance of voice use at the extremes, yelling, screaming, and throat clearing. Between weeks 2 and 4, the patient has at least 1 visit with the SLP who further evaluates the singer’s voice and makes necessary corrections in the speaking voice.5

The third stage is the reintroduction and rehabilitation of the speech and singing voice, which takes place between weeks 4 and 12. During this time, the SLP and the SVS assist the patient in the use of the voice in a less costly fashion. The protocol includes education and treatment in the care of the voice or vocal hygiene and modification of the physiology of voice production. The psychological approach taken by the SLP and the SVS during this stage is crucial to the success of the intervention. For instance, a patient who has had a successful singing career does not want to be told that everything he did prior to the surgery was wrong. As the patient made a lot of

Table 29–2.  Postoperative Guidelines for Voice Use First postoperative visit — speech-language pathologist takes you off voice rest. Guidelines for gradual return to voice use

Morning

Evening

Postoperative visit

5 minutes

5 minutes

Second day

10 minutes

10 minutes

Third day

20 minutes

20 minutes

Fourth day

45 minutes

45 minutes

Fifth day

1 hour

1 hour

Sixth day

2 to 4 hours spread over the day

Seventh fay

4 to 6 hours spread over the day

Eighth day onward

Add half an hour a day to the total talking time

These are the maximum amounts of cumulative voice use each day. This is a progression. If you have any trouble, stop and do not progress until you are ready. Everyone heals at different rates. Remember

Use an easy, natural voice. No phone use until the end of the third week after surgery. Always avoid extremes—yelling, singing, throat clearing, talking for a long period of time without a break, heavy lifting, and strenuous exercise. If any pain, fatigue, or hoarseness, call the speech-language pathologist or physician. Drink lots of water, no caffeine, no alcohol. Take vocal breaks—for 20 minutes of use, take a 10-minute break. Specific instructions and exercises will be given to you by your speech-language pathologist.

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money singing that way, he will not want to jeopardize his career by changing the way he sounds, as this could end his career. The patient should be informed that he will not be asked to make any changes in his voice production but will be given some more choices as to how to produce his sound. Imagine how this approach will register with the singer. If told he must change, he will be resistant, but if told he will be given more choices, the singer will be motivated to listen further and explore the possibilities. A patient who depends on his voice for primary livelihood can be very anxious during this stage and want to return to voice use sooner than the protocol allows. However, the patient needs to agree in advance of the surgery to the duration of the postsurgery rehabilitation period and not violate that time commitment.

Stage 4 The fourth stage occurs after week 12 and encompasses the reintroduction of the singer to his or her career. Although some practices have introduced this stage earlier in carefully selected patients, we have followed these protocols after years of successful experience. We estimate that the singer’s vocal health is typically far better at this point than it has been for several months, and may be approximately 80% of capacity. Additional percentage points will be gained over the next 18 to 24 months, according to the singers themselves. The singers will be given directives, including the incorporation of voice rest times during the show, for example, to add variety to the show by not singing every song but by including a guitar solo, a drum solo, and so forth after every 3 or 4 songs. During this time, the singer is able to rest the voice, rehydrate, and get ready for the next group of songs. “Meet and greet” times before or after the show can be dangerous for the singer. Exposure to illness can he heightened, and the noisy environment in which the events occur can compromise the singing voice before the show gets started. Washing the hands after the “meet and greet” can help the patient avoid infections, and managing the surroundings of the “meet and greet” can reduce the chance for injury. By this time, 3 months postsurgery, the patient is allowed to take up professional

engagements in a normal fashion. It is hoped that at this time, the patient has incorporated the concepts and techniques presented in sessions with the SLP and the SVS.

Secondary Postoperative Care Secondary postoperative care begins at the end of the third month and singers are reexamined every 6 months for the next 2 years. This reexamination includes stroboscopy at each visit, as needed, with intermittent visits to the SLP and the SVS, as required.

Exceptions to the Primary Care Plan Delayed healing or complications can lengthen any stage of the postoperative care protocol. Complications are usually caused by acute laryngitis due to upper respiratory infection or patient noncompliance to postsurgery protocol. In some rare cases, a microhemorrhage can occur requiring the reintroduction of voice rest or limited voice use. The interested reader will find a case study below of a patient who developed complications during his rehabilitation. This case study reveals how complications can postpone the introduction of voice use and singing for an undetermined time, a change that is usually agreed upon by the surgeon, the SLP and the SVS, and the patient.

Case Study Patient presented on July 14 with a right true vocal fold (TVF) vascular polyp. Reported loss of upper and lower range, voice fatigue, and hoarseness. Patient had been placed on 20 mg of Nexium and Humibid by the referring physician. On July 29 direct microlaryngoscopy (DML) microflap excision. Acoustic and airflow measures taken presurgery. Voice Handicap Index (VHI) and SF-36 taken (Figures 29–1 and 29–2).

Figure 29–1.  Preoperative photo of vocal folds.

Figure 29–2.  Postoperative photo of vocal folds.

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On August 14, patient was healing well. Placed on normal rehab program with SLP. On August 26, there was reduced mucosal wave on the R, but vocal fold pliability and mucosal wave were beginning to return. Perceptually the voice was slightly hoarse and slightly breathy. Patient work leave was continued until September 13. On September 29, the voice was hoarse and the patient reported fatigue by the end of the day. Still had stiffness with divot on the right TVF. Anterior-posterior (A-P) squeeze at the upper F0. R reduction in wave (Figure 29–3). On November 3, recurrent polyp R. Stay on meds, modified voice use. See exam (Figure 29–4) below. On December 1, patient improving, lesion R improved, wave improving, microphone approved so patient to use microphone in work. On March 29, R TVF continues to improve, edema R, stay on meds and continue therapy. On September 9, slight erythema medial edge R. Obvious wave B, obvious VPD B, good closure, stay on meds, and therapy. On October 3, TVF healing well (Figure 29–5). On October 27 reexamined. Polyp lower leading

edge R returned, pitch lower than normal and voice was slightly rough, erythema R. Patient had upper respiratory infection with cough, yellow-green production. Placed on voice rest 1 week, augmentin 875  mg × 10 days, prednisone 40 mg for 4 days, taper for 4 days. Return in 7 to 10 days. On November 17, no evidence of recurrent polyp. Patient has no complaints.

Medications Patients who are not already on reflux medications prior to surgery are usually given proton pump inhibitors postsurgery.6 In addition, guaifenesin, 1200 mg twice a day, is standard. Antibiotics are typically not needed and Loratab is given for tongue pain. For patients who develop edema due to postsurgery complications, steroids may be necessary. Depending on the etiology, degree, and frequency, vascular changes are usually addressed with voice rest.

Figure 29–3.  Vocal fold appearance showing divot on right vocal fold (September 29).

Figure 29–4. Recurrent polyp (November 3).

Figure 29–5.  Vocal fold healing well (October 3).

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Surgical Side Effects Although rare, neuropraxia of the tongue can occur and can manifest as parathesia, ageusia, or gustatory metalica.7 The neuropraxia subsides in a few days to weeks but, in extremely rare cares, can last for up to 6 months. Singers are told of the possibility of this side effect prior to surgery.

Stroboscopy in the Healing Process Stroboscopy postsurgery provides 2 important functions. First, reviewing the vibratory patterns of the vocal folds is essential to understanding the healing of the folds. The color, edema, mucosal wave, and vertical phase difference signal certain plateaus of healing. Individuals will respond differently, depending on the degree of surgery and the patient’s own personal healing factors. Stroboscopy is useful in helping to determine timing of onset of vocalization, progression of voice use, or later timing of returning to performance. Second, the stroboscopic exam provides patients with a yardstick to show improvement in their vocal folds. During the healing process and even thereafter, any and every twinge of discomfort in the throat can strike fear in the mind of singers, making them wonder if they have had reinjury. The stroboscopy can help restore a singer’s confidence by showing that the folds continue to heal well.

Special Considerations for Singers Singer surgery affects not only the life of the singer but a wide array of ancillary people as well. Band members, church congregations, opera companies, management, record companies, and a vast population of fans waiting for the singer to return to professional life as soon as possible can create undue pressure on the singer. Consequently, singers may want to skip some of the phases of the postoperative protocol and return to work. Regardless, the singer must stay within the time lines of the protocol and not rush the rehabilitation process. One of the greatest concerns of the singer postsurgery is, “Will I ever sing again?” and, if so, “What can I do to keep from injuring myself again?” As a result, singers may use the voice incorrectly, trying to protect it, not realizing that they are actually doing more harm than good. They may have a tendency to speak or sing too softly, thinking that this will protect the voice. Often this creates an underclosure of the folds, preventing efficiency, while promoting voice fatigue and possibly reinjury. The SLP and the SVS need to help the patient learn to monitor voice use efficiency and help prevent this faulty production. The singer may already have a lack of confidence due to the difficulties experienced prior to surgery. The SLP and the SVS work to assist the singer in regaining lost confidence.

