Vocal Health and Hygiene

8/24/12 9:30 AM

Florida outline Vocal Health Button: Voice Funtion Button: Voice Problems Button: Treatment Button: Vocal Health Button: General ENT Button: Procedures Button: Clinical Staff Button: Contact Us Button: Links VOCAL HEALTH TIPS Vocal Hygiene Vocal hygiene refers to the practice of caring appropriately for the vocal mechanism. This includes measures to ensure overall good health as well as specific ways to care for parts of the vocal system. Careful attention to good vocal hygiene can make a significant positive impact on vocal performance and vocal stamina, regardless of the level of demand on the voice. "Don'ts" "Do's" 1. Don't abuse your voice * Identify and Eliminate Vocally-Abusive Behaviors A) Don't clear your throat or cough habitually * Swallow slowly * Drink some water * Relax your throat and let your voice rise above any sensation of obstruction B) Don't yell, cheer or scream * Use non-vocal sounds, noise or instruments to attract attention from a distance, at sporting events, etc.; substitute whistling, clapping, ringing a bell or blowing a horn for yelling C) Don't talk over a long distance, especially outside.

* Move close enough to the person you are talking with to be heard without yelling. * Learn to project your voice without vocal tension or strain, by relaxing your throat, using breath allowing our voice pitch to rise slightly to project freely. D) Avoid talking in noisy situations: over loud music (e.g. at noisy parties); in cars/buses; over noisy machinery, heavy equipment or motors, etc. * Adjust your environment as much as possible to reduce background noise. * Always face the person(s) you are talking to. * Position yourself as closely as possible to the people you are talking with, especially when there is competing noise. E) Don't try to lecture or speak to large audiences without the aid of a amplified sound. * Use a microphone for public speaking. * Practice microphone techniques: keep your voice relaxed, and at a comfortable level and let the microphone amplify your voice. F) Don't try to teach or instruct above musical instruments, singing, students talking or running equipment motors. * Wait until the audience or class is quiet and attentive. * Find ways to discipline students or your children that are nonvocal. G) Don't sing beyond comfortable pitch and loudness ranges. * Don't try to sing loudly at any high pitch that you cannot manage at a quite volume.

* Use an auditory monitoring system that provides adequate feedback of your voice during a singing performance, especially in lounge/bar/nightclub settings where the background noise is high. H) Avoid nervous, vocally abusive habits during lecturing/public speaking /debating: * * * * * * Throat clearing Talking quickly Holding your breath Talking on insufficient breath Talking on a monotone pitch Aggressive or low-pitched filler "um, ah..."

* Monitor and reduce habits that detract from your vocal presentation. * Practice transferring relaxed, optimal voice use to situations of gradually higher degrees of communicative stress/pressure I) Avoid prolonged loud and vocally aggressive laughing and crying. * Be aware of the effect stress/emotions have on your voice, especially if it causes muscle tension in your throat, chest, jaw, face, etc. J) Don't yell or speak extensively during strenuous physical exercise. * Wait until your breathing pattern can accommodate optimal voice production.

"Don'ts" "Do's" 2. Don't Misuse Your Voice Learn Optimal Voice Use

A) Don't talk in a low monotone pitch. Don't allow your vocal energy to drop so low that the sound becomes gravelly ("glottal fry") * Allow your voice pitch to vary freely and expressively. * Keep your voice powered by breath flow, so the tone carries, varies and rings. B) Don't hold your breath, as you're planning what to say, or how to say it. At the beginning of a phrase, avoid initiating voice with a harsh and sudden "glottal attack" * Allow for a relaxed inflow of breath before a phrase. * Initiate voice gradually on the outflowing breath, as on a sigh: "aaahhh." C) Don't speak beyond a natural breath cycle: avoid squeezing out the few words of thought without sufficient breath. * Speak slowly, pausing often, at natural phrase boundaries, to allow the breath to replace, before you go on. D) Don't tighten your upper chest, shoulders, and throat to breathe in or to push voice out. * Allow breath to replace itself naturally, without raising your shoulders and upper chest. * Keep your shoulders and upper chest relaxed during speech. * Be aware of and allow natural expansion/release in the lower torso, abdomen, and back and sides during the breathing cycle. E) If you sing, don't force your voice to stay in register beyond its comfortable pitch range. Especially, don't force your chest voice too high, and in men, don't force head tone too high into falsetto range. * Allow registers to change pitch rises and drops. This is a natural and mechanically essential phenomenon.

* If you need assistance in singing through register changes smoothly, consult your singing teacher. * Be sensitive to, and eliminate throat tension caused by pushing registers too far. F) Never clench your teeth. Don't hold your jaw tense. Don't move your jaw too stiffly to speak. * Keep upper and lower teeth separate. * Allow you jaw to remain passive and to "float" as you speak. G) Avoid making "unconventional" sounds with your voice for prolonged periods: - don't whisper - avoid making "special effects" sounds: motor noises, reverse vocalizations, very high or low pitch sounds, etc. * Use a soft voice tone in place of a tense harsh whisper. * If you must produce special voice effects for acting/singing performances learn to identify/ use the best technique to use the voice in versatile ways without vocal abuse/misuse strain. * Consult your singing teacher/voice therapist.

"Don'ts" "Do's" 3. Maintain A Healthy Lifestyle and Healthy Environment A) Don't demand more of your voice than you would of the rest of your body. * Allow several period of voice rest during the day B) Don't use your voice extensively when you have a cold or when you feel tired. * Rest your voice, with the rest of your body, when you're ill or tired.

C) Don't use your voice when it feels strained. * Learn to be sensitive to the first signs of vocal fatigue: hoarseness, throat tension, dry throat, poor vocal projection. D) Don't ignore prolonged symptoms of vocal strain/hoarseness/pain/fullness/heartburn or allergies * Consult your doctor if you experience throat discomfort or hoarseness for more than ten days E) Don't expose your voice to excessive pollution: cigarette smoke, chemical fumes, etc. Don't smoke. Don't drink alcohol excessively. * Maintain proper humidity, both inside your body (drink plenty of fluid daily) and in your environment (30%) F)Practice safe driving skills * Use a shoulder-type seat belt in an automobile to prevent laryngeal injury in the event of an accident.

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Vocal Health (Music Educators)

8/24/12 9:30 AM

Feder,R.J.(1990). Vocal health: A view from the medical profession. Choral Journal (February), 23-25.

VOCAL HEALTH A View from the Medical Profession

by Robert J. Feder

Vocal music educators are on the front line of defense against their students' vocal misuse. They see their students regularly and are aware of obvious and sometimes subtle changes in their health and lifestyle. Vocal instructors and choral directors, both of whom are especially sensitive as to how voices should sound, are encouraged to listen to their students' voices in normal conversation --to pay particular attention to how students use their voices in their daily lives. This can be a factor in recognizing potential vocal abuse and in taking steps to prevent or remedy it. The potential for the abuse of vocal cords is always present, regardless of the age of the student, his or her talents, or level of ability. To help protect their students' voices, teachers can caution children (and adults) against such common abusive activities as yelling, loud stage whispers, and gargling, and instruct them in the basic, common sense elements of good vocal hygiene. Young, elementary school-age children are especially vulnerable to a variety of colds and infections which often result in sore throats, hoarseness, and laryngitis. Teachers should be especially alert to their students' voices when they return to school after an absence due to colds and flu. Hoarseness can be caused by croup and

epiglottis (an infection of the larynx), or any number of typical childhood diseases. The hoarseness should disappear as the child recovers from the causing ailment. However, if a child speaks with a roughened voice that appears to improves, only to worsen several days later, the problem may be "screamer's nodules" --calluslike nodules on the vocal cords. The child should exercise complete vocal rest for two to three days. If the hoarseness persists, a physician should be consulted. In general, children with vocal-related problems should be referred to a physician more quickly than adults with vocal ailments. This is so because a child's airways can be compromised more quickly than an adult's, and a child can suffer possible damage if a problem is not treated in a timely fashion. Children usually do not develop polyps on their vocal cords--probably because their vocal cords are small. However, respiratory papillomas, which are wartlike growths, are more common to children than to adults. Perhaps one percent of child patients who are seen for persistent hoarseness have developed papillomas. They are dangerous to the vocal development of children, and can be avoided with proper vocal care. As children grow older --as they approach and go through the adolescent years-- their voices are subject to remarkable changes that make them extremely vulnerable. In addition, the opportunities for vocal abuse during these years are probably the most prevalent of any in their lives. General exuberance, yelling at sporting events or at any social gathering, and improper singing can all, if done to excess or during a period of illness, cause damage to a youngster's voice. The teacher should encourage students, especially during the critical period of voice change, to speak without yelling, to vocalize (speaking and singing) in a comfortable middle vocal range, to sing without straining, and to rest if they become hoarse. If it is possible, the teacher should also advise parents of proper vocal production -especially parents of children who demonstrate poor habits and a predilection for hoarseness.

