9
The Singing Voice Specialist
Margaret M. Baroody, Robert Thayer Sataloff,
and Linda M. Carroll
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.
We live in an age of constant communication. People
of the 21st century are experiencing a level of human-
to-human contact that could not have been imagined
even 50 years ago. An inhabitant in the most remote
area of the world can experience voices and cultural
expressions of people thousands of miles away. While
much modern communication takes the form of the
written word through social media, the voice is still
prominent. We are bombarded nearly continuously
by the human voice through the 24-hour news cycle,
TV singing competitions and literally hundreds of
TV shows, movies, and other forms of voiced enter-
tainment that can be accessed in the comfort of one’s
own living room. As people live longer, a healthy
voice becomes an important factor not only in main-
taining needed social interaction but also in enabling
the basic communication necessary to meet the needs
of daily living.
Is it any wonder that in the field of Western medi-
cine, laryngology with an emphasis on voice medicine
has become one of the fastest growing areas of spe-
cialization? Thanks in part to meaningful advances
in scientific research and knowledge combined with
technological developments, we now have a sophisti-
cated and continually evolving paradigm for under-
standing, diagnosing, and treating voice disorders.
Fruitful collaborations among the practitioners of the
disciplines involved in voice, including laryngology,
Copyright 2017. Plural Publishing, Inc.
voice science, speech-language pathology, singing,
and acting pedagogy as well as singers, actors, and
others have been critical in fueling progress in voice
care. The “team approach” to medical diagnosis and
treatment is now embraced as an effective method
to improve outcomes. This understanding has led to
the development of the role of the singing voice spe-
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cialist (SVS) in voice medicine in which the concept
of “the voice team” has become part of the standard
of care.
How many people have wished “If only I could
sing . . . ”? The fact is, virtually everyone can. Any-
one who has pitch variation in his or her speaking
voice and can tell whether 2 musical tones are the
same or different can be taught to sing on some level.
The muscles targeted in coordination, ear training,
and breath control during singing lessons can be
extremely helpful in strengthening the speaking
voice. A comprehensive voice team incorporates the
benefits provided by a singing teacher with those
of a speech-language pathologist (SLP) and, where
appropriate, an acting voice trainer to optimize and
expedite voice improvement.
History, Qualifications, and Training
of the Singing Voice Specialist
The singing voice specialist (SVS), more recently
called by some the singing voice rehabilitation spe-
cialist, was originally defined broadly as a singing
teacher who was trained specifically to work with
patients with vocal pathology. In 1981, the term SVS
was coined in the practice of Dr Robert Sataloff where
this field was established as a full-time model within
a medical practice. When singing teachers began to
participate more formally in the medical treatment
of vocal pathology, the training usually occurred
through close association with a laryngologist spe-
cializing in singers. When this unique patient group
needed rehabilitation of the singing voice following
an injury or vocal surgery, the logical choice at the
75
 76 TREATMENT OF VOICE DISORDERS
time was an experienced singing teacher who pos-
sessed expert knowledge of vocal production. Some
laryngologists even referred their patient popula-
tion to singing teachers for help with speaking voice
recovery. From this close association, both singing
teachers and laryngologists learned from one another
and through this rather unstructured process singing
voice specialization emerged and apprenticeships
for training were established. One of the early and
better-known SVSs (although the term SVS was not
in use at that time) was Oren Brown, a professional
singer and singing teacher whose association with
laryngologists propelled him to pursue education
in aspects of vocal anatomy and medical diagnosis
and treatments. Another prominent pioneer from
the singing and teaching world was William Ven-
nard whose seminal book, Singing: The Mechanism
and Technic,1 introduced scientific research in human
anatomy and physiology to the study of singing. This
was followed in 1951 by another book on vocal peda-
gogy based on a modern perspective of voice pro-
duction, written by the renowned singing teacher E.
Herbert-Caesari entitled, The Voice of the Mind.2
This original prototype for the SVS is gradually
being replaced by the trained professional singer and
singing teacher who have obtained a degree in speech-
language pathology. This combination of performance
experience and medically based training creates the
potential for the voice clinician who is well qualified
to work with both the injured speaking and sing-
ing voice techniques. For a medical practice whose
reimbursements rely on insurance approvals, this
certified voice clinician might be the likely person to
be hired. As more people have sought to enter this
field and as demand for this specialization in medi-
cal practices has grown, the necessity for appropriate,
standardized, and authorized training protocols has
become widely recognized as an urgent need. It is
illegal in most states for a singing teacher to provide
“therapy” for an injured or pathologic voice. Voice
therapy is reserved for that provided by an SLP who
meets the certification and licensure requirements
established by the American Speech-Language-Hear-
ing Association (AHSA) and their state of residence
and practice. At present, if an independent singing
teacher accepts a student for “voice therapy” without
having the student work concurrently with a licensed
SLP, that teacher may be subject to litigation, even if
the student is referred by a laryngologist. The terms
rehabilitation and habilitation when used in a medical
context may imply recognized certification or licen-
sure. Since there are currently no programs offering
this kind of authorized training to an SVS, in some
states the use of these words to describe the work of
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an SVS who is not also an SLP could be considered
illegal. For the duration of this chapter and to sim-
plify the discussion, the work of the SVS, regardless of
whether he or she has an SLP degree, shall be referred
to as Singing Voice Specialist Intervention (SVSI).
Interestingly, most SLPs receive little training in the
remediation of voice disorders and often none in care
of the professional voice. Most SLPs are not singers
and therefore are not appropriately qualified to work
with the singing voice. However, demand is driving
the market, and educational institutions are respond-
ing with a growing number of graduate programs
designed to train the SLP clinician who will be work-
ing with injured voices. The vocology program at the
University of Iowa and the Singing Health Specialist
program at Ohio State University are just 2 examples.
However, there remains a need for training programs
that lead to the credentialing for the singing teacher
interested in becoming an SVS who does not wish to
pursue a speech-language pathology degree.
Within the field of established SVSs, a pathway
to certification is being investigated, debated, and
pursued. Currently, there are several programs that
provide some education not only to singing teach-
ers interested in working with the injured-pathologic
voice but also to speech-language pathologists who
have had insufficient background in voice produc-
tion. Most notably is the Summer Vocology Institute
in Salt Lake City, Utah, which offers course work in
voice for credit. Individuals and medical practices
have offered apprenticeship training opportunities
for those interested in becoming an SVS. However,
none of these situations provides the licensure or
industry-wide recognized certification that is needed
to firmly and ethically establish this field within the
medical profession.
There is consensus within the field of experienced
SVSs and laryngologists regarding many of the basic
requirements for anyone wanting to pursue this
career. An SVS should be an experienced singing
teacher, preferably with at least an undergraduate
degree in vocal performance or pedagogy, who has
professional singing performance experience. It is
desirable but not essential for the SVS to have basic
keyboard skills. In addition, the SVS should have
course work in vocal anatomy and physiology, neu-
roanatomy of the voice, voice disorders, and objective
voice measurement equipment and assessment. The
SVS must gain a basic understanding of the princi-
ples of laryngology and current treatment modalities,
including surgical interventions and medications.
A fundamental knowledge of the principles and
practices of voice-specialized SLPs is also needed.
