November 24, 2009 Feature

Team Management of Voice Disorders in Singers

As vocal athletes, singers require special diagnostic and treatment consideration when voice difficulty develops because they must maintain higher-than-normal levels of phonatory agility, strength, and stamina to repeatedly execute complex laryngeal maneuvers (Zeitels et al., 2002). At the Massachusetts General Hospital (MGH) Center for Laryngeal Surgery and Voice Rehabilitation, a team of speech-language pathologists and laryngologists performs and coordinates the management of vocal difficulties in singers. This discussion will review state-of-the-art assessments and describe the team's use of medical, phonomicrosurgical, and voice therapy treatments to manage vocal difficulty effectively in this population.

Laryngology Assessment

It is imperative that a laryngologist experienced in treating singers conduct the initial assessment. This examination by a physician ensures full exploration of any medical problem affecting the voice with focus on the special needs of an active vocalist. Assessment begins with a thorough history and physical examination that encompasses pertinent past medical history, vocal history, voice demands, description of the difficulty, and videostroboscopic visualization of the structure and function of the larynx. This evaluation establishes a working diagnosis and provides critical information for the laryngologist-SLP team to offer appropriate treatment. The most common discrete lesions encountered in performing vocalists are fibrovascular nodules (Zeitels et al., 2002), polyps (Zeitels et al., 2002), ectasias/varices (Zeitels et al., 2006), and cysts (Burns et al., 2009).

Because treatment strategies are customized to the performer—including a combination of medical management, surgical management, and voice therapy—accurate assessment of the problem is essential. For example, most singers want to know if their current voice problem is related to a structural change on their vocal cords. They are often surprised when factors such as environmental exposures, dehydration, medication side effects, diet, and behavioral habits are found to contribute to their difficulties.

For these patients, proper assessment leads to healthy preventive vocal hygiene measures that can be introduced during the initial visit and reinforced during subsequent treatment sessions. Sometimes the reassurance that the performer does not have nodules restores the patient's confidence to a level that no further therapeutic intervention is required. When pathology is identified that requires the skills of a voice therapist, pertinent information about ongoing medical management (such as nasal sprays for the rhinitis symptoms of seasonal allergies, inhaler use for asthma, or medical and dietary management of reflux) is passed on to the clinician so that the patient's progress in treatment can be assessed in the proper context.

Initial assessment of voice disorders in singers focuses on a description of dysphonia including symptom onset, aggravating or alleviating factors, associated pain, prior evaluations and treatment, and specific problems with the singing or conversational voice. Accompanying upper aerodigestive tract symptoms such as dysphagia, odynophagia, aspiration, cough, throat clearing, and globus sensation are investigated as well. The assessment aims to determine if the primary problem is one of acoustic quality, aerodynamic efficiency, or both. For example, thick secretions and mucosal inflammation from post-nasal drip or reflux disease might affect acoustical quality only; a mass lesion such as a cyst or polyp, however, might affect aerodynamic efficiency by preventing complete glottic closure. Finally, a complete review of past and current medications will identify those that have the potential to dry out upper respiratory mucosa, which can often be a side effect of common prescription and over-the-counter medications.

Laryngology Treatment    

Following a thorough assessment of the singer's voice disorder, treatment usually follows one or more of a combination of therapies. Structural lesions are treated within the context of the patient's vocal needs, and initial management almost always involves voice therapy. Proceeding with surgical management for structural lesions (such as nodules) requires the singer's complete understanding of the surgical procedure and expected risks and benefits (Zeitels, 1998). Thus, the informed consent for surgery is extremely important and engenders a mutual responsibility for the decision of pursuing an invasive elective procedure (Zeitels et al., 2002).

Voice therapy is an integral part of surgical management of structural lesions causing dysphonia, and the singer ideally has worked with the voice therapist/singing specialist pre-operatively. After a period of voice rest (typically two weeks) following surgery, all patients are instructed to return to active singing only after post-operative exam confirms optimal healing, and then only under direct supervision of the voice therapist (Figures 1 and 2 [PDF]).