If proper habits are developed during the adolescent years, vocal cords are generally able to withstand the rigors of adult life and to operate freely and efficieintly. High school and college students should avoid prolonged yelling or forcing their voices. (The voice usually becomes fully mature after age 28). Even prolonged speech can be problematic. Speaking in a higher vocal range, singing and speaking with considerable breath flow --especially at high volume level, and frequent pauses or rests during extended speaking or singing can all help maintain good vocal health. If hoarseness or laryngitis persist for more than a week, a physician should be consulted. Hoarseness Hoarseness is often the first sign of more than an upper respiratory tract infection; it can indicate a number of different vocal problems. Primarily, they are: 1. Malignant and benign tumors. Squamous cell carcinoma of the larynx, nearly always due to smoking and excessive consumption of alcohol, is by far the most common of malignant tumors. Benign growths commonly include nodules, polyps, and Reinke's edema (swelling). The latter is a form of polypoid degeneration that runs the entire length of the vocal cords. Contact ulcers often result from reflux of stomach acid, but also can be caused by other forms of chronic irritation and by hypothyroidism. Other, but less common causes of benign growths, are respiratory papillomas and granulomas. Granulomas form when, as a result of the constant banging together of the cords, the mucosal covering of the vocal cords becomes irritated. This usually is caused by people who talk excessively, are under tension , or are chronic throat-clearers. 2. Vocal cord paralysis. Some people have voice problems when a vocal cord becomes fixed in an inappropriate position. The degree of hoarseness is determined by the position of the cord; the

voice may be reduced to a whisper or may have difficulty phonating at a loud volume. Paralysis can occur as the result of a virus, heart surgery, thyroid survery, or intubation (the placing of a tube down the throat). 3. Trauma. External neck injury is another source of hoarseness. Frequent causes are sports mishaps and motorcycle, trail bike, and automobile accidents involving trauma to the Adam's apple. Medical diagnosis of laryngeal fracture is critical because damage can cause total obstruction and even death. 4. Functional voice disorders. Various forms of abuse of the vocal apparatus or psychological disturbances are often the source of this problem. They stem from: a. vocal misuse and abuse syndrome. This can be a cause of hoarseness if it comes on unexpectedly or if the voice gives out after speaking, even when examination reveals the larynx to be normal. Often, such patients have poor breath control and pitch their voices so low that a great deal of energy is required to produce sound; they may be straining to emulate th low tones so admired in our society. Similarly, nodules and polyps on the larynges, analagous to calluses on the hand, are due to abusive, non-organic causes. b. conversion reaction. Some patients experience a hysterical truama, or conversion, losing their voices after an upsetting event. c. falsetto disorders. Males sometimes begin to speak in an unnaturally high voice after an upsetting event. d. relapsing aphonia. People with this condition lose their voices repetitively, such as at a stressful time every year. e. habituated hoarsenes. Hoarseness in people having had laryngitis may persist long after the illness has passed. The patient has

adapted a mechanixm of speaking and stayed with it; they have adapted to the low pitch and gruff tone of hoarseness. The cause of hoarseness has many sources. While not a substitute for experienced medical examination and advice, being able to spot the non-medical source may avert further damage and point to the need for a change in behavior or environment, medical attention, or speech therapy. Obviously, hoarseness resulting from heavy use of tobacco and alcohol can be the first symptom of laryngeal cancer. Smoking frequently leads to the formation of benign polyps on the vocal cords. Recent usage of drugs also contributes to hoarseness. The drying effect of antihistamines and decongestants on the laryngeal and broncial mucosa can cause or worsen hoarseness that accompanies a respiratory condition. Taking these medications typically results in throat irritation and a cracking voice pitch, especially on awakening after sleep, although the medications do not harm the larynx. Read medication labels carefully. Corticosteroid sprays such as nasal and oral beclomethasone dipopionate contain liquid fluocarbon (Freon) radicals that may cause yeast infections and pain in the throat. Other drugs that can cause hoarseness and therefore vocal damage are birth control pills (especially those of an older vintage; they can cause enlargement of the larynx), steroids (which cause a deepening of the voice), and marijuana and cocaine. In addition, common colds, respiratory infections, and throatrelated diseases can cause hoarseness. Such connective tisue disorders as rheumatoid arthritis and scleroderma can affect joint movement, adversely affecting the vocal cords, and hypothyroidism can manifest itself in the larynx first. In fact, people who are hoarse have a comparatively high incidence of previously undetected hypothyroidism.

Gastric disorders are being increasingly considered as a major cause of hoarseness. Heartburn, solid belches, regurgitation, or choking on awakening may suggest that stomach acid is backing up, bathing the vocal cords and causing chronic inflammation of the arytenoid (cartilage of the larynx). Such conditions are often traced to an over-abundance of or low tolerance to spicy foods in the diet. The vocal music educator should be aware of the above conditions and should listen for such everyday occurrences as habitual clearing of the throat or coughing. Males who are chronic throat clearers run the risk of developing ulceration and granulomas. If speech is in a rough, low tone, it is a clue to a possible ganuloma. Where your students are and what they do during the day or week can affect their vocal quality and performance. School yard yelling, office noise, air environments, and certain professional voice user occupations (such as clergymen, lawyers, auctioneers, choir directors, and aerobics instructors) contribute to vocal problems ranging from simple strain to chronic nodules on the vocal cords. To deomonstrate the potential causes, one new patient, a fulltime choral director, had suffered a continual problem of nodules for several years; this was despite every previous remedy attempted, including voice rest. Some detective work revealed that the school room heating/air conditioning system was releasing an irritant to her voice. After some mechanical alterations to the system, her vocal nodules shrank and her voice returned to normal. Persistent hoarseness, the symptoms of many possible causes, whould be a warning bell to teachers. At the first sign of something amiss, music educators are well-advised to heed the warning and suggest remedial action to their students. Don't forget to safeguard your own voice, too.

VOCAL HYGIENE

Dos and Don'ts for keeping a voice healthy. Some commonsense rules you can share with your students...and keep in mind for yourself. 1. Drink 10-12 glasses of fluids a day, preferably without ice. (The temperature range between iced beverages and the larynx is too great). Ice cream is not as cold and is therefore permissible. The best beverage for singers is plain hot water with dashes of lemon and honey. 2. Avoid alcohol and all forms of smoke. Limit spicy foods. 3. Avoid all forms of whispering, including loud "stage" whispers. Whispering puts too much strain on the voice. 4. Avoid throat clearing, yelling , or gargling; the vibrations irritate the vocal cords. 5. Keep environmental temperatures comfortably constant. 6. Avoid drying medications. If they are necessary, increase intake of fluids. 7. For hoarseness, sore throat, or laryngitis: rest the voice completely inhale steam five minutes every three to four hours avoid aspirin or gargles. Take only Tylenol. suck on glycerin-based lozenges (Only black currant pastilles, Pine Bros. honey or cherry). avoid mint, menthol, or medicated ones as these are drying and irritating.

