Chapter 9 Health Lucinda Halstead, MD & Scott MeCoy, DMA The material in this chapter is intended to provide rudimentary information about disorders of the voice. It is not meant for use as a diagnostic or therapeutic tool, nor as a substitute for con- Sultation with an otolaryngologist, preferably a laryngologist, who specializes in the voice. Under normal use, the voice is resilient and rapidly recovers from everyday wear and tear through rest, good nutrition and proper hydration. Pathologic disorders commonly result from abuse, misuse, overuse, trauma or medical illness. While there are no guarantees, if you follow the rules outlined below, you will improve your chances of preserving your vocal health. Speak Well Good speaking habits are very important for maintaining vocal health. This applies to all people who rely on their voices in their work, and is crucial for professional voice users such as teach- ers, doctors, salespeople, public speakers and singers. ‘* Speak with correct breath support and a resonant voice quality + Avoid speaking with “vocal fry" or other raspy qualities; aim for a clear pitch and avoid breathiness in your speech Speak with well-modulated vocal inflection (not monotone) Find your optimum speaking range, which might be higher or lower than you usually speak © Prolonged use of a low pitched voice, often called the “Bogart-Bacall Syndrome” after the actors that embodied this vocal style, will eventually cause problems in the singing voice due to excessive tension in the laryngeal muscles (Koufman, 1988) * Use electronic amplification when speaking to groups, especially in noisy environments Sing Well Itis important to sing with healthy technique at all times. ‘+ Maintain effective breath support and control + Keep extrinsic laryngeal, tongue and jaw muscles free from excess tension * Avoid excessive glottal onsets and offsets of tone * Avoid air pushing during tone initiation, between consecutive tones, and at phrase ends. * Sing in your optimum tessitura * Sing with proper body alignment and correct laryngeal position (neither too high nor too low) Moderation The voice was not designed for unlimited hours of strenuous use. ‘+ Limit the number of hours spent singing and talking ‘+ Never use the voice in any situation to the point of noticeable hoarseness Know your personal limits, which are likely to be different from those of your friends and colleagues Hydration The vocal folds require adequate hydration for normal function. * Drink 8-12 large glasses of water per day. Laryngologists say to “sing wet, pee pale” (with appropriate hydration, urine will be nearly colorless) * Avoid dehydrating beverages that contain caffeine or alcohol Page 127Your Voice: An inside View © IF you need caffeine, use it in moderation and offset its drying effect as much as possible ounce for ounce with water * Don't smoke! Rest The voice is naturally resilient, but requires adequate rest for recovery. ‘© Try to maintain regular sleep patterns * Avoid strenuous voice use when the body is abnormally fatigued Use good hygiene Colds and upper respiratory infections sometimes can be avoided through frequent, thorough hand washing, ‘* Viruses often infect our bodies through hand contact with mouth, nose and eyes. Wash- ing the hands frequently (especially after exposure to public articles such as hand rails and door knobs) helps reduce the risk of viral and bacterial transfer Avoid unnecessary drug use Many prescription and over-the-counter drugs can affect the voice. * Ask your doctor about possible voice-related side effects for any medications you regu- larly take * Because of their dehydrating effect, many singers find it helpful to avoid antihistamines and decongestants, whether obtained over-the-counter or with a doctor's prescription * Avoid aspirin, ibuprofen and other non-steroidal anti-inflammatories (NSAIDS) because of increased risk of vocal fold hemorrhage. ‘© Alll these products increase this risk because they thin the blood by coating the platelets that form the clot. A single dose of aspirin will affect the platelets for 7 days; a single dose of ibuprofen or other NSAID will affect them for 48 hours ‘© Acetaminophen, such as found in the brand name Tylenol®, has neither of these effects and is generally considered safer for singers The most popular NSAIDS are listed in the chart presented in Table 9/1 © A complete list of aspirin & NSAIDS can be found at http:/hwww.green-lipped- musseloil.comllist-of-nsaids.htm! Generie name ‘Brand name Aspirin Anacin,Ascriptin, Bayer, Butfetn, Eeotin, Excedrin Celecox Coiebrox Diclofenac sodium Voltron, Voltaren XR Diclofenac sodium wih misoprostol Arthrotec iturisa Doiobid Ibuprofen ‘Advi, Moin, Motrin 18, Nupin Indomethacin Inet Indosin SR Magnesium saicyate ‘Atitab, Bayer Select, Doan's Pls, Magan, Mobisin, Mobogesic Naproxen Naprosyn, Naprelan Naproxen sodium ‘Aleve, Anaprox Oxaprozin Daypro Proxicam Felgene Rofecox Viowe Page 128.Chapter 9: Health Salsalate Amigos, Analex 750, Osa, Marthe, Mono-Gesic, Safle, Salsa | Socium style various gonerios Sulindac Cling | Tometn sodium Toloctin Valdecoxs Bextia - ‘Table 9-1. Popular Non-Steroidal Antitnflammatory Drugs (NSAID) and their common brand names Vitamins are not always safe. Fat soluble vitamins A, D and E taken in above normal doses for prolonged periods of time can thin the blood and cause vocal fold hemorrhage. Small and very thin individuals may develop problems with prolonged use of regular adult doses of these vitamins Performance altering drugs affect singers by altering their perception of their perfor- mance, usually causing them to think that it is better than it actually is, and also by caus- ing alterations in physiology, fine motor control and memory that can predispose the vo- cal folds to injury, as well as the mind and body © Beta blockers, which sometimes are prescribed to inhibit performance anxiety, depress the heart rate and muscular tremor. The feeling is described as being analogous to driving with the parking brake on + Although these drugs seem to work well for instrumentalists, the effect is usually very negatively evident in a vocalist’s performance, causing it to lack sparkle, drive and energy. This effect is surprisingly easy for the au- dience to spot and there exist only rare reports of very low dose beta- blockade being imperceptible to a vocalist’s audience Alcohol has vocal side effects beyond dehydration © The immediate effect of alcohol is to decrease inhibitions & fine motor control. Limit alcohol intake and avoid strenuous voice use if “under the influence.” © Long-term overuse (more than 15 alcoholic beverages per week) can lead to permanent impairment of memory & fine motor control, and metabolic imbalance