This page contains several articles on vocal health related issues from noted centers for vocal health. Please visit their sites for this and additional vocal health content.
Jamie Koufman, M.D
Reprinted from THE VISIBLE VOICE, The newsletter of the Center for Voice Disorders
Visit The Wake Forest University Baptist Medical Center website
Since President-elect Clinton first appeared on television with hoarseness, millions of Americans have become aware that voice disorders in public figures may have far-reaching implications. Indeed, a voice disorder in any professional vocalist may have emotional, social, professional, and even political consequences. While Mr. Clinton is not a vocalist per se, while he is president and therefore speaks for all of us, his voice is as important as that of any professional vocalist. This article addresses the medical care of vocal professionals who require prompt and effective treatment when a voice problem arises.
The causes of such voice disorders are often multifactorial, and may be both functional and organic in nature. Among the most common causes are upper respiratory infection, gastroesophageal reflux, muscle tension dysphonia, and the vocal abuse/misuse/overuse syndromes.
Medicine in the Vocal Arts is an emerging field devoted to the diagnosis, treatment, and prevention of voice disorders in professional voice users. Today, the multispecialty voice center has become an important clinical resource, and most patients with voice disorders can be treated.
The voice is not an organ, but rather, the external phonatory output of the vocal tract. While this may seem obvious, it has important implications for all voice clinicians (laryngologist, speech language pathologist, voice teacher, voice coach, and voice scientist).
The vocal tract consists of four component systems:
The term voice disorder implies that the problem is laryngeal (within the vibrator); however, it is important to remember that the four component systems of the vocal tract interact in complex ways. For example, poor breath support often gives rise to muscle tension dysphonia (abnormal muscle tension in the larynx that alters the voice). It is also important to remember that the neural regulation of these systems is complex and involves many sensory, motor, and integrating pathways within the brain. In actuality, the vocal tract is the entire person, since any abnormality of the psyche or soma can give rise to an abnormality of the voice. The voice is therefore a measure of a person's overall sense of well-being.
Voice disorders are ubiquitous and may have a profound influence on a person's ability to communicate effectively; when they occur in professional vocalists, they may cause social, emotional, and professional hardship. Furthermore, just as professional athletes are prone to certain athletic (orthopedic) injuries, so too, are professional vocalists prone to specific injuries. Tennis players get tennis elbow; football players get knee injuries; and vocalists get voice disorders. The scheduling demands of successful vocalists (travel, rehearsal, promotion, performance), make it more likely for them to suffer a serious voice problem than for the average person. Consequences of a voice problem in a well-known performer can also include public scorn, loss of reputation, and loss of income. It is therefore not surprising that professional vocalists with voice problems usually arrive at a physician's office in a state of panic.
Who gets a voice disorder? And why? How are voice disorders treated? And how if possible, can they be prevented? The purpose of this article is: (1) to outline an approach to the management of these voice patients; and (2) to address specifically the more common voice problems of vocalists.
Approach To The Vocalist With A Voice Problem
Three somewhat distinct patient populations fall into the category of "professional vocalist," each with a somewhat different set of problems and demands. I call these three groups elite vocal performers, vocalists, and vocal professionals. An example of an elite vocal performer is the opera singer, in whom even the slightest aberration of voice may have dire consequences. Most other professional singers fall into the vocalist group, while actors, clergy, radio and television personalities fall into the vocal professional group. While all three levels of vocalists earn their living with their voices, the degree of "incapacity" in each varies with the vocal occupational demands and the severity of the voice disorder. Elite vocal performers seek medical attention for any and every acute condition that they perceive may have an effect on the voice, e.g., upper respiratory infection (a cold), allergy, etc. Other, less-demanding patients seek medical attention when the problem becomes more severe or chronic. Consequently, the voice clinician must take into account the vocal demands and needs of each patient. Table 1 lists (in decreasing order of frequency of occurrence) commonly encountered problems of vocal professionals.
