8.3.2.1 Counselling

The overall success rate of voice therapy depends on several factors, including the disorder being treated, the method being used and the clinician’s skills. However, one of the more important factors is the patient. The patient’s motivational state and coping strategies should be taken into account through the whole process. Patients need to know the nature of the problem they have. Because the vocal apparatus is hidden inside the neck, visual biofeedback is not possible from the vocal organ, but kinaesthetic biofeedback may help; auditory biofeedback seems to be the most reliable feedback type to monitor voice. Basic knowledge of anatomy and physiology according to the patient’s personal level of awareness and data need may be provided with stroboscopic self-images of vocal folds.

Only after explaining the order can the clinician determine the disorder. The patient’s side of the diagnosis depends on his knowledge and acceptance. The clinician must help the patient understand the problem and provide reasonable and realistic strategies for management. Coping strategies and readiness for behavioural change in patients determine the ultimate success of voice therapy. This depends on motivation of and adherence to strategies by the patient. Various stages can be mentioned (Prochaska and Velicer 1997) in this respect: pre-contemplation (problem not realised), contemplation (possibility of addressing the problem is considered), preparation (intending to take steps to change) and action (evident attempts to change) followed by maintenance (working to prevent relapse and consolidate gains).

Self-awareness may be awakened by simple statements. For example for a puberphonia case, after explaining the physiological events in puberty, the clinician’s statement that the falsetto voice is not the normal one may be quite impressive. Sometimes the puberphonia patient has already developed a healthy modal voice, but the problem is about choices. The answer of the patient to the question ‘Do you have another voice?’ may be ‘Yes but I don’t like it, it is too dark’. The treatment is then only about convincing the patient to accept and use the natural sound of modal register.

Therapeutic compliance is a critical issue for the treatment outcome. To increase the patient’s adherence to therapy, effective exercise instruction, choosing the proper technique (haute couture, easy-to-use and trust in the method) and feedback detection may help. Social environment counselling (family, business, school, etc.) is also important, because intensive everyday life may impair vigilance. Noisy environments may cause vocal abuse (Lombard effect) unintentionally. Treatment of childhood dysphonia should include in-house vocalisation behaviour and family training in addition.

8.3.2.2 Voice Rest

Voice rest is not used to change vocal habits. The main goal of voice rest is to give some time for recovery of traumatised tissues, especially the vocal fold mucosa (Sataloff et al. 2005a). There are two types of voice rest: absolute and modified.

8.3.2.3 Vocal Hygiene

Vocal hygiene is about avoiding mechanical and chemical trauma, as well as treatment by hydration and humidification.

8.3.2.4 Breath Support

8.3.2.5 Posture

Potential adverse effects of poor posture on the phonation process have been known for centuries, especially in singing pedagogy. Proper posture means a perfect balance between deep extensor muscles and flexors, which leads the body to a ‘maximum muscular economy’ state. The larynx is suspended from the basicranium without any direct bony attachment.

The head is the pivot point, being a powerful moment-bearing mass for the whole balance system. Forward head posture (FHP) is carrying the head forward of the centre of the shoulder, which puts increased stress on the cervico-thoracic spine and requires more work from the erector spinae muscles to maintain an erect posture. Forward head posture is one of the major posture abnormalities that effects voicing by altering the vocal tract shape, elevating vertical larynx position and disturbing the cricothyroid activity. Breathing dynamics will also change with FHP.

Various techniques such as Alexander, Feldenkrais, Yoga and Qigong exist for postural study. The basic principle is being in ‘conscious awareness’ of the body, which is fit, but not fixed. General rules for posture involve relaxed jaw, balanced head, ear-shoulder-hip-knee on gravity line, active spine and unlocked knees in summary.

8.3.2.6 Biofeedback

8.3.2.7 Relaxation

Various relaxation methods (Boone 2000b) may be used for helping the voice system to turn to its factory settings.

8.3.2.8 Psychotherapy

Various psychiatric conditions may interfere with voice problems. Psychiatric intervention or psychotherapy may be needed in specific pathologies such as psychogenic aphonia/dysphonia, performance anxiety, major depression, generalised anxiety disorder, gender identity disorder and neurotic personality.

8.3.2.9 Conscious Medical Hypnosis

Conscious medical hypnosis can be used for relaxation as well as psychogenic aphonia/dysphonia.