8. While traveling--land or air--be aware of road or cabin noise which is often louder than you think. Keep your conversation to a minimum. Also, be aware of temperature and drafts. Keep warm, drink warm fluids (preferably herb teas) or drink a glass of water every hour, sit as far away from smokers as possible, and stretch and walk around frequently. 9. Avoid travel the day of performance, especially before difficult or repeated performances, so that the body can rest. 10. See a doctor if throat problems last more than five days, especially if a fever develops, if there is a loss of appetite or lethargy, or if the small glands under the jaw become swollen, tender, or painful. Note: After reading this article you may want to view the Gallery of Laryngeal Pathology and other voice- care related webpages from The Center for Voice Disorders, Wake Forest University.

10 Most Common Problems

THE 10 MOST COMMON PROBLEMS OF SINGERS

8/24/12 9:30 AM

Visit The Wake Forest University Baptist Medical Center website In dealing with the physical production of the singing voice, one encounters many problems, all of which are interrelated, and often addressed simultaneously. The ten problems listed below are prevalent in different types of singers, regardless of training and experience. 1. POOR POSTURE: The efficient alignment of the body is of primary importance to voice production. Problems in posture range from "collapse" of the chest and rib cage, with corresponding downward "fall" of the head and neck, to the hyper-extended, "stiff" posture of some singers, that results in tension throughout the entire body. Effective posture evolves from the kinesthetic awareness, that may be developed through the study of a physical discipline such as Hatha yoga or Alexander Technique. 2. POOR BREATHING AND INAPPROPRIATE BREATH SUPPORT: Some beginning voice students seem to "gasp" for air, and exhibit clavicular or shallow breathing patterns. Trained singers, on the other hand, use primarily diaphragmatic breath support. The muscles of the lower back and abdomen are consciously engaged, in conjunction with lowering of the diaphragm. As the breath stream is utilized for phonation, there should be little tension in the larynx itself. Sometimes, in an attempt to increase loudness (projection), a well-trained singer may oversupport or "push" the airstream. This extra effort may affect vocal quality by producing undesirable harmonics. 3. HARD GLOTTAL OR "ASPIRATE" ATTACK: "Attack" or "onset" (a preferable term for singers) occurs with the initiation of phonation. Some singers (possibly related to poor speech habits) use a glottal attack, which is too hard (produced by to much tension in closure, hyper adduction. Vocal cord nodules may develop with habitual use of a hard glottal attack. The opposite problem is the "aspirate" attack, in which excessive air is released prior to phonation. While this type of

attack rarely damages the vocal cords, it causes a breathy tone quality. (This technique may, however, be utilized to help correct a hard glottal attack). 4. POOR TONE QUALITY: Many terms are commonly used to describe a singer's tone, and among those familiar to singers are: clear, rich, resonant, bright, . . . dark, rough, thin, breathy, and nasal. Although, "good tone" is highly subjective, according to the type of singing and personal preference of the listener, in general, a tone that is "clear" (without extra "noise") and "resonant" (abundant in harmonic partials) is acknowledged as "healthy" and naturally will have sufficient intensity for projection without electric amplification. Opera singers strive to develop a "ring" (acoustic resonance at 2,500-3,000 Hz), that enables the voice to project over a full orchestra, even in a large hall. However, for other styles of singing, the use of amplification may allow a singer the choice of employing a less acoustically efficient vocal tone for reasons of artistic expression. A breathy tone, for example, may be perceived by the listener as "intimate" or "sexy", and even a "rough" sound, such as was used by Louis Armstrong (false vocal cord voice), may represent a the unique persona of a performer. 5. LIMITED PITCH RANGE, DIFFICULTY IN REGISTER TRANSITION: All singing voices exhibit an optimal pitch range. Typically, untrained voices have narrower pitch range than trained singers, due to lack of "register" development. The term "register" is used to describe a series of tones that are produced by similar mechanical gestures of vocal fold vibration, glottal and pharyngeal shape, and related air pressure. Some common designations of registers are the "head" register, "chest" register, "falsetto", etc. Singing requires transitions from one register to another; each of these transitions is called a "passaggio" ("passageway"). Lack of coordination of the laryngeal musculature with the breath support may result in a "register break", or obvious shift from one tone quality to another. Untrained male voices and female "belters" tend to "break" into falsetto/head voice in the upper range. Regardless of the style of

singing, a "blend", or smooth transition between the registers is desirable. 6. LACK OF FLEXIBILITY, AGILITY, EASE OF PRODUCTION, ENDURANCE: Traditional voice training in the 18th-19th century "bel canto" ("beautiful singing") method places emphasis on vocal flexibility or agility -- for example, the singer's ability to execute rapid scales and arpeggios. Virtuosic technique demands excellent aural conceptual ability, coordination of an abundant airstream with energetic diaphragmatic support (sometimes perceived as "pulsations of the epigastrium"), and clear, resonant tone quality. The use of rapid melodic passages in vocal training helps to develop a relaxed, yet vital voice production, that contributes to the development of increased vocal endurance. 7. POOR ARTICULATION: Pronunciation with excessive tension in the jaw, lips, palate, etc., adversely affects the tonal production of the voice. Problems of articulation also occur when singers carry certain speech habits into singing. The longer duration of vowel sounds in singing necessitates modification of pronunciation; the increased "opening" of certain vowels in the high soprano voice, or elongation of the first vowel in a diphthong, are examples. Retroflex and velar consonants (such as the American "r" and "l") need careful modification to allow sufficient pharyngeal opening for best resonance, and the over anticipation of nasal consonants ("m", "n", "ng") may result in a "stiff" soft palate and unpleasant tone. 8. LACK OF DISCIPLINE, COMMITMENT, COMPLIANCE: As any athlete knows, regular practice is essential for optimal development and performance. Unfortunately, the need for disciplined training is not always apparent to singers. Furthermore, "artistic temperament" may contribute to a lack of compliance with the advice of teachers on issues of vocal technical development. When a teachers advice is contrary to a singer's own established ideas and work habits, the singer may tend

to overwork, overperform, or simply "try too hard" in practice. The singer's practice and performance regimen must be sensible, productive, and acceptable to both teacher and student alike. 9. POOR HEALTH, HYGIENE, VOCAL ABUSE: Many students ignore common sense and good vocal hygiene. The physical demands of singing necessitate optimal health, beginning with adequate est, aerobic exercise, a moderate diet (and alcohol consumption), and absolute avoidance of smoking. College voice students often test the limits of their vocal health by overindulgence in "partying", alcohol or drugs, and by screaming at sports events. Many singers are careful with their voices but abuse their voice by employing poor speaking technique (see, for example, Bogart-Bacall Syndrome in this issue). Professional singers who travel are frequently confronted with changes in their sleep and eating patterns. (Specifically, singers should avoid talking excessively on airplanes that are both noisy and dry). Performing in dry, dusty concert halls, or singing over the din in smoke-filled clubs increases the risk of vocal fatigue and infection. A minor cold or allergy can be devastating to a professional singer, who is obliged to perform with swollen (edematous) vocal cords. Good vocal hygiene, good travel habits, and vigilant protection of ones instrument (good judgment) is an important responsibility of every singer. 10. POOR SELF-IMAGE, LACK OF CONFIDENCE: Although many singers appear to have "healthy egos" and may display the aggressive behavior that is known as "prima donna" temperament, such behavior is a cover-up for anxiety and/or insecurity. Since the slightest aberration - phlegm, for example - can result in momentary loss of voice (even in the greatest of performers!), singers often feel that they are always in a state of vulnerability. Despite unpredictability in vocal performance, the singer does gain confidence through repeated performance and increased self awareness. T.Radomski

Teresa Radomski, MM, is an accomplished operatic soloist and Assistant Professor of Voice and Theatrical Singing at Wake Forest University. In addition, Ms. Radomski is a consultant for the Center For Voice Disorders, and a contributing editor of this newsletter. Her column, "A Singer's Notes" will appear as a regular feature of THE VISIBLE VOICE. Ed.

