PROFESSIONAL VOICE USERS

People who use their voice for a living are more at risk for developing voice problems. It has been suggested that some groups of workers are at more risk than the others. Professional voice users constitute an ever increasing segment of population. The use if voice for the specific professional performances varies greatly with the content and purpose of verbal communication.

DEFINITION:

•      Professional voice users are those individuals who are directly dependent on vocal communication for their livelihood

                                                           - Stemple, 1991 

•      Professional voice users are also often considered ‘athletic’ voice users because their voice use is more extensive and strenuous than that of a non-professional voice user  

                                                            - Khambato, 1979

•      Professional voice users of three types:

ü  Those who use their voice of a long period of time (politicians, teachers, telephone users)

ü  Those who use their voice under adverse circumstances persons working in noisy environments (Factory workers, sports arenas)

ü   Those who use their voice for special purpose (singer, theater artists)

Koutman & Isakson (1991)

Level I: The elite vocal performer: professional singers and actors for who even slight aberration of voice may cause serious consequences. Members of this group require maximum vocal performance in all parameters. They are sometimes referred to as vocal athletes because of the superior quality, pitch range and loudness that they are able to achieve.

Level II: The professional voice user : for whom moderate vocal problem might prevent adequate job performance e.g. Teacher, Telephone Operator, Barristers, Clergy. They frequently require considerable vocal stamina over prolonged periods and in many cases have to make themselves heard by large group of listeners. If affected by aphonia or dysphonia, would be discouraged in their job and seek alternative employment (Titze etal, 1997). Even low levels of vocal impairment are not able to perform the job adequately.

Level III: Non-vocal professional: this include doctors, business executives and lawyers, for whom a severe vocal problem would prevent adequate job performance.

Level IV: Non-vocal non-professional: for whom vocal quality is not a pre-requisite for adequate job performance e.g. clerks, laborers.

OCCUPATIONAL GROUPS AT RISK:
For some groups of workers, voice impairment can be employment threatening, as some jobs cannot be performed without adequate vocal capacity. Certain groups such as teachers and singers have been studied extensively and have been reported to have higher frequencies of voice disorders than the general population.

Occupations that require significant voice use include:

·         Teaching

·         Singing

·         Acting

·         Sales

·         Telemarketing

·         Customer Service

·         Lawyers

·         Waiter/Waitresses

Recreational activities can also be vocally demanding, such as:

·         Singing

·         Acting

·         Coaching

·         Athletics

·         Sporting Events (e.g., yelling at the football game, etc.)

·         Public Speaking

·         Volunteer Work (that requires extended voice use)

TEACHERS:

Teachers form a large group of a professional voice user and are thought to be at risk for voice problems compared to the general population (Fritzell, 1996; Russel, Oats & Greenwood, 1998). 

The reported prevalence of voice problems in teachers depends on whether the diagnosis is based on objectively diagnosed vocal cord pathology or on subjective symptoms. Studies have reported prevalence rates of 4.4% and 90%. Smith et al analyzed 242 responses from primary and secondary teachers in the United States and compared the frequency of voice problems with those of individuals in other occupations. They found that teachers were more likely to have a voice problems (15% vs 6%) when asked about ten specific voice symptoms of discomfort. They found that:

·         47.5% of teachers complained of hoarseness compared to 21.3% of controls. Teachers averaged almost two symptoms compared to none in other occupations.

·         20% of teachers but 0% of nonteachers reported resultant time lost from work.

·         4.2% of teachers said that the voice problem was significant enough for them to consider a change of occupation.

Similar findings were found in a study by Russell et al in Australian teachers. Sapir et al confirmed the findings regarding work capability in a study that found that more than one-third of teachers with voice problems missed work as a result.

Using MDVP, Gopal.S, Krishna and Nataraja.N.P (1995) studied susceptibility criteria for vocal fatigue using 5 normals and 5 teachers. The subjects were selected based on a questionnaire study, 2 sets of phonation before & after the subject underwent fatiguing task of reading continuously for ½ hrs duration. It was found that ½ hr duration was sufficient to induce vocal fatigue and Fo parameters reflect changes in the vocal system earlier than other parameters.

Gopikrishna (1995) measured a range of acoustic parameters on 3 groups of subjects before and after half an hour and 1 hour of reading at 65 dB. 1 group consisted of 5 normal subjects and the other groups consisted of 5 teachers prone to fatigue and 5 teachers not prone to fatigue. The authors found a significant difference in Fo related measures (mean, min and max Fo) and perturbation measures (pitch, perturbation quotient, Fo variation). There was an increase in measure as jitter values. The author suggested that the loading task of half an hour is sufficient to induce fatigue and concluded that teachers are more susceptible to fatigue, although no significant difference was found two experimental groups of teachers.

Shobha Menon (1996) studied vocal fatigue in 20 primary and secondary school teachers by administering a questionnaire and recording phonation of /a/ /i/ /u/ and speech samples  in both pre fatigue and post fatigue (6-7 hrs after teaching) condition. She reported the major symptoms as tiring of voice, dryness of the throat, vocal fatigue, burning sensation in the throat. Phonation samples were audio recorded and analyzed to obtain mean, max, min, range of frequency and intensity fluctuations per second and extent of fluctuations in frequency and intensity. The results showed a significant difference between both the conditions with respect to speed and extent of frequency and intensity fluctuations, mean, max and min intensity. There was reduction in the mean intensity and intensity range in post fatigue conditions.

Preciado J, Pérez C, Calzada M, Preciado P  (2005) analyzed the risk factors of voice disorders among teaching staff . 527 teachers of random sample took part in study: 332 female (63%) and 195 male (37%). All teachers filled in a standard questionnaire and they underwent an, ENT and functional vocal cord examination, videolaryngostroboscopy and acoustic analysis with MDVP. Results indicate the prevalence of voice disorders among teachers was 57%

           - 20% for organic lesions

           - 8% for chronic laryngitis

           - 29% for functional disorders.

Cooper (1973) found a high prevalence of single and multiple symptoms of vocal attrition in class room teachers.

Excessive use misuse and abuse of the vocal mechanism alone or in combination with biological and psychosomatic factors may result in chronic or acute symptoms of vocal attrition (overall reduction in vocal capabilities, wear and tear of the vocal mechanism) such as vocal fatigue, hoarseness, throat discomfort or pain and benign mucosal lesions (Sapir, 1990, 1992, Sapir, Keidari, Reisch, Bastain, 1990).

SINGERS:

Another occupational group that has been highlighted as experiencing a higher prevalence of voice disorders is singers. Miller and Verdolini looked at frequency of self reported voice problems in voice or singing teachers by sampling 10% of the membership of the National Association of Teachers of Singing in the United States. Each recipient also received a second questionnaire to be completed by a friend or colleague who was not a singer. 125 singers and 49 controls completed the questionnaires. 21% of the singing teachers and 18% of controls thought that they currently had voice problem, however 64% of teachers and only 33% of controls reported a voice problem in the past. Risk factors for the singing and nonsinging teachers included a history of past voice problems. Current use of specific dehydrating medications, female gender and a younger age also increased the risk. When looking at different types of singers, Perkner et al compared 3 specific types of performer- opera, musical theatre, and contemporary singers with controls. They found a significant increase in voice disorders in the singers and in voice disability, but no difference was found among the different styles of singer.

Brodnitz (1954) reported that common voice problems of actors, singers were acute laryngitis, polyps, vocal nodules, contact ulcers which were attributed to vocal abuse.

Reid.K.L, Davis.P et al (2007) studied members of a professional opera chorus.

·         Subjects sung with equal or more power in the   singer's formant region in choral versus solo mode in the context of the piece as a whole and in individual vowels.

•      No difference in vibrato rate and extent between the two modes.

•      Singing in choral mode, therefore, required the ability to use a similar vocal timbre to that required for solo opera singing.

Sheela Kumar (1974) compared the vocal parameters between 30 trained and 30 untrained singers (19-54 yrs). Vocal parameters were optimum frequency, Fo while phonating /a/ in the speaking pitch, Fo while phonating /a/ in the singers pitch, phonation time, pitch range and vital capacity. Results indicated significant differences exist between optimum frequency and fo while phonating /a/ in the speaking pitch. Trained singers tend to use their optimum freq while speaking unlike the untrained singers. Optimum frequency is neither used by trained singers or untrained singers while singing. Trained singers possess significantly greater pitch range than untrained singers. No significant difference was observed in phonation time and vital capacity between the two groups.

Janani (2004) conducted a study to determine the voice changes that take place over the years due to the developmental processes in a female professional singer for fo, f1, f2, jitter & shimmer. Songs sung by the singer from 12-74 yrs were collected. The phonated vowels /a/, /i/ & /u/were extracted from the songs & analysed using MDVP. Fo, F1 &F2 of these vowels reduces as age advances. Jitter % changes for all the vowels were remained 2%. Shimmer % increase with age. Maximum change was between 62-74 yrs. Conclusion was singers must use their optimum pitch while singing & follow a good vocal hygiene program.