due to poor nutrition. It also can cause liver damage, which will cause thinning of the blood and predispose the vocal folds to hemorrhage Be aware that cannabis (marijuana) smoke is significantly more damaging to the vocal folds than tobacco smoke—which is bad enough! © Short-term use decreases inhibitions and causes loss of fine motor control, pre- disposing to vocal injury o Long-term use causes permanent alteration of brain function. It is unclear if the alterations in brain are reversible or if the brain re-pattems after abstinence, but some recovery of function can occur Methylenedioxymethamphetamine (MDMA, ecstasy) causes permanent, irreversible al- terations in brain function, including marked verbal memory deficits, impairments in learning, consolidation, recall, and recognition. These impairments affect multiple areas. of the brain so that brain remodeling/retraining is almost impossible © These changes occur EVERY time the drug is taken, making it the most danger- ous drug Stay physically fit Almost all singers benefit from ongoing cardiovascular exercise Good physical fitness helps stave off illness Good physical appearance aids in winning competitions and getting roles Singers need aerobic fitness to sustain the energy levels required for performing ‘© Regular exercise routine is essential Page 129Your Voice: An inside View © Exercise smart! Make it fun or you will not stick with it = Develop aerobic and flexibility/strength training routines that you enjoy * Dancing of all types—musical theater, ballet, jazz, ballroom, tap, hip hop—improves musicality, stage presence and movement, and is great exercise + Try unusual sports, such as fencing, Karate, or kick boxing + Get a buddy! Having a friend to exercise with is one of the best long-term. motivators Revamp your routine regularly to avoid plateauing and loss of maximal benefit. Your muscles adapt to a routine and will burn fewer calories as they become more efficient, Studies on women doing the same exercise routine for 5 years (stationary bicycling for an hour 5x/week) showed the women gained an average of one pound a year, plateauing being part of the problem * The American Council of Exercise (www.acefitness.org) is an excellent source of information on good exercise practices, Singers need to maintain their ideal body weight for their height to achieve optimal stam- ina, hormonal balance & health ‘© Try to eat a diet that emphasizes foods with a low glycemic index. These foods cause a slow release of glucose into the blood stream, which helps you to feel fuller and have more energy for longer periods of time, Substitution of low glyce- mic index food for high glycemic index food is very easy to do * For more information visit www.glycemicindex.com Eating Disorders are not just for dancers anymore—Anorexia, Bulimia and Binge Eating © With the increasing pressure for believability in operatic and musical theater roles, the pressure for individuals to be at or below their optimal body weight is tremendous. Some music and choral programs have strict height to weight re- quirements and dismiss those who cannot maintain them © The difference between careful diet and exercise and an eating disorder is im- mense. Each eating disorder has an underlying psychological basis and can lead to severe, occasionally irreversible, health problems, malnutrition, and death. In anorexia, there is the need to control one’s body by severe dietary restriction, ex- cessively vigorous exercise and purging with laxatives, diuretics, and enemas, and to relate the success of that control to self-worth. Binge eaters are driven un- controllably to eat and will consume a very large quantity of food. The motivation is usually stress and depression. After binging, depression and poor self-esteem intensify and the process begins again. Bulimics often have a combination of these disorders. They feel driven to eat large amounts of food and then purge themselves, primarily by vomiting, but also use the methods that anorexics em- ploy (9/1). * For singers, bulimia is especially punishing on the voice as the large amounts of gastric acid in the vomit causes swelling of the vocal folds and loss of range, timbre, and endurance. The acid also will eat the enamel off the teeth and give the person horribly bad breath * Encourage anyone you know with these disorders to seek comprehensive medical treatment: it may be lifesaving! Practice “Safe Sex” ‘Some sexually transmitted diseases (STDs) including herpes, gonorrhea, HPV, and HIV/AIDS can infect the vocal tract and larynx. People with immune systems that are suppressed by AIDS are susceptible to secondary infections, such as pneumonia and candidiasis (a fungal infection), which can severely impair vocal function. Page 130Chapter 8: Health Herpes and gonorrhea are easily transmitted to the mouth, pharynx and larynx through unprotected oral sex with an infected partner. Aside from being physically painful, the le- sions associated with these STDs can make singing virtually impossible The virus that causes genital warts (human papilloma virus, or HPV) can cause extreme- ly large lesions to develop on the vocal folds with devastating impact on voice quality, HPV lesions can actually be life-threatening—they can totally block the ainway—and in rare cases become cancerous Remember, unless you are absolutely certain of your partner's STD status, oral sex without the use of a condom or dental dam is not safe sex Wear your seatbelt Wearing a seatbelt is one of the simplest ways to prevent serious injury or death Ifyou are in a car accident while not wearing a seatbelt, your larynx is at high risk of be- ing crushed. This injury will permanently ruin your voice (not to mention your reduced likelihood of being cast as a romantic lead after your head and face have gone through the windshield) Proper seat belt position is extremely important—it should cross over your shoulder and across your waist, and should not be rubbing against your neck. In an accident, a seat belt rubbing against your neck can cause damage to the larynx and the laryngeal nerves, which can be @ more significant problem for smaller stature individuals. A seat belt adapter, usually found next to children’s car seats in stores, will prevent this injury and make your seat belt more comfortable to use. (As a small-statured laryngologist, | use one all the time!) Don’t sing if you are ill ‘Sometimes it's best to be quiet If @ cold, influenza or respiratory infection is having a negative impact on your voice, DON'T SING. Laryngitis and/or hoarseness often accompany these illnesses. Strenuous or even limited singing—even with excellent technique—often can delay recovery or lead to serious vocal injury. Remember that you can stil