Table 1: Common Problems of Professional Vocalists
· Upper respiratory tract infection (URI, "cold," laryngitis)
· Gastroesophageal reflux-related voice abnormalities
· Overuse syndromes ("decompensation")
· Vocal abuse syndrome
· Misuse of the speaking voice
· Environmental factors
· Singing out of range
· Substance abuse
The Spectrum Of Vocal Dysfunction
Traditional medical thinking has created a dichotomous model of disease, organic vs. functional. The term organic means, literally, "related to an organ"; thus, an organic condition is one that is usually associated with structural alteration(s) in the tissues of an organ, i.e., congenital, inflammatory, or other histopathologic changes. The term functional means "related to a function"; thus, a functional condition is the result of abuse or misuse of an anatomically intact organ or organ system. A functional abnormality is not primarily the result of a structural abnormality, although secondary histopathological alterations may be present. "Tennis elbow" is a good example of a functional condition from which secondary histologic changes may result. Likewise, organic conditions also may have a functional component.
Many voice disorders are multifactorial, and simultaneously both organic and functional. This is because compensatory alterations of vocal function occur in virtually every case. Furthermore, the compensatory component may obscure the underlying condition. Thus, the dichotomy between organic and functional appears to have little relevance to the understanding and management of voice disorders.
In approaching the diagnosis of each voice disorder patient, the clinician must therefore assess the degree of impairment related to the compensatory or functional component, as well as any organic problem. For example, a vocalist with viral laryngitis may present with "no voice" prior to a performance. When examined, the degree of vocal fold edema and inflammation may be mild, and abnormal laryngeal muscle tension (maladaptive compensation) may account for "most" of the loss of voice. While it may not be possible acutely to restore the voice to normal, with treatment, it is often possible to restore enough of the voice to permit the vocalist to perform a "modified program." Often successful treatment may take the combined efforts of the patient's otolaryngologist, speech ("voice") pathologist, voice coach, and manager. The effective management of chronic voice disorders, though somewhat different from the management of acute disorders, also requires a multidisciplinary team.
The Multidisciplinary Voice Center: Medicine In The Vocal Arts
In the U.S., within the last decade, a number of multidisciplinary voice centers have been established. Using new technology, these centers have focused the collaborative efforts of voice specialists on the diagnosis, treatment, and prevention of voice disorders. In addition, since the establishment of The National Institute on Deafness and Other Communication Disorders (NIDCD) in 1985, research in this area has increased. Today, most patients with voice disorders can be treated effectively; "arts medicine" has become a new subspecialty; and a national network of voice centers has been established.
At most voice centers, the core clinical unit consists of an otolaryngologist and a speech language pathologist; virtually every voice patient should be seen by both. The laryngologist is primarily responsible for the patient's overall care, but the speech pathologist is responsible for the diagnostic voice laboratory and for actually doing most of the speech/voice therapy. Videostroboscopy is performed by the laryngologist, and acoustical voice analysis by the speech pathologist; both are involved in the diagnosis and treatment of voice patients. The voice teacher is also involved in the "rehabilitation" of many singers.
When appropriate, patients are referred to the department of gastroenterology for ambulatory 24-hour double-probe pH monitoring, a diagnostic test for gastroesophageal reflux , which is a condition common in voice disorder patients. Occasionally, patients also are referred for evaluation to specialists and laboratories in other departments, including neurology, psychology, psychiatry, gastroenterology, gynecology, and internal medicine.
Clinical Assessment Of Voice Patients
Table 2: Elements of the Vocal History
Table 3: Common Vocal Complaints and Their Definitions
While the laryngologist is usually primarily responsible for the patient's overall medical management, the speech pathologist assumes several key responsibilities in this management: (1) baseline voice documentation, (2) acoustical voice analysis, (3) therapeutic manipulation (so-called "unloading"), (4) independent diagnosis, (5) performance of speech/voice therapy, and (6) determining dismissal criteria. Sometimes the speech pathologist assumes some of the functions of the laryngologist, and vice versa.
