Voice problems in professional voice users are largely the same as those that occur in the general population, but with one important caveat-the potential consequences. Many nonprofessional voice users have the same vocal problems as voice professionals, but the consequences of such problems are different, said Robert T. Sataloff, MD, Professor and Chair of Otolaryngology-Head and Neck Surgery at Drexel University College of Medicine in Philadelphia. An industrial shop foreman who has very mild hoarseness or loses one or two notes at the top of his range is likely to have his personal and professional life unaffected. A singer with the same symptoms may be totally disabled.
As one of the most prolific writers on caring for the professional voice, and as an otolaryngologist who sees many professional voice users in his practice, Dr. Sataloff emphasizes the challenges faced by otolaryngologists who care for professional voice users. The definition of ‘normal’ is more narrow than the definition we usually enjoy in general otolaryngeal practice, he said, adding that professional voice users, such as singers, demand and require physiologic perfection, not just a functioning voice with a normal range like the rest of us. This difference-the consequence of vocal problems for the professional voice user-has driven the need for special training and a team approach to diagnosing and treating vocal problems in the professional voice user.
Common Voice Problems
Vocal problems commonly seen among professional voice users can be divided into two etiological categories: functional and organic. Functional problems include voice use issues-overuse, abuse, or misuse of the voice. Organic problems refer to physiologic changes brought on by environmental exposure (such as allergies), alterations in hormones, or other systemic conditions that can adversely affect the voice, such as gastroesophageal reflux disease, acute infectious laryngitis, and benign vocal fold masses. Table 1 lists the etiology of common disorders.
Some data suggest that the majority of voice disorders are caused by functional misuse of the voice or to psychogenic factors resulting from a voice that is not working properly, with the minority of patients experiencing organic causes of voice problems. According to Peak Woo, MD, of the Grabscheid Voice Center at Mount Sinai Medical Center in New York, heavy voice use is the cause of some of the most common vocal problems. There are certain lesions and patterns associated with voice abuse, he said. Common ones are vocal nodules, vocal polyps, and laryngeal granulomas. Other problems that cause voice dysfunction include vocal cysts, Reinke’s edema, vocal scars, vocal fold hemorrhage, laryngeal papillomas, and cancer.
Differential Diagnosis
For many professional voice users, the first symptoms that typically warrant a medical examination are a sudden change in voice, or persistent and/or unexplained hoarseness.
Because of the many potential causes of voice problems, a critical first step in diagnosing a patient is to take a comprehensive history and physical examination of the patient that includes an examination of both the head and neck areas and other areas of the body as indicated. Also essential is a full voice history that includes the level of voice training, voice demands, and environmental problems that may adversely affect the voice, said Dr. Sataloff.
According to Robert H. Ossoff, MD, DMD, Chairman of the Department of Otolaryngology at Vanderbilt University Medical Center in Nashville, specific questions that should be asked to singers include whether their range is normal for them or if they have problems with the upper or lower ranges, or whether the clarity of their voice is the same or has changed. Other questions should include whether the patient has noticed any specific vocal fatigue or loss of confidence in his or her singing.
Typically, such an evaluation of voice history includes a team approach that includes voice specialists such as a speech pathologist and singing voice specialist. Dr. Woo says he frequently refers a patient for a voice therapy evaluation to see if they have specific vocal faults that are associated with excessive functional overuse, such as using a voice gesture that is too aggressive or if the patient has too much tension in the neck. We work as a team effort in the voice center, he emphasized.
For all three otolaryngologists, an essential part of a thorough examination is the use of strobovideolaryngoscopy, a diagnostic instrument that permits examination of the vibratory characteristics of the vocal fold that will detect subtle problems such as mild inflammation, subtle swelling of the vocal fold, white patches, or excessive mucus. This test is often coupled with different measures of air flow and with digital voice recordings, said Dr. Ossoff, who emphasized, If I would recommend only one specialized test, I would recommend strobovideolaryngoscopy.
