vocal health and hygiene

7/28/2019 Vocal Health and Hygiene

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Vocal Health and Hygiene 8/24/12 9:30 AM

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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.


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* 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 riseslightly 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 ata 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 non-

vocal.

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.


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* 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/publicspeaking /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


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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 inor 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.


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* 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.


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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.

Return to Main Page


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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 takingsteps 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


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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" --calluslikenodules 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 theadolescent 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.


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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 voiceusually 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. Benigngrowths 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


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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 calluseson 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


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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 ableto 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 throat-

related 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.


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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 toan 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 full-

time choral director, had suffered a continual problem of nodules forseveral 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


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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.


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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 oftemperature 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.


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10 Most Common Problems 8/24/12 9:30 AM

THE 10 MOST COMMON PROBLEMS OF SINGERS

Visit The Wake Forest University Baptist Medical Center website

In dealing with the physical production of the singing voice, oneencounters 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 backand 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 over-

support 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


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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 asinger'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: Allsinging 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


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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 "belcanto" ("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 certainvowels 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


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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 ignorecommon 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 onesinstrument (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


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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'sNotes" will appear as a regular feature of THE VISIBLE VOICE. Ed.


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Medicine in the Vocal Arts 8/24/12 9:30 AM

Medicine In The Vocal Arts

Jamie Koufman, M.D

Reprinted from THE VISIBLE VOICE, The newsletter of the Center forVoice Disorders


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 beboth 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


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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 isable 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


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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 isthe 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 aphysician'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


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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


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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 littlerelevance 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")


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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 bythe 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


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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, thissequence 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


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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


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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 vocalfolds 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);


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(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 afunctional 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 brieflyaddressed 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


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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


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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 drugso 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


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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 todrainage 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 drugdependent 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-


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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.


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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 developreflux, 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


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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


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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 theBogart-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


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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 thencome 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.


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CONCLUSIONS

I know of no other area in medicine that could more appropriately be

called "holistic." Voice clinicians can now begin to make suggestionsthat 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 yourdoctor.

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


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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.


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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


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Warming-Up 8/24/12 9:30 AM

WARMING-UP THE VOICE


While singing may seem heavenly, vocal production itself is a down-to-earth 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 "get-

in-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 andsmall, 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


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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 air-flow. 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 thecountless 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,


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and likewise, the singer who has extended himself should "warm-

down" 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 laryngealtension 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.


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Maintaining Vocal Health 8/24/12 9:30 AM

Maintaining Vocal Health

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


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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 anecessary 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.


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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 collegiatesinger 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, thewarm-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.


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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 thesinger 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.


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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 SingingHurts 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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