AEROBICS INSTRUCTORS:

A number of reports have recently appeared in the literature describing voice problems in aerobics instructors. The demands of the job require verbal instructions to be given to clients at the same time as performing often strenuous exercise. This makes control of breathing and airflow movement more difficult. Long et al carried out a questionnaire study of 54 aerobics instructors in Alabama. 44% reported experiencing voice loss and 42.6% reported partial loss during or after instructing a class. Overall, the results showed a significant number of instructors experienced voice loss and episodes of hoarseness.

Gelder, Marks (1987), among aerobic instructors there is increasing concern that vocal abuse and vocal injury may occur at high prevalence level.

CHEERLEADERS:

Investigations on cheerleaders indicated that they have a number of characteristics similar to aerobics instructors. Cheerleaders have been found to suffer from exercise and more frequent hoarseness.

Gillispie and Cooper (1973) the prevalence of both chronic and acute dysphonia among this population is higher than 0.45% reported for high school girls and directly proportional to age and no: of yrs of cheerleading experience.

Andrew and Shanes, 1983 reported 37% of the 102 high school cheerleaders have history of vocal problems. 

TELEMARKERS:

Jones et al carried out a study in which 373 employees from 6 firms were invited to complete a survey and were compared with 187 college students. Telemarkers were found to be twice as likely to report one or more symptoms of vocal attrition compared to controls after adjusting for age, sex and smoking status.

Other groups of workers with essential voice use include tour guides, particularly of working outdoors or in poor acoustic environments.

Jones K, Sigmon J, Hock L, Nelson E, Sullivan M, Ogren F.(2002) investigated whether there is an increased prevalence of voice problems among telemarketers compared with the general population and if these voice problems affect productivity and are associated with the presence of known risk factors for voice problems. 304 employees completed the survey. 187 community college students similar in age, sex, education level, and smoking prevalence served as a control group. Telemarketers were twice as likely to report 1 or more symptoms of vocal attrition compared with controls. 31% reported that their work was affected by an average of 5.0 symptoms. These respondents tended to be women and were more likely to smoke; take drying medications; have sinus problems, frequent colds, and dry mouth.

 ARMY COMMANDERS:

The job of army commanders is to give commands to army (Defence soldiers).  They have to do this for quite a long duration in a day, many days and years under background noise or open field. Army commanders are also required to project authority and toughness achieving, which will put additional pressure on their vocal mechanism. They have to use loud voice in sharp powerful bursts which many of them achieve using ‘glottal stroke’. Continuous employment of glottal strokes leads to thickening of vocal fold overtime or formation of vocal nodules.

Sapir (1993) surveyed the symptoms of vocal attrition in female army instructors; a high risk group of vocal attrition and in 386 women recruits (low risk). A questionnaire was used and it was found that high prevalence of symptoms in both groups and high prevalence among instructors. There was a significant correlation between no: of symptoms and rapid excessive and loud speech habits in both the groups and significant correlation between no: of symptoms and difficulties in performing instructional duties.

INDUSTRIAL WORKERS:

In industrial set up the need to speak louder and in excessive noisy levels put further strain on the vocal muscles resulting in tension and vocal abuse. The fumes, dust, smokes and their mental feelings compound the effect of high noise level directly on the middle lining of the vocal mechanism and leads to vocal strain. There is some evidence in the literature to show that female larynx is more susceptible to vocal cord dysfunction than males from speaking in a noisy environment (Rontal, Jacob Rotnick, 1979).

Ohlsson, Lofquist (1987) did a study to assess vocal behavior in welders. 8 welders and 8 clerks were selected (exposed to noise level of 95 dB at work place).  A tape recording was made of each subjects reading aloud of a standard test and sustained phonation of /a/. These recordings were judged by a panel of 5 trained speech pathologists on a 11 point scale. Results revealed that voice and throat problems were more frequent among welders than for clerks. The result of the listeners judgement on voice was that welders voice is hyperfunctional, unstable and clerks voice as hypofunctional stable.

ETIOLOGY OF VOICE DISORDERS IN PROFESSIONAL VOICE USERS:

Numerous medical conditions adversely affect the voice. Many of these conditions have their origins primarily outside the head and neck. A large majority of disorders are related to abuse, misuse, and psychogenic factors. In the 2286 cases of all forms of voice disorders reported by Brodnitz in 1971, 80% of the disorders were attributed to voice abuse or to psychogenic factors resulting in vocal dysfunction. Of these patients, 20% had organic voice disorders. Of women with organic problems, approximately 15% had identifiable endocrine causes. In the author's experience, a much higher incidence of organic disorders, particularly reflux laryngitis and acute infectious laryngitis, is found more frequently.

Sataloff (1991) considers causes of voice disorders in Professional voice users as follows:

·         Misuse and abuse: poor singing/speaking techniques, singing out of range, chronic coughing, throat clearing, poor hydration, overuse of voice.

·         Chronic medical problems: esophageal reflux, allergies, upper respiratory tract infection, poor diet, fatigue, illicit drug use.

·         Environmental factors: performing in smoky, dry environment, exhaustive schedule, poor acoustics, and loud music.

·         Emotional factors: stage fright, anxiety, depression, performance stress.

Diseases and medical conditions that commonly affect the voice:

Vocal abuse: voice abuse is defined as normal vocal physiology carried out to an abnormal degree usually either in loudness or duration. Experimental evidence shows that the elevated pitch may be deleterious as well. Johnson has pointed out that the use of even normal vocal loudness and duration in the presence of infectious processes also may contribute. When voice abuse is suspected or observed in a patient with vocal problems. Voice abuse and/or misuse should be suspected particularly in patients who report voice fatigue associated with voice use, in those whose voices are worse at the end of a working day or week, and in those who are chronically hoarse. Technical errors in voice use may be the primary etiology of a voice problem, or the condition may develop secondarily as a result of a patient's efforts to compensate for voice disturbance from another cause.

Vocal symptom mainly seen in professional voice users is vocal fatigue. Signs of vocal fatigue: compromise in posture, hoarseness, excessive throat clearing, loss of intensity on extremes of pitch range, high and low notes become weaker, special signs of vocal fatigue in singers are lack of ability to sustain long phrases, loss of tone focus and irregularity in vibration.

Speaking in noisy environments (eg, cars, airplanes) is particularly abusive to the voice. Other activities that are abusive to the voice include backstage greetings, postperformance parties, choral conducting, voice teaching, and cheerleading. All these vocal activities can be done safely with proper training; however, most patients (surprisingly, even singers) have little or no training for their speaking voice. Abuse of the voice during singing is an even more complex problem.

Specialized singing training may be helpful to some voice patients who are not singers, and it is invaluable for patients who are singers. Initial singing training teaches relaxation techniques and develops muscle strength, and it should be symbiotic with standard speech therapy.

Neurological voice disorders: the vocalist requires coordinated fine movements, strength, speed and endurance which are moderated by the central and peripheral nervous sytem. Central or peripheral voice quality characteristics are identifiable in different nervous system disorders. Some of them, such as myasthenia gravis, are amenable to medical therapy with drugs such as pyridostigmine (Mestinon). Such therapy frequently restores the voice to normal. However more commonly the voice disorder presents a part of a complex oral, pharyngeal, and laryngeal disorder resulting from paralysis and paresis of multiple organs of voice, speech and swallowing. Tremor can be a significant problem for some vocalists. This may be due to essential tremor or to a tremor of another etiology such as Parkinson disease. Some of the other neurological diseases that results in voice problems are multiple sclerosis, dysarthria, spasmodic dysphonia etc.

Systemic disease:

Endocrine dysfunction

Endocrine (hormonal) problems warrant special attention. The human voice is extremely sensitive to endocrinologic changes, and many of these are reflected in alterations of fluid content of the lamina propria just beneath the laryngeal mucosa. This causes alterations in the bulk and shape of the vocal folds and results in voice change. Hypothyroidism is a well-recognized cause of such voice disorders, although the mechanism is not fully understood. Hoarseness, vocal fatigue, muffling of the voice, loss of range, and a sensation of a lump in the throat may be present even with mild hypothyroidism. Even when thyroid function tests results are within the low-normal range, this diagnosis should be considered, especially if thyroid-stimulating hormone levels are in the high-normal range or are elevated. Thyrotoxicosis may result in similar voice disturbances.

Voice changes associated with sex hormones are commonly encountered in clinical practice and have been investigated more thoroughly than other hormonal changes. Although a correlation appears to exist between sex hormone levels and the depth of male voices (higher testosterone and lower estradiol levels in basses than in tenors), the most important hormonal considerations in males occur during the maturation process.