Summary The Role of the SLP and the SVS Once the surgery is performed, the SLP and SVS must take the repaired vocal folds and, over time, correct the technical issues that likely caused the problem initially.8 Those service providers who do it best are able to sell the concepts and techniques to the singer in a productive, nonthreatening manner, always having the best interest of the singer at heart. Most SLPs and SVSs have an arsenal of techniques to assist with technical issues.

The postsurgery regimen is extremely important to the success of the surgery and the voice restoration of the singer. A multidisciplinary team, composed of at least a laryngologist, speech-language pathologist, and a singing voice specialist, each with his or her own area of responsibility, should provide the expertise needed for postoperative care. Singers who receive this care have the greatest opportunity to reenter their career and sustain that career with fewer problems. Nevertheless, just as professional athletes have the need for ongoing monitored care



Postoperative Voice Care of the Singer

received from coaches, trainers, and physicians, singers should continue to avail themselves of the highest level of care from teams that are trained and experienced in the appropriate disciplines for singers. Originally written by Robert H. Ossoff and Thomas F. Cleveland for the first edition of The Performer’s Voice, this chapter has been updated by the editors for the second edition.

References 1. Johns MM, Garrett CG, Hwang J, Ossoff RH, Courey MS. Quality-of-life outcomes following laryngeal endoscopic surgery for non-neoplastic vocal fold lesions. Ann Otol Rhinol Laryngol. 2004;113(8):597–601. 2. Misono S, Banks K, Gaillard P, Goding GS Jr, Yueh B. The clinical utility of vocal dosimetry for

assessing voice rest. Laryngoscope. 2015;125(1):​ 171–176. 3. Coombs AC, Carswell AJ, Tierney PA. Voice rest after vocal fold surgery: current practice and evidence. J Laryngol Otol. 2013;127(8):773–779. 4. Sulica L. Laryngoscopy, stroboscopy and other tools for the evaluation of voice disorders. Otolaryngol Clin North Am. 2013;46(1):21–30. 5. Ju YH, Jung KY, Kwon SY, et al. Effect of voice therapy after phonomicrosurgery for vocal polyps: a prospective, historically controlled, clinical study. J Laryngol Otol. 2013;127(11):1134–1138. 6. Franco RA, Andrus JG. Common diagnoses and treatments in professional voice users. Otolaryngol Clin North Am. 2007;40(5):1025–1061, vii. 7. Rosen CA, Andrade PA, Scheffel L BA, Buckmire R. Oropharyngeal complications of suspension laryngoscopy: a prospective study. Laryngoscope. 2005;115:1681–1684. 8. Radionoff SL. Preparing the singing voice specialist revisited. J Voice. 2004;18(4):513–521.

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Part VI Building a Professional Voice Practice



Chapter 30 The Professional Voice Practice Robert T. Sataloff Claudio F. Milstein

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ven for a well-trained laryngologist, the task of building a practice specializing in the care of voice professionals may seem daunting. However, with forethought, passion, and diligence, it should be possible to build an excellent and gratifying professional voice practice in most communities. In remote, rural areas, such a practice is unlikely to attract high volumes of metropolitan opera stars, but there are many other voice professionals and serious avocational vocalists who constitute the majority of patients in the practices of most laryngologists who specialize in voice. Such patients may include teachers, politicians, clergy, sales personnel, shop foremen, football quarterbacks, secretaries, choral conductors, avocational singers, actors in community theater, attorneys, physicians, and practitioners of many other disciplines who depend on vocal quality and endurance to succeed in their careers and enhance the quality of their lives. The “3 As” of building a successful medical practice are known to virtually all interns and residents, and they should not be forgotten when establishing a voice practice. They are availability, affability, and ability (in that order). Although this guidance has been given somewhat “tongue in cheek” to medical trainees for decades, there is wisdom in it. A physician’s availability to see voice patients in the office, perform in-hospital consultation, perhaps make the

occasional house call or theater call, and talk to referring professionals (not just physicians, but also nurses, speech-language pathologists, singing teachers, and others) is critical to establishing and maintaining a successful practice. Affability is important not only between health care providers and patient but also between the physician and other physicians, other health care providers, secretaries, and everyone else with whom we interact. Every voice specialist should be (and sound) enthusiastic every time he or she is called on to consult in the care of a patient. Although it has been said (only somewhat facetiously) that “ability” is less important than availability and affability in establishing a successful practice, ability is certainly central to caring for the challenging, fragile, and highly self-analytic population of professional voice users. In considering the establishment of a professional voice practice, this author (RTS) takes the “3 As” as given and thinks in terms of “3 Cs”: competence, communication, and compassion. All 3 Cs must be addressed. Each practitioner has to decide the scope of his or her planned practice, initially and over time. If it is not possible to put all desired components of a voice practice in place initially (eg, because of equipment or staff costs), a 5-year strategic and business plan should be developed to codify strategies through which an optimal voice care environment will be established.

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Competence The Voice Care Team Optimal voice care is delivered by an interdisciplinary team consisting of physicians and nonphysicians. The physician may be an otolaryngologist (a specialist who practices all aspects of ear, nose, and throat medicine) or a laryngologist who specializes in voice disorders. The physician commonly collaborates with other professionals such as a speech-language pathologist, singing voice specialist, acting-voice specialist, voice scientist, nurse clinician, and others who constitute the voice care team.1 Under the best of circumstances, all members of the team (including the otolaryngologist) have received special training in not just the general aspects of their disciplines but also additional training in care of the voice. Although even the best training does not guarantee clinical excellence, it does improve the probability that a practitioner will provide superior, ideally state-ofthe-art, voice care. It is helpful for patients to understand the background and role of each member of the voice team, as reviewed in a chapter by Sataloff et al,1 from which part of this discussion has been modified. The core voice team may practice in one location or be located in different offices. Either model can serve patients well, as discussed below.

Otolaryngologist/Laryngologist The leader of the voice care team is ordinarily an otolaryngologist. Laryngologists are otolaryngologists who specialize in care of disorders of the larynx and, in some cases, related problems such as swallowing. Most otolaryngologists’ clinical practices include many or all components of the specialty, such as otology (disorders of the ear and related structures), laryngology, head and neck cancer, head and neck neoplasms (including benign or malignant lesions), facial plastic and reconstructive surgery, allergy and immunology, bronchoesophagology (lower airway and swallowing disorders), rhinology (nose, sinus, taste, and smell disorders), and pediatric otolaryngology (ear, nose, and throat disorders of children). Most otolaryngologists and laryngologists care for patients of all ages from early

childhood through advanced years. Some otolaryngologists subspecialize, caring for disorders in just 1 or 2 areas of otolaryngology. This subspecialization can either be a keen interest in a specific area while still providing a broad range of ear, nose, and throat care or the focused practice of only 1 or 2 of the components of otolaryngology. Laryngology is one such subspecialty. Most of the senior physicians specializing in laryngology today did not receive laryngology fellowship training. That is always the case as a new field develops. Modern laryngology evolved out of an interest in caring for professional voice users, especially singers. The first comprehensive article guiding otolaryngologists on care of professional singers was not published until 1981,2 the first major modern American otolaryngology textbook with a chapter on care of the professional voice was published in 1986,3 and the first comprehensive book on care of the professional voice was published in 1991.4 So, most of the senior laryngologists practicing at the turn of the 21st century were involved in the evolution of the field before fellowships were developed. Most fellowship training programs started in the 1990s, although a few informal fellowship programs existed in the 1980s and earlier. It is reasonable to expect most voice specialists who finished residency training the 1990s or later to have completed a fellowship in laryngology. At present, completion of a fellowship is a reasonably good indicator of superior knowledge and clinical training in laryngology. Most laryngology fellowships include training in the diagnosis and treatment of voice disorders in adults and children, neurolaryngology, swallowing disorders, airway reconstruction, and laryngeal cancer. The training includes medical diagnosis and treatment, including sophisticated laryngeal surgery. Typically, laryngologists care for both routine and complex problems that affect the voice. Such problems include voice dysfunction associated with something as simple as a common cold, especially when it affects the voice of a professional singer or actor. However, laryngologists also are called on to diagnose and treat structural lesions such as nodules, cysts and polyps, prolonged infections of the vocal folds, cancer, traumatic injury from fracture or internal trauma (intubation injuries from anesthesia, vocal fold injuries from previous surgery),