Medicine in the Vocal Arts

Medicine In The Vocal Arts Jamie Koufman, M.D

8/24/12 9:30 AM

Reprinted from THE VISIBLE VOICE, The newsletter of the Center for Voice Disorders Visit The Wake Forest University Baptist Medical Center website Abstract Since President-elect Clinton first appeared on television with hoarseness, millions of Americans have become aware that voice disorders in public figures may have far-reaching implications. Indeed, a voice disorder in any professional vocalist may have emotional, social, professional, and even political consequences. While Mr. Clinton is not a vocalist per se, while he is president and therefore speaks for all of us, his voice is as important as that of any professional vocalist. This article addresses the medical care of vocal professionals who require prompt and effective treatment when a voice problem arises. The causes of such voice disorders are often multifactorial, and may be both functional and organic in nature. Among the most common causes are upper respiratory infection, gastroesophageal reflux, muscle tension dysphonia, and the vocal abuse/misuse/overuse syndromes. Medicine in the Vocal Arts is an emerging field devoted to the diagnosis, treatment, and prevention of voice disorders in professional voice users. Today, the multispecialty voice center has become an important clinical resource, and most patients with voice disorders can be treated. INTRODUCTION

The voice is not an organ, but rather, the external phonatory output of the vocal tract. While this may seem obvious, it has important implications for all voice clinicians (laryngologist, speech language pathologist, voice teacher, voice coach, and voice scientist). The vocal tract consists of four component systems: 1. The "Generator", which is the breath support provided by the lungs. A regulated breath stream is the principal force that drives the vibration of the vocal folds. Without air flowing through the larynx, the vocal folds can make no sound. Thus, the condition of the lungs and how efficiently the breath stream is utilized have a great influence on vocal function. 2. The "Vibrator", which is the larynx; specifically, the vocal folds themselves. The folds are actually little more than a vibrator. The richness of sound and the subtleties of articulation are the result of the "resonator" and the "articulator" above the larynx. Problems of the vibrator include all problems of the larynx and its supporting structures. 3. The "Resonator", which consists of the space above the larynx, and includes most of the pharynx. This resonating cavity gives the voice its harmonic overtones, its richness. (The trained opera singer is able to manipulate the resonator to produce resonance at 2,500 Hz, which allows the singer's voice to be heard above an entire orchestra.) Problems with the resonator are uncommon, although, for example, tonsillectomy in a singer may temporarily adversely alter the resonator. 4. The "Articulator", which is made up of the tongue, lips, cheeks, teeth, and palate. These structures shape the sound from below into words and other vocal gestures. Medical problems involving the articulator are uncommon; for the singer, most problems of the articulator are corrected by the voice coach or teacher. The term voice disorder implies that the problem is laryngeal (within the vibrator); however, it is important to remember that the four component systems of the vocal tract interact in complex ways. For

example, poor breath support often gives rise to muscle tension dysphonia (abnormal muscle tension in the larynx that alters the voice). It is also important to remember that the neural regulation of these systems is complex and involves many sensory, motor, and integrating pathways within the brain. In actuality, the vocal tract is the entire person, since any abnormality of the psyche or soma can give rise to an abnormality of the voice. The voice is therefore a measure of a person's overall sense of well-being. Voice disorders are ubiquitous and may have a profound influence on a person's ability to communicate effectively; when they occur in professional vocalists, they may cause social, emotional, and professional hardship. Furthermore, just as professional athletes are prone to certain athletic (orthopedic) injuries, so too, are professional vocalists prone to specific injuries. Tennis players get tennis elbow; football players get knee injuries; and vocalists get voice disorders. The scheduling demands of successful vocalists (travel, rehearsal, promotion, performance), make it more likely for them to suffer a serious voice problem than for the average person. Consequences of a voice problem in a well-known performer can also include public scorn, loss of reputation, and loss of income. It is therefore not surprising that professional vocalists with voice problems usually arrive at a physician's office in a state of panic. Who gets a voice disorder? And why? How are voice disorders treated? And how if possible, can they be prevented? The purpose of this article is: (1) to outline an approach to the management of these voice patients; and (2) to address specifically the more common voice problems of vocalists. Approach To The Vocalist With A Voice Problem Three somewhat distinct patient populations fall into the category of "professional vocalist," each with a somewhat different set of problems and demands. I call these three groups elite vocal performers, vocalists, and vocal professionals. An example of an elite vocal

performer is the opera singer, in whom even the slightest aberration of voice may have dire consequences. Most other professional singers fall into the vocalist group, while actors, clergy, radio and television personalities fall into the vocal professional group. While all three levels of vocalists earn their living with their voices, the degree of "incapacity" in each varies with the vocal occupational demands and the severity of the voice disorder. Elite vocal performers seek medical attention for any and every acute condition that they perceive may have an effect on the voice, e.g., upper respiratory infection (a cold), allergy, etc. Other, less-demanding patients seek medical attention when the problem becomes more severe or chronic. Consequently, the voice clinician must take into account the vocal demands and needs of each patient. Table 1 lists (in decreasing order of frequency of occurrence) commonly encountered problems of vocal professionals. Table 1: Common Problems of Professional Vocalists Upper respiratory tract infection (URI, "cold," laryngitis) Gastroesophageal reflux-related voice abnormalities Overuse syndromes ("decompensation") Vocal abuse syndrome Misuse of the speaking voice Environmental factors Singing out of range Substance abuse Medications

The Spectrum Of Vocal Dysfunction Traditional medical thinking has created a dichotomous model of disease, organic vs. functional. The term organic means, literally, "related to an organ"; thus, an organic condition is one that is usually associated with structural alteration(s) in the tissues of an organ, i.e., congenital, inflammatory, or other histopathologic changes. The term functional means "related to a function"; thus, a functional condition is the result of abuse or misuse of an anatomically intact organ or organ system. A functional abnormality is not primarily the result of a structural abnormality, although secondary histopathological alterations may be present. "Tennis elbow" is a good example of a functional condition from which secondary histologic changes may result. Likewise, organic conditions also may have a functional component. Many voice disorders are multifactorial, and simultaneously both organic and functional. This is because compensatory alterations of vocal function occur in virtually every case. Furthermore, the compensatory component may obscure the underlying condition. Thus, the dichotomy between organic and functional appears to have little relevance to the understanding and management of voice disorders. In approaching the diagnosis of each voice disorder patient, the clinician must therefore assess the degree of impairment related to the compensatory or functional component, as well as any organic problem. For example, a vocalist with viral laryngitis may present with "no voice" prior to a performance. When examined, the degree of vocal fold edema and inflammation may be mild, and abnormal laryngeal muscle tension (maladaptive compensation) may account for "most" of the loss of voice. While it may not be possible acutely to restore the voice to normal, with treatment, it is often possible to restore enough of the voice to permit the vocalist to perform a "modified program." Often successful treatment may take the combined efforts of the patient's otolaryngologist, speech ("voice")

pathologist, voice coach, and manager. The effective management of chronic voice disorders, though somewhat different from the management of acute disorders, also requires a multidisciplinary team. The Multidisciplinary Voice Center: Medicine In The Vocal Arts In the U.S., within the last decade, a number of multidisciplinary voice centers have been established. Using new technology, these centers have focused the collaborative efforts of voice specialists on the diagnosis, treatment, and prevention of voice disorders. In addition, since the establishment of The National Institute on Deafness and Other Communication Disorders (NIDCD) in 1985, research in this area has increased. Today, most patients with voice disorders can be treated effectively; "arts medicine" has become a new subspecialty; and a national network of voice centers has been established. At most voice centers, the core clinical unit consists of an otolaryngologist and a speech language pathologist; virtually every voice patient should be seen by both. The laryngologist is primarily responsible for the patient's overall care, but the speech pathologist is responsible for the diagnostic voice laboratory and for actually doing most of the speech/voice therapy. Videostroboscopy is performed by the laryngologist, and acoustical voice analysis by the speech pathologist; both are involved in the diagnosis and treatment of voice patients. The voice teacher is also involved in the "rehabilitation" of many singers. When appropriate, patients are referred to the department of gastroenterology for ambulatory 24-hour double-probe pH monitoring, a diagnostic test for gastroesophageal reflux , which is a condition common in voice disorder patients. Occasionally, patients also are referred for evaluation to specialists and laboratories in other departments, including neurology, psychology, psychiatry, gastroenterology, gynecology, and internal medicine. Clinical Assessment Of Voice Patients