practice your music mentally and work on memorization, meaning, interpretation, motivation, character development, and all the other non-singing elements that contribute to your performance Know a good laryngologist Singers need ready access to a trusted laryngologist (otolaryngologist who specializes in voice) who can do a detailed laryngeal exam. If one is not available in your community, an ear nose and throat doctor (ENT) who loves mu: and singing will be more attuned to your special needs Schedule a “well” visit so the doctor can establish a baseline and document laryngeal appearance when you are healthy. This allows subtle changes in the appearance and function of the larynx to be detected and leads to earlier, more accurate diagnosis of problems (9/2) Visit the doctor sooner rather than later if there is any prolonged vocal distress or a sud- den change in vocal quality Learn to recognize the symptoms of voice disorders, particularly acute or chronic chang- es in voice quality and/or pitch range Make the effort to find a doctor whose specialty is the singing voice. Names of laryngol- ogists near you can be obtained through the Voice Foundation (www.voicefoun- dation.org) ® videos for this chapter include all relevant information concerning case histories, treatments, and outcomes. You are strongly urged to view these videos while you are reading the chapter. Page 131Your Voice: An Inside View Portable Health Insurance All singers should make certain their health insurance covers them in every state of the union. If not, they might face very costly medical bills while on tour ‘© Make sure that your insurance will cover visits to a laryngologist © Many singers end up having their tonsils removed by a general otolaryngologist, even when the problem is really in their larynx. This happens because the gen- eral otolaryngologist does not have the equipment and expertise that is required to correctly diagnose the problem © Insurance should cover procedures such as laryngeal videostroboscopy, which easily costs $1,000 or more * Students should discuss with their parents the importance of having an insurance plan that covers them at the college or university they are attending, as well as when touring with the college. Frequently, treatment of voice problems in students is denied, delayed, or suboptimal because of insurance restrictions © Most student health insurance plans will not cover a visit to a laryngologist or pay for laryngeal videostroboscopy The Unique Singer/Laryngologist relationship The trust and total honesty that should be present in any doctorfpatient relationship is a thou- sand-fold more important for the singer. Total truth about compliance with medical and voice therapy is essential because further treatment of your condition will be based on the appear- ance of your larynx in response to the treatment prescribed '* Surgery may be recommended based on exaggerated reports of compliance with therapy © Surgical failure and recurrence of the lesions will result if the underlying vocal behaviors or medical conditions causing the problem still exist. A typical example is the singer with nodules who appears to be compliant with but is unresponsive to behavioral voice and speech therapy. He undergoes surgery, but has rapid re- turn of the lesions after surgery by reverting to or continuing his vocally abusive behaviors (9/3) * Finally, lack of honesty with your laryngologist will cost you more money by prolonging treatment Voice Disorders Laryngitis Laryngitis is the medical word that indicates laryngeal inflammation, just as tonsilitis indicates inflamed tonsils. Inflammation is a vascular event that results in swelling. The inflammation gen- erally affects the superficial and intermediate layers of the lamina propria, inhibiting free move- ment of the cover over the body of the vocal folds, thereby preventing formation of a normal mucosal wave. The vocal folds appear puffy and stiff. The color can vary from very pale to deep red depending on the inciting factor. The structures above and below the vocal folds can be ei- ther very pale or very red and swollen. Laryngitis can be acute, lasting up to 3 weeks, or chronic, lasting many months. As inflammation persists, the changes in the lamina propria become more fibrotic and slower to resolve. A more detailed discussion of the stages of laryngitis can be found in Brown, 1996. Laryngitis can be caused or exacerbated by a wide range of environmental and behavioral irri- tants, as well as infectious diseases. Mild laryngitis is a common symptom of allergies, alcohol or tobacco use, overuse of the voice, dehydration or gastro-esophageal reflux disease (GERD). Page19200Chapter 9: Health GERDILPR GERD is @ medical condition in which acid from the stomach flows back into the esophagus through the sphincter located at the top of the stomach, called the lower esophageal sphincter. In some cases, this acid spills over from the esophagus to the larynx, causing irritation of the laryngeal tissues and the vocal folds themselves. When the larynx is involved, reflux is often referred to as laryngopharyngeal reflux (LPR). Singers are especially prone to LPR because of the higher than normal abdominal pressures exerted during singing, and from lifestyles that of- ten include late-night repasts following performances ‘Symptoms of LPR in singers include vocal fatigue, prolonged warm-up, loss of range, change in timbre, throat clearing, or a feeling of “something in the throat” around the level of the larynx. Heartburn is rare—only 30% of people with LPR experience it. The laryngeal examination also can besuggestive of LPR. Telltale signs include edema (swelling) of the true & false vocal folds, blunting or redness of the laryngeal ventricles, thick mucus coating the vocal folds and supra- glottic structures, and posterior glottic edema. The diagnosis of LPR is based on a combination of symptoms and laryngeal findings. Treatment should be supervised by a medical doctor and might include dietary changes and restrictions, elevation of the head of the bed for sleep, use of acid-controlling medications and, in some cases, surgery. Reflux has been shown to be a causative factor in a variety of vocal problems beyond laryngitis. (9/4) Fungal laryngitis Laryngitis also can result from a fungal or yeast infection. The most common culprit is the Can- la fungus, which is present in the environment and resides benignly in the bodies of most people. Those with healthy immune systems usually are able to resist infection in spite of re- peated exposure. People with weakened immune systems, such as those with HIV/AIDS and diabetics, generally are more susceptible to infection. However, healthy individuals who are treated with