According to Dr. Sataloff, if strobovideolaryngoscopy is used by an expert and can get very high-quality stroboscopic images, a number of subtle abnormalities along the vibratory margin of the vocal folds can be detected, such as small cysts, scars from previous injury, and other minor abnormalities. Early diagnosis of such abnormalities is critical, he said. Early diagnosis of serious problems such as vocal fold hemorrhage or mucosal tear allows early prescription of voice rest, and, we believe, a better chance of good spontaneous healing without scar formation and prolonged hoarseness, he said. For more minor problems, such as an upper respiratory infection, strobovideolaryngoscopy is important to determine whether a singer can still perform without doing damage to his or her vocal folds.
Treat with Care
Three main modalities of treatment are used to treat vocal problems, ranging from the most noninvasive to the most invasive. You have behavioral treatment, which is essentially speaking and singing therapy. You have medical treatment, which treats allergies and reflux and dryness and things of that nature. And then you have surgical treatment, said Dr. Ossoff.
According to Dr. Ossoff, because many benign vocal lesions are acquired through overuse, misuse, or abuse of the voice, a behavioral or medical approach is first used, with surgery reserved only if these other methods fail. He emphasized, however, that if noninvasive measures do not work, surgery is needed because if they [singers] don’t get [the problem] corrected, their career is on the sidelines.
For problems that commonly plague singers, such as symptoms of allergies and reflux, the use of medications is critical so that further damage is not done. Simple measures such as increasing water intake for better lubrication and reducing the amount of substances that thicken the mucus (such as caffeine, chocolate, alcohol, and dairy products) can help with symptoms of upper respiratory allergies. The use of antihistamines and nasal steroid therapy are also options when used with care.
Although there is controversy over use of steroids, both Dr. Woo and Dr. Ossoff agree that their judicious use is acceptable-that is, if they are not used on a chronic basis. However, Dr. Ossoff cautioned that singers need to be aware that although steroids will help their condition and allow them to perform, the steroids are also masking their symptoms. They may not realize that they may be singing away on damaged property or causing some damage because the steroids could be masking those symptoms, he said.
When Surgery Is Needed
Any time a singer needs surgery, it is a much bigger decision process than for the average person. Even minor structure problems can be a big problem for a singer, said Dr. Woo, cautioning that surgery in a professional voice user requires a more complex decision tree that must address issues about the timing of surgery, recovery period, and when a singer can return to performance.
For Dr. Ossoff, surgery really should be the last resort for non-neoplastic or benign vocal lesions when all other noninvasive modalities have failed. For those patients in whom surgery is determined necessary, he emphasized the need to try to select your patients appropriately and carefully and obtain informed consent from the patient so that the expectations you set for the patient are understood.
However, Dr. Ossoff was adamant about the responsibility of otolaryngologists to refer a patient for surgery for a suspected neoplasm. If you think that someone may have a cancer, you have a major-league obligation to take them to the operating room to biopsy it and prove or disprove that, he said.
Need for Expert Laryngologists for the Professional Voice User
Recognition of the particular needs of professional voice users has given rise to more intensive training for otolaryngologists who treat them. A number of fellowship programs within otolaryngology departments now exist throughout the country in which otolaryngologists receive an additional year of advanced training in different areas, including laryngology. The need for this special training is perhaps highlighted by the relatively recent case of the unexpected adverse effects that occurred after Julie Andrews underwent surgery to correct vocal problems. Although Dr. Sataloff doesn’t think the focus on the Andrews case has changed protocols for how patients are treated by laryngologists, he does think that her story may have increased awareness of the need for expert, state-of-the-art care in all voice professionals and certainly world-class performers.
For Dr. Woo, the experience highlights two aspects of the specialized nature of working with professional voice users. One is to recognize that certain surgeries are a subspecialty within otolaryngology and should be done only by experts in that area. And the second, he says, is almost a backlash. An average otolaryngologist sometimes doesn’t feel comfortable taking care of these people [professional voice users], so sometimes these people are shunted, he said. A lot of doctors are afraid and it’s actually a disservice to the singers because doctors don’t want to treat singers.
©2007 The Triological Society