With new voice patients, the laryngologist is usually the first member of the team to see the patient; then the speech pathologist should see the patient, on the same day if possible. (With return patients, this sequence is usually reversed.) The laryngologist takes a complete medical history and a "vocal history" (table 2); and the specific vocal complaint(s) must be elicited carefully (table 3). Next, an otolaryngologic examination is performed followed by videoendoscopy, including transnasal fiberoptic laryngoscopy and stroboscopy with a telescopic or optical rod. Ideally, the speech pathologist should be present during this phase of the examination. If he or she is not present, the videotaped examination can be reviewed later. At the very least, the otolaryngologist should communicate the findings and the presumed diagnosis to the speech pathologist. Table 2: Elements of the Vocal History * What are the patient's symptoms? * What is(are) the vocal complaint(s)? * Is there a history of vocal misuse or abuse? * Does the patient have any respiratory symptoms? * Does the patient have any gastroesophageal reflux symptoms? * Is the patient under the care of a physician? For what reason? * Is the patient taking any medications? * Is there a history of substance abuse? * What are the vocal needs of the patient? * What is the practice/performance schedule? * Are there any environmental factors that may be important? * Has the patient had vocal training? If so, how much, when, and with whom? Table 3: Common Vocal Complaints and Their Definitions Aphonia

Loss of voice Dysphonia

Abnormal voice; hoarseness Odynophonia

Discomfort or pain associated with speaking or singing; also usually associated with abnormal laryngeal muscle tension Vocal fatigue

Dysphonia(hoarseness) and/or dysphonia specifically associated with prolonged vocal usage Voice break

A "momentary" pitch-specific dysphonia; a voice "crack" Loss of range

A reduction in the pitch-range, usually a loss of a portion of the high range Dysresonance

An abnormality of resonance

While the laryngologist is usually primarily responsible for the patient's overall medical management, the speech pathologist assumes several key responsibilities in this management: (1) baseline voice documentation, (2) acoustical voice analysis, (3) therapeutic manipulation (so-called "unloading"), (4) independent diagnosis, (5) performance of speech/voice therapy, and (6) determining dismissal criteria. Sometimes the speech pathologist assumes some of the functions of the laryngologist, and vice versa. Before moving on to a discussion of treatment, two specific aspects of clinical voice assessment must be clarified. First, the laryngologist's examination should include both fiberoptic and telescopic laryngeal examination. The former method allows assessment of laryngeal function during connected speech and singing and across the dynamic and pitch ranges of the voice. This is important in assessing laryngeal biomechanics, particularly for identifying abnormal patterns of laryngeal muscle tension. Telescopic examination involves placing a rather large-bore instrument in the mouth so that during this examination, the patient can only phonate a vowel, e.g., /i/. Nevertheless, even though telescopic examination may significantly alter laryngeal biomechanics, the superior magnification and optics of this method allow optimal examination of the free edges of the vocal folds for lesions such as nodules, polyps, cysts, and hematomas. Thus, the two techniques are complementary, and both should be employed in the professional vocalist. Second, the speech pathologist's role in "unloading" the patient may be crucial to accurate diagnosis and effective treatment. Unloading is the term used for voice therapy designed to remove any temporarily compensatory vocal behaviors. The details of unloading are beyond the scope of this paper; however, these are similar to the techniques of voice therapy for patients with functional, especially "hyperkinetic," voice disorders, such as the vocal abuse/misuse or nodule groups of patients. These therapeutic techniques include: (1) obtaining optimal breath support (efficient use of the breath stream); (2) softening the hardness of glottal attack (reducing the effort of initiating phonation);

(3) reducing the rate of speaking; and (4) reducing laryngeal and neck muscle tension through digital manipulation and other relaxation methods. As mentioned above, almost all patients with voice disorders have a functional or compensatory component that can readily be reversed in voice therapy. Through unloading of voice during evaluation, the processes of diagnosis and treatment become intertwined -- only when compensatory behaviors are removed can the voice clinician truly appreciate the true underlying glottal condition. Common Problems Of Vocalists Professional vocalists have some unique problems and risk factors for the development of voice difficulties. As a group, vocalists are often subjected to adverse working environments, e.g., smoke, dryness, dust, a high level of ambient noise, and inadequate amplification. These problems may contribute to "poor vocal hygiene," poor diet, and in some cases, substance abuse. In addition, successful vocalists may suffer from stressful schedules, anxiety, and fragmented -- sometimes inappropriate -- medical care. Table 4 lists some of the unique problems of vocal professionals, the most common of which are briefly addressed below. Inflammatory Causes: "Laryngitis" Infectious and noninfectious causes of laryngeal inflammation are among the most common reasons that professional vocalists seek medical attention. Often the patient will simply complain of "laryngitis," whether or not a specific cause is evident. Indeed, to the layman, the term laryngitis is mistakenly used as a synonym for hoarseness or dysphonia. From the voice clinician's point of view, laryngitis implies inflammation of the larynx, and the vocal abuse/misuse/overuse syndromes are separate entities. While tonsillitis, sinusitis, and allergy may occasionally involve the larynx and cause secondary laryngeal inflammation, by far the most common

causes of true laryngitis are viral infection and gastroesophageal (laryngopharyngeal) reflux.

Table 4: Unique Problems Of Professional Vocalists

Vocal Overuse * Heroic schedule * Inappropriate time management Vocal Misuse/Abuse * * * * * * * Bogart-Bacall syndrome Singing out of range Inappropriate role selection Use of certain character voices Vocal-fold hemorrhage Yelling/Screaming Vocal nodules

Environmental Risk Factors * * * * * * "Noise pollution" Ambient dryness Inadequate amplification Dehydration Air travel Poor diet

Anxiety/Panic * Bulimia/Anorexia * Substance abuse

Reflux Laryngitis * Substance Abuse o Tobacco o Alcohol * Drugs o Cocaine o Marijuana o Beta-blockers o Stimulants * Medications o Antihistamines o Corticosteroids o Anti-inflammatory drugs o Throat sprays Suboptimal Medical Care * Inappropriate surgery * Inappropriate medicine * Inappropriate advice