8.3.2.10 Acupuncture-Acupressure

Various acupuncture points are known to be related with voice production. S-10 is known as singer’s point; St9, Li18, Li15, Lu1, Lu7 and Ki6 points are also stated to affect voice in some way (Yiu and Yee-Ian Kwong 2005).

8.3.2.11 Phytotherapy

Several herbal recipes (licorice extract, slippery elm, etc.) are defined to help vocal mechanism; none of them has been proven to be effective. Nevertheless, phytotherapy may help to make the throat feel more relaxed, so that it may be easier to lower the larynx and relax the muscles. In addition, some herbs (e.g. pineapple fruit containing bromelain) may alter mucus composition and may have moisturising effect (Seidman 2006).

8.3.2.12 Neuromuscular Electro-phonatory Stimulation (See Also Sect. 8.4)

Electrotherapy by transcutaneous nerve stimulation (TENS) is defined as a therapeutic modality to change the threshold of elicitation of nerves or muscles in physical therapy. Various types of electrical current may be used for different aims (i.e. to stimulate the paralytic muscles or to relax the spasmodic muscles) (Gilman and Gilman 2008). This kind of therapy is still under controversial discussion and needs evidence-based study. Neuromuscular electro-phonatory stimulation (NMEPS) can be used in combination with direct voice therapy methods in treatment of dysphonia (Guzman et al. 2014).

8.3.2.13 So-called Alternative or Complementary Approaches

These are the approaches that may be labelled as irrational and not scientifically proven but that make the dysphonic patient feel better. Regulation, licencing and usage of alternative approaches vary from country to country. They may have placebo effect and additional sociocultural aspects especially in psychogenic aphonia. Energy therapies (bioenergy by touching the body’s energy fields; magnetic field therapy), alternative medicine (traditional Chinese medicine and Ayurveda), mind-body interventions, biologically based therapies and manipulative methods may be mentioned among these approaches.

8.3.3.1 Holistic Approaches

Holistic therapy programmes integrate all of the voice subsystems—respiration, phonation and resonance—into the rehabilitation of the voice disorder. They provide vocal hygiene counselling, attention to vocal symptoms, emotional support and direct physical exercise through manipulation of respiration, phonation and resonance. These programmes are multidimensional and may be applied to both hyperfunctional and hypofunctional voice disorders.

Semi-obstructive Vocal Tract (SOVT) Exercises

Semi-obstructive vocal tract exercises (Titze 2006; Nix and Simpson 2008) have been well-known in singing pedagogy for centuries. The main mechanism is to increase inertia of the vocal tract by applying a backpressure to the system. According to the type of the backpressure, SOVT exercises may be classified as follows:

Consistent Backpressure

Consistent backpressure can be provided with or without devices:

• 
  
  Artificially lengthened vocal tract assisted continuous backpressure
  

  
  

  
  
  • 
    

    Resonance tubes of glass (Sovijarvi) (Simberg and Laine 2007) or silicone (Sihvo) (Denizoğlu 2013) provide low backpressure (wider inner diameter) and higher formant effect.

    
    
  • 
    

    Drinking straws (Titze 2006) provide high backpressure and low formant effect.

  
  
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  Voiced fricative consonants: [v], [z] and [j]

  
  
• 
  

  Nasal consonants: [m] or humming

  
  
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  Semivowels: [y] and [w]

  
  
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  Hand-over-mouth exercises

Transitory Backpressure

This provides high backpressure over a short duration by voiced stop consonants ([b], [g], [d]) followed by a vowel.

Oscillatory Backpressure

Trills are widely used in training singing and for warming up the voice as well. Three kinds of trills are popular:

• 
  

  Bilabial trill (liptrill)

  
  
• 
  

  Tongue trill (rolled [r])

  
  
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  Lip-tongue trill (raspberries)

Combined Consistent and Oscillatory Backpressure with Artificial Elongation of the Vocal Tract

The method of using tubes to extend and constrict the vocal tract by terminating them into a volume of water provides a combination of consistent and oscillatory backpressure to the voice system. It may be applied by different tools such as glass tubes (Simberg and Laine 2007), silicone tubes (Sihvo’s LaxVox Tube) (Denizoğlu 2013) and devices (doctorVOX^®, pocketVOX^®, maskVOX^®) (Denizoglu et al. 2018).