antibiotics for bacterial infections in any part of the body also are at risk because the antibiotic alters the balance of the normal bacteria in your body: this also causes the predi- lection for women to get vaginal yeast infections while taking antibiotics. Because antibiotics tend to be over prescribed, many healthy individuals end up at risk. Also, asthmatics who are on steroid inhalers are at higher risk of fungal laryngitis. Treatment is with fluconazole (Diflucan®) for one to two weeks and occasionally longer depending on the severity of the infection (9/5). Steroid Myesthenia Chronic laryngitis also can be caused by long-term exposure of the vocal folds to steroid inhal- ers, called steroid myasthenia (weakness). Chronic exposure to the steroid causes thinning of the muscles of the vocal folds. Stroboscopically, the glottic closure becomes spindle shaped. The sound of the voice is thin and thready. In most cases, these findings will resolve after stop- ping the inhaler, but the effect may take weeks to months to reverse, depending on the length of inhaler use (9/6). Laryngitis Treatment For most cases of moderate to severe laryngitis due to vocal overuse or misuse, the treatment of first choice is voice rest, accompanied by thorough hydration. Do not sing and especially do not go to the practice room to try to “pound your voice back into shape.” Remember the general vocal health guidelines; if your voice doesn't feel or sound right and you have any suspicion that you might be ill or injured, KEEP QUIET! If rest and hydration do not resolve the problem after a week, consider seeking attention from a laryngologist. If the laryngitis is the result of voice abuse or misuse, the abusive behavior must be stopped or you will risk serious injury and long- term voice impairment. Page 133‘Your Voice: An inside View If laryngitis is the result of illness, allergies or other medical problems, your doctor might be able to help with medications specific to your illness. Under emergency situations when you simply MUST quickly recover your voice, your doctor might prescribe a short course of corticosteroids to reduce vocal fold inflammation. However, steroids are not without risks. By enabling you to perform, you are also at increased risk of doing further injury to your voice. Occasionally, the steroids will decrease the swelling in the vocal folds so much that the singer becomes aphonic and cannot perform at all. This is a risk that needs to be discussed with every singer, especially if they have never used steroids prior to a performance. Muscle Tension Dysphonia Muscle Tension Dysphonia, or MTD, is a condition in which excessive tension occurs in the in- trinsic and extrinsic muscles of the larynx, resulting in hoarseness (laryngitis), vocal fatigue, and frequently pain with singing or speaking. MTD can be caused by prolonged speaking with ab- normally high or low pitch as described earlier in the chapter, use of hard glottal onset in the speaking or singing voice, poor breath support for speech, and poor vocal technique. It is com- mon for singers to not pay attention to their speaking voice; consequently, poor habits in the speaking voice will affect the laryngeal muscles to such an extent that they cannot perform op- timally while singing, Physical manifestations of MTD include pain in the thyrohyoid area, high laryngeal position in the neck and excessive tension in the tongue base and neck muscles. Stroboscopically, MTD manifests in a variety of ways. Most common are the posterior glottic chink and laryngeal iso- metric tension. Treatment for MTD should be supervised by a certified, highly specialized voice thera- pist/pathologist or laryngologist who specializes in voice disorders. Therapy is commonly based ‘on exercises designed to realign and relax the muscles of the larynx and neck, and focusing the ‘sound forward in the vocal tract. Laryngeal massage also might be used to relax the suspensory muscles of the larynx (9/7), Lesions and Masses Most lesions and masses that affect vocal quality occur in the cover and lamina propria of the vocal fold. Because there are fewer fibroblasts in these layers, the majority of the lesions de- scribed below can, with careful treatment, resolve without scarring. Lesions that extend into the muscle commonly result in scar formation and disruption of the vocal wave, resulting in impair- ment of the voice (see figures 8/1-2 on page 103 to review the layered structure of the vocal folds). Vocal Fold Hemorrhage, Vascular Ectasias and Polyps Hemorrhages occur when one or more blood vessels rupture within the vocal folds, either in the epithelial layer or within the lamina propria, and generally are caused by trauma. The voice will quickly become impaired—perhaps severely—because blood accumulates in the fold, prevent- ing normal mucosal wave formation and inhibiting vocal fold oscillation. ‘As was noted earlier in this chapter in the discussion of drug use, singers must be aware of substances and certain conditions that can predispose to vocal fold hemorrhage. Drugs that in- hibit blood clotting—such as aspirin, NSAIDS and alcohol—can contribute to hemorrhage Women also are slightly more susceptible to hemorrhage during menses, as is discussed in lat. er in this chapter under the heading of hormonal issues. Hemorrhages often are the result of dilated blood vessels in the cover of the vocal fold, called vascular ectasias. A hemorrhage can progress to a vascular polyp if the trauma to the vocal fold continues. Let's follow a singer with a vocal fold hemorrhage (9/8) Page 124 -Chapter 9: Health Treatment for hemorrhage generally includes a period of total voice rest. They usually will re- solve spontaneously, but sometimes require surgical intervention to stop bleeding and prevent scar formation. Diagnosis of a hemorthage can only be made through a laryngeal examination. Vascular Ectasias Vascular ectasias are dilated vessels in the cover of the vocal fold. They present as a tiny bump where the vessel protrudes out of the cover. Frequently, there is a small amount of swelling as- sociated with the ectasia that causes it to have the shape of a nipple, hence the term “nipple ectasia.” These lesions develop because of excessive medial compression of the vocal folds, as a result of vocal style, abusive vocal gestures, and faulty singing and speaking technique. Vascular ectasias may resolve with correction of the vocally abusive behavior, but not always. Treatment of vascular ectasias usually is limited to those that repeatedly hemorrhage. Visible light laser surgery is often used if excision is needed. Otherwise, these lesions are watched carefully (9/9), Vocal Fold Polyps Vocal fold polyps are discrete lesions that often