Singing Voice Special Considerations for Evaluation and Treatment Features
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Features  |   July 01, 2002
Singing Voice
Author Notes
  • Mary J. Sandage, is a senior SLP at the University of Wisconsin Voice Clinic, Division of Otolaryngology, where she specializes in the rehabilitation of the performing voice. She is a member of the National Association of Teachers of Singing. Her other clinical interests include articulation and resonance disorders secondary to repaired cleft lip and palate, chronic cough, and vocal cord dysfunction.
    Mary J. Sandage, is a senior SLP at the University of Wisconsin Voice Clinic, Division of Otolaryngology, where she specializes in the rehabilitation of the performing voice. She is a member of the National Association of Teachers of Singing. Her other clinical interests include articulation and resonance disorders secondary to repaired cleft lip and palate, chronic cough, and vocal cord dysfunction.×
  • Kate Emerich, is a voice pathologist and singing voice specialist at the W.J. Gould Voice Center at the Denver Center for the Performing Arts. She devotes her practice to care of the professional voice and is an active performer herself.
    Kate Emerich, is a voice pathologist and singing voice specialist at the W.J. Gould Voice Center at the Denver Center for the Performing Arts. She devotes her practice to care of the professional voice and is an active performer herself.×
Article Information
Speech, Voice & Prosodic Disorders / Voice Disorders / Speech, Voice & Prosody / Features
Features   |   July 01, 2002
Singing Voice
The ASHA Leader, July 2002, Vol. 7, 6-15. doi:10.1044/leader.FTR.07132002.6
The ASHA Leader, July 2002, Vol. 7, 6-15. doi:10.1044/leader.FTR.07132002.6
The clinical evaluation and management (medical, behavioral, and environmental) of singing voice disorders share many components with the state-of-the-art assessment and treatment of speaking voice disorders. There are specific areas of consideration for singing voice assessment and rehabilitation that can markedly enhance service to your patient population.
Clinical Evaluation
A comprehensive voice assessment generally includes most, if not all, of the following components: a thorough medical history, behavioral/social history, videostroboscopic assessment of the structure and function of the larynx, objective voice measures (aerodynamic and acoustic), and auditory/visual perceptual assessment. There are several key ways to enhance each of these components to evaluate and rehabilitate the singing voice.
A thorough medical history should include information regarding the patient’s perception of the voice problem. Singers often have very specific language that they use to describe the difficulty. The SLP with ready vocabulary for the language of singing—registers, passaggio, head/chest voice—and knowledge of singing techniques will be able to make more specific judgments regarding the nature of the voi ce difficulty.
Interestingly, singing voice impairments are often not accompanied by speaking voice difficulties. In fact, many singing voice disorders may be difficult for the SLP to “hear.” Patients may describe “air” in the tone or a “sticky” feeling, particularly in the upper register or only on the highest 2–3 notes (the “money” notes). Singers also may report fatigue and/or increased effort without associated hoarseness, and also may have concerns about an unstable mid-range, difficulty singing softly, loss of flexibility, difficulty singing loudly, or shortness of breath.
Major illnesses, medication, surgeries (with or without intubation), gastroesophageal reflux symptoms, hormonal changes (including thyroid dysfunction), allergies, asthma, previous vocal fold injuries (vocal fold tear, hemorrhage, etc), and viral infections may all play a role in the voice difficulty. Clinicians need to consider all of these along with the timeline of the voice difficulty to discern the etiology of the disorder. Many singers won’t get paid if they cancel a performance when they are ill, so they may sing anyway, making the singing voice vulnerable to pathology or to the development of maladaptive behaviors.
Medications
Medications can be drying to the vocal fold mucosa, leading to increased subglottic pressure requirements to produce the highest notes. Examples of drying medications include antihistamines, Accutane, beta-blockers, diuretics, diet pills, and high doses of vitamin C. Many of these medications can be avoided, or the supervising physician may be able to change the medication to a less-drying alternative. Accutane may produce the most alarming change in the singing voice—many young sopranos seen in our clinics have lost the entire top octave of their original singing range.
Inhaled steroids prescribed for asthma and other pulmonary conditions may cause some wasting of the body of the vocal fold, making glottic closure less efficient. Management of the pulmonary system takes priority over voice, and therefore singers must make sure that any medication they take for asthma is adequate and not excessive.
Small hormonal changes that don’t affect the speaking voice may have large effects on the singing voice. For approximately 5% of women, birth control pills may have a temporary lowering of the fundamental frequency, thereby making the highest notes of the range more difficult to produce. Hormone replacement may help restore the “ring” to the singing voice for women going through menopause. A number of women singers notice voice changes before the start of the menstrual cycle that are characterized by a breathier vocal quality and increased effort for the highest notes. Some elite singers may avoid any performance during certain stages of their cycle.
The vocal hygiene history should include questions regarding smoking history as well as intake of caffeine and alcohol—all drying agents that may make singing more effortful. Singers may burn the vocal fold tissue when inhaling marijuana smoke and experience pain with voicing immediately after. This should be addressed directly, as many singers may leave this information out of the medical history.
Singers and actors also may be exposed to stage fog or stage/set “snow,” both of which contain chemicals that may cause throat discomfort and irritation as well as asthma symptoms. Thorough questioning regarding the symptoms of laryngopharyngeal reflux disease (LPR) is also essential, as many singers notice effects of LPR irritation to the larynx without the typical heartburn or lower esophageal symptoms.
Symptoms of LPR include, but are not limited to, hoarse voice, “morning” voice, frequent throat clear or cough, frequent tickle in throat, burning/acid feeling in throat, dry mouth or throat (despite drinking adequate water), persistent phlegm in throat, difficulty with the top of the singing register, difficulty with the mid-range/transition register, feeling of a lump in the throat (globus), and difficulty singing softly. Clinical signs of LPR, as seen by the otolaryngologist/ENT during examination or during the videoendoscopic assessment, include dark pink or red vocal fold tissue, dark pink/red or swollen tissue at the back of the larynx, thick mucous at the back of the vocal folds, and swollen vocal folds (may be infraglottic edema or polypoid tissue changes).
A current theory is that singers, much like athletes, are more vulnerable to the occurrence of LPR due to increased thoracic pressures during singing. Behavioral suggestions are listed in the sidebar at right. For moderate or severe cases of LPR, medical management may be warranted via medication or, as a last resort, surgery.
The final component of the patient interview should address use of the voice at work, home, socially, and for singing. It is useful to know what percentage of the day the voice is used. For most school music teachers, the speaking voice demands match or exceed the singing demands, and each has an impact on the other. Is there any ambient noise to contend with? Are there opportunities for voice breaks? What is the alignment of the patient’s body while working at the piano, talking on the phone (cradling the receiver), or working on the computer?
Behavioral Changes to Improve LPR
Avoid:
  • Coffee (even decaffeinated)