DoctorVox Voice Therapy (DVT) has been developed by Denizoglu but is based on Sihvo’s LaxVox Method. DVT is a direct voice therapy technique that directly aims to change vocal behaviour. DVT combines phonation, resonance and breathing in a holistic approach to voice therapy. Artificially elongated vocal tract and backpressure (continuous and alternating) are the main tools. DVT provides multichannel biofeedback and enhances treatment adherence in clinical applications.

DVT is a multidimensional-multilevel treatment strategy, not an exercise of phonating into a tube submerged into a certain amount of water. It is an integrative approach for a given voice patient with three levels: the clinician’s action plan, exercise patterns and the monitoring of the patient. DoctorVox Voice Therapy Technique is defined (Denizoglu et al. 2018) as a comprehensive method (Fig. 8.1). Instruction of DVT is as follows:

• 
  
  Preset
  

  
  

  
  
  • 
    

    Counselling: the primary concern for the patient in this phase is to understand what to do, how to do it and why. Proper and sufficient cognitive data help a lot for motor learning process.

    
    
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    Posture: take a balanced posture; the noble posture, which is well-known in singing pedagogy (dynamic spine, high sternum, head upright, low jaw), is ideal for both breathing and laryngeal functions. Breathing and appoggio: expiration by lower back and lower abdominal muscles, defocus breathing function from the upper chest and shoulders. Don’t move your sternum during breathing (and phonation) as in the noble posture.

    
    
  • 
    

    Relaxation: it does not define a slouched posture; it is fit-not fixed. The face, neck, upper back and upper chest muscles are relaxed and do not interfere with laryngeal posture.

  
  
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  Bubbling without phonation
  

  
  

  
  
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    Finding the primal sound is the main goal of this step.

    
    
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    Hold the device close to your rib cage.

    
    
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    Dip the tube into water (1–2 cm deep at the beginning).

    
    
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    Place the tube into the mouth between the incisor teeth and above the tongue.

    
    
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    Enclose the tube with the lips (elongate your lips as in phonating [u] to prevent air leak).

    
    
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    Inhale through the nose as in yawning or sniffing slightly.

    
    
  • 
    

    Exhale into the water and try to monitor bubbling without phonation. First you can bubble in a constant rate, and then change the bubbling rate. By this way you can see, hear and monitor your breathing consciously.

  
  
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  Bubbling with phonation (finding the sound of target voice)

  
  

  Try to hear a primal sound by various vegetative phonation manoeuvres (yawning, sighing, humming, coughing, laughing, crying, grunting, sobbing, moaning, trilling) before phonating into tube. This sound should be nonlinguistic (with no meaning).

  
  
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  Bubbling with phonation (skill acquisition)

  
  

  Phonate into tube by this sound, add some linguistic meaning, and sustain a monotonous [huuu].

  
  
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  Skill retention

  
  

  Various tonal exercises (sostenuto, glissando, portamento, staccato) can be used to develop the new phonatory pattern (see Sect. 1.​8).

  
  
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  Behavioural transfer

  
  

  Take the tube out, and maintain the same pattern in syllable-word-sentence-reading-conversation hierarchy.

DVT, in physical terms, adds a subsystem to the physical process of phonation (artificial elongation of vocal tract and oscillatory backpressure). The technique also provides a multichannel biofeedback, which is useful to support home exercises in a correct way by reifying the abstract concepts used in voice therapy.

8.3.3.2 Specific Approaches

Techniques that are used in specific conditions can be classified according to the pathology.

Techniques Used in Hyperfunctional Voice Disorders

Yawn and Sigh

The technique (Boone and McFarlane 1993) appears to be especially effective in counteracting the tension symptoms of elevated larynx and constricted vocal tract that so often characterise vocal hyperfunction.

The application of the technique is as below:

• 
  

  Watch the patient yawning and sighing.

  
  
• 
  

  Demonstrate a yawn and explain how it feels; show figures for comparison.

  
  
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  Let the patient imitate your yawn and add a sigh slightly to the end of the yawn.

  
  
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  Once the yawn and sigh phonation is easily achieved, add one syllable or a word to the sigh beginning with open-mouthed vowels.