When castrato singers were in vogue, castration at approximately age 7-8 years resulted in failure of laryngeal growth during puberty, and voices that stayed in the soprano or alto range boasted a unique quality of sound. Failure of a male voice to change at puberty is uncommon today and is often psychogenic in etiology; however, hormonal deficiencies, such as those seen in cryptorchidism, delayed sexual development, Klinefelter syndrome, or Fröhlich syndrome, may be responsible. In these cases, a persistently high voice may be what causes the patient to seek medical attention.

Voice problems related to sex hormones are more common in female singers than in male singers. Although vocal changes associated with the normal menstrual cycle may be difficult to quantify with current experimental techniques, they unquestionably occur. Most of the ill effects are observed in the immediate premenstrual period and are known as laryngopathia premenstrualis. This common condition is caused by physiologic, anatomic, and psychological alterations secondary to endocrine changes.

The vocal dysfunction is characterized by decreased vocal efficiency, loss of the highest notes in the voice, vocal fatigue, slight hoarseness, and some muffling of the voice. The dysfunction is often more apparent to the singer than to the listener. Submucosal hemorrhages in the larynx are common in the premenstrual period. Premenstrual changes cause significant vocal symptoms in approximately one third of singers. Although ovulation inhibitors have been demonstrated to mitigate some of these symptoms, in some women (approximately 5%), oral contraceptives may deleteriously alter voice range and character even after only a few months of use. When oral contraceptives are used, closely monitor the voice. Under crucial performance circumstances, oral contraceptives may be used to alter the time of menstruation, but this practice is justified only in unusual situations. Symptoms very similar to laryngopathia premenstrualis occur in some women during ovulation.

Pregnancy frequently results in voice alterations known as laryngopathia gravidarum. The changes may be similar to premenstrual symptoms or may be perceived as desirable changes. In some patients, alterations produced by pregnancy are permanent. Although hormonally induced changes in the larynx and respiratory mucosa secondary to menstruation and pregnancy are discussed widely in the literature, the author has found no reference to the important alterations in abdominal support. Uterine muscle cramping associated with menstruation causes pain and compromises abdominal support. Abdominal distension during pregnancy also interferes with abdominal muscle function. Discourage any singer from singing whose abdominal support is substantially compromised until the abdominal function is resolved.

Estrogens are helpful in postmenopausal singers but generally should not be administered alone. Sequential replacement therapy is the most physiologic regimen and should be used under the supervision of a gynecologist. Under no circumstances should androgens, even in small amounts, be given to female singers if any reasonable therapeutic alternative exists. Clinically, these drugs most commonly are used to treat endometriosis. Androgens cause unsteadiness of the voice, rapid changes of timbre, and lowering of the fundamental frequency (ie, masculinization). These changes are usually permanent.

Recently, an increase in the abuse of anabolic steroids has occurred. In addition to their many other hazards, these medications may alter the voice. They are (or are closely related to) male hormones; consequently, anabolic steroids are capable of producing masculinization of the voice. Lowering of the fundamental frequency and coarsening of the voice produced in this fashion are generally irreversible.

Other hormonal disturbances may also produce vocal dysfunction. In addition to the thyroid gland and the gonads, the parathyroid, adrenal, pineal, and pituitary glands are included in this system. Other endocrine disturbances may also alter voice. For example, pancreatic dysfunction may cause xerophonia (dry voice), as in diabetes mellitus. Thymic abnormalities can lead to feminization of the voice.

Anxiety

Good singers are frequently sensitive and communicative people. When the principal cause of vocal dysfunction is anxiety, the physician can often accomplish much by assuring the patient that no organic problem is present and by stating the diagnosis of anxiety reaction. The patient should be counselled that anxiety is normal and that recognition of it as the principal problem frequently allows the performer to overcome it.

Tranquilizers and sedatives are rarely necessary and are undesirable because they may interfere with fine motor control. For example, beta-adrenergic blocking agents (eg, propranolol hydrochloride) have become popular among performers for the treatment of preperformance anxiety.

Beta-blockers are not recommended for regular use; they have significant adverse effects on the cardiovascular system and many potential complications (eg, hypotension, thrombocytopenic purpura, mental depression, agranulocytosis, laryngospasm with respiratory distress, bronchospasm). Beta-blockers impede increases in heart rate, which are needed as physiologic response to the psychological and physical demands of performance.

In addition, the efficacy of beta-blockers is controversial. Although they may have a favorable effect in relieving performance anxiety, beta-blockers may produce a noticeable adverse effect on singing performance, as shown by Gates et al. Because the blood level of the drug established by a given dose of a beta-blocker varies widely among individuals, initial use of these agents before performance may be particularly troublesome. Although these drugs have a purpose under occasional extraordinary circumstances, their routine use for this purpose is potentially hazardous and violates an important therapeutic principle.

Performers have chosen a career that exposes them to the public. If such persons are so incapacitated by anxiety that they are unable to perform the routine functions of their chosen profession without chemical help, this should be considered symptomatic of an important underlying psychological problem. For a performer to depend on drugs to perform is neither routine nor healthy, whether the drug is a benzodiazepine, a barbiturate, a beta-blocker, or alcohol. If such dependence exists, psychological evaluation should be considered by an experienced arts-medicine psychologist or psychiatrist. Obscuring the symptoms by fostering the dependence is insufficient; however, if the singer is on tour and will be under a particular otolaryngologist's care only for a week or two, the physician should not try to make major changes in personal customary regimen. Rather, the physician should communicate with the performer's primary otolaryngologist or family physician to coordinate appropriate long-term care.

Because professional voice users constitute a subset of society, all the psychiatric disorders encountered in the general public are observed in professional voice users from time to time. In some cases, professional voice users require modification of the usual psychological treatment, particularly with regard to psychotropic medications.

When voice professionals, especially singers and actors, have a significant vocal impairment that results in voice loss or the prospect of voice loss, they often experience a psychological process very similar to grieving. In some instances, fear of discovering that the voice is lost forever may unconsciously prevent patients from trying to use their voices optimally following injury or treatment. This can dramatically impede or prevent recovery of function following a perfect surgical result, for example. Otolaryngologists, performers, and their teachers must be familiar with this fairly common scenario, and including an arts-medicine psychologist, psychiatrist, or both as part of the voice team is ideal.

Other psychological problems

Psychogenic voice disorders, incapacitating psychological reactions to organic voice disorders, and other psychological problems are commonly encountered in young voice patients.

Substance abuse

The list of substances ingested, smoked, or snorted is disturbingly long. Whenever possible, patients who care about vocal quality and longevity should be educated by their physicians and teachers about the deleterious effects of such habits upon their voices and on the longevity of their careers.

Gastroesophageal reflux laryngitis

Gastroesophageal reflux laryngitis is extremely common among patients, especially singers, with voice conditions. In this condition, the sphincter between the stomach and esophagus is inefficient, and acidic stomach secretions reach the laryngeal tissues, causing inflammation. The most typical symptoms of gastroesophageal reflux laryngitis are hoarseness in the morning, prolonged vocal warm-up time, sore throats, halitosis and a bitter taste in the mouth in the morning, recurrent respiratory tract infections, a feeling of a lump in the throat, frequent throat clearing, chronic irritative cough, and frequent tracheitis or tracheobronchitis. Any or all of these symptoms may be present. Heartburn is not common in these patients; thus, the diagnosis is often missed. Gastroesophageal reflux laryngitis is associated with the development of Barrett esophagus, esophageal carcinoma, and laryngeal carcinoma.

Physical examination usually reveals erythema and edema of the arytenoid mucosa and interarytenoid pachydermia. A barium swallow radiographic study with water siphonage may provide additional information, but it is not routinely needed. However, if a patient complies strictly with treatment recommendations and does not show marked improvement within a month, or if there is a reason to suspect more serious pathology, complete evaluation by a gastroenterologist should be done. This is often advisable for patients who are older than 40 years or who have had reflux symptoms for more than 5 years. Twenty-four hour pH impedance monitoring of the esophagus is often effective in establishing a diagnosis. The results are correlated with a diary of the patient's activities and symptoms. Bulimia should also be considered in the differential diagnoses when symptoms are refractory to treatment and other physical and psychological signs are suggestive.

The mainstays of treatment for reflux laryngitis are elevation of the head of the bed (not just sleeping on pillows), antacids, H2 blockers or proton-pump inhibitors, medications that decrease or block acid production, and avoidance of eating for 3-4 hours before going to bed. This is often difficult for singers and actors because of their performance schedules, but if they are counseled about minor changes in eating habits (such as eating larger meals at breakfast and lunch), they can usually comply. Avoidance of alcohol, caffeine, and specific foods is beneficial.