develop as a result of trauma, usually involving only one vocal fold. They can be filled with blood or clear gelatinous material and can ocour an- ywhere on the vocal fold. This is in contrast to nodules, which almost always occur bilaterally at the junction of the anterior third and posterior two thirds of the vocal folds; however, the polyp can damage the opposing vocal fold at the site of impact, causing fibrosis or swelling. Polyps often are preceded by a hemorrhage and might have a noticeable blood vessel that feeds the lesion. Because of this tendency for hemorrhages to lead to polyp formation, it is crucial that 2 timely and accurate diagnosis be made. Polyps generally form within the superficial layer of the lamina propria and can grow to alarm- ingly large size. Voice impairment can range from mild to severe, depending on the exact loca- tion and size of the lesion. For example, if it ies on the vibrating margin of a vocal fold, it will prevent complete glottal closure and produces symptoms similar to those of vocal nodules; in this position, a large polyp would severely impair phonation. If, however, itis found above or be- low the vibrating margin, there might be less impairment. Polyps do not respond well to voice or drug therapy. If detected in the aoute phase, voice rest might help; however, if the polyp is chronic, surgery is indicated to remove the lesion and treat the vascular feeder. Visible light lasers, KTP or Pulse Dye, are being used increasingly in the treatment of polyps. The lasers remodel the collagen and scar in the polyp and treat the vascu- lar feeder without cutting open the vocal fold. They also treat the underlying fibrosis that can cause residual stiffness in the vocal fold, something that is very difficult to treat with convention- al “cold steel” excision. This "no touch” surgery is commonly done under topical anesthesia in the office. The effect of the laser energy continues for 4-6 weeks after it is applied to the lesion. Usually, the patients observe 2 weeks of vocal rest and then begin to gradually increase voice use At 4 weeks, singers usually can resume singing and begin to work back up to their pre- injury vocal activities. Post-surgical voice therapy is suggested as needed (9/10), Vocal Nodules Vocal nodules, formerly known in the literature as “singer's nodules” because of the high inci- dence in that population, are callous-like lesions located along the vibrating margin of the vocal folds. They impair normal phonation by creating a physical obstacle between the vocal folds and by damping mucosal wave formation. Nodules almost always occur bilaterally (one on each fold) at a point one-third to one-half the distance from the anterior commissure to the vocal pro- cess (near the middle of the vibrating portion of the fold). They can come in different shapes and forms, with varying degrees of stiffness. Morphologically, the two most basic forms are broad- Page 135.‘Your Voice: An Inside View based or fusiform (occupying a relatively large segment of the length), and pinhead or spicule (occupying a discrete, smalll segment of the length), Nodules are almost exclusively a problem for women; men rarely acquire them (if they do, they are usually tenors). Small to moderate sized nodules (and other swellings) generally impair the voice from the top down. High pitches become increasingly difficult to sustain, as do quiet dy- namic levels. This might be the reason nodules are more frequently diagnosed in sopranos than mezzos; they sing higher pitches and are more likely to “get caught.” In an otherwise healthy voice, nodules usually do not produce hoarseness or huskiness in the lower register. This is an important symptomatic distinction between nodules and MTD, in which the entire voice be- comes excessively breathy. Nodules are caused by misuse, overuse or abuse of the voice. In other words, nodules are strictly related to the amount (how much) and manner (how) of voice use. While these might sound similar there are clear distinctions that can be made’ «Misuse is unintentional abuse of the voice that might ocour in someone with improper speaking or singing technique, poor breath support or incorrect resonance. The voice is being used in a damaging manner, but the person has not received instruction that would lead to more healthy voice production. Misuse might also include singing in a tes- situra that is not optimal for an individual (often too high), singing too loudly for extended periods, belting without proper technique, and carrying the chest register too high. © Overuse is just that—too much of something that is otherwise acceptable. Remember, the voice was not meant for unlimited hours of strenuous use! Too much practicing, re- hearsing (even in choir) or performing can result in injury even with excellent singing technique. Too much talking can be just as damaging as too much singing. * Abuse is voice use in a damaging manner in spite of conscious awareness of potential ‘consequences. Examples include shouting at sporting events, loud talking at parties (especially after consumption of alcohol), or deliberately making sounds that “hurt.” In singing, excessive use of strong glottal onsets can often lead to nodule formation, as does singing with a pressed sound, especially in a high tessitura, Itis possible for a well-trained singer to make beautiful sounds even if nodules are present, es- pecially at lower and middle pitches; however, careful listening by a teacher and honest self- appraisal by the singer usually will reveal even the most subtle impairment. There are specific warning signs that indicate a visit to the laryngologist is in order. Since some of these symptoms are hard to differentiate from lack of proper vocal training, it is helpful to have a history with a student before jumping to conclusions. The following symptoms oocurring in a voice that has previously been healthy or normal sounding should raise caution flags (Bastian, 1996): Loss of high notes, especially at quiet dynamic levels, accompanied by increased effort in their production; Newly-appearing inability to quietly sing staccato vocalises (e.g. sol, sol, sol, sol, sol, fa, mi, re, do); Newly-appearing breaks during glissandi; Newly-appearing significant delays in phonatory onset or stoppages during phonation. ‘As with other laryngeal pathologies, the only way to confirm a diagnosis of nodules is through direct laryngeal examination by a qualified physician or speech pathologist. Because individual cycles of vibration can be visualized, stroboscopy is strongly preferred over indirect observation with the laryngeal mirror. Stroboscopy also helps prevent mucus from being mistakenly identi- fied as a nodule. Even under stroboscopic