As with any voice clinician, it is critical that the SVS
 9. THE SINGING VOICE SPECIALIST
has an exceptional ability to hear minute changes in
vocal quality and maintain the highest of standards
when it comes to efficient and healthy vocal produc-
tion. The SVS should spend a substantial amount of
time observing interaction between laryngologists
and experienced SVSs and SLPs and their patients.
An important aspect of the training of the SVS should
be an established number of clinical hours in which
the aspiring SVS is working with patients under the
direct supervision of an experienced voice clinician.
Singing Lessons: An Overview
To understand the special considerations for the SVS
in working with injured voices, one must be familiar
with singing training under normal circumstances.
The constructs of vocal technique applied in the sing-
ing studio are essential tools for the success of the
SVS. Application of modern scientific insights has
improved the training of teachers of singing in the
last few decades and was popularized by Vennard
whose book was mentioned earlier in this chapter.
In recent years, increasing interest in interdisciplin-
ary information disseminated through gatherings
such as the Voice Foundation Symposia and NATS
(National Association of Teachers of Singing) meet-
ings has contributed to more sophisticated curricula
in undergraduate and graduate training programs in
vocal pedagogy.
In this chapter, we make no effort to define good
singing teaching or to promulgate any one technique
as the correct approach. In fact, there is great varia-
tion of response from students in the singing studio,
and good singing teachers have a large repertoire of
techniques and exercises that allow them to individu-
alize approaches to meet the goals of voice training,
despite this challenge.
Within the academic world of voice teachers, the
study of the workings of the voice and the techniques
for training are known as vocal pedagogy. There are
traditions and schools of thought in vocal pedagogy
that date back centuries. These have been reviewed in
numerous works by authors such as Richard Miller3
and James Stark.4 There are basically 2 types of tra-
ditional singing instructors: voice teachers and vocal
coaches. The singing or voice teacher works primar-
ily on developing vocal technique through building
coordination of musculature in the vocal mecha-
nism. The vocal coach works primarily on repertoire
(songs) and interpretation. Many singers work with
both a singing teacher and a vocal coach. It is not
unusual to find a singing teacher who also offers
expert artistic coaching or a good vocal coach who
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77
can elicit better vocal production through artistic and
linguistic input. However, extensive experience as a
singing or voice teacher is necessary to acquire the
tools needed for SVIS.
There are a few basic principles that can be used
to understand singing teaching in general. Naturally,
many details are omitted. However, for the reader
who is not a singing teacher, the following informa-
tion should provide a basic idea of what a singing
teacher does. In general, singing teaching begins
with an assessment of the student usually by listen-
ing to the student sing a song or two or some spe-
cific exercises or vocal tasks, which may be chosen
by the teacher. This leads to a determination of the
singer’s vocal potential and problems, which guides
the development of a lesson plan. Specific exercises
are chosen to correct problems and improve vocal
control and eventually artistry. Areas of inappro-
priate muscle tension are identified, and methods
to eliminate these tensions are introduced. Training
addresses all pertinent areas of the singer’s anatomy.
Pulmonary control, also known as breath control or
breath management, and correct alignment of pos-
ture, often with the addition of abdominal exercises,
are used to cultivate the power sources of the voice.
Vocal exercises are designed and individualized to
increase neuromuscular strength and coordination at
the laryngeal level, improving not only range, qual-
ity, and vibratory symmetry, but also smooth control
over changes in subglottic pressure, vocal registers,
and other variables. The supraglottic vocal tract (the
oral and pharyngeal space) also is trained, develop-
ing optimal vocal tract shape to create the desired
harmonics and improved resonance without unnec-
essary muscle tension. In general, principles of artis-
tic economy apply. That is, if a good sound can be
made without involving a specific muscle group (eg,
those muscles that retract the tongue), then using
extraneous muscles is generally wrong and delete-
rious to vocal health and optimal performance. In
most cases, singing lessons result in steady, gradual
improvement in voice quality, range, efficiency, and
endurance. Singing lessons should not end in hoarse-
ness or physical discomfort in the neck or throat
(although abdominal and back muscles may fatigue
and ache).
The principles of proper voice production are
largely the same in speaking and singing. In fact,
many people believe that the singing voice is simply
a natural extension of a good speaking voice. In any
case, if a singer is working with an SLP to improve
the speaking voice while continuing to take singing
lessons with his or her singing teacher, the training
supplied by a singing teacher and the SLP should
 78 TREATMENT OF VOICE DISORDERS
be compatible and symbiotic. If a singer is receiving
contradictory information from these 2 voice profes-
sionals (and is correctly interpreting their instruc-
tions), that could be indicative of incorrect training
from one of them. Close scrutiny is warranted, and
open dialogue between the singing teacher, the SLP,
and the laryngologist should occur.
It is worth noting that although many singing
teachers work with the speaking voice, most are not
formally trained speakers or speech trainers. It is also
important to reiterate that many SLPs do not have
appropriate experience and knowledge in voice and
voice production. In addition, there is not a set of
requirements that must be fulfilled in order to call
oneself a singing teacher. Consequently, it is essen-
tial for other professionals to investigate the qual-
ity, training, experience, and reputation of singing
teachers with whom they anticipate collaborating in
patient care. Membership in NATS is an encourag-
ing sign, but the requirements for membership are
certainly not rigorous enough to ensure that all mem-
bers are high-quality teachers.
The Role and Responsibilities of
the Singing Voice Specialist
The trained SVS aids in the remediation of voice
disorders utilizing singing exercises specific to the
patient’s vocal condition. The SVS works with a voice
patient when recommended by the laryngologist,
following strobovideolaryngoscopic examination
and objective voice assessment (acoustic, aerody-
namic, and other measures). An SVS should never
work with a patient without a comprehensive medi-
cal examination and diagnosis from a laryngologist,
because (among other reasons) voice work is contra-
indicated in some conditions such as a recent vocal
fold hemorrhage or vocal fold tear. Most injured
singers are working with an SLP for speaking voice
therapy while working concurrently with the SVS.
An SVS can be useful in the remediation of sing-
ers and nonsingers. However, it is essential that sing-
ers work with the SVS to ensure safe, healthy vocal
production and to identify and eliminate poten-
tially dangerous compensatory technical errors in
the singing voice that often develop in response to
vocal injury or dysfunction. The SVS is not a replace-
ment for the patient’s established singing teacher.
Often, the injured singer will forego regular singing
lessons during the early stages of vocal rehabilita-
tion. The singing teacher may be brought into this
process early on or defer until the patient’s voice is
less pathologic. The SVS may work with the sing-
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ing teacher to educate him or her about the patient’s
voice disorder, may include the singing teacher in the
sessions (if approved by the patient and desired by
the teacher), and always instructs the patient regard-
ing appropriate vocal exercises and goals in light of
medical limitations established by the laryngologist.
In the case of the patient who has an established sing-
ing teacher, the goal is to return that singer to regu-
lar singing lessons as soon as is safe to do so. In the
case of the singer who does not have an established
teacher, often the SVS can provide guidance in help-
ing the patient find appropriate vocal instruction.
For nonsingers, supplementing traditional voice
therapy (by the SLP) with singing voice training often
facilitates and expedites therapy. There are many dif-
ferences between singers and typical speakers. For
example, the pitch range of conversational speech
usually covers about a major sixth. Most singers uti-
lize at least a 2-octave range in singing. Interestingly,
physiological frequency range is about three and
one half octaves in both singers and nonsingers, so
most people have more potential than they realize.