neurological disorders, and other voice problems. The laryngologist is responsible for establishing a medical diagnosis and implementing or coordinating treatment for the patient. The laryngologist may prescribe medication, inject botulinum toxin, perform microsurgery on the vocal folds, or operate through the neck on the laryngeal skeleton. He or she is also usually responsible for initiating evaluation by other members of the voice team and for generating referrals to other specialists as needed. Laryngologists may practice in university medical centers or private offices, and in major cities in the United States, they are usually affiliated with a voice team, including at least a speech-language pathologist with expertise in voice care, often a singing voice specialist, and sometimes an acting-voice specialist or voice scientist. Laryngologists also should have, or have access to, a clinical voice laboratory with equipment to analyze the voice objectively and a stroboscope to visualize the vocal folds in slow motion. Newer technology such as high-speed video and narrowband imaging can also be part of the voice specialist armamentarium. They should be familiar with physicians in other specialties who have an understanding of and interest in arts medicine. Even for patients with a voice disorder who are not singers and actors, such knowledge and sensitivity is important. Just as nonathletes benefit from the orthopedic expertise of a sports medicine specialist, voice patients receive more expert care from physicians trained to treat singers, the “Olympic athletes” of the voice world. Currently, there is no official additional certification for those who have completed a laryngology fellowship. However, there are organizations with which many of the leading laryngologists are affiliated. Essentially all laryngologists in the United States are fellows of the American Academy of OtolaryngologyHead and Neck Surgery (http://www.entnet.org), and laryngologists in other countries are members of their nation’s analogous organizations. A few are also members of the American Laryngological Association (ALA), the most senior otolaryngology society in the United States (http://www.alahns.org). The ALA also accepts “associate members” from other countries. Some laryngologists belong to the American Bronchoesophagological Association (http://www​ .abea.net) and the Voice Foundation (http://www

The Professional Voice Practice

.voicefoundation.org). The Voice Foundation was founded in 1969 and is the oldest organization dedicated entirely to voice education and research. It provides seed grants for research, has sponsored an annual symposium on care of the professional voice since 1972, and fosters voice education through conferences, educational video recordings, books, and publications such as the Journal of Voice and the Voice Foundation Newsletter. In recent years, several countries have developed organizations similar to the Voice Foundation, such as the British, Canadian, and Australian Voice Foundations. Laryngologists in such countries are usually members of their national organization, and many are also members of the Voice Foundation (Philadelphia, PA). Although membership in these organizations is not a guarantee of excellence in practice, it suggests interest in and knowledge of laryngology, particularly voice disorders.

Speech-Language Pathologist A speech-language pathologist is a certified, licensed health care professional, ordinarily with either a master’s degree (MA or MS) or doctorate (PhD). Like otolaryngology, speech-language pathology is a broad field that includes care of patients who have had strokes or other neurological problems affecting speech and swallowing, have undergone laryngectomy, have swallowing disorders, have articulation or stuttering problems, have craniofacial disorders, or have other related fluency disorders of speech. Some speech-language pathologists subspecialize in voice care. The speech-language pathologist affiliated with a voice team is usually such a subspecialist and may call himself or herself a “voice pathologist” rather than a speech-language pathologist, although voice pathologist is not a term recognized officially by the American Speech-Language-Hearing Association (ASHA, the organization that certifies speechlanguage pathologists in the United States), yet. Relatively few speech-language pathology training programs provide extensive education in voice, and there are virtually no voice fellowships for speechlanguage pathologists. Many speech-language pathology training programs do not include even a single comprehensive course on voice disorders. Thus, it cannot be assumed that all speech-language pathologists are trained in or comfortable with caring for

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individuals with voice problems. Most acquire the subspecialty training they need through apprenticeships, extra courses, vocology training programs and symposia, or by obtaining doctoral degrees that include voice-related care and research. Speech-language pathologists are responsible for evaluating the functional aspects of laryngeal and vocal control, and devising therapeutic and rehabilitation programs to help patients with any type of laryngeal and voice disorders. A variety of techniques is utilized to accomplish optimal vocal function. Some speech pathologists with expertise in voice have additional degrees in vocal performance or pedagogy and are particularly suited to work with rehabilitation of the singing voice. Speech-language pathologists may be found in universities, private offices, or freestanding speech and hearing centers. In the United States, most are members of both ASHA and its voice-related special interest division (SID-3). Many speech-language pathologists with special interest in voice in the United States and elsewhere are also members of the Voice Foundation. Like otolaryngologists, speechlanguage pathologists who subspecialize in voice provide more incisive, state-of-the-art treatment for voice disorders than most general speech-language pathologists who care for patients with various problems encompassing the entire field. So, it is worthwhile for patients with voice disorders to seek out a subspecialist to improve the likelihood of a rapid, excellent treatment result. Referrals to speech-language pathologists specializing in voice are usually obtained through a laryngologist or otolaryngologist. A voice practice should employ or affiliate closely with an expert voice pathologist.

Phoniatrists Phoniatrists do not exist in the United States, but they provide voice care in Mexico and many European countries. The phoniatrist is a physician who is in some ways a hybrid of laryngologist and speechlanguage pathologist. Phoniatrists receive medical training in diagnosis and treatment of voice, swallowing, and language disorders, including voice therapy, but they do not perform surgery. In countries with phoniatrists, surgery is performed by otolaryngologists and phoniatrists provide voice therapy. In many

cases, the phoniatrist and otolaryngologist collaborate as a team, just as otolaryngologists and speechlanguage pathologists do in the United States and elsewhere. A physician who has completed training in phoniatry is generally well qualified to diagnose voice disorders and provide nonsurgical medical care, as well as voice therapy.

Singing Voice Specialist The singing voice specialist is a singing teacher with special training equipping him or her to practice in a medical environment with patients who have sustained vocal injury. Most singing voice specialists have a degree in voice performance or pedagogy, although some have only extensive performing and teaching experience without a formal academic degree. Nearly all have professional performance experience, as well as extra training in laryngeal anatomy and physiology of phonation, training in the rehabilitation of injured voices, and other special education. The singing voice specialist must acquire knowledge of anatomy and physiology of the normal and disordered voice, a basic understanding of the principles of laryngology, familiarity with medications, training in the rehabilitation of injured voices, a fundamental knowledge of the principles and practices of speech-language pathology, and other special education. This information is not part of the traditional training of singing teachers. Moreover, so far there are no formal training or fellowship programs that assist singing teachers in becoming singing voice specialists. Their training is acquired by apprenticeship and observation. Many take courses in speech-language pathology programs, but usually not as part of a formal degree or certification program,5 because there is no certification of singing voice specialists. A few of the best singing voice specialists are also certified, licensed speech-language pathologists. This combination is optimal, provided the speech-language pathologist has sufficient experience and training not only as a performing artist but also as a teacher of singing. In patients with vocal injuries or problems, the fundamental approach to training the singing voice is different in important ways from that used by many teachers for healthy students. Hence, even an excellent and experienced voice teacher may harm an



injured voice if he or she is not familiar with the special considerations for this population. In addition, most voice teachers do not feel comfortable working with a singer who has had a vocal injury or surgery. Virtually all singing voice specialists are affiliated with voice care teams. Most are members of the National Association of Teachers of Singing (NATS), or the equivalent organization in another country, and of the Voice Foundation. In many cases, their practices are limited to work with injured voices. They work not only with singers but also with other patients with voice disorders. As a member of the voice treatment team working with nonsingers, they help teach speakers the “athletic” techniques utilized by singers for voice production. Singing is to speaking as running is to walking. When rehabilitating someone who has difficulty walking, if the person can be helped to jog or run, leg strength and endurance improve quickly, and walking rehabilitation is expedited. The singing voice specialist applies similar principles to voice rehabilitation in collaboration with the speech-language pathologist and other voice care team members.

Acting-Voice Specialist Acting-voice trainers are also called voice coaches, drama voice teachers, and voice consultants. Traditionally, these professionals have been associated closely with the theater. Their skills have been utilized as a part of a medical voice team since the mid-1990s.6 Consequently, few acting-voice trainers have any medical experience, but their contributions have proven valuable. Acting-voice trainers use a variety of behavior modification techniques designed to enhance vocal communication, quality, projection, and endurance in theatrical settings. They train actors to speak or scream in a safe manner, sometimes through 8 shows a week, and/or theatrical runs that may last years, without tiring or causing injury to their voices. They also teach techniques for adding emotional expression to vocal delivery, and they work with body language and posture to optimize vocal production and communication of information. They may be a great asset to the voice team in teaching people how to apply the many skills learned through the speechlanguage pathologist and singing voice specialist to

The Professional Voice Practice

their everyday lives. Acting-voice trainers are especially valuable for people who speak professionally such as teachers, lecturers, politicians, clergy, sales personnel, and others concerned with effective vocal delivery and endurance. There are no formal programs to prepare actingvoice trainers to become acting-voice specialists and work in a medical milieu. Those who are interested generally receive training through apprenticeships and collaboration with medical voice care teams under the direction of a laryngologist, and in collaboration with speech-language pathologists and singing voice specialists. Acting-voice trainers interested in working with voice patients are usually members of the Voice and Speech Trainers Association (VASTA) and the Voice Foundation.