Voice disorders not accompanied by a structural lesion that requires surgery are referred directly to the SLP for voice therapy. The stroboscopy exam is reviewed, pertinent exam findings are conveyed, and the team discusses management of any associated medical conditions that affect the voice. Effective communication among the treating team members and with the patient allows for complete understanding of realistic treatment outcomes and any other confounding factors associated with a particular patient's voice outcome.

This type of interaction between the SLP and laryngologist often occurs informally during the course of treatment when collaboration over medical management or the appearance of a new symptom leads to a different approach. The concept of a "voice center," in which all team members are in close proximity and are therefore available for immediate consultation with the patient, allows for efficient management of most voice disorders.

Vocal Emergencies

Team management of voice disorders in singers is perhaps most important in cases of vocal emergencies, which typically arise when a high-level performer becomes ill during a performance or just prior to an important exam or recording session. Difficulties range from acute severe upper-respiratory infections to perceived loss of control of the singing voice. Prompt evaluation of the patient and collaboration between the SLP and laryngologist is imperative because the singer usually must return immediately to maximum performance singing. Medical assessment by the laryngologist must determine if a pathology exists that would make it dangerous for the singer to continue singing, thereby requiring a decision to postpone or cancel a performance and go on complete voice rest.

Together, the SLP and laryngologist work with the performer to optimize vocal hygiene, laryngeal biomechanics, and general management if the singer makes an informed decision to continue performing. Management often requires multiple voice therapy sessions and repeated exams over a short period of time. Availability and flexibility in scheduling are necessary for optimal management. The singer must be invested in the treatment plan and proper follow-up must ascertain that the plan is working so that appropriate adjustments can be made within short periods of time.

Speech-Language Pathology Assessment

With the exception of vocal emergencies, a full voice evaluation—including hearing screening, oral mechanism examination, and acoustic and aerodynamic testing—is completed prior to surgical management or behavioral therapy at the MGH Voice Center. This evaluation provides information regarding areas of inefficiency and potential treatment targets (e.g., reduction of elevated subglottal pressure via muscle tension reduction techniques).

Additional subjective measurements are obtained from the vocalist by using the V-RQOL (Voice-Related Quality of Life, Hogikyan et al., 1999) and a questionnaire outlining specific difficulty related to the singing voice and the CAPE-V (Consensus Auditory-Perceptual Evaluation of Voice, Kempster et al., 2009). Note that the SVHI (Singing Voice Handicap Index, Cohen et al., 2007) is a viable subjective assessment. Further, the SLP may wish to complete further endoscopy such as a transnasal videostroboscopy to determine laryngeal function during specific speech and/or song tasks.

Comprehensive assessment by the SLP encompasses postural symmetry/alignment, respiratory management, resonance, articulation, and psychological considerations. These subjective observations can help tailor treatment tasks to the singer's unique needs. It is important, however, that assessment standards (formant tuning resonance and laryngeal positioning, for example) be considered carefully in identifying which aspects negatively affect voice production; specific singing genres may warrant modification of what is considered appropriate function.

The SLP and Singing Voice

Because of the unique needs of this population, the treating SLP requires specialized skills to identify concerns and tailor treatment appropriately, whether the difficulty is most readily observed in speech and/or song. An SLP specializing in voice, but who is not necessarily a singer, can appropriately treat the speaking voice. For managing singing voice difficulties, however, it is advantageous for the treating SLP to have formal singing training. Such background typically provides additional insights and skill sets (e.g., music knowledge, listening skills, etc.) that facilitate all phases of management, particularly during voice treatment. In addition, being able to teach the concepts behind singing technique/rehabilitation is just as essential as being able to sing for improved transference of knowledge and/or skills. The necessary level of singing skill likely correlates with the composition of the SLP's caseload.