Pulmonary demands are also much greater during
singing than speech. In speech, we typically use 10
to 25% of vital capacity. The singer frequently uses
65% of vital capacity. In many ways, it could be said
that singing is to speaking as running is to walking.
In rehabilitating a patient who has difficulty walk-
ing, if the patient can learn to run, walking becomes
relatively easy, since the patient is not working at his
or her physiological limits during this activity. Like-
wise, once patients have acquired some of the athletic
vocal skills employed routinely by singers (including
increased frequency range, frequency and intensity
variability, prolonged phrasing, breath management
and support, etc), the demands of speech seem much
less formidable. In many cases, even nonsingers uti-
lize a more “open” resonance space and an anteriorly
placed voice while performing sung or chant-like
phrases. In these instances, there may be an instinc-
tive use of increased airflow and greater oral-pha-
ryngeal space, which is vocally beneficial and easily
transferable to speech. There may be added benefit in
that the inappropriate compensatory muscle tension
that has become part of a patient’s speech produc-
tion may not have habitualized into the lesser-used
singing or chant mode. Singing potentially makes it
easier for the patient to produce more relaxed and
efficient phonation.
It is worth reiterating that the SVS should not work
with the injured speaking voice without the collab-
oration and input of a SLP, especially in the early
phases of rehabilitation. The course of the speaking
voice rehabilitation should be directed principally by
 9. THE SINGING VOICE SPECIALIST
the SLP and the laryngologist with the SVS in regular
consultation regarding appropriate singing exercises
and overall goals for the speaking voice. It is critical
to the patient’s progress that the input of the SLP and
the SVS be totally symbiotic and in no way contradict
each other.
The SVS Studio
The basic equipment for the SVS studio should
include a piano or keyboard, a full-length mirror, a
handheld mirror, and good lighting. When possible,
the studio should have reasonably “live” acoustics.
It should be temperature controlled and humidified
and drinking water should be readily available. The
studio also should include recording equipment (ie,
CD recorder) not only to document the evaluation
but also to provide the patient with a recording of the
exercises to facilitate home practice. When possible, a
video recording of the session can provide the patient
with valuable visual feedback.
History, Assessment, and
Exercise Protocols
The assessment of the injured voice begins with the
SVS taking a systematic, comprehensive patient his-
tory. While this may seem redundant in a medical
practice in which the patient’s history may have
already been taken by several other members of
the medical team, repetition frequently yields new
information of importance that has not been revealed
to other members of the voice team. This history is
intended to give the SVS an extensive knowledge
of the experience, habits, health, and state of mind of
the patient. It also allows for the opportunity to con-
nect with the patient and can help to establish the
trust necessary to facilitate a more effective rehabili-
tation process. Taking a history also allows the SVS
to observe the speaking habits of the patient. Typi-
cal questions asked in the history are the same as
those asked by the physician and are summarized
in Appendix IIa. If a history form has not been com-
pleted for the laryngologist, the SVS asks the patient
to complete a similar questionnaire. In the case of
the injured singer, the SVS will seek to establish a
full understanding of the singer’s training (past and
current), performance experience, and daily singing
(and speaking) demands, and the singer’s own self-
assessment of his or her current vocal dysfunction.
Other pertinent questions for the singer might
include the following:
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79
1. What kind of music do you perform most often?
2. What do you consider your comfortable range?
Do you often sing out of that comfort zone?
3. Do you play an instrument while singing or
between songs during performances? What
instruments?
4. What are the environments and acoustics of the
performances spaces in which you sing?
5. Do you use amplification, and if so, do you use
monitor speakers or in-ear monitors?
6. Are special costumes and staging involved dur-
ing singing?
7. What are your career goals and the current status
of your career?
8. How much of your income is derived from vocal
performance?
Questions concerning general health and routine
life patterns should be reviewed for both the singer
and nonsinger. Inquiries regarding exposure to
smoke, alcohol and recreational drug use, and sleep
patterns, exercise, medications, stress levels, family
and social interactions, and work-related demands
are just a few of the areas that can give a more com-
plete picture of issues that might have an impact on
the patient’s voice and recovery process.
Early in the process of evaluation by the SVS, it
can be extremely helpful for the SVS to review the
physician’s diagnosis with the patient. There are
research data5 to support the link between successful
treatment outcomes and a patient’s understanding
of the physician’s explanation of the diagnosis and
the subsequent reasoning behind the treatment plan.
The education of the physician is extremely different
from that of the singer. Consequently a communica-
tion gap between the voice patient and the laryngolo-
gist may exist, in part because they do not speak the
same “language.” The SVS can provide an invaluable
service by helping to facilitate clear communication
between the physician and the voice patient through-
out the treatment process.
Additionally, the patient is often in a state of extreme
emotional distress during the exam and may be unable
to comprehend fully the physician’s diagnosis. The
“white coat” syndrome, in which the patient expe-
riences measurable physiologic changes, such a rise
in blood pressure is well documented.6 It is reason-
able to assume that this change in physiologic status
could impact a patient’s ability to focus.
There is a surprising reluctance on the part of
some singers to ask for a more detailed explanation
of the diagnosis. This may be the result of fear or
shock or it may represent a lack of knowledge of the
basic mechanics and physiology of the voice. Never
 80 TREATMENT OF VOICE DISORDERS
assume what a singer knows about the voice. Many
professional singers lack formal education in either
vocal technique or the mechanics of vocal function.
Singers may be self-conscious about these limita-
tions. The challenge is to impart this information to
the singer without creating or exacerbating feelings
of inadequacy.
It is important to consider the psychological and
emotional stress that is often caused by a voice prob-
lem. Most people have a strong sense of self-iden-
tification related to sound of their speaking voice.
Any disruption in this area has the potential to cause
distress. When the severity of a vocal problem inter-
feres with normal socialization and even disrupts or
prohibits the work life of the patient, the potential for
stress is increased greatly. These issues can be magni-
fied substantially for anyone who self-identifies as a
singer. The loss of the ability to sing is likely to cause
extreme distress, particularly in those individuals
who rely on singing for financial stability. The SVS
must consider the impact of this stress on the patient
and when, appropriate, suggest professional psycho-
logical counseling.
The next phase of the assessment involves a dem-
onstration of the patient’s singing voice. The purpose
of this part of the assessment with regard to singers
is to give the SVS an understanding not only of the
range, quality, and dynamic variability of the disor-
dered voice but also understanding of the singer’s
normal approach to his or her singing voice.
The nonsinger is often self-conscious about his or
her singing abilities, so it is important to establish
a comfortable and nonthreatening environment to
enable the patient to relax and provide a more accu-
rate demonstration. With the nonsinger, one can use
a familiar melody such as Happy Birthday or part
of a children’s nursery rhyme, such as the first three
notes of Three Blind Mice, and move the keys up
and down to establish approximate singing range.
Variation in vowel and consonant combinations can
provide a clearer vocal picture. For some nonsing-
ers, scales may prove too abstract and unfamiliar
to duplicate. Whatever the method, it is essential to
take the time needed to evaluate accurately the qual-
ity of the singing voice versus the speaking voice, as
well as to note any technical differences in produc-
tion between the sung and the spoken voice. If the
nonsinger instinctively utilizes a more efficient sys-
tem of breath management or increased resonance
space in singing than in speech, this difference can be
pointed out to the patient, and this may then help to
facilitate easier adaptation of better vocal technique
in speech.