Upper Respiratory Tract Infection (Viral Laryngitis) Upper respiratory tract infection (URI) may be bacterial or viral; however, viral URIs are the most common, and they may or may not

directly involve the larynx in degrees that vary with the virulence of the invading organism and its site of predilection. In other words, some viruses cause primary laryngeal inflammation that is associated with the development of marked laryngeal edema and hoarseness, while others may cause only minor, secondary inflammation due to drainage of the byproducts of the inflammatory process higher up. A "cold" is an example of the latter. Treatment consists of modified voice rest (no nonessential talking), hydration, and use of a vaporizer (and steamy showers). Antibiotics, decongestants (usually not combinations containing antihistamines), and expectorants should be prescribed, and, on occasion, a single large intramuscular dose of corticosteroids, e.g., betamethasone 20 mg, may be given to counter the effects of the acute laryngeal swelling. Betamethasone has a half-life of 36 hours, so that a single dose may exert its effects for days and requires no "tapering". As an alternative, an oral dosing regimen of betamethasone or prednisone may be used. When prescribing corticosteroids, it is important to inquire if the patient has received such treatment previously, since these drugs may have adverse side effects. In addition, some patients may be drug dependent and may be seeing several physicians in several states to get corticosteroids. The patient who repeatedly uses steroids in order to perform may develop Cushing's syndrome. Finally, the use of inhaled steroids and/or anesthetic sprays is contraindicated because they seldom help, and they may harm the patient. URIs are self-limiting, and symptoms usually resolve within several days. During the acute phase of infection, it is important for the patient to avoid voice strain or overuse because this may result in prolonged difficulties. The severity of laryngeal inflammation, the degree of vocal impairment, and the short-term "performance" schedule of the vocalist are all important factors in the decision-

making process and the approach to treatment. If, for example, a performer has severe laryngitis and a heavy performance schedule, then the upcoming "program" should be drastically modified or the performances canceled. On the other hand, if a performer has mild to moderate inflammation and only a few imminent, but important, performances, medical treatment and voice therapy, in addition to some modification of the performance program, may be a satisfactory solution. Gastroesophageal Reflux ("Reflux Laryngitis")

Gastroesophageal reflux, specifically laryngopharyngeal reflux, is the cause of, or an important cofactor in, voice disorders in approximately half of all professional voice patients who seek medical attention. In addition, these patients often appear to have "occult reflux," in that many deny having any heartburn or regurgitation, symptoms generally thought to be necessary to make a diagnosis of reflux. Voice patients who complain of chronic or intermittent hoarseness, "a lump in the throat" (globus pharyngeus), difficulty in swallowing (cervical dysphagia), excessive throat mucus or post-nasal drip, chronic throat clearing, and/or cough may have clinically significant laryngeal reflux. This diagnosis should be entertained in every patient with any of the above symptoms or findings of unexplained laryngeal swelling, particularly diffuse swelling. Reflux is a factor in the development of vocal fold granulomas, Reinke's edema (polypoid degeneration), and vocal fold carcinoma. In addition, reflux often is causally associated with the muscle tension dysphonias and vocal nodules. Patients with laryngopharyngeal reflux are different from the "typical" reflux patients with esophagitis commonly encountered by gastroenterologists. Voice patients with reflux laryngitis appear to have a high incidence of upright (daytime) reflux, a low incidence of esophagitis, and a high rate of treatment failure using traditional antireflux therapy, such as dietary and lifestyle modifications and H2 blockers.

The most sensitive diagnostic test in the reflux laryngitis group of patients is ambulatory 24-hour double-probe pH monitoring. Omeprazole, 20 mg. b.i.d., appears to be the most effective treatment. Vocalists appear to be extraordinarily prone to develop reflux, but why they are so inclined remains unknown. Vocal Abuse, Misuse, And Overuse Syndromes: The Muscle Tension Dysphonias This group of disorders is very common in professional vocalists, and may be lumped together under the heading of muscle tension dysphonias (MTDs). The MTDs may occur in isolation, after a URI, or, as mentioned above, in association with reflux. It is important for the voice clinician to evaluate each patient for each of these possible causative factors, since every underlying cause must be identified and corrected if treatment is to be effective. Vocal Abuse Yelling, screaming, singing too loudly or "out of range," and using certain character voices may result in traumatic laryngeal damage, including the development of contact ulcers of the vocal processes, vocal fold hemorrhages, nodules (localized vocal fold swellings), or diffuse vocal fold swelling. These lesions are the consequences of traumatic vocal behavior and they result in vocal impairment. The best treatment for all of these dysphonias is prevention. Vocalists should strictly avoid screaming (to the point of causing hoarseness) at athletic events and at other times, including when performing. Professional vocalists who demonstrate findings of vocal abuse should be offered a program of vocal education designed to modify the abusive vocal behavior(s). Vocal-fold hematomas are best treated by voice rest, occasionally by surgical drainage. Contact ulcers on the vocal processes may be due to use of a loud speaking voice alone, but also often are associated with poor breath support, very low

pitching of the voice, and chronic throat clearing. Such ulcerations may produce referred pain to the ipsilateral ear (often during performance), and yet may only minimally alter the vocal quality. Patients with contact ulcers and granulomas usually need treatment for both reflux and vocal abuse/misuse (voice therapy). Vocal nodules, small discrete swellings at the junction of the anterior and middle thirds of the vocal folds, are common in vocalists, and are always the result of vocal trauma. These swellings may represent nothing more than discrete areas of mucosal thickening, or the nodules may be keratinized (like a callus), or angioma-like (vascular). Most patients with vocal nodules do not need to have them removed, and in many cases, the nodules do not significantly alter vocal quality. However, when the nodules are associated with an underlying submucosal cyst or have a red "angioma-like" appearance, then surgical treatment should be considered, but only after voice therapy has been instituted. It is important to remember that these are functional lesions and that, with the exception of cysts and "red nodules" (as above), they are reversible -- that is, they may resolve completely when vocally abusive behavior is eradicated. Relatively few patients with vocal nodules ever require surgery. All patients with traumatic vocal-fold injuries should be subjected to intense scrutiny by the voice team. Abusive vocal behaviors, including chronic traumatic throat clearing, should be eliminated, and voice therapy designed to optimize vocal efficiency should be provided. Vocal abuse in a vocal professional is tantamount to a musician's leaving his or her instrument out in the rain: it is inappropriate and neglectful. For most vocal abuse patients, including those with vocal nodules, vocal education (or reeducation) is effective remedial therapy. Vocal Misuse

Vocal misuse is somewhat different from abuse, in that misuse tends to be less acute, more habitual, and more insidious in its effects. Speaking or singing out of range and the use of certain character voices are the most common forms of misuse. In many singers who seek medical attention for a voice problem, it is actually the speaking voice that is at the root of the problem. In both men and women, the habitual use of a very-low- pitched speaking voice may be the cause. To produce a low-pitched voice requires considerable muscular tension. This type of muscle tension dysphonia is termed Bogart-Bacall syndrome. (This syndrome is named after these two great actors, not because they had anything wrong with their voices, but because the term suggests that people with the voice disorder often have voices that are similar in pitch to Bogart's or Bacall's). Patients with this condition almost always speak using the lowest note of the pitch range, and also usually demonstrate poor breath support. Why this condition occurs is conjectural; however, in contemporary society, a low-pitched speaking voice is considered desirable. In men, a low-pitched voice confers authority and masculinity; in woman, it confers sophistication, worldliness, and confidence. Diagnosis of the Bogart-Bacall syndrome requires a high index of suspicion, and correction of the syndrome depends upon the cooperative efforts of the patient, the laryngologist, and the speech pathologist. Singing out of range is also a common problem. Most vocalists know their own tesitura, that is, their "best range", but occasionally, a vocalist will take on a role that is inappropriate, and when this happens, vocal difficulties may result. Similarly, actors may take on roles that require use of a "character voice" that pushes beyond the limits of "safe vocal physiology." Laryngeal muscle tension increases dramatically when a vocalist is speaking or singing out of range, and thus the likelihood of laryngeal trauma increases. When singers and actors sound as if they are

straining, they are straining. Occasionally, the voice clinician must point out the obvious when vocal misuse of this type occurs. Vocal Overuse Vocal overuse can happen to anyone; however, in many cases it can be avoided. It is particularly prone to occur following an URI. While there is no surefire way to estimate the vocal capacity of a performer, the demands of touring, especially, may sometimes lead to chronic fatigue and a voice disorder. When this occurs, it is the physician's role to facilitate a reexamination of the performer's schedule and circumstances. In addition, the physician should look for previously unidentified cofactors that may contribute to the process of vocal decompensation. Short-Term and Long-Term Issues When the physician is called upon to see a vocalist, it is important to recognize that the problem may be acute, chronic, or both (leading to sudden "vocal decompensation"). Indeed, many vocalists with "poor technique" who are young and strong seem to survive vocally until an additional acute factor, such as an URI, occurs. The vocalist may then come to the physician complaining only of the acute problem, whereas, more often than not, the cause of such a voice disorder is multifactorial. Consequently, the premorbid characteristics of the patient's schedule, lifestyle, vocal hygiene, and previously unreported symptoms also should be elicited, examined, and possibly modified. Communication with other members of the voice team, including the vocalist's manager, coach, teacher, or other physician(s), not only is appropriate, but also is necessary to sort out the short-term from the long-term problems, and to address their optimal solutions. For example, after a URI-related vocal decompensation (cough, granuloma formation, etc.), a vocalist might also need treatment for reflux, voice therapy directed at improving the efficiency of the speaking voice, and singing lessons.