Voice Scientist Many voice centers include a voice laboratory that has equipment to measure phonatory and respiratory output.7 The clinical voice laboratory may be directed by a clinical speech pathologist, an informally trained voice technologist, or ideally by a clinical voice scientist. Voice scientists usually have a doctoral degree in communication science, physics, computer science, or some related discipline. Many are certified speech-language pathologists. Some voice scientists devote their entire careers to laboratory research and are not involved in patient care. Others include clinical research among their patient care efforts and can be extremely valuable members of the voice team. They are particularly skilled at gathering and analyzing objective data in the voice laboratory, assessing outcomes, ensuring reliability and validity of data, and designing and facilitating clinical research to advance the field of voice care.

Nurse Nurses are indispensable assets in medical offices, and they are important members of the voice team in many centers. Nurses who work closely with the voice team generally have vast experience in the diagnosis and treatment of voice disorders. They are wonderful information resources for patients and frequently provide much of the patient education

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in busy clinical settings. Such nurses are often members of the Society of Otolaryngology-Head and Neck Nurses (SOHN). Nurses with advanced knowledge and skills can become certified (by SOHN) and are identified as such by the initials “CORLN” (certified otolaryngologic nurse) after their names. Nurse practitioners are advanced practice nurses with master’s degrees, who are licensed to provide independent care for patients with selected medical problems. They are identified by the initials “CRNP” (certified registered nurse practitioner). They work in conjunction with a physician, but they can examine, diagnose, and treat selected problems relatively independently. A few nurse practitioners specialize in otolaryngology and work with voice teams. They ordinarily receive special training “on the job” from the otolaryngologist, and they provide care within their scope of practice. Nurse practitioners also can become members of SOHN, become certified through examination by SOHN, and on certification will also use the designation CORLN after their names.

Physician Assistants and Medical Assistants Physician assistants, like nurse practitioners, function in association with a physician. Physician assistants graduate from a training program that usually lasts 4 years and teaches them various aspects of medical diagnosis and physical examination. They use the initials “PA” (physician assistant) after their names. They practice in conjunction with physicians but can perform examinations and treat patients independently. They are licensed in many states to write prescriptions. A few physician assistants specialize in otolaryngology, and a smaller number have had extensive training and experience in voice care. In collaboration with a laryngologist and voice teams, they are qualified to evaluate and treat patients with voice disorders. Physician assistants should be distinguished from “medical assistants” who have less training and are qualified to assist in medical care and patient education but not to diagnose and treat patients independently. Medical assistants generally are trained to perform tasks such as phlebotomy and perform electrocardiograms. In a laryngology office, a good medical assistant can be trained to perform many

other tasks such as taking histories, assisting with strobovideolaryngoscopy, assisting during the performance of surgical procedures in the office, participating in research, and other activities.

Consultant Medical Professionals Otolaryngologists often refer voice patients for consultation with other medical professionals. Other specialists consulted commonly include neurologists, pulmonologists, internists, gastroenterologists, endocrinologists, psychologists, and psychiatrists. However, physicians in virtually any medical specialty may be called on to care for voice patients. Traditional and nontraditional ancillary medical personnel also may be involved in voice care, including nutritionists, physical therapists, chiropractors, osteopaths (for manipulation), acupuncturists, and others. Within virtually all of these fields, there are a select few professionals who have an interest in and an understanding of arts medicine. Just as caring for voice professionals (especially singers) involves special considerations and challenges for the otolaryngologist, caring for hand problems in a pianist or ankle problems in dancers also requires special knowledge and skill in an orthopedic surgeon. Orthopedic surgeons, neurologists, pulmonologists, and others who are accustomed to working with performing artists (dancers, wind instrumentalists, etc) are most likely to have the insight, sensitivities, skills, and state-of-the-art information needed to provide optimal care to voice professionals. Many such physicians tend to be associated with arts-medicine centers or are performers themselves. There is no certification or broad-based national or international organization that guarantees excellence in such physicians, although many are members of the Performing Arts Medicine Association (PAMA). In most fields, there are no formal arts-medicine training programs or associations. Physicians acquire such training through their own interest and initiative, and through apprenticeship or observation with colleagues. If there is no arts-medicine center in the area in which a patient is seeking care, arts-medicine physicians are identified best by word of mouth or through arts-medicine-related websites. Referrals can be obtained through the local laryngologist or voice specialist or by consulting with eminent per-



forming arts teachers in the community. For example, the leading private university and conservatory violin and piano teachers often know who the best hand specialists are, the wind instrument teachers know who to see for neurological and pulmonary problems that affect musicians, and dance teachers know the best foot-and-ankle physicians.

A Voice Clinic: Common Models Although not necessary, it is ideal for the core members of a voice team (laryngologist, speech-language pathologist, singing voice specialist, acting-voice specialist, and voice scientist) to practice in the same building in close proximity. This arrangement facilitates communication among members of the voice team, allows team members to see patients simultaneously during portions of the evaluation and treatment, and facilitates interchange of ideas, as well as feedback, regarding clinical strategies among members of the voice team. In this paradigm, it is important for the voice team to be cognizant of the sensitivities of professionals within the community, particularly voice teachers. Generally, singing voice specialists should limit their practices to patients with vocal injuries and should make every effort to return patients to the guidance of excellent singing teachers within the community as soon as appropriate. When a voice clinic cannot be established “under one roof,” an excellent “virtual” team can be established. In some ways this arrangement requires even more work and diligence on the part of the voice team than the single-site model. It is essential for voice team members to meet and communicate on a regular basis. This may mean establishing a frequent “voice conference” at a time when everyone including the physician can be depended on to attend. The “virtual” paradigm can have some potential advantages. For example, it may allow a team to train a larger number of singing voice teachers in the community, some of whom may spend only part of their time working with voice patients. However, it is best if these singing voice specialists are provided with the same depth of diagnostic information (including an opportunity to review stroboscopic images) to which they would have access if they

The Professional Voice Practice

were in a medical office. They also must maintain medical confidentiality, write progress notes for the medical record, and perform all the other functions expected of voice specialists. In some practices and in many communities, this level of documentation may be difficult, but the fundamental need for communication should not be compromised. Otolaryngologists are accustomed to referring to speech-language pathologists who are not located in their medical offices. So, this would seem to be a routine and comfortable approach for a voice team, as well. However, several pitfalls must be avoided. First, the speech-language pathologist (SLP) must have access to all diagnostic information, stroboscopic images, and medical treatment plans. Second, the SLP must have easy and frequent communication with the singing voice specialist and acting-voice specialist, as well as the laryngologist. Team treatment is most effective when it is coordinated closely and when all members of the therapy team know exactly what they are doing for each patient and how the patient is responding. If treating professionals are not working in the same office where they can talk with each other easily, they must commit to frequent communication. Telephone calls work well. However, another good solution is preparing progress notes at the end of each treatment session and sending them by secure e-mail to the physician and other members of the voice team treating the same patient. This approach ensures that each member of the voice team will have his or her own notes in good order, that they will be in the physician’s medical record, and that they will be in the hands of all members of the treatment team before the patient can move from one practitioners’ office to the next. Acting-voice specialists and voice scientists require the same procedures. Third, there is one particularly important pitfall relating to speech-language pathologists that must be avoided if a “virtual” practice paradigm is selected. Strobovideolaryngoscopy is performed initially (and often primarily) to establish a medical diagnosis. Medical diagnosis is the responsibility of the physician and is outside the scope of practice of a speech-language pathologist. There have been communities in which physicians are unwilling to invest in a stroboscope for their offices and have arranged for a stroboscope to be purchased by a

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hospital and for the stroboscopic procedures to be performed by the speech-language pathologist in a hospital setting (remote from the physicians’ offices). This arrangement usually starts out with a marginally acceptable theory and good intentions: the physician will review each study and render a diagnosis. Unfortunately, in practice, physicians often do not review the stroboscopy and rely on the analysis provided by the speech-language pathologist. This puts the SLP in the uncomfortable position of practicing outside his or her scope of practice and being the only member of the team with experience in reading stroboscopy. This arrangement should be avoided. The primary purpose of videostroboscopy as performed by speech-language pathologists is not to diagnose vocal pathology but to evaluate vocal function. Understanding individual patterns of vocal behavior is invaluable to devise individualized treatment protocols. In addition, videostroboscopy can be used as a biofeedback tool to determine whether a particular vocal technique or therapeutic approach has the desired effect on vocal function. Ideally, when a patient is being considered a candidate for voice therapy, stroboscopic exams should be read by both the otolaryngologist and the speech-language pathologist. It is best if this can be done while the patient is still present. If this is not practical, every effort should be made to acquire stroboscopic equipment for each physician’s office in which voice patients will be treated so that the team can rely on its physician for expertise in and responsibility for medical diagnosis of voice disorders.