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Most singers are uncomfortable with demonstrat-
ing less than their best vocal tones. Even professional
singers may need encouragement to expose the prob-
lems in the voice that led them to seek treatment. The
SVS should help the singer understand that demon-
strating his or her vocal vulnerability and thus iso-
lating the problem can aide in the choice of more
effective treatment modalities. If the physician has
not placed restrictions on the singing voice, as in the
case of a recent vocal fold hemorrhage or tear or an
initial postsurgical session, then the singer might be
asked to demonstrate his or her habitual warm-up
regimen. If the singer has no regular warm-up, the
SVS can take the patient through a series of vocal
patterns designed to demonstrate quality, range, and
dynamic variability. Singers with no formal training
may give a more accurate presentation of habitual
technique and voice quality by singing a song from
his or her standard repertoire. During this part of
the assessment, the SVS should recognize any areas
of forced or strained vocalization and should limit
the singer to demonstrating only what he or she can
without unacceptable levels of strain.
In most instances, the “normal,” baseline voice
of the patient is not known to the SVS. So, record-
ings, either audio alone or visual with audio, of the
preinjured voice can be very helpful in establishing
the vocal goal of treatment. If such recordings do not
exist, the patient’s own explanation of the preinjured
voice as compared with the current injured voice can
be useful.
It is critical for the SVS to remember that different
styles of singing require different aesthetics. The very
narrow quality requirements of the classical operatic
voice do not apply, for instance, to the rock-belt voice
of a specific musical theater style. Breathiness, raspi-
ness, overt nasality, and other qualitative differences
may be essential to success in particular styles of
singing. The voice team, and especially the laryngol-
ogist and the SVS, must be familiar with the special
techniques, demands, and problems of the singing
style of each individual patient. It is neither helpful
nor scientifically justified to dismiss any particu-
lar genre of singing (including hard rock) as medi-
cally unacceptable. With sufficient understanding,
patience, voice team skill, and patient compliance, a
“right way” can be found to do almost anything with
the voice.
The singing evaluation can be done with the patient
standing or sitting, according to his or her normal
position during singing. The patient is assessed for
stance/posture, breath control and general breath
support, general muscle tension, oral-pharyngeal
 9. THE SINGING VOICE SPECIALIST
space including jaw position, range, and quality of
sound. The SVS may use a form such as Figure 9–1
to record observations. Regardless of the vocal tasks
used to evaluate the singing voice (scales, parts of a
song, the singer’s standard repertoire), it is best to
begin with soft to moderate volume and in the lower
or middle frequency range of the voice and to prog-
ress gradually to the comfortable limits of pitch and
volume. In the case of the singer whose vocal fold
pathology makes soft singing impossible, increased
volume may be acceptable. In some cases, such as
the patient with extreme vocal fold scar, it may not
be possible for the patient to sing in the lower or
modal register, and the patient may be able to the
phonate only in the upper range of the voice. Time
and patience are required to assess accurately the
patient’s singing voice quality, range, dynamic vari-
ability, and technique, particularly in light of limita-
tions imposed by particular pathologies. To minimize
the risk of further injury, under no circumstances
should the singer be allowed to use excessive force
or strain during this assessment.
Specific Assessment Considerations
Relating to Traditional Vocal Technique
Stance/Posture
The head, neck, and shoulders should be in neutral
position. The shoulders should not be elevated, rolled
Figure 9–1. Evaluation form used by singing voice specialists. + = minimal cues; ++ = considerable tactile and visual cues
required. (continues)
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81
forward, or held back, as these maneuvers introduce
unnecessary tension. The patient should stand com-
fortably straight but not in a rigid, military posture.
Dynamic, not static, muscle engagement should be
pursued. The knees should be flexible, not locked,
and the body weight should be aligned over the cen-
ter of the feet, not resting back on the heels. The feet
should be slightly apart, but not more than the appar-
ent width of the shoulders. Many singers prefer to have
one foot slightly forward. This athletic, well-balanced
stance optimizes breathing and support. It benefits
the SVS to acquire special knowledge of postural
analysis and muscle conditioning. Basic principles of
posture and alignment, such as those promoted in
the Alexander, Feldenkrais, and Yoga techniques can
be found in the literature,7–9 and in Chapter 15, and
consultation with a skilled physiatrist or physical
therapist may be valuable in selected cases.
In the case of the injured voice, it is common to find
excessive, counterproductive compensatory muscle
tension at any point in the body. This may represent
an instinctive, unconscious effort to reestablish nor-
mal vocal fold function (eg, to force closure of the
vocal folds or to create a tone quality familiar to the
patient). The SVS must be on constant alert for these
tensions, as the patient often does not realize that
unnecessary contraction is taking place. The patient
must be able to identify his or her own areas of ten-
sion and be given specific maneuvers and exercises
that allow for the release of these tensions. Special
attention should be given to enabling the patient to
 82 TREATMENT OF VOICE DISORDERS

Figure 9–1. (continues)

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 9. THE SINGING VOICE SPECIALIST
Figure 9–1. (continued)
identify and eliminate muscle tension in the area
of the throat and larynx. The patient’s kinesthetic
awareness of a relatively relaxed and “neutral” throat
is a central component to the success of any lasting
vocal recovery process.
Respiration
Inhalation
The rib cage should be expanded, so that the upper
thoracic area appears slightly fuller than during com-
fortable speech. This area should not rise excessively
on inhalation as this might contribute to muscle ten-
sion in the upper thorax, supraclavicular area, or neck
region. Most of the action of breathing is abdominal,
and expansion should occur in the front, back, and
sides. Inhalation should be relatively relaxed and
quiet. Nasal inhalation may have the added benefit of
warming and filtering the air but may require more
time to accomplish and does not allow for simultane-
ous palatal elevation. Oral inhalation is also accept-
able and often necessary between musical phrases
where time for inhalation is limited. High, thoracic
inhalation and noisy inspiration can indicate tension
which may be carried over into vocalization. Abdom-
inal movement during inspiration and expiration
should be efficient. Excessive abdominal activity may
occur in singers struggling to optimize breathing and
support. Such excessive contraction and distension of
abdominal muscles may undermine the adjustment
process between inhalation, effective support, and
vocal fold efficiency. Abdominal movement should
be fluid, with the exception of necessary rapid inhala-
tion (when a fast breath must be taken between musi-
cal phrases) causing a quick expansion, or a staccato
(short) phonation gesture that requires quick contrac-
tion of the abdominal muscles.
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83
Inhalation can be impacted negatively by chronic
vocal fold pathology. As mentioned above, the body
instinctively tries to create “normal voice,” even
when the vocal folds are not capable of producing
this sound. The resulting compensatory effort exerted
to support the voice upon exhalation can contribute
to overly contracted abdominal musculature. This
contraction can become difficult to release, thus pre-
venting the complete descent of the diaphragm dur-
ing inhalation resulting in restricted inhalation and
cumulative, self-perpetuating muscle tension.
Exhalation and Support
Support is a difficult concept for many singers and
patients to comprehend and execute. Various con-
structs are used to teach it. The fundamental prin-
ciple is to generate a vector of force underneath the
airstream in order to establish consistent control as
the air moves upward between the vocal folds. Sup-
port should be continuous, not static. Some good
abdominal support many be experienced during
various spontaneous maneuvers such as laughing,
coughing, or the act of blowing out a candle. Singing
a rolled /r/ or singing on a scale or phrase on /v/
also may illicit spontaneous abdominal engagement.