exam, however, caution should be exercised in mak- Page 136Chapter 8: Health ing a diagnosis. Small acute swellings are common among singers during the refractory period following strenuous voice use; they normally resolve spontaneously in a matter of hours or days. Nodule Treatment Treatment for nodules has significantly changed in recent years. Previously, the first line of at- tack was total voice rest for a period of several weeks to several months. It has now been shown, however, that voice therapy, generally without total voice rest, is more effective. Working under the supervision of a well-trained voice therapist, the patient learns new voice-use patterns that will not exacerbate nodule formation. While this will not always make chronic nodules go away, in many cases, itis sufficient to restore acceptable voice function. Stroboscopically, the nodules will become more compressible, and the mucosal waves less stiff. In cases where sur- gery is required, the outcome is usually excellent with full restoration of normal voice as long as the nodule and any underlying fibrosis are removed. Again, visible light laser surgery offers many advantages to treatment of this lesion. There is no reason for a singer to believe her ca- reer is over following a diagnosis of vocal nodules (9/11). Vocal Fold Cysts Vocal fold cysts can be similar in appearance to polyps, but usually have the appearance of a discrete egg shaped mass just under the cover of the vocal fold. Cysts generally attach to the ‘cover of the vocal fold and extend more deeply into the lamina propria, sometimes attaching directly to the vocal ligament or even to the thyroarytenoid muscle. As with polyps, they usually are unilateral, but can damage the opposing vocal fold at the site of impact, which can result in a misdiagnosis of nodules. They can be the result of trauma, but are often of unknown origin. There are several different types of cysts that can develop in the vocal folds. Some are small mucus cysts and others derive from the epithelium of the vocal fold cover. The factor common to all cysts, however, is a rigidity of the vocal fold that inhibits normal oscillation. Voice impair- ment can be mild to severe, depending on the size and location of the lesion. As with many polyps, voice therapy alone will not correct cysts; a laryngologist who specializes in phonosur- gery must surgically treat them. The vocal fold is dissected to remove all traces of debris result- ing from the cyst. Since these lesions extend deeply into the lamina propria and often into the muscle, a certain amount of fibrosis or scarring resulls from their removal. Minor revision sur- gery to address this stiffness is sometimes required. A prolonged recovery period is likely; how- ever, with appropriate voice therapy, good voice function should be restored. A ruptured cyst is thought fo be one cause of a vocal fold sulcus (plural "sulci"), which is a groove or furrow that forms along the medial edge of the true vocal fold (9/12). Contact Ulcers and Granulomas Contact Ulcers are ulcerative sores that develop at or near the vocal process and can be unilat- eral or bilateral. They can be caused by infections, laryngeal irritants and vocal misuse/overuse. Uleerations due to coughing from infections such as pertussis (whooping cough) or walking pneumonia (mycoplasma pneumonia) are increasingly common because these infections are epidemic on college campuses and in the workplace. Adults are very prone to contracting these diseases because the immunity conferred by childhood vaccination has wor off. GERD, severe asthma or allergies, or voice misuse and abuse, including hyperfunctional adduction, excessive ly low-pitched or loud speech, excessive throat clearing, glottal phonatory onsets and pressed phonation also will produce inflammation and breakdown of the mucosa over the vocal process. In singers, they are sometimes seen in “verismo” type singers (especially tenors) who approach higher tones with too much breath pressure and laryngeal tension. Contact ulcers also can result from injury during endotracheal intubation, such as for general anesthesia. This is one of the reasons that singers should speak with the anesthesiologist prior to any surgery to ensure methods will be used that pose the least risk of vocal fold injury, such as use of a laryngeal mask airway if appropriate to the surgical procedure. Page 137Your Voice: An Inside View ‘Symptoms of contact ulcers include hoarseness, loss of vocal stamina and, in some cases, lar- yngeal discomfort or pain. Treatment consists of aggressive treatment for reflux, which is always present, and suppression of cough, if it is present. Speech therapy to remove behavioral causes such as hard glottal attack, coughing and throat clearing can be helpful. Because of poor blood supply to the cartilaginous vocal processes and thin mucosa at this location, contact ulcers can be slow to heal, usually needing several months of treatment. Vocal process granulomas are benign growths of inflammatory tissue occurring at the vocal processes. Granulomas generally are preceded by contact ulcers and actually are part of the healing process from this disorder. The causative factors and symptoms are the same as those for contact ulcers. Vocal process granulomas will only affect the voice if they are large enough to interfere with glottic closure and mucosal wave. Treatment includes voice therapy to reduce any behavioral contribution and very aggressive treatment for GERD, which is found in an extremely high percentage of people with vocal pro- cess granulomas. Usually aggressive GERD management will cause the granulomas to resolve. Surgical management is reserved for large lesions blocking the airway. Rarely, weakening the vocal fold with Botox is necessary to reduce vocal trauma. Because they do not attach to the vibrating portion of the vocal folds, the voice recovers very quickly after surgery and singers are able to return to active performing within a period of a few weeks (9/13), Neurological Disorders Vocal Fold Paralysis Paralysis and paresis (weakness) stem from problems with either the superior or recurrent lar- yngeal nerves. As a reminder, the superior nerve, or SLN, innervates the cricothyroid muscles for vocal fold elongation. All other laryngeal muscles are innervated by the recurrent laryngeal nerve, or RLN, which loops into the thorax before returning to the larynx. Paralysis impacts the voice in a variety of ways, depending on which nerves and muscles are affected. Symptoms can vary in severity and include dysphonia with breathiness, hoarseness and reduced amplitude, limited pitch modulation (monotone), aperiodic vocal fold oscillation, dysphagia (problems swal- lowing), loss of chest