Recognize that control of acidity is not the same as control of reflux. In many cases, reflux is provoked during singing because of the increased abdominal pressure associated with support. During the first 10 or 15 minutes of a performance or lesson, reflux often causes excessive phlegm and throat clearing, as well as other common reflux laryngitis symptoms, all of which may be present, even when acidity has been effectively neutralized. Laparoscopic Nissen fundoplication has proven extremely effective and should be considered a reasonable alternative to life-long treatment with medications in this relatively young patient population.

Allergy

Even mild allergies are more incapacitating to professional voice users than to others. Allergies commonly cause voice problems by altering the mucosa and secretions and causing nasal obstruction. Management of allergies is not covered in depth here, as this subject can be reviewed elsewhere. Patients with mild, intermittent allergies can usually be treated with antihistamines, although antihistamines should never be tried for the first time immediately before a performance. Because antihistamines commonly produce unacceptable adverse effects, trial and error may be needed to find a medication with an acceptable balance between positive effect and adverse effects for any individual patient, especially a voice professional.

Patients with allergy-related voice disturbances may find hyposensitization a more effective approach than antihistamine use, if they are candidates for such treatment. For voice patients with unexpected allergic symptoms immediately before an important voice commitment, corticosteroids should be used rather than antihistamines in order to minimize the risks of adverse effects (eg, drying and thickening of secretions) that may make performance difficult or impossible.

Aging

This subject is so important that it has been covered extensively in other literature. That many of the voice changes commonly associated with aging are not irreversible aging changes but rather consequences of conditioning or other correctable factors must be remembered. Geriatric voice conditions offer exciting possibilities for intervention.

Hearing loss

Hearing loss is often overlooked as a source of vocal problems. Auditory feedback is fundamental to speaking and singing. Interference with this control mechanism may result in altered vocal production, particularly if the person is unaware of the hearing loss. Distortion, particularly pitch distortion (diplacusis), may also pose serious problems for the singer. This appears to be not only because of aesthetic difficulties in matching pitch but also because of the vocal strain that accompanies pitch shifts.

Respiratory dysfunction

Respiratory impairment is especially problematic for professional performers. The importance of the breath has been well recognized in the field of voice pedagogy. Respiratory disorders are discussed at length in other literature. However, recognizing that obstructive pulmonary disease and its treatments may cause difficulty for voice professionals is important. Even mild asthma interferes with expiration, thereby undermining the power source of the voice. This commonly leads to compensatory hyperfunction, voice fatigue, and vocal injury.

Most pulmonologists treat asthma primarily with inhalers, which commonly cause laryngitis; steroid inhalers are also associated with fungal (candidal) laryngitis and possibly with vocal fold muscle atrophy. Whenever possible, singers and other voice professionals with obstructive lung disease should be treated with long-acting oral medications alone, minimizing or eliminating the need for inhalers. Recognizing that asthma can be induced by the exercise of phonation itself is particularly important, and in many cases, a high index of suspicion and a methacholine challenge test are needed to avoid missing this important diagnosis.

Infection and inflammation:

Upper respiratory tract infection without laryngitis

Although mucosal irritation is usually diffuse, patients sometimes have marked nasal obstruction with little or no sore throat and a seemingly normal voice. If the laryngeal examination shows no abnormality, singers or professional speakers with supposed head colds should be permitted to use their voices but advised not to try to duplicate their usual sound. Instead, they should try to accept the alterations in self-perception caused by the changes in the supraglottic vocal tract and auditory system. The decision as to whether performing under these circumstances is advisable professionally rests with the voice professional and his or her musical associates. The patient should be cautioned against throat clearing, as this is traumatic and may produce laryngitis. If a cough is present, nonnarcotic medications should be used to suppress it. In addition, the patient should be taught to "silent cough," as this is less traumatic.

Laryngitis with serious vocal fold injury

Hemorrhage in the vocal folds and mucosal disruption associated with acute laryngitis are contraindications to singing. When these are observed, treatment includes strict voice rest and correction of any underlying disease. Vocal fold hemorrhage in skilled singers is most common in premenstrual women who are using aspirin products for dysmenorrhea. Severe hemorrhage or mucosal scarring may result in permanent alterations in vocal fold vibratory function. In rare instances, surgical intervention may be necessary. The potential gravity of these conditions must be stressed, because singers are generally reluctant to cancel an appearance.

At present, acute treatment of vocal fold hemorrhage is controversial. Most laryngologists allow the hematoma to resolve spontaneously. Because this sometimes results in an organized hematoma and scar formation requiring surgery, some physicians advocate incision along the superior edge of the vocal fold and drainage of the hematoma in selected patients.

Laryngitis without serious damage

Mild-to-moderate edema and erythema of the vocal folds may result from either infection or from noninfectious causes. In the absence of mucosal disruption or hemorrhage, edema and erythema are not absolute contraindications to voice use. Noninfectious laryngitis is commonly associated with excessive voice use in preperformance rehearsals. It may also be caused by other forms of voice abuse and by mucosal irritation produced by allergy, smoke inhalation, and other causes. Mucous stranding between the anterior and middle thirds of the vocal folds is commonly observed in inflammatory laryngitis. Laryngitis sicca is associated with dehydration, dry atmosphere, mouth breathing, and antihistamine therapy. Deficiency of mucosal lubrication causes irritation and coughing and results in mild inflammation.

If no pressing professional need for performance exists, inflammatory conditions of the larynx are best managed with relative voice rest in addition to other modalities. However, in some instances, singing may be permitted. The singer should be instructed to avoid all forms of irritation and to rest the voice at all times except during warm-up and performance. Corticosteroids and other medications discussed below may be helpful. If mucosal secretions are copious, low-dose antihistamine therapy may be beneficial, but it must be prescribed with caution and should generally be avoided. Copious, thin secretions are better for a singer than scant, thick secretions or excessive dryness.

A singer with laryngitis must be kept well hydrated to maintain the desired character of mucosal lubrication. The singer should be instructed to consume enough water to keep urine diluted. Psychological support is crucial. For the physician to intercede on the singer's behalf and convey "doctor's orders" directly to agents or theatre management is often helpful. Such mitigation of exogenous stress can be highly therapeutic.

Infectious laryngitis may be caused by bacteria or viruses. Subglottic involvement frequently indicates a more severe infection, which may be difficult to control in a short period. Indiscriminate use of antibiotics must be avoided; however, when the physician is in doubt as to the cause and when a major performance is imminent, vigorous antibiotic treatment is warranted. In this circumstance, the damage caused by allowing progression of a curable condition is greater than the damage that may result from a course of therapy for an unproven microorganism while culture results are pending. When a major performance is not imminent, indications for therapy are the same as those for nonsinging individuals.

Voice rest (absolute or relative) is an important therapeutic consideration in any case of laryngitis. When no professional commitments are pending, a short course of absolute voice rest may be considered because it is the safest and most conservative therapeutic intervention. This means absolute silence and communication with a writing pad. The patient must be instructed not even to whisper, which may be an even more traumatic vocal activity than speaking softly. Whistling through the lips also involves vocal fold activity and should not be permitted. The playing of many musical wind instruments also involves vocal activity.

Absolute voice rest is necessary only for serious vocal fold injury, such as hemorrhage or mucosal disruption. Even then, it is virtually never indicated for more than 7-10 days. Absolute voice rest for 3 days is often sufficient. Some excellent laryngologists do not believe voice rest should be used at all. However, absolute voice rest for a few days may be helpful for patients with laryngitis, especially those gregarious verbal singers who find it difficult to moderate their voice use to comply with relative voice rest instructions.

In many instances, considerations of finances and reputations mitigate against a recommendation of voice rest. In advising performers to minimize vocal use, Punt counseled, "Don't say a single word for which you are not being paid." This admonition frequently guides the affected singer away from preperformance conversations and backstage greetings and allows a successful series of performances.

Singers should also be instructed to speak softly and as infrequently as possible (often at a slightly higher pitch than usual), to avoid excessive telephone use, and to speak with abdominal support as they would in singing. This is relative voice rest, and it is helpful for most patients. An urgent session with a speech-language pathologist is extremely helpful for discussing vocal hygiene and for providing guidelines to prevent voice abuse. Nevertheless, the singer must be aware that some risk is associated with performing with laryngitis even when singing is possible. Inflammation of the vocal folds is associated with increased capillary fragility and increased risk of vocal fold injury or hemorrhage. Many factors must be considered in determining whether a given performance is important enough to justify the potential consequences.