  
  
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  Add a word and eventually more words on one exhalation following a yawn-sigh.

  
  
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  Demonstrate the sigh phase of the exercise in detail (prolonged, easy, open-mouth exhalation with an easy phonation).

  
  
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  Maintain the sigh posture with [h].

  
  
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  Skip yawn-sigh and say syllables beginning with [h] ([hah], [hoh], [huh]).

  
  
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  Sustain (sostenuto or glissando) vowels with the same posture ([haaaa], [hoooo], [huuuu]).

  
  
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  Blend the same posture to the words beginning with open-mouth vowels.

  
  
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  Maintain the relaxed phonation simply by imagining the sigh posture with conversational speech.

Laryngeal Massage

The application of physical therapy (massage and osteopathy) aims to reduce tension in the upper body and to allow the larynx to relax into a more comfortable position from that which is too high because of excessive muscle contraction. In addition to muscles included in the phonation process, laryngeal joints and jaw tension are considered for manipulation. The techniques use the same mechanisms of physical therapy in general: a strained muscle is short and stiff, and when elongated by massage, it is relaxed. The procedure is applied through pressing on selected areas of the neck (especially laryngeal joints and extrinsic laryngeal muscles) with the thumb and forefinger.

The Manual Laryngeal Muscle Tension Procedure (Aronson 1990) steps are as follows:

• 
  

  Focal palpation.

  
  
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  Circumlaryngeal massage: moderate pressure is applied initially upon the contracted thyrohyoid space in small circles, from front to back.

  
  
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  Manual repositioning of the larynx during phonation.

  
  
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  This is a transient relaxation that gives auditory and kinaesthetic feedback; you must add some vocal exercises so that the patient is able to maintain easy voice production in the absence of manual manipulation.

Confidential Voice Therapy

Confidential voice (Casper-Colton and Casper 1996) is a temporary breathy voice production used to help tissue recovery (especially vocal fold mucosa). It is often used in acute (short-term) voice problems and after surgery as a modified voice rest or as part of a longer-term programme that alternates periods of voice rest with more demanding voice use. Confidential voice has a light sound of voice with a soft and easy phonation. It is a breathy sound with low effort and low airflow but not a breathy whisper. Important features of the technique are:

• 
  

  Pitch must not be lowered (and may be even slightly increased).

  
  
• 
  

  Focus should be proper (larynx should not be pushed down).

  
  
• 
  

  Mouth opening must not be reduced.

  
  
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  Prosody should be preserved normal (which tends to be monotonous).

It is important to inform about the goal and rationale of the technique and warn patients that it is a transient behaviour.

Chewing Approach

It is Emil Froeschels’ quotation (Froeschels 1952) that:

humans invented language by combining the various sounds they made while eating.

The main idea of the chewing approach is to make use of the more stable primary function of nutrition to stabilise the secondary function of phonation (communication). The process of chewing involves a very natural (a bit exaggerated) and free motion of the muscles of the jaw, tongue and pharynx. This method is structured on the functional relations between chewing and speaking (Froeschels 1952). The theoretical basis is considered rather speculative but in therapeutic practice has proven to be an appreciated relaxation tool for hyperfunctional phonation.

In the following the technical application is explained:

• 
  

  Fulsome, appreciative chewing (with a mouth full of biscuits)

  
  
• 
  

  Humming during chewing

  
  
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  Closed-mouth chewing: focused voice freed from articulation

  
  
• 
  

  Open-mouth chewing: phonation with slightly opened mouth

  
  
• 
  

  Meaningless and meaningful syllables during chewing

  
  
• 
  

  Joining [m] with [n]—[emenyem], [emenyam], [emenyim] and so on

  
  
• 
  

  Adding plosives: [kyam], [pyam], [tyam] and so on

  
  
• 
  

  Chewing with counting (auditory and visual feedback)

  
  
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  Chewing with speaking

  
  
• 
  

  Chewing with imagining speaking (skill-to-behaviour transfer)

Stretch and Flow Technique

Stretch and flow phonation focuses on airflow management and aims to lower the laryngeal resistance subglottal pressure and prevent breath-holding tendencies. The model incorporates five skill levels increasing the conscious awareness about the relations between breathing and phonation. Each skill is used in a hierarchy of anxiety-producing speaking situations (from sustained sounds to repeated words up to conversational speech) (Stone and Casteel 1982).