  • Caffeine

  • Carbonated beverages

  • Citrus (this includes lemon juice pre-performance)

  • Nuts

  • Mint/menthol

  • Alcohol

  • Chocolate

  • Spicy or fried foods

  • Eating or sleeping 2–3 hours before performance

  • Wearing tight belts or clothes

  • Filling up your stomach (choose several small meals per day)

  • Exercising or singing right after eating

The patient may not even be aware of maladaptive postures of the neck, jaw, or spine during routine tasks that may undermine healthy voice production. With respect to singing voice use, it is useful to know the premorbid singing range, history of any singing training, singing style(s), performance schedule, warm-up/cool-down practice, amplification use, and room dynamics. Whereas the evaluation of speaking voice disorders may only require endoscopic assessment with either a rigid or flexible endoscope, the most thorough assessment of singing voice disorders will include both studies. The rigid endoscopic assessment will garner the best information for vocal fold edge contour/pliability (for normal pitch/normal loudness, high/low frequencies, inhalation phonation), glottic closure pattern, and open/closed quotient. The flexible endoscopic assessment will provide information regarding function of the vocal folds and the supraglottic structures during vocalizing and repertoire, thereby uncovering compensatory behaviors. Flexible endoscopy also may be useful for visual feedback during treatment.
The final area to consider in the patient evaluation is perceptual assessment of the disorder. This requires excellent auditory skills on the part of the SLP. The auditory-perceptual assessment should include judgment of vocal quality and consistency of quality throughout the range. Does it change in certain parts? That is, does it get rough at the transition register or only at the top? Does the voice quality change with changes in intensity or frequency?
A good test to determine if the disorder is functional in nature is to compare singing voice quality for tongue/lip bubbles against the voice quality during a song context. Lip bubbles are like “raspberries”; allow the lips to relax in a closed position and then let the air flutter out between the lips easily with little force. For tongue bubbles, allow the tongue to rest on the bottom lip, with the jaw slack and the mouth slightly open. Allow the air to gently “bubble” out from beneath the tongue against the lower lip.
For singers who have acquired muscle tension dysphonia, tongue/lip bubbles will often realize the premorbid singing range. Observation of any resonance changes may be an important piece of the puzzle. For singers with acute sinusitis or seasonal rhinitis, clogged nasal passages that result in a hyponasal vocal quality can prevent the sound from resonating in the sinus cavities. Many singers rely on the kinesthetic feedback from this ringing quality to know that they are using proper tone. Hyponasality can hamper loudness ability, potentially leading to overuse of other muscles in the neck for increased loudness demands.
Most importantly, does your judgment of vocal quality match what the videostroboscopic assessment indicates with respect to vocal fold structure and function? If vocal fold structure and function appear intact despite the perceptual judgment of hoarseness, then behavioral intervention is likely warranted. Visual-perceptual assessment should include any correlation of voice changes with any vis ible effort/strain, alignment of the spine, relationship of the head to the top of the spine, and use of breath.
Treatment
Discerning if the voice difficulty is acute or chronic is an important first step in treating singers. If “the show must go on” and the singer has a performance in a matter of days, surgical management will not be an option because there is not time for adequate recovery. Certain laryngeal pathologies (e.g., hemorrhage or vascular injury) may require that the singer cancel the performance to avoid permanent damage. Some singers with acute vocal fold edema secondary to an upper-respiratory infection or cold may benefit from a short course of steroids if the performance is within a week’s time, but the SLP should be aware that there are steroid “seekers” who may only be interested in obtaining a prescription from a physician.
The SLP serves a vital role for vocal hygiene counseling and designing any behavioral means to weather the acute voice disorder. Increased systemic hydration will be beneficial, as well as the elimination of any drying agents, such as caffeine, alcohol, or smoking. If possible, increasing the humidity of the rehearsal or performance space will also be helpful to help improve superficial moisture of the vocal folds. Ask the patient to reduce the length of each performance/set and adjust the repertoire to reduce strain by changing the key of the songs. Advise against use of “growling” or other voice effects used in many singing styles. Changes in the performance space and/or improvements in amplification use may be helpful to avoid additional strain.
There is not often time for a complete treatment plan, particularly if the singer is touring and will leave your area after the performance. If the singer does not already have a warm-up/cool-down practice, this is an ideal time to develop a personalized program. For chronic conditions, treatment is often multifaceted, with attention to LPR, rhinitis, allergies, asthma, hormones, behavioral strategies, and, perhaps, surgery. Behavioral management will be a combination of vocal hygiene counseling as described above, counseling regarding the nature of optimal voice production (e.g., the nose and sinuses need to be clear for the best voice), and specific instruction to optimize use of the vocal folds. Ask yourself the following questions when considering the videostroboscopic study:
  • “What are the vocal folds doing?”