Steam inhalations deliver moisture and heat to the vocal folds and tracheobronchial tree and may be useful. Some people use nasal irrigations, though these have little proven value. Gargling has no proven efficacy, but it is probably harmful only if it involves loud, abusive vocalization as part of the gargling process. Ultrasonic treatments, local massage, psychotherapy, and biofeedback directed at relieving anxiety and decreasing muscle tension may be helpful adjuncts to a broader therapeutic program. Psychotherapy and biofeedback, in particular, must be expertly supervised if used.

Voice lessons given by an expert teacher are invaluable. When technical dysfunction is suggested, the singer should be referred to one. Even when an obvious organic abnormality is present, referral to a voice teacher is appropriate, especially for younger singers. Numerous techniques permit a singer to overcome some of the impairments of mild illness safely. If a singer plans to proceed with a performance during an illness, the singer should not cancel voice lessons as part of the relative voice rest regimen; rather, a short lesson to ensure optimal technique can be extremely useful.

Sinusitis

Chronic inflammation of the mucosa lining the sinus cavities commonly produces thick secretions known as postnasal drip. Postnasal drip can be particularly problematic because it causes excessive phlegm, which interferes with phonation, and because it leads to frequent throat clearing, which may inflame the vocal folds. Sometimes, chronic sinusitis is caused by allergies and can be treated with medications; however, many medications used for this condition cause adverse effects, particularly mucosal drying, that are unacceptable for professional voice users. When medical management is not satisfactory, functional endoscopic sinus surgery may be appropriate. Acute purulent sinusitis is a different matter. It requires aggressive treatment with antibiotics, surgical drainage (sometimes), treatment of underlying conditions (eg, dental abscess), and surgery (occasionally).

Structural abnormalities:

Nodules

Nodules are callous-like masses of the vocal folds caused by vocally abusive behaviors, and they are a dreaded malady of singers. Occasionally, laryngoscopy reveals vocal nodules that do not produce symptoms and do not appear to interfere with voice production; in such cases, the nodules should not be treated. Some famous and successful singers have had untreated vocal nodules throughout their entire careers.

However, in most cases, nodules result in hoarseness, breathiness, loss of range, and vocal fatigue. They may be caused by abusive speaking rather than the singing voice. Voice therapy should always be tried as the initial therapeutic modality; it cures nodules in most patients, even if the nodules look firm and have been present for many months or years. Even apparently large, fibrotic nodules often shrink, disappear, or stop producing symptoms with 6-12 weeks of voice therapy with good patient compliance. Preoperative voice therapy is essential to prevent recurrence, even in patients who eventually need surgical excision of the nodules.

Care must be taken in diagnosing nodules. Consistent and accurate diagnosis is almost impossible without strobovideolaryngoscopy and good optical magnification. Vocal fold cysts are commonly misdiagnosed as nodules, and management strategies are different for the 2 lesions. Vocal nodules are confined to the superficial layer of the lamina propria and are composed primarily of edematous tissue or collagenous fibers. Basement membrane reduplication is common. Vocal nodules are usually bilateral and fairly symmetrical.

Exercise caution in diagnosing small nodules in patients who have been singing actively. In many singers, bilateral symmetrical soft swellings at the junction of the anterior and middle thirds of the vocal folds develop after heavy voice use. No evidence suggests that singers with such physiologic swellings are predisposed to development of vocal nodules. At present, the condition is generally considered to be within normal limits. The physiologic swelling usually disappears with 24-48 hours of rest from heavy voice use. The physician must be careful not to frighten the singer by misdiagnosing physiologic swellings as vocal nodules. Nodules carry a great stigma among singers, and the psychological impact of the diagnosis should not be underestimated. When nodules are present, these patients should be informed with the same gentle caution used in telling a patient that he or she has a life-threatening illness.

Submucosal cysts

Submucosal cysts of the vocal folds are probably traumatic lesions that, in many cases, result from blockage of a mucous gland duct; however, they may also be congenital or occur from other causes. They often cause contact swelling on the contralateral side and are usually initially misdiagnosed as nodules. Typically, submucosal cysts can be differentiated from nodules by strobovideolaryngoscopy when the mass is obviously fluid filled. They may also be suggested when the nodule (contact swelling) on one vocal fold resolves with voice therapy while the mass on the other vocal fold does not resolve.

Cysts may also be discovered on 1 side (occasionally both sides) when surgery is performed for apparent nodules that have not resolved with voice therapy. The surgery should be performed superficially and with minimal trauma. Cysts are ordinarily lined with thin squamous epithelium. Retention cysts contain mucus. Epidermoid cysts contain caseous material. Generally, cysts are located in the superficial layer of the lamina propria. In some cases, cysts are attached to the vocal ligament.

Polyps

Vocal polyps, another type of vocal fold mass, usually occur on only one vocal fold. They often have a prominent feeding blood vessel coursing along the superior surface of the vocal fold and entering the base of the polyp. In many cases, the pathogenesis of polyps cannot be proven, but the lesions are thought to be traumatic and sometimes start as hemorrhages. Polyps may be sessile or pedunculated. They are typically located in the superficial layer of the lamina propria and do not involve the vocal ligament.

In those polyps arising from an area of hemorrhage, the vocal ligament may be involved with posthemorrhagic fibrosis that is contiguous with the polyp. Histological evaluation most commonly reveals collagenous fibers, hyaline degeneration, edema, thrombosis, and often bleeding within the polypoid tissue. Cellular infiltration may also be present. In some cases, even sizable polyps resolve with relative voice rest and a few weeks of low-dose steroid therapy (eg, 4 mg methylprednisolone twice daily); however, most require surgical removal.

If polyps are not treated, they may produce contact injury on the contralateral vocal fold. Patients should receive voice therapy to ensure good relative voice rest and prevention of abusive behavior before and after surgery. When surgery is performed, care must be taken to not damage the leading edge of the vocal fold, especially if a laser is used. In all laryngeal surgery, delicate microscopic dissection is now the standard of care. Vocal fold stripping is an out-of-date surgical approach that was used for benign lesions. Vocal fold stripping often resulted in scarring, poor unserviceable voice function, or both; therefore, it is no longer an acceptable surgical technique in most situations.

Granulomas

Granulomas usually develop in the cartilaginous portion of the vocal fold near the vocal process or on the medial surface of the arytenoid. They are composed of collagenous fibers, fibroblasts, proliferated capillaries, and leukocytes. They are usually covered with epithelium. Granulomas are associated with gastroesophageal reflux laryngitis and trauma (eg, voice abuse, intubation). Therapy should include reflux control, voice therapy, and surgery if the granuloma does not resolve promptly.

Reinke's edema

Reinke's edema is characterized by an "elephant ear" floppy vocal fold appearance. It is often observed during examination in many nonprofessional and professional voice users and is accompanied by a low, coarse, gruff voice. In Reinke's edema, the superficial layer of lamina propria (Reinke's space) becomes edematous. The lesion usually does not include hypertrophy, inflammation, or degeneration; however, other terms for the condition include polypoid degeneration, chronic polypoid chorditis, and chronic edematous hypertrophy.

Reinke's edema is often associated with smoking, voice abuse, reflux, and hypothyroidism. Underlying conditions should be treated; however, the condition often requires surgery. Perform surgery only in the presence of justified high suspicion of serious pathology (eg, cancer) or airway obstruction or if the patient is unhappy with personal vocal quality. For some voice professionals, abnormal Reinke's edema is an important component of the vocal signature. Although the condition is usually bilateral, surgery should generally be performed on one side at a time.

Sulcus vocalis

Sulcus vocalis is a groove along the edge of the membranous vocal fold. Most of these lesions are congenital, bilateral, and symmetrical, although posttraumatic acquired lesions occur. When it produces symptoms (it often does not), sulcus vocalis can be treated surgically if sufficient voice improvement is not obtained through voice therapy.

Scar

Vocal fold scarring is a sequela of trauma that results in fibrosis and obliteration of the layered structure of the vocal fold. It may markedly impede vibration and, consequently, may cause profound dysphonia. Recent surgical advances, as described by Sataloff et al, have made this condition much more treatable than in the past; however, restoring voices to normal in the presence of scarring remains rarely possible.

Hemorrhage

Vocal fold hemorrhage is a potential disaster for singers. Hemorrhages resolve spontaneously in most cases, with restoration of normal voice. However, in some instances, the hematoma organizes and fibroses, resulting in scarring. This alters the vibratory pattern of the vocal fold and can result in permanent hoarseness. In specially selected cases, avoiding this problem through surgical incision and drainage of the hematoma may be best. In all cases, vocal fold hemorrhage should be managed with absolute voice rest until the hemorrhage has resolved (usually about 1 wk) and relative voice rest until normal vascular and mucosal integrity have been restored. This often takes 6 weeks, sometimes longer. Recurrent vocal fold hemorrhages are usually due to weakness in a specific blood vessel, which may require surgical cauterization of the blood vessel using a laser or microscopic resection of the vessel.