Communication Although the need for good communication seems obvious, inadequate communication is common in medical practice, and this problem is the source of considerable misunderstanding, anguish, and litigation, as discussed in Chapter 31. It is exceedingly important for laryngologists to understand the problems and goals of every professional voice patient and for each voice patient to understand the realistic goals, limits, and time constraints of treatment. No matter how skilled a communicator the laryngologist may be, such mutual understanding cannot be

accomplished dependably in one patient visit. The collaboration of the entire voice team is invaluable in ensuring real understanding. Speech-language pathologists, singing voice specialists, acting-voice specialists, voice scientists, nurses, and other members of the team spend hours with voice patients during the analytic and therapeutic process. Relationships are established that allow team members to gain insights into professional and emotional issues that may have great bearing on outcomes in voice professionals. Each team member should be aware of the importance of this component of his or her responsibility, and there should be excellent communication among all members of the voice team (including the patient, who is the most important member of the team) so that these insights have appropriate influence on therapeutic decisions. This is important for patients undergoing therapy alone, as well as for those undergoing surgery. Issues regarding surgical consent are discussed at greater length in the chapter on medical legal issues. It is often helpful for the voice team to involve other key players, such as the patient’s singing or acting teacher, manager, stage director, or voice coach in the decision-making process. Everyone must understand not only the risks of surgery but also the risks involved in deciding against surgery and relying on technical maladjustments. In many cases, there is no “good” or “right” choice, and the voice care team must combine great expertise with insight into the career and concerns of each individual patient to help the voice professional make the best choice. It must also be understood fully by everyone (doctor and patient particularly) that the therapeutic choice is the patient’s. The physician and other members of the health team educate, guide, and advise the patient, but ultimately, the patient decides. As voice team care proceeds, the patient ordinarily comes to understand how much the team cares about making the voice professional better, the complex and unpredictable outcomes of voice treatment, the reasons why surgical decisions are delayed until nonsurgical therapy has been tried, and that every effort has been made to improve the patient’s voice without operative intervention. The insights and relationships developed during this process should communicate the voice team’s concern for the patient’s best interest and outcome, and make



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clear the patient’s ultimate control of the therapeutic process. Establishing such a culture is essential to creating an excellent voice practice. In addition to patient communication, communication with families and referring professionals within the community also is essential in building a voice practice. Community outreach initiatives are extremely important, as discussed below. In addition, laryngologists should not underestimate the importance and value of clinical research and publication in building a voice practice. Research activities are valuable in their own right. They help us advance our field by communicating new insights to our colleagues. As a convenient by-product of this effort, they also constitute excellent marketing in our progressively “better educated” patient population. Many voice professionals are computer literate and concerned enough about medical intervention to research physicians before they select a doctor or a practice. If such patients have a voice problem, they are often more comfortable going to the doctor who “wrote the book” or an article on the subject than someone who simply paid for marketing.

Compassion Despite the best care, communication through the laryngologist and all other members of the voice team and all efforts to achieve a perfect outcome, bad results occur. It is essential for the physician to empathize and continue communicating with the patient. Physicians should understand (and feel) that an unfavorable result is as troubling to the physician as it is to the patient, and this should be true. Surgery is our art, and patient care is our passion; any doctor is upset when results are poor. We need not hide these reactions from our patients. We also need to be sensitive to each patient’s reaction to a bad voice outcome. The consequences of voice impairment or “loss” can be overwhelming, and the assistance of a psychological professional who specializes in voice problems can be extremely effective in helping the patient.8 Psychological professionals are invaluable assets to the voice team and may provide insights not only to patients but also to voice care providers who have to interact with angry or disappointed

patients. It is especially important for the physician and other members of the team to remain engaged with the patient who has had a bad result. At times, these patients may require more time than those who have enjoyed good results. As hard as it is for us to remind ourselves frequently that we have not succeeded in a particular patient’s care, we need to remember that they are reminded of the result much more frequently than we are, and we need to resist any temptation to avoid them just when they need us most. Every patient can be helped, and helping these whose final results may remain disappointing is a special challenge and ethical obligation intrinsic to good practice.

Building a Voice Practice: Where to Start? The information provided in this chapter so far has described the components of a good voice team but not the practical aspects of establishing one. Dr Michael Benninger challenged me to address this, and he posed the question, “What would you do if you were starting out today or moving to another city? . . . How would you build a patient base?” In reflecting upon the interesting challenges these questions raise, I (RTS) have concluded that the strategies that worked for me years ago remain as appropriate now as they were in 1980. I believe that I would use all of them again if I were starting over in Philadelphia or elsewhere, and I suspect that they will be equally effective for any practitioner who applies them with diligence. The first priority in establishing a voice practice is to truly have expertise in and commitment to voice care. Obviously, this means acquiring special knowledge and credentials (ideally a fellowship), but it also means more than that. The physician must be willing to acquire basic, essential equipment such as a stroboscope and basic voice laboratory, even when such an acquisition is financially taxing and return on investment is uncertain. The physician must be able to rest comfortably in the knowledge that he or she is providing premier care for every voice patient seen (starting on the first day) and that his or her former fellowship or residency director

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would be justified in referring even the most illustrious voice patient. It also means establishing working relationships with the speech-language pathology, singing, and acting communities immediately. As discussed above, it is not necessary to hire a full-time speech-language pathologist and singing voice or acting-voice specialist at the outset, but appropriate collaborators must be recruited. This can be done in several ways. Before moving to a community, or immediately thereafter, community outreach programs should be instituted. They include lectures for music and acting programs, presentations to choirs or school assemblies, talks to groups of speech-language pathologists, singing teachers, and acting teachers; presentation of grand rounds for physicians in other specialties; educational programs for school teachers; radio and television interviews; and presentations in others venues. Ideally, a 1- or 2-day educational program for the voice community (speech-language pathologists, singing teachers, acting teachers, physicians, and any other interested parties) should be presented. It may be helpful to invite one’s fellowship director or other luminary as a guest presenter. This may help draw attendees and establish a new doctor’s credibility. I (RTS) routinely offer to co-present one training program for each of my graduating fellows in his or her new locale. Such a program should include ample time for questions and answers and ample break time during which the new physician and the community voice professionals can get to know each other. The physician should arrange to visit various singing teachers, acting teachers, and speechlanguage pathologists to observe a few sessions of their work and should invite voice professionals to observe in the physician’s office and operating room. Such visitors should also be made familiar with HIPPA (Healthcare Information Privacy and Portability Act) requirements and should sign a document agreeing to respect confidentiality restrictions. The physician also should look continuously for opportunities to lecture in music classes, music pedagogy courses, and acting courses and to provide health lectures for local schools, theaters, and musical organizations. This enhances the level of understanding about voice and voice care in the community and usually improves the level of vocal

health. In addition, knowledgeable voice users are an excellent source of referrals, and it is important to remember that speech-language pathologists, singing teachers, and acting teachers are referring professionals who appreciate a letter (as would be written to a referring doctor) about the patients they send. A laryngologist’s routine HIPPA compliance document should address the issue of permission to communicate with referring teachers and SLPs so that such permission is provided (or specifically denied) by each patient. If laryngologists have any performance talent at all, it is worth joining a choir, community theater, or some other performance group. Such activity is fun and educational in and of itself. Moreover, it demonstrates knowledge of performance that enhances physician credibility, and it establishes contacts in the performing community. For most practices, patient-to-patient referrals and referrals from singing and acting teachers and speech-language pathologists are at least as numerous as physician referrals (especially early in a practice) and often considerably more so. Of course, establishing contact with physicians in various specialties also is extremely important. These may include lectures or grand rounds to pulmonologists on special management of respiratory problems in singers and other voice professionals; gastroenterologists on current concepts about laryngopharyngeal reflux disease; neurologists on neurolaryngologic diagnosis and treatment, laryngeal electromyography, tremor management, and other problems; gynecologists and endocrinologists on hormonal aspects of voice disorders, with special emphasis on iatrogenic masculinization and on thyroid problems; psychologists and psychiatrists on psychological concomitants of voice dysfunction, as well as on vocal manifestations of psychological disease and on the effects of psychotropic medications on voice performance; physiatrists and physical therapists on postural and pain management in performers; and other physicians and affiliated practitioners. In each case, the laryngologist should emphasize that he or she will be referring frequently to practitioners in the given specialty, what special information will be sought from such referrals, and opportunities for collaboration. There is no better way to generate referrals from other physicians than