register—which can be devastating for men—and diplophonia. The nerve damage that results in vocal fold paralysis or paresis, which can be unilateral or bi- lateral, can come from stroke, some viral illnesses, or injury, including strong blows to the neck or chest. Nerve damage can also result from thyroid surgery and open thoracic procedures, which can harm the recurrent nerve. Voice quality sometimes can be improved through voice therapy and should always be tried Surgical techniques also are used. Temporary injections with collagen or aqueous gel can be used to facilitate glottal closure while giving the nerve a chance to recover. If the nerve does not recover, the paralyzed fold might also be permanently “medialized” with a gel containing calcium hydroxyl apatite microspheres or with a procedure in which an implant is embedded into the vo- cal fold to permanently place it in a central position, allowing the other fold to vibrate against it more efficiently. Vocal fold paralysis is not always permanently disabling for singers. Many sing- ers can compensate for the paralysis with vocal retraining or with surgery and may be able to return to singing at a high artistic level (9/14). Spasmodic Dysphonia In the condition known as spasmodic dysphonia, muscles of the larynx go into spasm, prevent- ing the production of easy, sustained speech. In severe cases, the spasms might be great Page 138Chapter 8: Health enough to threaten the airway. Symptoms include weak, strained and halting speech as the person struggles to produce sound. Vocal tremor is a related condition that produces a rhythmic disruption of the sound, Many of these individuals will also have a hand or head tremor. The cause of spasmodic dysphonia originally was believed to be psychogenic; recent research, however, demonstrates @ neurologic origin. It is now classified as a movement disorder, neuro- logically based in the basal ganglia, and is a form of focal laryngeal dystonia (Brown, 1996). Dystonia and tremor occurss when a muscle or group of muscles go into a sustained, involun- tary state of contraction. This may be general, regional, or focal, that is, limited to a specific muscle or group of muscles associated with the same task. Dystonia is aggravated by fatigue ‘and physical or emotional stress. In the larynx, either adductory or abductory muscles can be affected. Spasmodic adduction leads to a weak, choppy, and strangled sounding voice. Spas- modic abduction leads to uncontrolled moments of aphonia as the glottis is involuntarily forced ‘open. One of the notable and diagnostic characteristics of spasmodic dysphonia is the retention of the individual of the ability to sing, despite the problems in the speaking voice. Because of its neurologic origin, spasmodic dysphonia is unlikely to respond to voice therapy, although some strategies for controlling the voice for short phrases are very successful and help these individuals to cope in urgent situations. The treatment of choice has become injection of botulinum toxin (Botox®) into the affected muscles to temporarily paralyze them, a procedure also called chemical denervation. The voice will probably not sound normal, but speech will be possible and in many cases is good enough for patients to continue in careers that require a high level of vocal function, such as nursing, teaching, sales, and law. This type of spasm also can be seen in the singing voice. It is extremely rare, but should be considered especially if a singer has worked diligently on technique with an excellent teacher for many months. After about six months of intense effort by the singer and teacher, an examina- tion by an experienced, multidisciplinary team in a Voice Center is advisable. Often a subtle le- sion will be found, but occasionally this neurological disorder will be diagnosed (9/15). Smoking, Alcohol Abuse and Cancer ‘Smoking and Drinking In this day and age, virtually everyone is aware of the health hazards from smoking and exces- sive consumption of alcohol. Smoking can lead to lung disease-such as emphysema-or to can- cer of the lungs, mouth, throat, larynx or esophagus. One pack of cigarettes per day for 10 years, or its equivalent (2 packs per day for 5 years, etc.) places you at risk for developing can- cer in these areas, and the risk of getting cancer caused by cigarette smoking or tobacco in ANY form (snuff, dipping) does not decrease after quitting, as it does in the lung. Tobacco in- duced cancers are frequently seen in former smokers 10 -30 years after quitting. Remember ten pack years is the point of no return. Alcohol can contribute to problems with the liver, kid- neys and digestive tract. Drinking to the extent that the liver is affected, usually more than 15 alcoholic beverages per week for over a decade, can thin the blood and cause vocal fold hemor- rhage. Both vices can increase the chances of contracting heart disease or stroke and are known to statistically shorten a person's life span (9/16). Laryngeal Cancers The larynx and vocal folds are relatively common sites for cancer development, especially in tobacco and alcohol users. A discussion of this issue is beyond the scope of this document; the reader is referred to resources cited in the Bibliography. Sexually Transmitted Diseases Page 139Your Voica: An Inside Viow Several sexually transmitted diseases have the potential to impair voice function, including HIV/AIDS, human papilloma virus (HPV) and gonorrhea. HPV and gonorrhea can directly infect the vocal tract and larynx through orogenital contact (oral sex). People who are infected with HIV are prone to opportunistic infections, such as candidiasis (a fungal infection that can inhabit the oral tract, pharynx, esophagus or larynx) and pneumonia. In the later stages of the disease, neurological function may become impaired, impacting the ability to speak and sing, Laryngeal Papilloma (Recurrent Respiratory Papillomas) Laryngeal papillomas (RRP) usually are benign, wart-like lesions caused by one of the Human Papilloma Viruses, commonly referred to as HPV. This is the same virus that causes genital warts, a sexually transmitted infection (STI) The exact mode of transmission of RRP is unknown and thought to be related to the immune system. However, there is about a 4% transmission rate from infected patients who engage in orogenital contact (Clarke, 1991). Because of the devastating vocal impact of this infection, pro- fessional voice users are well advised to practice “safe sex" with partners whose STD status not certain. This includes use of a condom or dental dam during oral sex. This is a disease for which there is no cure as yet. The best treatment at this time is prevention by vaccination with the HPV vaccine. Although this vaccine