Clinicians may be asked to assist the patient beyond what an excellent singing teacher can offer. An intricate comprehension of musculoskeletal physiology is indispensible, similar to the knowledge a physical therapist needs when addressing a sports injury in a specific part of the body. Although the clinician may use various treatment approaches (from symptomatic to holistic) to achieve improved physical efficiency, the SLP benefits from understanding what physical change needs to take place in order to provide effective treatment. For example, the clinician's ear may perceive throat tension but the auditory or visual cue may not necessarily guide the SLP to an appropriate cause of this tension. Palpation can reveal a hyoid bone that is presenting asymmetrically or posteriorly in relation to the thyroid lamina, which can provide clues as to particular muscles that may be negatively affecting vocal function.

Team Approach to Treatment

The SLP's choice of treatment depends on prior medical management. A singer who has undergone phonomicrosurgery typically will not follow the same treatment progression as one treated solely for excessive or imbalanced muscle tension. Post-operative voice therapy must be sensitive to the need to "recalibrate" vocal function within a surgically altered laryngeal mechanism with possible distinct psychological considerations. For example, a singer likely will be more distressed by an injury requiring surgical management, voice rest with loss of verbal communication, and vocal conditioning—and an unknown professional future—than by a problem requiring behavioral therapy alone.

Further, breathiness caused by functional muscle patterns (which does not necessitate surgical intervention) as opposed to a lesion affecting glottic closure may affect methods of behavioral treatment because different etiologies are involved. As a very basic guideline, the SLP should use information from the referring laryngologist, acoustic and aerodynamic evaluation, and subjective assessment in all areas previously noted. Any inefficiency that affects adequate vocal function or is of concern to the patient is a viable treatment target.

SLPs at the MGH Voice Center regularly provide updates on patient progress and discharge from
treatment to the referring laryngologist. If behavioral treatment is not progressing, it is particularly important to discuss with the laryngologist the methods attempted to improve vocal function, level of accomplishment, and unmet goals prior to the laryngology re-assessment.

Although evidence is a critical consideration for successful treatment in all patient management, voice techniques proven efficacious in voice therapy may not fully address all difficulties of a higher-level professional singer. SLPs working with this population likely also need to seek non-traditional or self-developed techniques that have a solid basis in physiology.

Clinical Treatment and Singing Lessons

The importance of rehabilitation in this population and the distinction between the need for voice treatment and singing lessons is critical. At the MGH Voice Center, the laryngologist is the first person who has contact with the patient and forms an initial impression concerning the appropriateness of a voice treatment referral. If a structural abnormality is not present, it is sometimes difficult to define what degree of deviation from normal warrants medical treatment. At MGH, laryngologists and laryngology fellows participate in open discussion with the SLPs regarding appropriate referral guidelines in this population. Some vocal limitations reported by professional singers do not necessarily require medical voice rehabilitation from an SLP, but rather a good singing teacher, just as some athletes do not need a physical therapist, but rather a good coach.

Treatment sessions address neurological, osteopathic, and muscular/tissue imbalances. Medical treatment is based on scientific evidence and/or implementation of tasks focused on appropriate physiology; they do not merely utilize imagery or sound-based approaches without primary kinesthetic awareness. Vocal exercises are designed to improve vocal function within parameters of treatment concepts; the singer's musical repertoire is addressed only in assessment of treatment progress or the application of treatment concepts at a higher task level.

Unlike singing lessons, which can last years, voice rehabilitation is short-term. The goal of behavioral voice therapy is to return the singer to his or her "pre-morbid" condition; singing lessons seek to help singers improve beyond their "normal" level of function. In a singer, a voice disorder yields loss of function and potential negative occupational, financial, and social effects. For a singer to be denied treatment coverage by an insurance company is similar to a professional athlete being denied coverage for a potentially career-ending injury. Establishing the "medical necessity" that is required for singers to receive coverage for voice therapy services can be facilitated by maintaining a clear distinction between the role of the SLP in rehabilitating the injured voice versus the singing teacher's pedagogical approach to improving performance.

Final Assessments

At the conclusion of treatment at the MGH Voice Center, vocal function is re-assessed via the initial measures and compared to prior performance. Although improvement in objective measures is ideal, ultimately it is the singer's perception of regained function that is most important.