Papilloma

Laryngeal papillomas are epithelial lesions caused by the human papilloma virus. Histology reveals neoplastic epithelial cell proliferation in a papillary pattern and viral particles. Presently, symptom-producing papillomas are managed surgically, although alternatives to the usual laser vaporization approach have been recommended by Sataloff and others. At present, the author is also using intralesional injection of cidofovir, as described by Wellens et al.

Cancer

The prognosis for small vocal fold cancers is good, whether they are treated by radiation or surgery. Although perhaps intuitively obvious that radiation therapy provides a better chance of voice conservation than even limited vocal fold surgery, later radiation changes in the vocal fold may produce substantial hoarseness, xerophonia (dry voice), and voice dysfunction.

Consequently, from the standpoint of voice preservation, optimal treatments remain uncertain. Prospective studies using objective voice measures and strobovideolaryngoscopy should answer the relevant questions in the near future. Strobovideolaryngoscopy is also valuable for follow-up of patients who have had laryngeal cancers. It permits detection of vibratory changes associated with infiltration by the cancer long before they can be seen with continuous light. Stroboscopy has been used in Europe and Japan for this purpose for many years. In the United States, the popularity of strobovideolaryngoscopy for follow-up of cancer patients has increased greatly in recent years.

The psychological consequences of vocal fold cancer can be devastating, especially for professional voice users. The consequences can be overwhelming for individuals who are not voice professionals as well. These reactions are understandable and expected. In many patients, however, psychological reactions may be as severe following medically "less significant" vocal fold problems such as hemorrhages, nodules, and other conditions that do not command the sympathy afforded to a person with cancer. In many ways, the management of related psychological problems can be even more difficult for patients with these "lesser" vocal disturbances.

Vocal fold hypomobility or immobility

Vocal fold hypomobility may be caused by laryngeal nerve paralysis or paresis, arytenoid cartilage dislocation, cricoarytenoid joint dysfunction, and laryngeal fracture. Differentiating these conditions is often more complicated than would initially be expected. A comprehensive discussion is beyond the scope of this article, and the reader is referred to other literature. However, in addition to a comprehensive history and physical examination, evaluation commonly includes strobovideolaryngoscopy, objective voice assessment, laryngeal electromyography, and high-resolution computed tomography (CT) of the larynx. Most vocal fold motion disorders are amenable to management. Voice therapy should be the first treatment modality in virtually all cases. Even for many patients with recurrent laryngeal nerve paralysis, voice therapy alone is often sufficient to produce a satisfactory voice. When therapy fails to produce adequate voice improvement in the patient's opinion, surgical intervention is appropriate.

ASSESSMENT:

Assessment of professional voice users includes the following steps:

A) Detailed case history

B) Physical examination

C) Subjective evaluation

D) Objective evaluation

A) Detailed Case History:

•      Age: As the vocal mechanism undergoes normal maturation, the voice changes. The optimum time to begin serious vocal training is controversial. Vocal training and serious singing near puberty in female and after puberty in males is generally recommended (Sataloff, 1981). The voice also changes due to normal aging.  Generally the voice becomes breathy and the vocal range reduces. This is because abdominal, thorax and general muscle tone and elasticity decrease. Aging effect is more pronounced in female than in males. Excellent male’s singers may extend their voice to more than 70 years while it is usually 50 years for females.

•      Complaint: It is important to identify acute and chronic problems before beginning therapy to have realistic expectation and optimum therapeutic section.

Hoarseness – coarse or scratchy sound often associated with laryngitis or mass lesion.

Breathiness – vocal quality characterized by excessive loss of air during vocalization after associated with vocal cord paralysis, mass lesions.

Fatigue – Inability to continue to sing for extended periods.  The voice may become hoarse and change timbre.  Misuse of abdominal muscle, neck muscle overuse, singing too loud, too long cause fatigue.

Volume disturbance – Inability to sing loudly or inability to sing softly.

Warm up time – Most singer require about 10 min to half an hour of warm up time.

Pain – Infection or  gastric acid irritation of arytenoids vocal abuse.

Rehearsal: Physician should know how long he / she practices; at what time. Serious practice for one or two hour / day is usually recommended.  A laryngologist / SLP should also be certain that professional voice users ‘warm-down’ the voice. 

Vocal abuse in singing: The most common technical error involve excessive muscle tension in the tongue, neck and larynx. These may be due to inadequate preparation or limited vocal training or both voice abuse is more common in pop-singers.

General health: The vocal mechanism is finely tuned, complex instrument and is exquisitely sensitive to minor changes. Substantial fluctuations in weight frequently result in deleterious alterations of the voice, although these are usually temporary. A history of sudden recent weight change may be responsible for almost any vocal complaint.  Infections sinusitis may alter the sound of a singer’s voice. Reflux laryngitis is common among singers because of the high intra-abdominal pressure associated with proper support.

Exposure to irritants: Allergies to dust are aggravated commonly during rehearsals and performance in older concert halls because of the numerous curtains, backstage trappings and dressing room facilities that are rarely cleaned thoroughly. The drying effects of cold air and dry heat may also affect mucosal secretions, leading to decreased lubrication and a scratchy voice and tickling cough. Singers must be careful to avoid talking loudly and to maintain nasal breathing and good hydration during air travel.

Smoke: Stage smoke present a special problem, commonly encountered by actors. This smoke may be especially irritating and dangerous, especially if it’s oil-based. Smoking should not be permitted in serious singers because tobacco smoke and heat causes mild edema and generalized inflammation throughout the vocal tract.

Drugs: Singers should take all drugs very carefully as many have side effects and may alter the voice. Few drugs like antihistamines, antibiotics and diuretics which are popularly used by singers should be taken with caution. Cocaine use is increasingly common, especially among pop musicians. It can be extremely irritating to the nasal mucosa, causes marked vasoconstriction resulting in decreased voice control land a tendency toward vocal abuse.

Foods: Various foods are said to affect voice.  Traditionally milk and ice-cream are avoided by singers before performances. Coffee and other beverages containing caffeine also aggravate gastric reflux and seem to alter secretions and necessitate frequent throat clearing in some people. Lemon juice and herbal teas are both felt to be beneficial to the voice.

Surgery: Any history of surgery involving thoracic, abdominal laryngeal, supralaryngeal structures is a matter of great concern. Surgical traumas may also cause vocal dysfunction.  Tonsillectomy cause vocal dysfunction. It takes three to six months for a singer’s voice to stabilize to normal voice. Thoracic and abdominal surgery interferes with respiratory and abdominal support.

B) Physical examination:

Head and Neck Examination: a comprehensive head and neck evaluation should be completed in all vocalists who have a voice related compliant. An otologic examination is critical in the evaluation of the vocalist. Hearing loss may interfere with the prominent role of auditory feedback necessary for the fine tuning the vocal mechanism. Nasal examination should begin with external nose. Marked external deformities can result in internal derangements in breathing. After nasal, oral examination is to be carried out. Visualization of nasopharynx is particularly difficult. A small nasopharyngeal mirror with light directed from a head mirror will allow the otolaryngologist to observe the nasophayngeal structures. The epiglottis should be seen, looking for epiglottis cysts or abnormalities in epiglottic movement. Throughout the oral and nasal examination attention should be placed on observing the quality, amount and characteristics of the mucus.

The Neurologic examination: an assessment of most of the cranial nerves is easily achieved by just observing the patient throughout the interview process. A generalized neurologic examination is normally not indicated in a singer who has a focused head and neck or laryngeal complaint.

Musculoskeletal and postural issues: Primary musculoskeletal causes for dysphonia

•      Age related classification of the laryngeal costal cartilages

•      Muscular spasm

•      Poor posture

•      A prolapsed cervical disc

Secondary musculoskeletal issues: A high held larynx with tight suprahyoid musculature in patient with emotional stress. Supraglottic hyper function and laryngeal guarding may be evident in patient with gastro esophageal reflux, vocal fold palsy, bowing and sulcus vocalis. Limitation or restriction of movement of neck, laryngeal cartilages and cricothyroid joint have direct impact on performance and should be examined. Previous neck surgery could cause scar bands limiting laryngeal motion and thus have an impact upon the voice (Sataloff, 1991).

C) Subjective evaluation: Many vocal problems are the result of improper breathing technique. When evaluating respiration, the volume of air is important, but more critical is the manner in which the patient takes in air (inhalation) and how the air is used to produce the voice (exhalation). Abdominal / diaphragmatic breath control and support are desirable and are the most efficient manner of providing the power source of the voice. The patient’s respiration is observed in conversation speech and in reading.

I. Respiration: The following observation are made:

The pattern of breath support: Abdominal / diaphragmatic, Upper thoracic, Clavicular, Combined or mixed (thoracic and abdominal)

Posture: Head / neck misalignment, Improper sitting posture, Improper standing posture.