is designed to prevent HPV related cervical cancer and penile warts, the viral strains responsible for RRP of the larynx are in this vaccine. Both men and women should receive the vaccine, preferably before they become sex- ually active. If RRP is contracted, surgical treatment is needed. Papillomas can be excised by microdebriders, lasers, and scissors. Often in adults, the visible light lasers (KTP &PDL) are used in the doctor's office under topical anesthesia to treat papillomas. Also, anti-viral agents such as cidofovir are used to involute the papillomas and to push patients into remission. Be- cause papillomas can recur many years later, remission, not cure, is the term used when a per- son is free of papilloma (9/47), The vocal symptoms of papilloma growth begin with hoarseness and can progress to severe dysphonia or complete aphonia. In adults, it is often symptomatically confused with chronic lar- yngitis, prior to laryngoscopy. Children can also acquire RRP. Discussion of the diagnosis and treatment of RRP in children is beyond the scope of this chapter, Hormones and Hormonal Medications Hormonal Issues Women often experience changes in voice quality around the time of menses. This is such a common problem that it has been given its own name: laryngopathia premenstrualis. General fluid retention and tissue changes can cause mild vocal fold edema that manifests in a slightly husky sound with reduced flexibility. Changes also occur on the cellular level, similar to the monthly changes observed in cervical cells (Abitbol, 1989). These changes thicken the viscosity of laryngeal mucus, which is essential for normal vocal fold oscillation. Uterine cramping also can interfere with normal patterns of breath support. Women who experience disruptive voice problems associated with their periods should consult with both their gynecologist and laryngol- ogist to determine the safest and most efficacious approach to treatment. Caution should be exercised in self-medicating with drugs such as ibuprofen (as found in the brand name drug Mo- trin®) because of the increased risk of vocal fold hemorrhage associated with its use. Concems have been raised in the past about the vocal consequences of oral contraceptives. The pills that are currently marketed and prescribed in the United States, however, are of very low dose and produce relatively few voice-related side effects. However, if all other causes of a Page 140. -Chapter 9: Health voice problem are excluded, investigation of the oral contraceptive and change of that contra- ceptive should occur in consultation with the singer's gynecologist. Other hormonal medications can be more problematic. Androgens, for example, often are prescribed for women who suffer from endometriosis. These drugs are known to sometimes produce irreversible voice changes, including lowering of average fundamental frequency, reduction in the ability to sing the highest notes, and a general darkening and thickening of the sound. While these side effects are not universal, they usually are permanent in the women who experience them. Women considering such a drug therapy should do so only in close consultation with the laryngologist as well as gy- necologist. Peri-menopausal women should avoid testosterone based vaginal creams for vagi nal atrophy because they also can cause permanent lowering of the voice (9/48) Women also often experience hormone-related voice changes at menopause. During this time, the vocal folds might lose some of their natural elasticity, the viscosity of the lubricating mucus might change and average fundamental frequency tends to lower. Hormone replacement thera- py can improve vocal symptoms, but may lead to other long-term health issues. Male menopause or low androgen states can be reversed with supplemental androgen, which rarely has an adverse effect on the voice. Conclusion DON'T PANIC! Remember: under normal use, the voice is resilient and rapidly recovers from daily wear and tear through rest, good nutrition and proper hydration. Pathologic disorders commonly result from abuse, misuse, overuse, trauma or medical illness. Exercise good vocal hygiene, reasonable care—not paranoia—and you should have few, if any, problems. Page 141 :Your Voice: An Inside View References and Recommended Reading Abitbol, Jean, et al (1989): “Does a hormone vocal cord cycle exist in women? A study of vocal premenstrual syndrome in performers by Videostroboscopy-glottography and cytology on 38 women.” Journal of Voice, vol. 3, no. 2, pp 157-162. Bastian, Robert W. (1993). “Benign Mucosal and Saccular Disorders: Benign Laryngeal Tu- mars.” from Otolaryngology—Head and Neck Surgery, vol. 3, Cummings, et al editors. St Louis: CV Mosby Bastian, Robert W., Anat Keidar and Katherine Verdolini Marston. (1988) “Simple Vocal Tasks for Detecting Vocal Fold Swelling.” Journal of Voice, vol. 4, no. 2. Bastian, Robert W (1996). “Vocal Fold Microsurgery in Singers.” Journal of Voice, Vol. 10, no. 4, pp. 389-404. Brown, William S., Betsy P. Vinson and Michael A. Crary (1996). Organic Voice Disorders: As- sessment and Treatment. San Diego, CA: Singular Publishing Group, Inc. Davies, D. Garfield and Anthony F. Jahn (1988). Care of the Professional Voice: a management Guide for Singers, Actors and Professional Voice Users. Oxford: Butterworth-Heinemann. Forrest, L. Arick and Harrison Weed (1998). “Candida Laryngitis Appearing as Leukoplakia and Gerd.” Journal of Voice, Vol. 12, no. 1 Halstead, Lucinda (2012). Assorted excerpts from stroboscopic video laryngoscopies and clini- ‘cal examinations (previously unpublished). Used with all appropriate permissions and re- leases. Keidar, Anat (2004). Assorted excerpts from stroboscopic video laryngoscopies and clinical ex- aminations (previously unpublished). Use with all appropriate permissions and releases. Keidar, Anat (1997). "Occupationally Related Injuries in Singers.” Encyclopedia for Occupational Health and Safety, vol. 96, no. 25. Koufman J.A., and Blalock P.D. (1988). “Vocal fatigue and dysphonia in the professional voice user: Bogart-Bacall syndrome.” Laryngoscope, 98(5):493-8. Sataloff, Robert Thayer (1995). “AIDS in Singers.” Journal of Singing, vol. 51, no. 4. Sataloff, Robert Thayer (1998). Vocal Health and Pedagogy. San Diego, CA: Singular Publish- ing Group, Inc. ‘Saunders, William H (1964). The Larynx. Clinical Symposia. Summit, NJ: Ciba Pharmaceuticals Division, Ciba-Geigy Corporation Stemple, Joseph C., Leslie Glaze and Bernice Gereman (1995). Clinical Voice Pathology: Theory and Management. San Diego, CA: Singular Publishing Group, Inc. Verdolini, Katherine with Kate DeVore, Scott McCoy & Julie Ostrem (1998). Guide fo Vocology. Denver: National Center for Voice and Speech. Page 142+