  • “What should the vocal folds be doing?”

  • “What variables are preventing optimal function?”

The answers to these questions will guide your treatment. The answer may be as simple as improving the environment of the larynx through increased superficial and systemic hydration and/or reduction of chemical irritation from LPR.
Counseling patients about the importance of clear sinus passages for adequate resonance is another example of indirect treatment that will improve voice production. If the vocal folds are not vibrating in the most efficient manner, then specific treatment goals should be designed. Two common goals for behavioral management are to restore optimal vocal fold closure pattern and reduce/eliminate extraneous muscle effort. To restore the best vocal fold closure pattern, thereby improving the valving of the glottis for voice by making it work more efficiently, the following sub-goals may be considered:
  • establish complete closure of the glottis when voicing

  • normalize open/closed quotient to create more efficient valving

  • restore/establish phase symmetry during vibration so that the vocal folds appear to be mirror images of one another

For reduction/elimination of extraneous muscle effort, the following areas may be targeted following your visual-perceptual assessment: tension in the jaw, base of tongue, neck, shoulder, and abdomen.
These goals are interrelated to achieve the best voice. In fact, working on the reduction of base-of-tongue tension may result in a normalized open/closed quotient. There are many well-documented behavioral approaches that may be considered: Resonance/Tone (Verdolini, Lessac), Vocal Function Exercises (Stemple), or manual inhibition of muscle tension (Roy, Aronson). If you are also a singing teacher, you can design specific singing exercises to restore tone and flexibility. If you are not a singing teacher, find a good voice teacher in your area and collaborate. Any combination of these strategies will be useful to restore optimal valving of the vocal folds for effortless, clear singing.
Although it is difficult to separate use of the breath from vocal fold vibratory characteristics, it is helpful to consider how they work—or don’t work—together. If the vocal fold closure pattern is “pressed” with a high closed quotient, it will require greater subglottic pressures to start voicing and maintain voicing, leaving the singer with the feeling of being out of breath. Conversely, if the voice is breathy and the vocal fold closure pattern has a high open phase or incomplete glottic closure, the singer will also feel out of breath. Many will assume that they are not breathing correctly “from the diaphragm” when, in fact, it is the poor function of the vocal fold valve that creates the feeling of poor breath support. Many singers with choral training learn to “breathe from the diaphragm.” For some, this translates into pulling the abdomen in hard at the initiation of voicing, creating hard glottal attacks. Consider all angles of the patient’s presentation to design the most efficient treatment plan.
Surgical management, performed by an otolaryngologist/ENT who has experience with vocal fold surgery, should only be considered if proper behavioral intervention cannot restore the desired vocal quality, if restoration of optimal vibratory function of the true vocal fold(s) is primary (unless airway management is primary, e.g., papillomatosis), if the patient clearly understands the benefits and risks, and if the patient has adequate counseling for post-surgical voice use.
The evaluation and treatment of singing voice disorders is complex, requiring knowledge beyond our typical training in graduate school. For SLPs who want to improve knowledge in this area, we offer a few suggestions:
  • take singing/acting voice lessons

  • explore techniques used by singing and acting teachers, such as the Alexander technique, Feldenkrais Method, and Lessac Method

  • apprentice with a mentor.

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FROM THIS ISSUE
July 2002
Volume 7, Issue 13