by sending patients to them. Eventually, they reciprocate, and when they do, a new laryngologist has the opportunity to provide them with a report more comprehensive, insightful, and practical than any they have seen before. Generating referrals from other otolaryngologists in one’s new community is often the greatest challenge. The voice course presented with the laryngologist’s fellowship director, or other well-known laryngologist, is often helpful in establishing these relationships and credibility. Setting a 1- or 2-day course, at a time when otolaryngologists can attend, may help (such as on a Saturday). Inviting members of one’s own practice or department to attend as guests (without charge) is an appropriate courtesy to a fellow department member or practice associate. Presenting departmental rounds on specific aspects of voice care and commenting judiciously at academic conferences on voice matters also can be helpful. Many otolaryngologists will be more comfortable referring to a new doctor if he or she has established expertise in the field by having written significant papers or a book related to voice. This is one of the many reasons to remain academically productive regardless of whether the laryngologist’s setting is private or an academic, salaried position. As with other physicians, referring nonlaryngology cases to other otolaryngologists is also an excellent way to establish new relationships. It also may be helpful to establish a special relationship with a conservatory or particularly excellent music school. When I (RTS) first started in practice, I offered to see all the incoming students at our primary opera conservatory in Philadelphia at no charge to the patient. Most of them were financially challenged and had no health insurance, and without this help, the students would not have been able to get laryngologic care when they needed it. I have also taught a voice pedagogy course at that institution since 1980. There have been several interesting consequences of this policy. First, the overall level of vocal education improved noticeably, and since the first few years, I have rarely seen students from this institution who have presented with preventable voice problems, and when they do, they are embarrassed about them because they know better. Second, each student undergoes a baseline strobovideolaryngoscopic examination and objective voice

The Professional Voice Practice

evaluation as a freshman. These data have not only uncovered an impressive number of asymptomatic “abnormalities” that would have been confusing if they had been seen for the first time during an illness, but they have also provided years of longitudinal information about a population of healthy, high-level singers. Third, this policy establishes relationships with students that have lasted throughout their professional careers. Many graduates from the Academy of Vocal Arts (Philadelphia, Pennsylvania) sing with the Metropolitan Opera and other major companies, and many still come to the author (RTS) for their medical voice care and often send their students here, as well. Caring for the students at no charge has been a joy, but it has also helped build the practice over time.

Telepractice Advances in telecommunication technologies have created new opportunities to provide distance care as an adjunct to medical management of patients. Vastly different specialties, from cardiology, pediatrics, to psychiatry, are offering distance services. Numerous articles on this topic can be found in the medical literature, including prominent journals such as JAMA and The Lancet.9,10 The treatment of voice patients by a specialized voice team is more readily accessible in large urban centers. However, there is a scarcity of specialists with expertise in elite vocal care in smaller areas, rural areas, and many countries in the developing world, and telepractice allows clinicians to connect with patients at a distance for assessment, intervention, consultation, or therapy. Even though face-toface contact with a patient is essential, and an initial evaluation in person is critical, telepractice, at least presently, seems best suited for long-distance administration of voice therapy. Practitioners need to adhere to the Code of Ethics, Scope of Practice of their healthcare associations, and state and federal laws (eg, licensure, HIPAA). Services need to be in accordance with national, state, institutional, and professional regulations and policies. In addition, type of service delivery has to be consistent with regulation and payment policies.

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This is a nascent specialty with many issues, from patient safety, licensure, financial and reimbursement challenges, that still need to be worked out. The American Telemedicine Association (ATA), established in 1993, is the leading international resource and advocate promoting the use of advanced remote medical technologies. Standards and guidelines for the practice of telemedicine can be found at their website (http://www.americantele med.org). Telepractice is a valuable tool for providing much-needed specialty care services in places where they are not readily available. Tools such as Skype and texting already are being used with increasing frequency.

Website When someone is diagnosed with a disease, the Web is the first place used to search for information. There are many advantages to having a good informative website promoting your voice care services. It plays many roles, as it provides a window to your practice. It allows current and prospective patients to become familiar with voice-related conditions and disorders, provides treatment options, and allows introduction to all the voice team members. A face picture, a short bio, and listing of services and areas of expertise can help the patient better understand the role of each team member and become more comfortable with their care. A strong website builds brand awareness and provides content to information seekers, treatment seekers, and provider seekers. The website can become a practice front door, presenting itself to the world, and content should be robust, be credible, and provide an experience.

Summary Opportunities for establishing a successful voice practice remain unlimited. With focus, commitment,

and enthusiasm, any well-trained laryngologist should be able to create an environment in which voice care professionals and professional voice users can flourish together.

References 1. Sataloff RT, Heman-Ackah YD, Hawkshaw MJ. Voice care professionals: a guide to voice care providers. In: Sataloff RT. Professional Voice: The Science and Art of Clinical Care. 3rd ed. San Diego, CA: Plural Publishing; 2005:1421–1426. 2. Sataloff RT. Professional singers: the science and art of clinical care. Am J Otolaryngol. 1981;2(3):​ 251–266. 3. Sataloff RT. The professional voice. In: Cummings CW, Frederickson JM, Harker LA, et al, eds. Otolaryngology-Head and Neck Surgery. Vol  3. St. Louis, MO: CV Mosby; 1986:2029–2056. 4. Sataloff RT. Professional Voice: The Science and Art of Clinical Care. New York, NY: Raven Press; 1991:1–542. 5. Emerich KA, Baroody MM, Carroll LM, Sataloff RT. The singing voice specialist. In: Sataloff RT. Professional Voice: The Science and Art of Clinical Care. 3rd ed. Vol 3. San Diego, CA: Plural Publishing; 2005:1021–1041. 6. Freed SL, Raphael BN, Sataloff RT. The role of the acting-voice trainer in medical care of professional voice users. In: Sataloff RT. Professional Voice: The Science and Art of Clinical Care. 3rd ed. San Diego, CA: Plural Publishing; 2005:​1051–1060. 7. Heuer RJ, Hawkshaw MJ, Sataloff RT. The clinical voice laboratory. In: Sataloff RT. Professional Voice: The Science and Art of Clinical Care. 3rd ed. Vol 1. San Diego, CA: Plural Publishing; 2005:​ 355–393. 8. Rosen Caputo D, Sataloff RT. Psychology of Voice Disorders. San Diego, CA: Singular Publishing Group; 1997. 9. Kahn JM. The use and misuse of ICU telemedicine. JAMA. 2011;305(21):2227-2228. 10. Anker SD, Koehler F, Abraham WT. Telemedicine and remote management of patients with heart failure. Lancet. 2011;378(9792):731–739.

Chapter 31 Medical-Legal Implications of Professional Voice Care Robert T. Sataloff Michael S. Benninger

B

eing a defendant in a malpractice action is traumatic for any physician; we are all at risk. Not only does a lawsuit feel like an insult and assault, but it also emphasizes the fact that we have an unhappy patient. Because all of us strive to make our patients better, this component of a lawsuit is particularly troubling, even when we feel we have done “nothing wrong.” There is no formula for avoiding lawsuits. However, there are certain practices that may minimize our risk. The authors emphasize the “3 Cs” ​ — competence, communication, and compassion — as the most important factors in establishing a strong relationship with the patient and preventing potential legal action. It should be self-evident that competence is the keystone of good medical practice in all fields, including laryngology. However, all experienced laryngologists have encountered patients who have received laryngological care that is below the current standard of practice. In many cases, this care has been rendered by otolaryngologists who are outstanding in their area of expertise but not familiar with the latest teachings or technology in laryngology. All interventions should be reasonable and appropriate, and the patient should understand the reasons for the recommended therapeutic course. It is helpful if those reasons can be supported by research or expert opinion that is cited in the literature.