Phrasing: Too many words per breath, Too few words per breath, Failure to take appropriate pauses, Excessive pauses

Respiration: audible respiration, forced exhalation, labored breathing

II. Phonation: Judgements about the voice quality (hoarseness, breathiness), loudness (appropriate, too loud, too soft) and pitch are made during conversation speech and reading. 

The following characteristics are particularly important: Hoarseness, Breathiness, Glottal fry, Diplophonia, Phonation breaks.

Measures of respiratory and phonatory efficiency  are obtained using measurement of maximum exhalation or phonation for the following sounds /a/, /i/, /u/, /s/, & /z/. S/Z ratio provides useful information about the patients ability to control exhalation in the presence or absence of voicing i.e. it is an indicator of laryngeal efficiency. General observations are made regarding the patients habitual speaking pitch like appropriate pitch level, too high or too low.

III. Resonance: Excessive pharyngeal or ‘throaty’ resonance is a common characteristics and can be associated with physical discomfort in speaking. Oral resonance is desirable and is affected by the size and shape of the oral cavity. Many patients exhibit mandibular restrictions while speaking which diminishes the effectiveness of the oral cavity as a resonator. The presence of hyper or hypo nasality should be assessed carefully to rule out velopharyngeal inadequacy.

IV. Articulation: The ability of the articulators (tongue, lips, teeth, jaw & velum) to function in a smooth and connected manner in determined. Although articulation disorder is rare in this population, occasionally a ‘lisp’ has been identified.

 V. Prosody: The prosodic features of speech (rhythm, fluency, timing rate, pauses and intonation or inflection patterns are assessed generally.

D) Objective Evaluation:

Assessment of vibration:

Strobovideo laryngoscopy to assess Glottic appearance & configuration, supraglottic activity, appearanceVibratory motion, mucosal wave, amplitude, periodicity etc

ii) Aerodynamic measures:

Parameters assessed: Vital capacity, Mean airflow rate, Sub glottal pressure, Glottal resistance.

iii) Acoustic analysis:

It provides concrete information: Fundamental frequency, Jitter, Frequency range, Intensity, Shimmer, Dynamic range, Signal to noise ratio.

iv) Laryngeal electromyography

It is a technique in which electrodes are inserted directly into the muscle and the activity of muscle fibers are recorded.  It can help provide information that is helpful for the differential diagnosis of VF weakness and paralysis versus arytenoids fixation.

v) Inverse Filtering:

It is a method in which the factors contributing to the acoustic signal above the larynx are filtered.

vi) Electroglottography:

It is a method by which the contact area of the vocal folds is measured via surface electrodes applied to both sides of thyroid cartilage.

vii) Resonance:

The production of the appropriate balance of oral and nasal resonance is crucial. The overall quality of the singing tone is disturbed when there is poor resonance functionally or anatomically. There are several methods available for measuring resonance. One can measure oral vs nasal airflow, oral vs nasal resistance, and oral vs nasal accelerometer values. Some the measures used are spectrograph, nasometer.

viii) Videostroboscopy:

Stroboscopy is a technique used to observe motion in cases in which the movement is so quick that the human visual system cannot capture and process the image. Stroboscope allows to trace the vibration of vocal folds.

TREATMENT:

Clinical treatment of a voice problem fall into two main categories:

·         Medical and surgical treatment

·         Voice (speech) therapy and other conservative treatments

Voice therapy principles and techniques:

Voice therapy is a complex process that requires considerable skill from the clinician and significant motivation and insight from the patient. While voice therapy may follow a number of general principles, the specific treatment program will be customized to the individual patient’s needs and expectations. It is the clinicians task to select the appropriate technique to match these needs and expectations and to enable the patient to achieve maximal vocal rehabilitation in the most efficient and effective manner.

Indirect treatment approaches:

The aim of these indirect techniques is to manage the contributory and maintenance aspects f a voice problem. Indirect approaches are based in the assumption that inappropriate phonatory behaviour is a symptom of excessive vocal demands, vocally abusive behaviours, personal anxiety and tension and a lack of knowledge of healthy voice production. The techniques include the following:

Education and Explanation: all patients need an appropriate working knowledge of normal phonatory behaviour and how their voice production differs from this

. This places the rest of the treatment program in context and is likely to positively affect the patient’s motivation and compliance.

Vocal tract care/ Vocal hygiene: appropriate levels of vocal care and attention to hygiene are a vital step in vocal rehabilitation. This enables the patient to reflect on aspects of vocal abuse and misuse as well as observe healthy vocal habits such as adequate hydration and avoidance of laryngeal irritants.

Voice rest/ Conservation: these approaches are usually used in cases of vocalfold trauma or in the early days of vocal trauma or in the early days of postvocal fold surgery. Limiting vocal use obviously reduces the changes of mechanical damage of vocal fold vibration and allows spontaneous mucosal lining healing. Voice conservation is less strict than total voice rest and concentrates upon gentle/nonabusive modes of voice production that need to be clearly defined by the clinician and practiced by the patient.

Auditory awareness: many authors describe the need to train the voice patient’s auditory skills to help them identify the undesirable features of their voice quality. This may be done by repeated analysis of high quality taped recordings. The rationale is that by monitoring the auditory output, the patient can begin to voluntarily control the unconscious function.

Relaxation: reducing articulator and jaw tension may require specific exercises. These methods may be particularly useful for voice users in stressful jobs or those placed in vocally stressful situations (eg: telephone sales, motivational speakers).

Posture: poor body posture is likely to restrict breathing and contribute to muscle tension. Particular attention should be paid to habitual posture demands in the work place where regular voice use is also required.

Breath support: deep and regular diaphragmatic breathing is a prerequisite for good voice production. Particular attention should be paid to the controlled expiratory flow of the air for voicing. Anxiety levels, physical activity (aerobic activity), and postural restrictions (including tight clothing) may all affect appropriate diaphragmatic breathing patterns.

Manual therapy: excessive tension in the intrinsic and extrinsic laryngeal muscles may also be reduced by manual massage and digital mobilization. A number of authors reported rapid success with these techniques in reducing laryngeal tension.

Psychological counselling: the patient’s emotional and psychological status may be central to either the etiology or maintenance of the voice disorder. Many of these aspects can be addressed by the sensitive approach of a skilled clinician. Sometimes more specialist psychological help is required depending on the nature of the problem.

Direct treatment approaches:

The aim of these approaches is to modify aspects of faulty voice to promote appropriate and efficient voice production.

Reducing vocal strain: excessive laryngeal effort during phonation is a common feature of the disordered voice. A wide range of exercises exist to counteract hyperfunctional phonation and help the patient achieve good vocal fold adduction with appropriate laryngeal effort.

Changing voice quality: with guidance from the clinician, the patient may change the aspects of the method of voice production that, in turn will alter the quality of the voice produced. In effect, the patient learns to modify the breath support, air flow, VF adduction/tension, and resonance to produce the desired acoustic effect. The subject must then learn to reproduce and habitualize these features by using auditory and kinaesthetic feedback.

Pitch modification: a disordered voice may present with a habitual pitch that is either too high or too low. Experimentation with different vocal pitches frequently results in desirable changes of laryngeal effort, perceived voice quality, and enhanced vocal resonance.

Breath flow (transglottic air flow): improved control of the airflow that passes through the larynx and vibrates the VFs is likely to improve the regularity and stability of the resulting sound. Many clinic therapy programs emphasize the need for a controlled power source, which in turn allows the VFs to vibrate without requiring constant modification because of variable transglottic air flow.

Breathing and phonation coordination: coordination of breathing patterns with voicing is important for connected speech. Awareness and skilled execution of how to use two features in combination can be developed by using exercises concerned with phrase length, intentional pitch, and volume changes, extended speaking demands and so forth. This may help the patient generalize good vocal technique into more complex speaking tasks.

Enhanced resonance: improving vocal resonance enables the speaker to maximize the voice quality and carrying power. Furthermore, the sensory and auditory feedback achieved in many resonance exercises enables the speaker to increase the vocal loudness with minimum effort and with no additional hyperfunction. These skills can obviously be of great value for occupational voice users who require a loud voice (Eg: teachers, aerobic instructors, machine operators, and clergy).

Projection and amplification: appropriate voice projection requires a good breathing for speech technique, a relaxed laryngeal vibratory mechanism, and an open oral tract that is able to maximally resonant the sound. In addition, clear and precise articulation is essential for audibility in large and noisy spaces. A number of voice amplification systems are now available.

These speech and voice therapy treatment techniques cannot be done in an isolated clinical setting without also addressing the specific work environment and context voice user.