Before moving on to a discussion of treatment, two specific aspects of clinical voice assessment must be clarified. First, the laryngologist's examination should include both fiberoptic and telescopic laryngeal examination. The former method allows assessment of laryngeal function during connected speech and singing and across the dynamic and pitch ranges of the voice. This is important in assessing laryngeal biomechanics, particularly for identifying abnormal patterns of laryngeal muscle tension. Telescopic examination involves placing a rather large-bore instrument in the mouth so that during this examination, the patient can only phonate a vowel, e.g., /i/. Nevertheless, even though telescopic examination may significantly alter laryngeal biomechanics, the superior magnification and optics of this method allow optimal examination of the free edges of the vocal folds for lesions such as nodules, polyps, cysts, and hematomas. Thus, the two techniques are complementary, and both should be employed in the professional vocalist.
Second, the speech pathologist's role in "unloading" the patient may be crucial to accurate diagnosis and effective treatment. Unloading is the term used for voice therapy designed to remove any temporarily compensatory vocal behaviors. The details of unloading are beyond the scope of this paper; however, these are similar to the techniques of voice therapy for patients with functional, especially "hyperkinetic," voice disorders, such as the vocal abuse/misuse or nodule groups of patients. These therapeutic techniques include: (1) obtaining optimal breath support (efficient use of the breath stream); (2) softening the hardness of glottal attack (reducing the effort of initiating phonation); (3) reducing the rate of speaking; and (4) reducing laryngeal and neck muscle tension through digital manipulation and other relaxation methods.
As mentioned above, almost all patients with voice disorders have a functional or compensatory component that can readily be reversed in voice therapy. Through unloading of voice during evaluation, the processes of diagnosis and treatment become intertwined -- only when compensatory behaviors are removed can the voice clinician truly appreciate the true underlying glottal condition.
Common Problems Of Vocalists
Professional vocalists have some unique problems and risk factors for the development of voice difficulties. As a group, vocalists are often subjected to adverse working environments, e.g., smoke, dryness, dust, a high level of ambient noise, and inadequate amplification. These problems may contribute to "poor vocal hygiene," poor diet, and in some cases, substance abuse. In addition, successful vocalists may suffer from stressful schedules, anxiety, and fragmented -- sometimes inappropriate -- medical care. Table 4 lists some of the unique problems of vocal professionals, the most common of which are briefly addressed below.
Inflammatory Causes: "Laryngitis"
Infectious and noninfectious causes of laryngeal inflammation are among the most common reasons that professional vocalists seek medical attention. Often the patient will simply complain of "laryngitis," whether or not a specific cause is evident. Indeed, to the layman, the term laryngitis is mistakenly used as a synonym for hoarseness or dysphonia. From the voice clinician's point of view, laryngitis implies inflammation of the larynx, and the vocal abuse/misuse/overuse syndromes are separate entities. While tonsillitis, sinusitis, and allergy may occasionally involve the larynx and cause secondary laryngeal inflammation, by far the most common causes of true laryngitis are viral infection and gastroesophageal (laryngopharyngeal) reflux.
Table 4: Unique Problems Of Professional Vocalists
Upper Respiratory Tract Infection (Viral Laryngitis)
Upper respiratory tract infection (URI) may be bacterial or viral; however, viral URIs are the most common, and they may or may not directly involve the larynx in degrees that vary with the virulence of the invading organism and its site of predilection. In other words, some viruses cause primary laryngeal inflammation that is associated with the development of marked laryngeal edema and hoarseness, while others may cause only minor, secondary inflammation due to drainage of the byproducts of the inflammatory process higher up. A "cold" is an example of the latter.
Treatment consists of modified voice rest (no nonessential talking), hydration, and use of a vaporizer (and steamy showers). Antibiotics, decongestants (usually not combinations containing antihistamines), and expectorants should be prescribed, and, on occasion, a single large intramuscular dose of corticosteroids, e.g., betamethasone 20 mg, may be given to counter the effects of the acute laryngeal swelling. Betamethasone has a half-life of 36 hours, so that a single dose may exert its effects for days and requires no "tapering". As an alternative, an oral dosing regimen of betamethasone or prednisone may be used.
When prescribing corticosteroids, it is important to inquire if the patient has received such treatment previously, since these drugs may have adverse side effects. In addition, some patients may be drug dependent and may be seeing several physicians in several states to get corticosteroids.