CONCLUSIONS I know of no other area in medicine that could more appropriately be called "holistic." Voice clinicians can now begin to make suggestions that may heighten the awareness of vocalists to potential problems and therefore help prevent voice disorders. Table 5 lists some suggestions for the professional vocalist on how to save the voice. Table 5: Suggestions For The Professional Vocalist: "How To Save Your Voice" 1. Avoid abusing your voice. * You should do nothing to your voice that results in hoarseness and/or throat pain. * Avoid yelling or screaming to the point of causing hoarseness. * Avoid singing so loudly that you develop hoarseness, and avoid singing in situations that are so noisy that you cannot hear yourself singing. * When you have a cold or laryngitis, do not try to talk or sing "over" the problem, since this can lead to vocal-fold damage. See your doctor. 2. Avoid misusing your voice. * Be careful when using "character voices" not to strain, and use especially good breath support. * Do not attempt to alter your "normal" speaking voice to create an effect; particularly avoid pitching your voice too low. (If you are using the lowest note of your pitch range for everyday conversation, this is too low). * Avoid taking on roles that you cannot do, that is, don't attempt roles that are out of your range. * Avoid using long run-on sentences and a rapid speaking rate that stresses the vocal apparatus; good breath support for conversational speech is every bit as important as good breath support

for singing. (If you don't know what this means, you should consider taking voice lessons, and/or seeing a voice therapist). 3. Avoid overusing your voice. * In very noisy environments such as airplanes, keep conversation to a minimum. * Examine your "vocal schedule" carefully. Remember that all your vocal demands are not of equal importance. Avoid making a schedule that leaves no room for rest and recovery. * Use amplification when available and appropriate, especially for rehearsals. * Use "marking" techniques when appropriate, especially for rehearsals. 4. Monitor your work and home environments for possible problems. * Avoid, if possible, performing in smoky, dusty, and noisy environments. * Use humidification in your bedroom, especially during the winter. 5. Monitor your diet and life style. * Eat regularly, and eat a healthy diet. * Avoid fried and other fatty foods. * Avoid dehydration, since this adversely affects the vocal folds; drink plenty of water. * Avoid eating or drinking, particularly alcoholic beverages, within three hours of bedtime. * Minimize consumption of caffeine-containing foods and beverages. * Strictly avoid smoking or other tobacco consumption; if you already smoke, quit. * Exercise regularly; aerobic exercise is best. 6. Avoid unnecessary medications. * Don't treat yourself. * Avoid drying medications such as antihistamines. * Avoid anesthetic throat sprays. 7. Consider taking voice lessons, even if you have never had a voice problem; voice lessons have been shown to increase vocal efficiency, and decrease the likelihood of developing voice problems.

8. If you need a physician, consult with other singers to find an otolaryngologist who has experience in treating vocalists. SUGGESTED READING Boone DR, McFarlane SC: The Voice and Voice Therapy. 4th edition, Prentice Hall, Englewood Cliffs, N.J., 1988 Koufman JA, Blalock PD: Vocal fatigue and dysphonia in the professional voice user: Bogart-Bacall syndrome. Laryngoscope 98:493-498, 1988 Koufman JA: The otolaryngologic manifestations of gastroesophageal reflux disease. Laryngoscope 101:(Supplement 53) 1-78, 1991 Koufman JA, Isaacson G, Editors: Voice Disorders. Otolaryngology Clinics of North America 24:965-1286, October, 1991 Sataloff RT: Professional Voice: The Science and Art of Clinical Care Raven Press, New York, 1991

Warming-Up
WARMING-UP THE VOICE

8/24/12 9:30 AM

Visit The Wake Forest University Baptist Medical Center website While singing may seem heavenly, vocal production itself is a down-toearth physical experience, requiring athletic discipline as well as artistry. As any athlete knows, an effective warm up is essential for optimal performance. Why should singers warm up? No one would expect a gymnast to stand up and perform back-flips after a full meal, but singers who are dinner guests are frequently asked to perform "on-the-spot entertainment," after dessert and coffee. The wise singer will politely decline, rather than reveal his raw vocal product, which is further hindered by a bloated stomach! Warming up allows the singer to "getin-touch" with herself or himself, both physically and psychologically, and to experience that kinesthetic self-awareness which is the foundation of a secure vocal technique. Allowing time to warm-up . . . Ideally, the warm-up procedure should be unhurried -- a leisurely self-exploration that allows adequate time for gradual loosening and coordination of countless muscles, large and small, which contribute to vocal production. Warming-up should be an enjoyable experience, comparable to a luxurious massage. All too often, unfortunately, the singer is warming up while rushing to a rehearsal, or frantically trying to learn his music at the last minute. The pressure of "too little time" results in physical as well as mental tension, and warming-up is difficult, usually ineffective, or even counter-productive. The warm-up procedure . . . Singers develop distinctive warm-up regimens appropriate to their personal needs; these may vary considerably with changes in physical, mental, and emotional well being. Nevertheless, consistency in the overall approach is most beneficial. Many singers begin by warming-up the entire body with gentle physical exercise (e.g., stretching, yoga, Tai Chi). This helps to

alleviate the muscular tension that interferes with vocal production, as well as to stimulate the deep breathing which is necessary for good support of the voice. The muscles of articulation, which include the jaw, tongue, lips, and soft palate can be loosened with appropriate exercises, which also can help to activate the singer's expiratory airflow. Before beginning to explore the day's potential for vocal resonance, the singer should be relaxed, yet vital. If the singer is fatigued, or not feeling well, it will be necessary to "energize" himself, so that he can provide adequate breath support for singing. It is wise to begin vocalizing in the most comfortable mid-range of the voice, and gradually work out to the higher and lower extremes of pitch. High notes (faster vocal cord vibration) may require substantial air-flow and increased pharyngeal space. Low notes, which use a "heavier" mode of vocal cord vibration (thicker vibrating mass), also require appropriate support. Recent biomechanical studies at The Center for Voice Disorders have shown that singing at the extremes of pitch -- both the highest and lowest notes of the vocal range -- can strain the laryngeal muscles, and can result in undesirable (and potentially harmful) patterns of muscle tension. Therefore, it is good common sense to avoid the "outer extremes" of the voice until one is well warmed-up. In the mid range, the singer may safely begin the daily search adjustments in the size and shape of the pharynx. Considering the countless possible configurations of the vocal tract, the process of developing a resonant tone is an on-going one, even for seasoned professionals. Most of a singer's warm-up is devoted to the objective of obtaining a beautiful vocal timbre through the use of an enormous variety of vocal calisthenics. Finally, the singer is likely to test his vocal register transitions during the warm-up. Exercises that "blend" the "chest" ("heavy" laryngeal adjustment) and "head" ("light" laryngeal adjustment) registers eventually produce a smooth passaggio, resulting in an "even scale" from the "bottom" to the "top" of the vocal range. Warming-down . . . The long-distance runner will spend a good amount of time stretching and massaging muscles after a marathon,

and likewise, the singer who has extended himself should "warmdown" his voice, with exercises that "soothe" the vocal cords (vocalizing on "oo," for example). If the singer has been using a "belting" voice, it is especially helpful to sing in the "head" register (or falsetto), which stretches the vocal cords and alleviates laryngeal tension caused by the "heavy adjustment," or thick vibrating mass. Re-loosening the articulatory muscles, even without phonation, is therapeutic. Massaging the jaw -- the masseter ("chewing") muscles -as well as other muscles of the neck and shoulders, particularly the trapezius (which arise from the back of the head and vertebrae in the neck and chest, and extend to the collarbones and shoulder blades) provides welcome relief to the singer. T. Radomski Teresa Radomski, MM, is an accomplished soprano soloist and Associate Professor of Voice and Theatrical Singing at Wake Forest University. In addition, Ms. Radomski is a consultant for the Center for Voice Disorders, and a contributing editor of this newsletter. Her column, "A Singer's Notes" is a regular feature of THE VISIBLE VOICE. Ed.