VOCAL CARE FOR THE PROFESSIONAL:

Ensuring proper laryngeal lubrication, abstaining temporarily from voice use, limiting voice use, initiating voice training and re-establishing voice use following voice rest or surgery often help to eliminate and sometimes prevent voice problems.

Laryngeal lubrication: Increased productions of mucous are the most common laryngoscopic signs of inadequate VF lubrication. Improving lubrication of larynx involves the elimination of certain undesirable behaviours and implementation of desirable behaviours. The clinician who is attuned to the problem of thickened mucous and dryness may first suggest the individual avoid or at least limit dehydrating factors. This would include primarily smoking, which probably dries the larynx because of heat associated with burning tobacco. One also must consider the possibility of the irritating effects of passive smoking on the speaker’s larynx and consider ways of reducing it. The clinician may guide the client to avoid various sources of caffeine and to avoid alcohol. Milk products also are substances known by performers to create thick mucus; therefore they avoid milk products several hours prior to performance. To avoid the above the clinician recommends the patient to drink approx. 6 to 10 glasses of water per day. Individual may benefit from mucolytic agents. The oldest substance in existence may be lemon wedges. Individual divide lemon into 6 wedges and ta ke one six times a day chewing the pulp and discarding the peel.

One of the most common causes of laryngeal dehydration involves mouth breathing. Singing and speaking are nearly synonymous with mouth breathing. Voice professionals must establish ways to modify breathing characteristics and/or the atmospheric environment to effect a more physiologic and hygienic condition of the larynx.

Voice rest: Management of vocal problems may involve temporary elimination of VF vibration or decreasing amount of potentially abusive VF contact. Brodnitz has advised voice rest to promote undisturbed, quick healing. Voice rest that essentially makes the individual mute may not be met with full compliance by patients except in the most motivated individuals. A modified voice rest approach may enjoy greater receptivity; modified voice rest means use of a soft, easily produced whisper. Even teachers are able to conduct their classroom activities using this desirable type of whispered speech, particularly when it is supplemented with amplification.

Decreasing amount and/or force of vocal cord vibration may serve as an alternative when cessation of vibration or whisper is not a recommendation of choice. Limiting voice also may also be in terms of intensity and fundamental frequency. Accordingly, advice may be offered to give less than a 100% vocal effort and transpose songs to another. For necessary voice use such as in noncancelable radio or television interviews, patients are advised to use reduced intensity by suggesting they talk no louder than if the interviwer and listening audience were only 3 feet away.

Reduction of potential abuse in voice production judged by the client to be necessary, such as throat clearing, needs further consideration. In the professional, throat clearing is one of the most common abuses. Most clinicians seem inclined to admonish the performer not to clear the throat, the admonitions are hollow words when, while performing, a person finds difficulty because of mucus collected in the larynx. Proper laryngeal lubrication is outlined. One such activity is “laryngeal squeezes”. The individual engages in the valsalva like activity (such as bearing down or lifting heavy weights) relying on the construction of the larynx to move the mucus from one sensitive area of larynx that stimulates throat clearing to an area that does not bother the performer. If this does not work, one may try swallowing or ask the individual to engage in producing a high flow rate of air through the larynx without vocalization. Throat clearing may be necessary when all other alternatives fail, beginning with a soft easy throat clearing and then repeating it more vigorously on successive trails until relief is obtained.

One of the most difficult time periods during which to avoid vocal abuse seems to be immediately after a performance. To counter the influences after performance like greeting etc, the clients may be advised to implement time-out immediately after the performance. Performances first may be reminded to consider how loud their voices really need to be in the speaking situation at hand. Reduced vocal intensity for nontelephone use also is considered. When less intensity is not feasible individuals may be encouraged to employ greater resonance through some techniques. One approach found to be particularly helpful is through the use of yawn postures.

Alteration of environmental noise that might mask vocalizations is another way of modifying what seem to be necessary but abusive behaviours.

Voice training: vocal abuse reduction program include altering singing range and/or techniques. A voice teacher may be particularly helpful to SLP and the physician in assessing an artist’s range as well as evaluating singing technique. A voice teacher also would be indicated of modifying those aspects of singing that may be abusive. This specifically includes heightnened tongue position and hyperfunction of the pharynx, larynx, neck and secondary respiratory muscles.  The SLP’s role in helping to assss such techniques includes accessibility to instrumentation for phonetogram assessment, airflow assessment, electromyographic assessment, and endoscopic evaluation during vocal performance.

The reinstatement of voice is hum-dinger retreat from voice rest. It embodies four stages:

Stage 1: hum:

·          Producing a steady tone for several seconds without pitch change.

·         Humming various pitch contours modelled by the clinician

·         Humming various pitch and loudness contours without a model

·         Interrupting the hum to produce various time patterns that may resemble slow Morse code.

Stage 2:hum and say: the 2^nd stage also capitalizes on clinician modelling rather than verbal instruction and focuses in teaching the patient that voice may be sustained independent of various mouth and tongue postures and movements associated with speech units progressing from isolated vowels to sentence production. Each utterance consists of a hum that serves as a starter and a slow, smoothed voice transition to the speech unit. A progression of speech units may include: single vowels, connected vowel sequences, nonsense and then sensical single syllables featuring first voiced consonants and than multisyllable words, phrases and sentences without initial mixed consonants.

Stage 3: think hum and say: stage 3 involves the patient’s thinking of a hum and then giving an utterance. The behaviours should be similar to those in stage 2 with the exception that the hum is inaudible. Usually the patient can quickly be moved through the progression indicated above.

Stage 4: say: the patient participating in stage 4 is to produce voice in speech units in a spontaneous manner without resorting to hum or mental rehearsal of humming. The success achieved in the previous stages inclines the patient to use voice at the sentence level without the need to experience more elementary units in the progression of earlier stages.

Behavioral intervention in dysphonia of professional voice users typically involves helping the artist to manage the use of voice to avoid the overuse of pitch, intensity and amount of vocalization.

DO’s AND DON’Ts FOR PROFESSIONAL VOICE USERS

Vocal hygiene is the term used for the use and care of the human voice required to keep it healthy. Individuals who put extra strain on their voices must keep their vocal mechanism in better condition. This can be especially true if an injury has occurred, even if the individual previously had no extraordinary voice needs.

Consult an Ear, Nose, and Throat Doctor (ENT):  Consult an otolaryngologist, or ENT, to obtain a baseline evaluation of the voice when healthy.  Establishing a healthy picture of the larynx serves as a source of comparison if encounter voice difficulties in the future. 

Maintain adequate hydration: Many physicians and clinicians propose that consuming approximately 64 ounces of non-alcoholic fluids per day is necessary to maintain adequate hydration. Research supports that adequate hydration allows vocal cords to vibrate with less “push” from the lungs, especially at high pitches. In addition, well-hydrated vocal cords resist injury from voice use more than dry cords, and recover better from existing injury than dry cords.  Increased systemic hydration also has the benefit of thinning thick secretions, (Titze, 1988; Verdolini-Marston, Druker, & Titze, 1990; Verdolini, Titze, & Fennell, 1994; Verdolini et al., 2002; Titze, 1981; Verdolini-Marston, Sandage, and Titze, 1994). Individuals who experience external dehydration, such as those individuals living or working in a very dry environment, may benefit from the use of a humidifier or vaporizer.

Obtain a vocal amplification system if routinely need to use a “loud” voice especially in an outdoor setting. Try not to speak in an unnatural pitch. Adopting an extremely low pitch or high pitch can cause an injury to the vocal cords with subsequent hoarseness and a variety of problems.

Minimize throat clearing: Clearing throat can be compared to slapping or slamming the vocal cords together. Consequently, excessive throat clearing can cause vocal cord injury and subsequent hoarseness. An alternative to voice clearing is taking a small sip of water or simply swallowing to clear the secretions from the throat and alleviate the need for throat clearing or coughing. The most common reason for excessive throat clearing is an unrecognized medical condition causing one to clear their throat too much. Common causes of chronic throat clearing include gastroesophageal reflux, laryngopharyngeal reflux disease, sinus and/or allergic disease.

Avoid behaviors that may exacerbate acid reflux: Certain behaviors and foods may exacerbate acid reflux and yield poor vocal performance.  Avoid eating spicy foods. Spicy foods can cause stomach acid to move into the throat or esophagus (reflux).

Avoid smoking:  It is well known that smoking leads to lung or throat cancer. Primary and secondhand smoke that is breathed in passes by the vocal cords causing significant irritation and swelling of the vocal cords. This will permanently change voice quality, nature, and capabilities.

Limit intake of drinks that include alcohol or caffeine: These act as diuretics (substances that increase urination) and cause the body to lose water. This loss of fluids dries out the voice. Alcohol also irritates the mucous membranes that line the throat.