The patient who repeatedly uses steroids in order to perform may develop Cushing's syndrome. Finally, the use of inhaled steroids and/or anesthetic sprays is contraindicated because they seldom help, and they may harm the patient.
URIs are self-limiting, and symptoms usually resolve within several days. During the acute phase of infection, it is important for the patient to avoid voice strain or overuse because this may result in prolonged difficulties. The severity of laryngeal inflammation, the degree of vocal impairment, and the short-term "performance" schedule of the vocalist are all important factors in the decision-making process and the approach to treatment. If, for example, a performer has severe laryngitis and a heavy performance schedule, then the upcoming "program" should be drastically modified or the performances canceled. On the other hand, if a performer has mild to moderate inflammation and only a few imminent, but important, performances, medical treatment and voice therapy, in addition to some modification of the performance program, may be a satisfactory solution.
Gastroesophageal Reflux ("Reflux Laryngitis")
Patients with laryngopharyngeal reflux are different from the "typical" reflux patients with esophagitis commonly encountered by gastroenterologists. Voice patients with reflux laryngitis appear to have a high incidence of upright (daytime) reflux, a low incidence of esophagitis, and a high rate of treatment failure using traditional antireflux therapy, such as dietary and lifestyle modifications and H2 blockers.
The most sensitive diagnostic test in the reflux laryngitis group of patients is ambulatory 24-hour double-probe pH monitoring. Omeprazole, 20 mg. b.i.d., appears to be the most effective treatment. Vocalists appear to be extraordinarily prone to develop reflux, but why they are so inclined remains unknown.
Vocal Abuse, Misuse, And Overuse Syndromes: The Muscle Tension Dysphonias
This group of disorders is very common in professional vocalists, and may be lumped together under the heading of muscle tension dysphonias (MTDs). The MTDs may occur in isolation, after a URI, or, as mentioned above, in association with reflux. It is important for the voice clinician to evaluate each patient for each of these possible causative factors, since every underlying cause must be identified and corrected if treatment is to be effective.
Yelling, screaming, singing too loudly or "out of range," and using certain character voices may result in traumatic laryngeal damage, including the development of contact ulcers of the vocal processes, vocal fold hemorrhages, nodules (localized vocal fold swellings), or diffuse vocal fold swelling. These lesions are the consequences of traumatic vocal behavior and they result in vocal impairment. The best treatment for all of these dysphonias is prevention.
Vocalists should strictly avoid screaming (to the point of causing hoarseness) at athletic events and at other times, including when performing. Professional vocalists who demonstrate findings of vocal abuse should be offered a program of vocal education designed to modify the abusive vocal behavior(s). Vocal-fold hematomas are best treated by voice rest, occasionally by surgical drainage. Contact ulcers on the vocal processes may be due to use of a loud speaking voice alone, but also often are associated with poor breath support, very low pitching of the voice, and chronic throat clearing. Such ulcerations may produce referred pain to the ipsilateral ear (often during performance), and yet may only minimally alter the vocal quality. Patients with contact ulcers and granulomas usually need treatment for both reflux and vocal abuse/misuse (voice therapy).
Vocal nodules, small discrete swellings at the junction of the anterior and middle thirds of the vocal folds, are common in vocalists, and are always the result of vocal trauma. These swellings may represent nothing more than discrete areas of mucosal thickening, or the nodules may be keratinized (like a callus), or angioma-like (vascular).
Most patients with vocal nodules do not need to have them removed, and in many cases, the nodules do not significantly alter vocal quality. However, when the nodules are associated with an underlying submucosal cyst or have a red "angioma-like" appearance, then surgical treatment should be considered, but only after voice therapy has been instituted. It is important to remember that these are functional lesions and that, with the exception of cysts and "red nodules" (as above), they are reversible -- that is, they may resolve completely when vocally abusive behavior is eradicated. Relatively few patients with vocal nodules ever require surgery.
All patients with traumatic vocal-fold injuries should be subjected to intense scrutiny by the voice team. Abusive vocal behaviors, including chronic traumatic throat clearing, should be eliminated, and voice therapy designed to optimize vocal efficiency should be provided. Vocal abuse in a vocal professional is tantamount to a musician's leaving his or her instrument out in the rain: it is inappropriate and neglectful. For most vocal abuse patients, including those with vocal nodules, vocal education (or reeducation) is effective remedial therapy.