Maintaining Vocal Health

Maintaining Vocal Health

8/24/12 9:30 AM

David Otis Castonguay Radford University For many school-aged singers, the choral director is the only significant source of professional instruction and advice they willever receive about their voice. The choral director is their first line of defense for vocal health. A conductor's skill at diagnosis of vocal faults must be matched by a willingness to refer students to the proper health care professional. This is a copy of a handout presented to students in choral conducting and vocal pedagogy classes at Radford University. In addition to the sources cited in the bibliography, and my own experience, this material is drawn from the work of Van Lawrence, M. D., Otolaryngology and Paul Brandvik. 1. Try your best to maintain good general health. Avoid viral colds (a regimen of washing hands hasbeen shown to reduce the transmission of cold viruses). Some advocate vitamin C and zinc lozenges, while I find these effective I would recommend their use these only after the student has consulted a physician. 2. Emotional and physical stress both contribute significantly to vocal distress. Exercise regularly. Using your major muscle groups in jogging,etc. is an excellent way to diminish stress. NOTE: extensive power weight lifting will place some wear on the vocal folds, this should be avoided during times of extended vocal use or vocal fatigue. 3. Eat a balanced diet. At times of extended vocal use avoid large amounts of salt and refined sugar, spicy food such as Mexican, Szechuan Chinese, as well as excessive amounts of food and/or alcohol. One may note hoarseness in the larynx or dryness of the throat after drinking significant amounts of alcohol, caffienated, as well naturally or artificially sweetened beverages. The body needs water to metabolize these foods and beverages, excessive consumption of

these items will reduce the amount of water available to hydrate the voice. 4. Maintain body hydration (7-9 glasses of water a day) and avoid known dietary diuretics such as caffeine and alcohol. Moisture is a necessary lubricant of the vocal folds. When one's body is dehydrated laryngeal lubrication diminishes and wear takes place at a much greater rate than normal. 5. Avoid dry, artificial interior climates. Laryngologists recommend a humidity level of 40-50%. Much body moisture is lost while breathing air in low humidity climates, i.e., air conditioned or heated rooms (routinely 10-20% moisture), cars, buses, etc. 6. Avoid smoking cigarettes, cigars, pipes. These are bad for the heart, lungs, and vocal tract of not only yourself, but others around you as well. Avoid other irritant inhalants, i.e., marijuana. In addition to the debilitating effect on the vocal tract, you need your head on straight when you sing. 7. Avoid breathing smoggy, polluted air, i.e., car exhausts, smoky bars and lounges when you are vocally tired. 8. Avoid the use of local anesthetics when you are singing. The anesthetic effect masks any signs of injury, therefore encouraging further abuse of the folds. Additionally, singing under their influence is like playing the piano with gloves on (Chloroseptic, Parke-Davis Throat Discs, etc.). 9. Question the use of progesterone dominant birth control pills. These cause a virilization of the female larynx and a decrease of range in your upper register. There may be no other solution for your particular situation, however. The treatment of endometriosis often includes pharmaceuticals which cause permanent vocal changes. Inform your doctor that you are a singer if you are undergoing treatment for this disease.

Vocal Use Practices 1. Avoid hyperfunctional use of your voice, i.e., learn to use your voice with as little effort and tension as possible. A high school or collegiate singer in training should be able to sing for 3-4 hours per day (when healthy) without debilitating the next day's singing activity. If one cannot sing for this length of time without some disablement, then one should consider a reevaluation of present singing or speaking habits. 2. Keep in mind that the degree of individual vocal conditioning and innate vocal capacity to endure wear and tear relate directly to the amount of singing or speaking one can do each day. 3. Avoid singing in a tessitura which is continually near the extremes of your own range (both high and low). Carefully pace the use of register extremes (such as pushing the chest voice into the upper range for effect, i.e, belting). MISUSE OR OVERUSE HERE CAN BE VOCAL SUICIDE. 4. Before singing or using the voice in unusual ways (public/dramatic speaking), do some vocal warm-ups. As in any physical activity, the warm-up should proceed from general stretching through less strenuous to more strenuous usage. Loud volume and high range are the most strenuous of usages,therefore, begin in the mid-range with easy production. At every stage along the way, evaluate your present day vocal condition, and adjust your rehearsal activity accordingly. Every voice is different, but 7-10 minutes of warm-up is usually the minimum. 5. Reduce general voice use prior to a concert. While riding the bus to the program, have a quiet period when everyone can conserve energy for the task that is at hand.

6. Avoid shouting, screaming,loud laughter, and heavy throat clearing. Necessary coughing and sneezing should be as gentle and as nonvocal as possible. 7. If it feels bad, don't do it. Common Signs of Significant Vocal Abuse 1. Throat is tender to the touch after use. 2. Voice is hoarse at the end of singing. 3. Throat is very dry, with a noticeable "tickle" that is persistent. Check dehydration. 4. Inability to produce your highest notes at pianissimo volume. 5. Persistent hoarseness or an inability to sing with a clear voice after 24-48 hours of vocal rest. Treat your voice and body sensibly when you feel vocally run down. This necessitates the development of accurate perceptions by the singer of why the voice is feeling tired. Accurate self-evaluation will lead one to therapeutic practices which will return you to vocal health in the shortest period of time. In doubt? seek professional help. Recommended Reading Brodnitz, Friedrich S., M. D. Keep Your Voice Healthy . 2nd ed. Boston: College Hill Press, 1988. McKinney, J. C. The Diagnosis and Correction of Vocal Faults. Nashville: Genevox, 1994. Sundburg, Johan. The Science of the Singing Voice. Translation of Rstlara. Dekalb, Illinois: Northern Illinois University Press, 1987.

Thurman, Leon. "Putting Horses Before Carts: A Brief On Vocal Athletics." The Choral Journal (March 1983): 15-21 Thurman, Leon. "Putting Horses Before Carts: When Choral Singing Hurts Voices." The Choral Journal (April 1983): 23-28. The chart on the following page illustrates many of the points outlined above. While the chart is largely self-explanatory, three factors contributing to vocal distress taken from Thurman's articles perhaps need some explanation. Disease Circumstances (such as allergies or viral colds) and Aggravating Circumstances (such as lack of sleep, and spending time in smoky or polluted air) are factors which can cause vocal distress. Predisposing Circumstances include Psychological Stress Reaction becoming emotionally upset. The emotional tension often associated with such distress has a negative impact on the voice. Persons who suffer from what is commonly called "stage fright" experience the shortness of breath, "lump in throat" and other symptoms which impair good vocal production. Under Heredity, Thurman includes individuals whose vocal mechanism tires at an abnormally fast rate. The following graphic may be enlarged by clicking on the thumbnail. This flow chart graphically depicts procedures for maintaining good vocal health.

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