Muscles in the lower and upper abdomen and the
lower thorax and back are involved actively during
support efforts. Coordinated support should be initi-
ated just before a tone is heard. Almost any teaching
imagery may be effective, so long as the singer and
the teacher or SVS understand the difference between
the language of imagery and the actual physical effect
that they are trying to achieve.
Support may be assessed visually and by palpa-
tion. It is often best to evaluate support through a
series of vocal maneuvers including ascending scales
or vocal passages, softer singing, staccato or quick
 84 TREATMENT OF VOICE DISORDERS
notes, and various other tasks. Good support is
essential for efficient vocal fold action or flow pho-
nation. When the power source or breath support
system is not adequately engaged, many voice users
compensate with excess muscle tension in the intrin-
sic and extrinsic muscles of the neck and larynx, the
tongue, and the jaw. Such muscle tension can lead
to dysphonia and is in general inefficient and poten-
tially hazardous to the vocal folds.
The SVS should be aware that it is common for the
breath support effort to go into “overdrive” when
there is vocal fold pathology present. As mentioned
earlier, this may present as excessive abdominal
engagement on exhalation and the inability to release
abdominal contraction on inhalation.
Laryngeal Position
For most Western classical singing, the larynx is
usually slightly below its neutral vertical position
at rest. The larynx should remain relatively stable
and should not rise appreciably with ascending
pitch or fall with descending pitch. These caveats
are not necessarily true in other singing styles such
as Contemporary Commercial Music (CCM, which
encompasses many musical styles) and certain other
cultural and ethnic styles in which the singers are
not usually required to project the voice to fill a large
performance space, or in which they sing aided by
amplification.
When vocal fold function is compromised, it is
common to observe supralaryngeal hyperfunction
resulting in an excessively high laryngeal position.
This maladaptive positioning should be addressed
early in the retraining process. Visual feedback,
manual laryngeal massage, inhalatory gestures that
incorporate a “dropped” laryngeal maneuver and
slow, gentle inhalation through a straw all can be
used effectively to release laryngeal hyperfunction
and elevated position. Reducing vocal volume may
allow for greater laryngeal release, particularly if the
increased volume is a maladaptive behavior related
to the vocal fold injury or pathology.
Extrinsic Laryngeal and Neck Muscle Tension
Visual evaluation can be used for assessment of
extrinsic laryngeal muscle tension during vocaliza-
tion in all voice users. Protrusion of the strap muscles
or of any of the extrinsic laryngeal musculature may
be indicative of muscle tension that could contribute
to dysphonia, and such activity is considered indica-
tive of hyperfunctional vocal behavior. Healthy sing-
ers as well as voice patients demonstrating this kind
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of muscle engagement may complain of pain in or
around the larynx with prolonged voice use and may
present with a “throaty” or “posterior” vocal quality.
Such muscle tension can contribute to a pitch wobble
and voice fatigue. In pursuit of eliminating this kind
of counterproductive muscle tension, the concept of
a “neutral throat” or, in other words, minimal sensa-
tions in the region of the larynx and throat muscula-
ture, can be a helpful goal. Visual feedback is also an
effective tool in helping the patient reduce this tension.
It is rare to find a voice patient who does not dem-
onstrate some level of counterproductive compensa-
tory muscle tension because the unconscious urge to
produce “normal” voice at any cost drives the patient
to exert excessive effort that is not only ineffective but
potentially injurious.
Jaw Position
Jaw position may be assessed while singing the
vowel /ɑ/. The jaw should be allowed to open to its
maximum comfortable position, although this may
vary according to range. It should never be forced
open excessively. Appropriate jaw release might be
similar to that seen in most people just before a yawn.
A 2-finger span can be a comfortable benchmark for
the jaw opening, although no one should be forced
to meet this guideline if this degree of opening intro-
duces tension in the musculature of the jaw. The cor-
ners of the mouth should not be tensed, and the jaw
should not quiver or alter position with changes in
pitch. The masseter muscle should never be overly
tensed for any vowel. Decreased oral resonance due
to limited mouth opening can be a tell-tale sign of jaw
tension. Teeth clenching is characteristic of extreme
jaw tension. Mouth opening may change in relation
to pitch, although such changes may be less promi-
nent in well-trained than untrained singers.
Tongue Position
Tongue position may be most easily assessed on
the vowel /ɑ/. The tip of the tongue should rest in
a relaxed position against the mandibular central
incisors. It should not retract, curl anteriorly, or rise
posteriorly. The pharynx generally should be vis-
ible, not obscured by the arching of the posterior
tongue. Sudden tongue tension and retraction upon
initiation of voice is a classic compensatory muscle
tension response and can be a sign of delayed or inef-
fective breath support. Visualization of the tongue
as well as aural assessment of tonal quality can be
used to identify inappropriate tongue tension. It is
possible for an experienced singer to maintain the
 9. THE SINGING VOICE SPECIALIST
anterior tongue in an appropriately forward posi-
tion while still introducing posterior tongue tension
and retraction. This negative tension can contribute
to voice fatigue, decreased range, and decreased
flow phonation resulting in inefficient voicing. The
term pressed phonation correlates to overadduction of
the vocal folds, a habit that can exacerbate or pro-
long vocal fold pathology, and can result in a vocal
quality that is posterior in placement and limited in
vocal color. Posterior tongue tension can contribute
to this forceful adduction. There should be no altera-
tion in tongue position related to pitch change, and
the tongue and jaw should be able to work indepen-
dently of one another during articulation.
Facial Musculature
Excessive muscle tension in the corners of the mouth,
lips, chin, forehead, or any facial muscle group may
indicate hyperfunction. It must be acknowledged,
however, that the impact of the use of facial mus-
cles during singing varies widely, depending on the
individual. Eliminating unnecessary engagement of
facial muscle hyperfunction can be important not
only in optimizing technique, but also because the
singer and speaker need to be able to use facial mus-
cles independently to show expression and emotion
without affecting vocal production.
Tone “Placement”
Tone placement refers to the area of the anatomy
at which an individual has a physical sensation of
vibration from vocalization. There is general agree-
ment in the singing and voice therapy communities
that an anterior sensation of vibration is more likely
to be reflective of a properly produced voice. That
is not to say that this frontal sensation cannot be
achieved incorrectly. Nevertheless, the consensus is
that for both the healthy and the pathologic voice,
anterior or frontal tonal sensation should be the goal.
It is understood that the vocal source sound achieves
vibratory enhancement through an extended area of
the vocal tract and that sensations of vibration can be
identified in many areas of the upper body. However,
overly posterior tonal placement in a young singer
is often the result of an attempt to achieve a more
mature or “heavy” vocal quality. In the classically
trained singer, it can be the result of the pursuit of
increased volume. Whatever the reason in any voice,
an imbalance in this sensation can be indicative of
excessive muscle tension and can decrease the sing-
er’s formant and can impair projection in both sing-
ing and speaking.
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85
When working with an injured voice, it is impor-
tant to remember that if vocal fold function is com-
promised, then the source sound created by the
injured vocal folds and the breath may not be strong
enough to result in significant anterior sensations of
vibration, no matter how perfect the technique.