Vocal misuse is somewhat different from abuse, in that misuse tends to be less acute, more habitual, and more insidious in its effects. Speaking or singing out of range and the use of certain character voices are the most common forms of misuse.
In many singers who seek medical attention for a voice problem, it is actually the speaking voice that is at the root of the problem. In both men and women, the habitual use of a very-low- pitched speaking voice may be the cause. To produce a low-pitched voice requires considerable muscular tension. This type of muscle tension dysphonia is termed Bogart-Bacall syndrome. (This syndrome is named after these two great actors, not because they had anything wrong with their voices, but because the term suggests that people with the voice disorder often have voices that are similar in pitch to Bogart's or Bacall's).
Patients with this condition almost always speak using the lowest note of the pitch range, and also usually demonstrate poor breath support. Why this condition occurs is conjectural; however, in contemporary society, a low-pitched speaking voice is considered desirable. In men, a low-pitched voice confers authority and masculinity; in woman, it confers sophistication, worldliness, and confidence. Diagnosis of the Bogart-Bacall syndrome requires a high index of suspicion, and correction of the syndrome depends upon the cooperative efforts of the patient, the laryngologist, and the speech pathologist.
Singing out of range is also a common problem. Most vocalists know their own tesitura, that is, their "best range", but occasionally, a vocalist will take on a role that is inappropriate, and when this happens, vocal difficulties may result.
Similarly, actors may take on roles that require use of a "character voice" that pushes beyond the limits of "safe vocal physiology." Laryngeal muscle tension increases dramatically when a vocalist is speaking or singing out of range, and thus the likelihood of laryngeal trauma increases. When singers and actors sound as if they are straining, they are straining. Occasionally, the voice clinician must point out the obvious when vocal misuse of this type occurs.
Vocal overuse can happen to anyone; however, in many cases it can be avoided. It is particularly prone to occur following an URI. While there is no surefire way to estimate the vocal capacity of a performer, the demands of touring, especially, may sometimes lead to chronic fatigue and a voice disorder. When this occurs, it is the physician's role to facilitate a reexamination of the performer's schedule and circumstances. In addition, the physician should look for previously unidentified cofactors that may contribute to the process of vocal decompensation.
Short-Term and Long-Term Issues
When the physician is called upon to see a vocalist, it is important to recognize that the problem may be acute, chronic, or both (leading to sudden "vocal decompensation"). Indeed, many vocalists with "poor technique" who are young and strong seem to survive vocally until an additional acute factor, such as an URI, occurs. The vocalist may then come to the physician complaining only of the acute problem, whereas, more often than not, the cause of such a voice disorder is multifactorial. Consequently, the premorbid characteristics of the patient's schedule, lifestyle, vocal hygiene, and previously unreported symptoms also should be elicited, examined, and possibly modified.
Communication with other members of the voice team, including the vocalist's manager, coach, teacher, or other physician(s), not only is appropriate, but also is necessary to sort out the short-term from the long-term problems, and to address their optimal solutions. For example, after a URI-related vocal decompensation (cough, granuloma formation, etc.), a vocalist might also need treatment for reflux, voice therapy directed at improving the efficiency of the speaking voice, and singing lessons.
I know of no other area in medicine that could more appropriately be called "holistic." Voice clinicians can now begin to make suggestions that may heighten the awareness of vocalists to potential problems and therefore help prevent voice disorders. Table 5 lists some suggestions for the professional vocalist on how to save the voice.
Table 5: Suggestions For The Professional Vocalist:
"How To Save Your Voice"
DR, McFarlane SC: The Voice and Voice Therapy. 4th edition,
JA, Blalock PD: Vocal fatigue and dysphonia in the professional voice
JA: The otolaryngologic manifestations of gastroesophageal reflux disease.
JA, Isaacson G, Editors: Voice Disorders.
RT: Professional Voice: The Science and Art of Clinical Care
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