Application of the technique includes five skill levels as below:

• 
  

  Flow: control of airflow (blow without sound) encouraging patients to let unvoiced transglottal stable airflow (warm breath).

  
  
• 
  

  Stretch and flow (whisper): this skill uses unimpeded voiceless transglottal airflow and slow relaxed (stretched out) articulatory movements.

  
  
• 
  

  Phonate with stretch and flow: the parameter of voicing is added (gargling may be used to help) while maintaining stretched out sounds and airflow. Patients attempt not to hold their breath in conscious awareness.

  
  
• 
  

  Phonate and reduce stretch: reduced stretch and increased airflow aid in regaining a more appropriate rate and preventing hyperfunctional patterns.

  
  
• 
  

  Phonate and reduce airflow: fading the breathy voice quality is accomplished by asking the patient to hum or produce a louder voice without increasing extra effort.

The last step is the same as with the others, transferring the skill to behaviour.

Register Glide

Hyperfunctional voice behaviour generally affects modal (chest) register (see Sect. 4.​5). Fry register and falsetto register modes of phonation may stay free from the strained control patterns somehow. Fry register may be used for relaxation and maintaining a comfortably low laryngeal posture as a transient transfer phonation pattern by gliding the voice to modal register from the lowest pitches to the mid-range frequencies. Falsetto register, on the other hand, may also be used for relaxation of exaggerated downwards push of the vocal apparatus to the opposite side (Koufman and Blalock 1988).

Softening Glottal Attack

Glottal attack is crucial for managing hyperfunctional vocal behaviour. It is the conjunction moment of breath force and vibration. Several techniques can be used to soften, or rather balance, the glottal attack. Four types of attacks concerning breath can be distinguished (Fig. 8.2): the hard attack is a hyperfunctional uncontrolled resistive laryngeal behaviour. The breathy attack has a high prephonatory transglottal air leakage, whereas in soft attack this leakage is slightly more than effective but can be acceptable for most subjects. The most effective one is the balanced attack in which the glottal preset is similar to the one explained in resonant voice pattern (barely adducted).

Several methods may be used for balancing the glottal attack:

• 
  
  Phonating vowels with [h]
  

  
  

  
  
  • 
    

    Exaggerated [hhh] as in whisper.

    
    
  • 
    

    Add vowels [hhhaaa].

    
    
  • 
    

    Overdone [hhh] is faded while the patient learns to rely on kinaesthetic and auditory feedback to maintain improved voice, muscle balance and laryngeal positioning. This may be defined as the balanced attack by blending [h] with the vowel.

    
    
  • 
    
    Add words to the balanced attack:
    

    
    

    
    
    • 
      

      An easily pronounced keyword, which is a reminder of the intended vocal pattern, may be used to help skill-behaviour transfer.

      
      
    • 
      

      Word pairs (hot—out) may also be used to transfer the softened attack pattern.

  
  
• 
  

  Negative exercise: start with an overdone hard glottal attack, and make the patient feel the effects and kinaesthetic feedback consciously. This should be exercised for a short period, and then gradually diminish the strain to a balanced state.

  
  
• 
  

  Prephonatory pause: the patient pauses for 1 s and starts phonation afterwards. This may help to reduce prephonatory stress.

  
  
• 
  

  Gliding a sustained vowel to a lower note: some patients cannot lower the pitch to a more comfortable frequency. This will make it harder to soften the glottal attack. After having a moderate pitch, the patient terminates the phonation with a soft glottal damping. The soft termination of the vowel is succeeded by another vowel at the same breath ([aaaahhhaa]).

8.5.1 Introduction

Anyone interested in vocal health should also know something about singing and the singer’s voice, which includes visits to the opera, operetta, musicals, concerts, etc., as well as practical experience of vocal study. Professional interest is good, but a positive emotional appreciation is even better, if one truly wants to understand the world of singing and song and offer successful diagnosis and treatment. It is especially recommended to make contact with an opera house (including attending rehearsals), choir, music conservatory or other such cultural institution, as one can thus better gain experience in the responsibilities of phoniatrics and voice treatment. Of course, one’s clinical perspective and medical responsibility should not be neglected because of this appreciation.