Choosing a Treatment Plan
At the completion of the assessment process, obser-
vations and findings are reviewed with the patient.
Patient fatigue, nervousness, and other variables
can impact patient performance, but an experienced
SVS usually can draw accurate conclusions during
this initial evaluation. Specific areas of weakness are
explained and plans to remedy them are established.
Targeted exercises are selected, and the SVS teaches
them to the patient. A practice schedule is assigned,
and arrangements for follow-up sessions are made.
Throughout this process, the SVS is expected to
have taken meticulous notes of all interaction with
the patient which are transcribed into the SVSs ini-
tial report. This initial evaluation and all follow-up
reports are added to the patient’s medical file. The
SVS observes all Health Insurance Portability and
Accountability Act (HIPAA) confidentiality regula-
tions that pertain to medical practice. Any breach of
patient confidentiality on the part of the SVS is an
egregious error that cannot be tolerated.
In designing and individualizing training proto-
cols, the SVS commonly works toward goals that are
similar to and yet substantially different from those
familiar to most singing teachers. The SVS must be
disciplined enough to understand that appropriate
technique is paramount, regardless of vocal quality.
It is critical that someone with an injured voice learn
to sing “by feel” and not be guided by old, aural aes-
thetics. This is not a natural concept for singers or
even speakers. Ordinarily, a “good” sound is con-
sidered the goal by the singer and the teacher, and
even an injured singer will do whatever he or she
can to reach this goal. This natural tendency can
exacerbate an existing pathology and interfere with
the treatment process. In many instances, muscular
hyperfunction created the medical difficulty in the
first place. The best teachers strive to enable their stu-
dents to sing with optimum technique regardless of
aural feedback. However, in most situations, at least
initially, it is impossible for compromised vocal folds
to produce a source sound that will result in what the
patient would consider “normal voice.” Even minor
edema or swelling of the vocal folds can create this
lack of familiar voice. Maintaining perfect technique
 86 TREATMENT OF VOICE DISORDERS
regardless of the resulting voice quality is critical to
a successful and timely outcome. With the injured
voice, it is often true that the better the technique,
the “worse” the resulting voice, at least at the onset
of the recovery process.
While working with the injured voice following dis-
ease, injury, or surgery, it is essential to develop good
technique, to incorporate healthy muscle use, and to
minimize muscle atrophy. The timing of progression
in this work is determined by the SVS in collaboration
with the laryngologist and the SLP. One of the most
important aspects of training for the SVS is developing
the ability to understand medical limitations, goals,
prognoses, and expected duration of recovery (often
months). Only with a clear understanding of these
issues, and with full appreciation of the patient’s activ-
ities and progress with the SLP, can the SVS develop a
singing protocol that is medically safe and is effective
in aiding the patient’s progress toward full recovery.
There is no magic set of vocal exercises, no one-
size-fits-all paradigm for the recovery process. Each
patient has his or her own specific needs depending
on the pathology, extent of injury, age of injury, and
vocal demands. It is important to understand the
nature of the patient’s vocal pathology, to identify
probable causes of the pathology (when possible),
identify compensatory technical behaviors, and
understand the physiological and histological effects
of the pathology in order to work adequately with
an injured voice. Carefully chosen exercises are uti-
lized, addressing each area of deficiency. Exercises
are designed to develop all aspects of the vocal mech-
anism. At the onset of sessions, the initial goals may
focus on vocal fold stretching, flexibility, and effi-
ciency. Depending on the diagnosis, actual strength-
ening exercises may come later. Again, the order of
the exercise protocol should be based initially upon
the nature of the pathology and with consideration
given to the individual patient’s skills.
Specific Exercises
This section is not intended to be a comprehensive
guide for appropriate exercises for the injured voice.
Its purpose is to give the reader an overview of con-
siderations in choosing exercises and some general
exercise constructs that are part of our current treat-
ment modalities.
Relaxation Exercises
With both the injured and the healthy voice, the
identification and elimination of counterproduc-
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tive muscle tension and hyperfunction should occur
at the onset of sessions. Excessive muscle tension
is the enemy of efficient and safe vocalization, so,
addressing areas of tension throughout the body can
prove beneficial. Gentle stretching exercises for the
upper torso targeting the musculature of the back,
neck, intercostal, and abdominal regions should be
explored. In many patients, release of muscle tension
in the one part of the body triggers release of tension
in seemingly unrelated areas, as in the case of the
release of tension in the hamstring muscles produc-
ing greater relaxation of muscles in the lower back.
The tongue and jaw can be critical areas of hyper-
function. Tongue tension can be addressed with vari-
ous stretching, isometric, and articulation maneuvers,
as well as through visual feedback or tactile cuing
during phonation. Active stretching of the tongue by
extending it out of the mouth or passive stretching
it by having the patient manually pull the tongue
outward using a paper towel, piece of gauze or cloth
can release unwanted tension. No exercise or stretch
should be continued if the patient experiences pain
or discomfort. Phonation while extending the tongue
can enable the patient to identify tension at onset of
voice and to avoid habitual tongue retraction more
effectively.
Tension in the jaw musculature may be addressed
using manual massage of the masseter muscles,
stretching maneuvers, visual feedback, imagery, and
relaxation cues. In many cases of extreme jaw ten-
sion, intraoral massage is warranted. Gentle chewing
motions of the jaw while humming softly can facili-
tate release of jaw tension. Having the patient simply
rest the palms of the hands on either side of the face
during phonation (as if cradling a baby’s face in one’s
hands) can stimulate relaxation of the masseters.
Manual massage is also helpful for release of ten-
sion in other facial muscle groups. For release of
anterior neck and extrinsic laryngeal muscle tension,
the patient can be taught laryngeal self-massage tech-
niques. There is now a wealth of literature for safe
instruction in release of muscle tension including
such books as The Voice Book.10
Breathing/Inhalation Exercises
There are many exercises that work well for teach-
ing breath management to singers and nonsingers
alike. If the patient is a trained singer, then a review
and discussion of his or her concept of inhalation
can enable the SVS to assess whether clarification
in this area is needed. Again, never assuming what
the trained singer might know, a simple explana-
tion of the respiratory system should be offered to
 9. THE SINGING VOICE SPECIALIST
all patients. The goals of inhalation stated earlier in
this chapter should be clarified with emphasis on
unhindered diaphragmatic descent and rib cage and
abdominal expansion. Placing the patient in unusual
positions frequently helps him or her sense aspects of
breathing that are harder to feel in habitual postures.
In a standing position, the patient can place his or
her hands behind the neck, as if “under arrest,” and
then inhale and exhale slowly through the nose while
observing the expansion and contracting of the rib-
cage and abdominal areas that accompany this action.
Exercises may be done with the patient lying on the
floor with a small book under the head, knees bent,
and feet flat on the floor to facilitate proper spinal
alignment. Slow, gentle inhalation and exhalation are
then repeated with the patient monitoring abdominal
movement with his or her hands. Other useful posi-
tions include having the patient hang forward from
the waist, like a rag-doll with slightly bent knees and
the weight of the head and body slightly forward
over the balls of the feet. Slow inhalation and exha-
lation in this position usually results in the patient
being able to identify expansion in the regions of the
lower abdomen and lower back. Allowing the patient
to gradually resume an upright position while con-
tinuing slow respiration can result in carryover of
this more appropriate inhalation into normal pos-
ture. It should be remembered that the supine and
inverted postures create modifications in respiratory
function that may not be appropriate for long-term
voice development. These maneuvers are intended
to help establish body awareness early in the train-
ing process, and patients should be cautioned not to
practice these positions excessively or to overvocal-
ize in these positions.