Most litigation has its roots in communication, or lack thereof. In laryngology, this applies particularly to patients who have undergone voice surgery. Prior to performing voice surgery, it is essential to be certain that patient selection is appropriate and that the patient understands the limits and potential complications of voice surgery. Appropriate patients for voice surgery have not only voice abnormalities but also really want to change their voice quality, effort, and/or endurance. For example, not all people with “pathological” voices are unhappy with them. Sports announcers, female trial attorneys with gruff voices, and others sometimes consult a physician only because of fear of cancer. If there is no suspicion of malignancy, restoring their voices to “normal” (eg, by evacuating Reinke’s edema) may be a disservice and even jeopardize their careers, potentially leading to litigation. Similarly, it is essential to distinguish accurately between organic and psychogenic voice disorders before embarking on laryngeal surgery. Although a breathy voice may be caused by numerous organic conditions, it is also commonly found in people with functional dysphonias. Some people have vocal fold lesions that have not interfered with their voice use and recent changes that are secondary to acute inflammatory or functional disorders. The differentiation may require a very skilled voice team.

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Although all reasonable efforts should be made to avoid operative intervention in professional voice users, particularly singers, there are times when surgery is appropriate and necessary. Ultimately, the decision depends on a risk-benefit analysis. If a professional voice user is unable to continue his or her career, and if surgery might restore vocal function, surgery should not be withheld. Sometimes making such judgments is challenging. A rock or pop singer with a vocal fold mass may have satisfactory voice quality with only minimal technical adjustments. Pop singers, who perform with amplification, may obviate the need to sing loudly or project the voice in some cases (depending on the artist’s style). Such a patient might be able to “work around” pathology safely for many years. However, even much more minor pathology can be disabling in some demanding roles or performances, particularly in classical singers. For example, if a high soprano specializing in Baroque music develops a mild-to-moderate superior laryngeal nerve paresis, she may experience breathiness and instability. If she gives in to the temptation to compensate by slightly retracting her tongue and lowering her larynx, the breathiness will be controlled because of increased adductory forces, but she will lose the ability to perform rapid, agile runs, and trills. Similar problems may occur from compensatory maladjustments in response to other lesions such as vocal fold cysts. In such instances, the artist may be served better by surgical correction of the underlying problem than by long-term use of hyperfunctional compensation (bad technique) that can itself cause other performance problems, as well as vocal fold pathology. The patient must understand all of these considerations clearly, including the risks of surgery. He or she needs to acknowledge the risk that any voice surgery might make the voice worse permanently, and the patient must consider this risk acceptable in light of ongoing vocal problems. Another consideration is the urgency to move forward with an intervention such as surgery. There are times when a singer who has a critical career event in the relatively near future who has a lesion that could possibly be managed conservatively. Failure of this treatment may delay the surgery and the time needed for postoperative recovery may cause her or him to miss that engagement. Under such circumstances, it may be prudent to mutually agree

upon moving forward with surgery to allow for recovery in plenty of time to allow for the singer to proceed with the career critical engagement. Even in the best hands, an undesirable scar may develop, resulting in permanent hoarseness. Hence, the patient must be aware that there is a possibility that the voice may be worse following surgery even if the surgeon and patient have done everything correctly. Naturally, other complications also must be discussed such as complications of anesthesia, dental fracture, tongue numbness or change in taste, recurrence of laryngeal lesions, airway compromise, vocal fold webbing, and other untoward occurrences. This discussion and documentation should include relevant risks, benefits, and alternatives, with a thorough documentation of that discussion in the medical record. In addition to the hospital’s standard surgical consent, many laryngologists provide patients with additional written information prior to surgery. In such cases, the patient may receive one copy of the Risks and Complications of Surgery document, and one signed copy remains in the medical record. With electronic medical records, the patient will frequently have electronic access to these records. Specialized informed consent is also reasonable for other selected treatments such as injection of cidofovir and injection of botulinum toxin, even though such documents are not mandated. If medications are used for treatment purposes (rather than research purposes) and are off-label uses of medicines approved by the Food and Drug Administration (FDA) for other purposes, their use does not necessarily require institutional review board (IRB) approval or a special consent. However, these authors believe it is often helpful and prudent to provide patients with as much information as possible and to document that they have been informed. Preoperative objective voice assessment and documentation are essential in addition to routine documentation of informed consent discussions. At a bare minimum, a high-quality tape recording of the patient’s voice should be obtained before surgery. Auditory memories of physicians and patients are not good in general, and both the doctor and postoperative professional voice user often are surprised when they compare postoperative and preoperative recordings. Frequently, the preoperative voice is worse than either person remembers. In addition,



Medical-Legal Implications of Professional Voice Care

such documentation is invaluable for medical-legal purposes. Photographs or videotapes of the larynx obtained during strobovideolaryngoscopy are extremely helpful, as well. Ideally, complete evaluation by a voice team should be performed. We also routinely use validated quality of life instruments such as the Voice Handicap Index (VHI)1 or the Singing VHI2 to assess the singer’s pre- and posttreatment perception of voice. Comprehensive documentation is essential for assessing outcomes, even for physicians who are not interested in research or publication, as such information can be invaluable in a medical-legal context. Clearly, the most important action that a voice practitioner can take to prevent litigation is establishing a strong and supportive relationship with patients and, at times, also with their families. Although this is clearly important in all performers, surgical patients require a subtle additional level of trust and confidence in the surgical judgment, skills, expertise, and empathy of the laryngologist. Being honest about our experience and about our prior results allows the patient to determine whether he or she is willing to entrust the operation to us. Overselling such skills and experiences is likely to increase the potential for a less-than-optimal outcome leading to litigation. In complex cases, or those where the voice practitioner may not have the right skill set, it is more than reasonable to refer the patient to a more experienced provider. Even in the most skilled hands, if the patient is unsure of the recommended treatment, a second opinion from another skilled provider is reasonable. All decisions should be made jointly between the provider or surgeon and the patient in a partnership. We have also found that patients greatly appreciate feeling as if they have continuous access to their surgeon. We give them multiple ways to reach us and our staff through the office, answering service, and email. They rarely call, and if they do, it is almost always for something significant enough that the surgeon wants to know about it. This ready access goes a long way in alleviating any concern and furthering the strength of the relationship. Despite excellent care, bad results may occur. It is essential for the physician to continue communicating with the patient and to empathize. It is important that we not hide from our patients the

fact that we are also concerned that their outcome is not perfect and that we be honest with them in all other ways. The sooner these discussion are made, the more trust will be maintained and the risk of litigation will diminish. It is imperative that the medical record be complete and nonopinionated. The record should never be modified without a clear notation that the record has been changed. With electronic medical records, any changes are noted, and the time of any changes is permanently noted. The provider should bring together the appropriate resources and people to help resolve the patient’s problem, if possible. If there is any concern that litigation may occur, it is not unreasonable to discuss this with your institution and your legal counsel, even before any suggestion of litigation is present. Such consultation may allow for help with “damage control” and help focusing the plan for alleviating any potential legal issues. Despite the best efforts of the voice team, a poor result may persist. In such cases, “communication” and “compassion” become critical. Good listening skills are important, as it is often difficult to know what patients are most concerned about. In many cases, their perception of a less-than-expected outcome may not be based on the actual results but rather on either unrealistic expectations or some emotional aspect of their lives or careers. They may have hoped that all their career difficulties were based on this one problem and that everything would be terrific once they were treated. In many cases, supporting their emotional and psychological health is important. In this scenario, it may be worthwhile considering professional psychological intervention.3 The assistance of a psychological professional who specializes in voice problems can be invaluable in helping the patient, facilitating the efforts of the voice team, and channeling the patient’s frustration into therapeutic effort rather than litigation. A psychological professional can be especially helpful if concerns or extraordinary stresses are detected by the laryngologist or voice therapy team prior to surgery, allowing for preoperative psychological intervention and support that may be invaluable not only if there is a bad operative outcome, but even when the surgical result is good. Attending to our patients’ emotional needs and reactions to vocal injury and vulnerability is part of optimal laryngological care

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The performer’s VOICE

and invaluable in preventing anger and misunderstanding that can lead to litigation. Although the risks of legal action may seem more significant for the surgeon, any member of the voice team could be at risk. Voice pathologists and music teachers may be liable if they participate in the care of patients who develops a complication or bad outcome. Fortunately for these professionals, it is much more likely that a suit will be directed at the “deeper pockets” of the surgeon and/or hospital. It is important to remember that the 3 “Cs” are relevant to all aspects of professional voice practice. All voice care team professionals need to be very cognizant of informed consent and confidentiality issues, and they must be aware of the legal ramifications of the Healthcare Information Privacy and Portability Act (HIPPA) in the United States. It is often particularly difficult to maintain confidentiality for performers as there are so many people competing to obtain information about the status of their care and health. These include managers or agents, directors, promoters, the patient’s family, the media, and the public. In each of these cases, no information about the patient should be divulged without explicit consent from the patient, and preferably in writing. Pictures and videos should remain within the confidential relationship of the patient and provider, unless expressly released for wider exposure by written patient consent. With the aggressiveness of the media in obtaining any information on celebrities, medical records need to be protected carefully. Moreover, secretaries and other personnel must be trained not to discuss patients (including celebrities) with anyone, including their families. Although we all realize how much the performer’s illness may have an impact on all of the people involved with his or her production, explicit direction and formal release of information should be obtained from the patient prior to any discussion of their status or care even with their managers, agent, and families. Failing to do so may not only draw malpractice litigation, but it also may result in other civil or regulatory action and fines. Occasionally, patients will have had a poor outcome as a result of treatment by another doctor or team. They may ask whether the prior treatment was appropriate and up to the standard of care. It

is important to not be judgmental without a clear understanding as to what exactly was done and why. In almost all cases, it is important to avoid responding to such inquiries and to emphasize the focus on moving forward with your treatment and getting them back to health. Being outwardly critical of the other treatment usually will lead to more difficulties and create additional legal risks. If legal action is taken against the other provider and you are asked to comment or testify, maintaining balanced, nonjudgmental testimony is necessary.