Optimal treatment for the vocal athlete requires a balanced team approach between laryngologists who understand the unique needs of this population and an SLP with singing training. With effective collaboration and a tailored strategy to the individual singer, appropriate medical, surgical and/or behavioral treatment ideally will promote the singer's return to established singing activities and avoidance of further injury. 

Tara Stadelman-Cohen, MS, CCC-SLP, is a voice pathologist/singing specialist at the MGH Center for Laryngeal Surgery and Voice Rehabilitation (MGH Voice Center). A member of the National Association of Teachers of Singing, she has rehabilitated singers in numerous performance genres from national and international venues. Contact her at tstadelmancohen@partners.org. 

James Burns, MD, FACS, is a surgeon at the MGH Voice Center and assistant professor of surgery at Harvard Medical School. His clinical and research interests include endoscopic microlaryngeal surgery and photoangiolytic treatment of benign and malignant laryngeal lesions. 

Steven Zeitels, MD, FACS, is the Eugene Casey Professor of Laryngeal Surgery at Harvard Medical School and director of the MGH Voice Center. 

Robert Hillman, PhD, CCC-SLP, is co-director/research director of the MGH Voice Center and associate professor of surgery and health sciences at Harvard-MIT. 

cite as: Stadelman-Cohen, T. , Burns, J. , Zeitels, S.  & Hillman, R. (2009, November 24). Team Management of Voice Disorders in Singers. The ASHA Leader.

Case Study: Opera Singer

The patient highlighted in these photos is a professional opera singer (coloratura soprano). She came to the MGH Voice Center with concerns of vocal fatigue and areas of articulatory and laryngeal tension. Evaluation by the voice team revealed diagnoses of laryngopharyngeal reflux, environmental allergies, and muscle tension.

Medical management included use of a proton pump inhibitor and dietary modifications to manage reflux symptoms along with a nasal steroid spray for allergic rhinitis. Behavioral therapy tasks targeted tension in the torso, larynx, base of skull, velum, tongue, and jaw via postural symmetry/alignment, laryngeal massage/reposturing, and attention to improved range of motion in musculature surrounding selected joints of the body. General subsystem efficiency (respiration, phonation, resonance) and coordination also was addressed.

The patient has reported increased vocal stamina, improved respiratory management, increased vocal flexibility, and more vocal timbre consistency. Formal assessments (acoustic/aerodynamic testing, videostroboscopy) will be obtained at the time of patient discharge.



References

Zeitels, S.M. (1998). Phonosurgery: Considerations for the performing artist and voice teacher. Journal of Singing, 54, 45–48

Zeitels S.M., Hillman R.E., Desloge R., Mauri M., & Doyle P. (2002). Phonomicrosurgery in singers and performing artists: Treatment outcomes, management theories and future directions. Annals of Otology, Rhinology and Laryngology Supplement, 111(12), 21–40.

Zeitels, S.M., Akst, L.A., Burns, J.A., Hillman, R. E., Broadhurst, M.S., & Anderson, R.R. (2006). Pulsed angiolytic laser treatment of ectasias and varices in singers. Annals of Otology, Rhinology and Laryngology,115, 571–580. 

Burns, J.A., Hillman, R.E., Stadelman-Cohen, T., & Zeitels, S.M. (2009). Phonomicrosurgical treatment of intracordal vocal-fold cysts in singers. Laryngoscope, 119(2), 419–422. 

Hogikyan, N.D. & Sethuramon, G. (1999). Validation of an instrument to measure voice-related quality of life (V-RQOL). Journal of Voice,13, 557–569. 

Kempster, G.B., Gerratt, B.R., Verdolini Abbott, K., Barkmeier-Kraemer, J., & Hillman, R.E. (2009). Consensus auditory-perceptual evaluation of voice: development of a standardized clinical protocol. American Journal of Speech-Language Pathology, 18(2), 124–132.  

Cohen, S., Jacobson, B., Garrett, D., et al. (2007). Creation and validation of the singing voice handicap index. Annals of Otology, Rhinology and Laryngology, 116(6), 402–406.



  

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