Another approach is to have the patient inhale and
exhale slowly and without tension through a straw of
moderate diameter. This maneuver often allows for
excellent diaphragmatic release and abdominal and
rib expansion and also can help to facilitate laryn-
geal release. Narrower straws create more resistance
to airflow, which may, in some patients, result in
unwanted tensions. The smaller straw can be intro-
duced after the patient has shown success with a
straw of larger diameter.
Exhalation and Support Exercises
The concept of proper breath support has long been
an area of debate and contention in the world of voice
pedagogy. While there is agreement that a consistent
support system is essential to ensure safe and opti-
mal singing, there are divergent methodologies using
various constructs of muscle engagement to direct
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87
and control the airflow between the vocal folds. For
the SVS, the goal is to provide the simplest and most
efficient support gesture for each patient. In address-
ing breath support in a pathologic patient, the goals
may be different from those for a healthy singer.
For example, in the case of a singer with vocal fold
masses, breath support is not intended as a means
of controlling the use of the breath for singing long
phrases. Rather, the priority is to allow for adequate
airflow to facilitate vocal fold vibration. This might
require increased airflow to accommodate an increase
in vocal fold mass or incomplete glottic closure sec-
ondary to vocal fold masses. Because of the great dis-
parity in vocal technique and learning modalities in
the average patient population, the SVS should have
a number of “tools” in his or her exercise “tool box”
to meet the needs of such a diverse group.
There are many spontaneous vocalization activities
that can lead a patient to a better understanding of
appropriate abdominal support. A gentle cough or
laugh with the patient manually or visually monitor-
ing his or her abdominal contraction can be helpful.
Exhalation through a straw provides another good
facilitator as does a sustained chanted or sung /v/,
/z/, rolled /r/, or even a lip-trill (buzz). Once the
patient has a sense of this muscle coordination and
directed airflow, more extended vocalization can be
attempted. The SVS and the patient must alert be
at all times to any hyperfunctional muscle engage-
ment, as might be found in the musculature of the
neck or in the overcontraction of the targeted support
muscles. The basic concepts of healthy breath sup-
port reviewed earlier in this chapter are applicable
to both the singer and nonsinger patient population.
Vocal Exercises
Individual exercise programs must be designed to
accommodate the specific needs of each patient. Not
every exercise is appropriate for the remediation of a
particular pathology. For instance, staccato exercises
might be contraindicated in a patient with bilateral
masses or a recent vocal fold hemorrhage, as the
initial goal would be to decrease adductory vocal
fold contact pressure during phonation to minimize
phono trauma during healing.
It is not unusual to have a patient who has more
than one problem contributing to his or her dyspho-
nia. This requires the SVS to choose priorities when
designing exercise protocols. These decisions can be
made based upon the laryngologist’s assessment of
which pathologies are the primary contributing fac-
tors to the patient’s vocal complaints. In the case of
the patient who has both vocal fold masses and vocal
 88 TREATMENT OF VOICE DISORDERS
fold paresis, the SVS must give thoughtful consider-
ation in choosing the exercise protocols. For example,
exercises to decrease vocal fold contact force (such as
trills, straw phonation, gentle sung glides on facilitat-
ing vowels) used to promote reduction of the vocal
fold masses would not necessarily be the exercises of
choice to target improved vocal fold closure follow-
ing paresis. To correct glottic insufficiency related to
paresis, bowing, or even scar, exercises using greater
airflow resistance (scales sung on /v/ or /z/), messa
di voce exercises), as well as increased volume on
selected scales (assuming no compensatory tension)
can aid in better closure. Some exercises, such as
semioccluded vocal tract activities on lip and tongue
trills, can be used to enable the patient to stretch into
the upper range with minimal vocal fold contact
force and may be considered relatively safe for most
vocal fold injuries or pathologies, when done with-
out inappropriate muscle tension.
It is important to remember that there are relatively
few research data on the direct impact of a particular
vocal exercise on the physiology of the vocal folds. In
addition, there is not a significant body of evidence
focused on the vocal recovery process to indicate
which exercise might prove most effective in the
remediation of a specific pathology. Therefore, it is
incumbent upon the SVS to obtain as much experi-
ence as possible with different exercises and train-
ing techniques, to be able to assess patient response
rapidly and change training strategies promptly
when necessary. The SVS must use this experience
to study the possible effects of each exercise on vocal
fold function to more effectively assist the patient
in regaining normal voice and avoid inadvertently
causing further injury. The SVS is responsible not
only to help the patient to establish optimum vocal
technique, but also to understand all elements of
vocal health and behavior that could significantly
impact treatment outcome.
Clinical Applications
Many of the currently popular therapeutic vocal exer-
cises may aid in establishing more efficient phonation,
otherwise known as flow phonation. When done
correctly, these exercises can lead to more efficient
vocalization with a minimum of vocal fold adduc-
tory force. As mentioned before, semioccluded vocal
tract exercises including lip and tongue trills as well
as the popular straw phonation as codified by Dr
Ingo Titze11 can be safe and efficient tools for the
recovery plan. It is worth repeating that any exercise
can be done incorrectly so careful monitoring of the
patient’s technique is essential.
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It is important to remember that at the onset of
the treatment of certain vocal fold pathologies, the
initial goal may not be strengthening but rather rees-
tablishing symmetric, efficient vocal fold vibration.
For example, with vocal fold bowing, the exercise
strategy would be focused on a strengthening regi-
men to achieve firmer vocal fold closure with pos-
sible improvement in vocal fold tonicity. However,
when working with injury to the leading edge of the
vocal fold, as in instances of a vocal fold tear, post-
surgical mass excision or hemorrhagic lesions, exer-
cises involving minimal vocal fold adductory force
that are designed to promote improved myo-elastic-
aerodynamic function of the vocal folds would be a
safe and effective first choice.
Vocal Function Exercises, the work of Joe Stemple
and his voice team, originally designed to help bal-
ance and strengthen the laryngeal muscular construct
can be effective tools in a recovery plan.
Humming maneuvers on /m/, /n/, or /ng/ have
long been popular exercises in traditional voice peda-
gogy and voice recovery treatment, in part because
of the targeted sensations of anterior tonal vibration
that can be achieved from this action. Since humming
involves sustained voice on pitch, these exercises are
accomplished in a sung-like tone and can be per-
formed on single pitches, glides, or scale patterns.
Too often, this activity is approached with inappro-
priate tension. Careful monitoring for hyperfunc-
tion is needed during humming exercises, especially
when there is a deficiency in glottic closure. This lack
of glottic closure can create a source vocal tone that
does not easily result in frontal vibratory sensation.
Gentle and limited use of vocal fry can be a helpful
facilitator in achieving more efficient vocal fold clo-
sure. Again, caution should be exercised to prevent
hyperfunctional efforts on the part of the patient.