What Should Be Done If There Is a Lawsuit? Fortunately, adverse results do not lead to litigation commonly. Much of this has to do with the quality of the voice care that is currently available. However, there may be times when, despite appropriate care and diligence, compassion, and communication, the patient is unhappy with his or her voice or other outcome and might consider bringing a lawsuit. In such cases, one of the first questions that must be asked is whether or not we can continue with fair, unbiased, and supportive clinical care of the patient. If the answer is no, and if he or she has not been able to establish contact with another provider or team, it is important to help the patient identify other providers who can continue to provide voice care. This is important not only from a medical and legal (abandonment) standpoint, but it also shows our care and concern for the patient and may play a positive role should a claim be made. It is also very important to not develop an adversarial relationship with the patient or his or her family. All communication should be unbiased and balanced. A patient who is trying to find out whether he or she has a case might be convinced to pursue one if it is felt that he or she has been treated poorly or disrespectfully. It may be helpful to stay in close contact with legal counsel if there are issues that the physician is unsure how to handle. Disparaging comments should never be made about the patient as others, including office staff, may be asked to testify. The chart should include no



Medical-Legal Implications of Professional Voice Care

negative commentary and should be limited to an objective assessment of the clinical aspects of the patient’s care. It is important to remember that most laryngologists will experience at least one lawsuit in their careers. Such cases do not suggest that the laryngologist is a poor doctor. In most cases, the outcome may have been unavoidable, or the decision was one that most others also would have made. In other cases, it truly may have been a poor decision. Every doctor has made a wrong decision at some point in his or her career. The best doctors are the ones who evaluate the cause for the bad outcome critically and then take steps to prevent such occurrences in the future.

Summary The care of the professional vocalist may be fraught with potential legal risks. In most practices, it is highly unlikely that even a poor outcome will lead to legal action. The “3 Cs” of competence, communication, and compassion are important not only in optimizing clinical care and outcomes, but they are

also the best protection against litigation. Taking time to establish strong relationships with patients, supporting them with our knowledge and expertise, and being accessible for them are all important components of the high-quality, low-risk voice practice. In the rare occurrence of an adverse outcome, it is important that the laryngologist identify the key issues that have impacted the outcome, make every effort to mitigate their sequelae, and take appropriate steps to prevent them from occurring again in the future.

References 1. Jacobson B, Johnson A, Grywalski C, et al. The Voice Handicap Index (VHI): development and validation. Am J Speech Lang Pathol. 1997;6:​ 66–70. 2. Cohen SM, Statham M, Rosen CA, et al. Development and validation of the Singing Voice Handicap-10. Laryngoscope. 2009;119:1864–1869. 3. Rosen DC, Sataloff RT. Psychology of Voice Disorders. San Diego, CA: Singular Publishing Group; 1997.

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Appendix A Vocal Hygiene Vocal hygiene is a daily regimen to achieve and maintain a healthy voice. Vocal hygiene includes maintaining adequate rest and hydration (6–8 glasses of water per day), minimizing exposure to noxious chemicals, no smoking of cigarettes or other tobacco substances, and avoiding excessive shouting, screaming, or other nonessential loud voice use.    Proper nutrition is also part of a good vocal hygiene program. Excessive weight may lead to faulty use of the respiratory muscles that are important for generating the power of the voice. In addition, excessive weight adds to overall body fatigue and may restrict a singer or actor from certain roles that require a high level of physical activity.    The following tips apply to keeping and maintaining a healthy voice: n Good

general health

n Regular

exercise to maintain adequate muscle tone

n Rest

when fatigued or injured

n Use

a reduced voice usage schedule when tired

n Rehearse n Use

only after warming up

ear protection when the sound level is high

n Have

your hearing checked regularly

n Review

past recordings of your voice; note the changes if any

n Avoid

long telephone conversations prior to rehearsals or performances

n Warm

up your voice prior to singing

n For

school children — adequate hydration prior to after school rehearsals. A few minutes of stretching also helps.

Do’s and Don’ts of Vocal Hygiene n Drink

6 to 8 glasses of water per day (there is no substitute for plain water).

n Reduce

or eliminate caffeine and caffeinated drinks — coffee, tea, colas, and so forth.

n Rest

before performances. Allow plenty of time between long airplane flights and rehearsals or performances.

n Eat

a balanced diet. Avoid crash diets. They may contain substances that change the way you feel and produce voice.

n Examine

the details of food supplements. Excessive vitamin E may cause blood vessels in the vocal folds and other parts of the body to rupture.

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n Do

not clear your throat. Excessive throat clearing is an indicator of a problem and should be addressed by an otolaryngologist.

n Laugh.

The muscles of the body relax during laughter.

n Do

not shout.

n Do

not whisper with strain.

n Eliminate n Avoid n Do

and avoid all tobacco products.

areas of noxious chemicals/fumes.

not smoke cigarettes, cigars, or pipes.

n Avoid

secondhand smoke.

n Do

not use recreational drugs.

n Do

not share the prescription medications of other performers (such as antibiotics).

n Avoid

over-the-counter medications. Your voice is too important. Consult an otolaryngologist who specializes in the care of performers.

n Review

all prescription medications with your doctor in relationship to potential impact on your voice.

n Minimize

alcohol. Like caffeine, it dries out the mucous membranes that cover the vocal muscles, inside the mouth and throat.

n Be

cautious about weight lifting that requires grunting or straining. Use lighter weights and more repetitions if possible.

n Eat

light meals with plenty of water before rehearsals and performances.

n Take

steps to reduce stress. Exercise, rest, and counseling are proven ways to reduce stress.

n Humidify

your studio and bedroom during winter months. If you have mold allergies, try not to let the humidity get too high.

n Be

cautious about voice use in environments with loud background noise, such as clubs or airplanes.

n After

an injury or sickness, consult your vocal coach or singing teacher to see if you have modified or changed your vocal techniques.

n Women — select

birth control medications with the help of a physician who understands the effects of hormones on the voice.

n Do

not sing when sick — A cold or upper respiratory infection changes the way you use your breathing muscles, may cause the vocal folds to swell, and may affect the way you hear your voice.

n A

hoarse voice, change in the sound of the voice, or noticeable voice fatigue for 2 weeks requires attention by a qualified voice care team — otolaryngologist, voice pathologist, and voice teacher.

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Glossary Abduction. The action of bringing the vocal folds apart. Vocal folds abduct during the act of inhalation. Acoustic analysis.  Evaluation of the sound properties of voice. Measures considered important to acoustic analysis are fundamental frequency (F0), jitter, shimmer, signal-to-noise ratio, and maximum frequency range. Adduction. The action of bringing the vocal folds together to produce voice. Vocal fold adduction may occur at voice onset, during the production of voiced consonants such as /b/, /d/, and /z/, and during coughing or throat clearing. The vocal folds also adduct during swallowing. Aerodynamic analysis.  Evaluation of the amount of air and rate of airflow available to set the vocal folds into vibration. Measures include flow or phonation volume, phonation time, and airflow rate. Subglottic pressure, glottic resistance, and glottic efficiency are also measures that can be extracted using equipment designed for aerodynamic analysis. Pulmonary function tests, which measure an individual’s amount of lung capacity and use of air for breathing, could also be considered parts of aerodynamic analysis. Airflow rate. A measure of speed of airflow between the vocal folds during voice production. This generally is measured in millimeters per second (mL/s) or cubic centimeters per second (cc/s). The value is obtained by dividing the total amount of air expelled, for example, while saying “ah” (/ɑ/) by the amount of time it took to produce that sound. Higher airflow rates (>200 mL/s) are associated with “breathy” or “weak” voice, and low airflow rates (