In designing patient exercise protocols, specific
exercises, range, volume, and duration of practice
times are determined based on the patient’s diagno-
sis and his or her ability to produce voice without
strain. For instance, in the case of the initial SVSI
sessions following postsurgical mass excision or a
recent vocal fold hemorrhage, the sessions would
include gentle exploration of the voice using lim-
ited range and volume, possibly on an /ɑ/ or /u/
vowel. Once comfortable vocal range, volume, and
vowels are established, the SVS chooses appropriate
vocal exercises. Semioccluded exercises, lip or tongue
trills or straw phonation to start, again with limited
range and volume can be utilized first. These can be
performed on simple 3- to 5-note descending scales
or any pattern that is easy for the patient to execute.
Glides are another option and may allow for vocal
 9. THE SINGING VOICE SPECIALIST
fold stretch across intervals without requiring the
delineation of each pitch. These may be followed by
short scales on 12321 or 123454321 patterns on com-
fortable vowels. As the voice progresses, the exercises
can include more challenging vowels, with the easier
vowels providing a point of reference for target reso-
nance. The use of initial consonants may facilitate
easier voice onset. Brief voice rest periods may be
needed initially between vocalizations. Duration and
frequency of home practice are set by the clinician
and based on this initial visit. With each following
session, range, volume, and endurance are carefully
explored and, when possible, expanded.
Agility maneuvers on ascending-descending scales
patterns with rapid movement note to note can aid in
reestablishing refined coordination within the vocal
system. Scale patterns can include notes in half and
whole step patterns, graduating to arpeggios with
intervals of greater distance.
Exercises involving changes in volume (known
as messa di voce exercises in traditional vocal peda-
gogy) appear to be effective in strengthening the vocal
mechanism. Sustaining the voice on a hum or vowel
sound on a single note within the patient’s comfort-
able range, then gradually and evenly increasing
and decreasing the volume with no alteration of
tonal quality or pitch can serve to stabilize vocal fold
function. Examples of various vocal exercises may be
found in Figures 9–2 through 9–8.
Hypernasalized phonation can be useful in facilitat-
ing more efficient voice. Having the patient produce
sounds imitating the “twang” of a country western
singer, the “meow” of a cat, or the vocal quality of
the Munchkins in the movie “The Wizard of Oz,” fol-
lowed by normal vocalization often results in clearer
Figure 9–2. Five-note ascending/descending scale.
Figure 9–3. Five-note ascending/descending scale.
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89
voice with more anterior tonal presence. A helpful
sequence is to have the patient perform these nasal
sounds first with a fully occluded nose, then open or
release the nose but retain the nasal quality and last,
move into normal voice. Caution must be exercised
to avoid laryngeal hyperfunction during any hyper-
nasal vocalization.
The SVS must remember that while singing can be
considered an athletic activity for the voice, the old
sports adage “no pain, no gain” has no place in either
the vocal recovery process or standard singing les-
sons. Throughout the recovery process, the patient
must be alert to any sensation of strain or discomfort,
and be willing to immediately communicate it to the
SVS. If this occurs, the exercise, whether voiced or
unvoiced, should be discontinued, reassessed, and a
new approach chosen if warranted.
Singing for the Speaking Voice
The SVS can provide invaluable assistance in improv-
ing the recovery rate and general function of the speak-
ing voice for the nonsinger as well as the singer. As
mentioned before, singing may elicit an approach to
vocalization that is free from the patient’s inadequate
speaking voice habits. Singing exercises done correctly
can improve the overall strength and efficiency of the
vocal mechanism, thereby making speech less effortful.
It is reasonable to teach the nonsinger scales and
songs in order to practice concepts of vocal technique
and build vocal strength. Another useful construct is
to establish technically well-sung phrases in the gen-
eral frequency range of the patient’s habitual speak-
ing voice and then alternate singing, chanting, and
speaking the phrases with attention to concepts of
oral-pharyngeal space, consistent airflow, and ante-
rior resonance sensations. The learned (and some-
times instinctive) appropriate technical approach to
singing can then be easily applied to speech.
Some patients, both singers and nonsingers, are
unable to sing technically well in or near their speak-
ing range but can produce better singing voice in
their middle or upper register. Obviously, the goal
would be to extend the more effective voicing into
the speaking range. A descending scale, starting at
the point of optimum vocal quality, can be moved
step-wise or gliding downward, finally resting on a
note at the upper end of the speaking range. That
final note is then sustained and the patient gradu-
ally transitions from singing to speaking on that
pitch. This should be done on one breath if possible.
Each successive scale pattern begins one half-step
lower until the speaking range has been covered.
 90 TREATMENT OF VOICE DISORDERS

Figure 9–4. Repeated ascending/descending scales.

Figure 9–5. Slow ascending/descending slide of major third interval.

Figure 9–6. Arpeggio scales.

Figure 9–7. Descending scale with trill on last note.

Figure 9–8. Vowel variation exercise.

Other examples of singing to speech exercises may ing voice and speaking voice to singing that can help
be found in Figure 9–9. There are many possible facilitate better vocal production in the weaker mode
means of transitioning from singing voice to speak- of phonation.

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 9. THE SINGING VOICE SPECIALIST 91

Figure 9–9. Carryover exercise from singing voice to speaking voice. (continues)

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 92 TREATMENT OF VOICE DISORDERS

Figure 9–9. (continues)

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 9. THE SINGING VOICE SPECIALIST
Figure 9–9. (continued)
Conclusion of Treatment
In the case of the injured singer, the goal is to enable
the singer to return to the demands of his or her nor-
mal singing requirements in a safe and timely fash-
ion. Recovery times from a vocal injury or surgery
vary widely and are notoriously difficult to predict.
It is the responsibility of the SVS in conjunction with
the laryngologist and SLP to create a recovery plan
that remains flexible enough to be adjusted to the
unpredictable course of individual healing. Reper-
toire should be reintroduced into the recovery pro-
cess gradually and carefully only when singer is able
to sing the music while maintaining optimum tech-
nique. Singing rehabilitative sessions should continue
as long as the laryngologist and SVS deem necessary
and certainly until the singer feels confident in his
or her ability. Intermittent check-ups with the SVS
should be established, at least for a period of 1 year
following release from the initial treatment schedule.
For the nonsinger, the goal is to enable the patient to
meet the daily speaking demands on his or her voice.
Recovery of the speaking voice is directed primarily
by the SLP and the laryngologist. They establish the
pacing of recovery and determine when the patient is
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93
released from regular therapy sessions. Intermittent
check-up sessions should continue for a period of at
least 1 year following release from treatment.
This chapter has provided an overview of the his-
tory, the educational and training needs, and the
role of the SVS in current treatment paradigms for
the injured voice. We have suggested only a few
of the many possible singing voice exercises useful
in the treatment of the injured voice. We reiterate that
these exercises must not be considered prescriptive.
Individual programs must be designed with the spe-
cific pathologies, strengths, and weaknesses of each
patient in mind. Furthermore, no attempt has been
made in this chapter to address the extraordinarily
complex issues that often accompany voice prob-
lems. This infinite combination of variables presents
the SVS with many unique challenges. It is important
to remember that a singing voice exercise is a means
to an end, not an end in itself. The SVS must call
upon a refined and educated listening ability, broad
practical experience with numerous vocal technical
approaches, and a working knowledge of pertinent
human anatomy, physiology, and voice disorders
to efficiently and effectively impact this important
patient population.
 94 TREATMENT OF VOICE DISORDERS
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