It is self-evident that with singers, phoniatric responsibilities cannot be limited to exact collection of organic results. Rather, along with the indispensible voice assessment, it is necessary to take note of psychic and social circumstances, both professional and familial. There is an especially great risk to categorise singers fundamentally as emotionally unstable and not to take their complaints seriously. They are certainly accentuated in the sense of having ‘interesting personality structures’ and stronger emotional reactions than others; otherwise we wouldn’t want to experience them as artists. But the complexity of their complaints is almost always job-specific and only infrequently expresses itself in eccentric behaviour. Doctors’ lack of understanding of singers is often based on deficient professional competence, which is unfortunately all too often compensated for by inappropriate authoritarianism. Figures 8.3 and 8.4 mirror the arc of suspense between clinical and vocal issues.

8.5.2 Classical and Nonclassical Singing

Both categories of singing require their own understanding. Classical singing in the Western tradition (opera, oratorios, song/lied) must make do without electrical amplification, at least in opera houses and concert halls. The resonance capacity of the voice therefore plays an important role and must be rigorously built up over years of vocal technique study. This sound builds up (training of focus, placement, brilliance, ‘ping’, etc.) and creates the necessary resonance capacity of the voice to fill large halls and cut through an orchestra or choir. The classical style of singing is more a physiological category than an aesthetic one, which was developed later, or possibly simultaneously. The classical singer must sing as she or he does to survive. So, it can’t be discounted as ‘old-fashioned’ when the goal is to achieve a full, clear, resonant and flexible voice, resilient enough also to be able to sing large roles without difficulty. Moreover, certain aesthetically informed vocal techniques necessitate this production, namely, coloratura, messa di voce, trills, register, vowel blending, etc., such that vocal health is probably, but not absolutely, connected with this technique, because even the best technique cannot protect from illness, singing too often, too loud, too long or too high when the constitutional preconditions are not sufficiently observed. A full (i.e. not breathy) and clear (i.e. not rough) voice must always be the goal of all therapeutic efforts in the classical area.

In nonclassical singing, especially in pop music, these technical characteristics are not similarly required, since the voice sound is amplified by electronic equipment. Pop voice technique works to achieve a very different sound, one that is often hoarse or even pressed and screamed. From a medical perspective, it is somewhat problematical to accept hoarseness as a means of artistic expression, since it must generally always be taken seriously as a sign of illness. But questions of aesthetics are outside the realm of medical competence. The solution is to clarify a diagnosis of persistent or increasing hoarseness as soon as possible and to observe and resolve a possibly established psychological stress. When the vocal hyperfunction that often goes hand in hand with high breath pressure, marked laryngeal and vocal fold tension and forced declamation is often or exclusively used (as in pop singing), it can quickly become very dangerous for the voice. The voice is not necessarily damaged by gentle, short and controlled use of effects such as scream, rattle, growl, grunt, creak, vocal break, aspiration, etc. as long as these special vocal effects are only temporary.

‘Belting’, the specific means of expression used by singers, is assessed differently regarding possible vocal damage. By emphasising a calling voice function especially in the high register, the vocal strain of this sound production is less than with emphasis of declamation in the low register (chest register in women), where this sound production is only finitely possible. One must always bear in mind that constitutional predispositions are non-uniform. What one person is able to maintain effortlessly over longer periods of time in hyperfunction soon brings another singer to serious and chronic vocal damage that eventually even requires the singer to give up singing. A chronically hoarse voice that can only be produced with enhanced effort, effectively only hollering or screaming and thereby devoid of all flexibility, should better undergo intensive diagnosis and therapy than continue to be presented on stage as an artistic achievement. Gaining basic phoniatric knowledge of singing implies that every interested person should audit or even take multiple voice lessons themselves, preferably at a music school or conservatory. Only thus is it possible to understand the methods of voice teachers, who often work with strong emotions, expressive impulses and fantasy-rich metaphors and similes—unusual tools for doctors. The ends justify the means! In any case, one will realise that teaching of singing is intense work that requires much patience and that should be treated with respect. It is especially interesting to get to know the differences between classical and nonclassical singing in this way. And you should definitely try singing in a choir!

8.5.3 Phoniatric Findings

In addition to detecting illness, phoniatric examinations also serve to clarify questions and problems related to singing and vocal pedagogy. Sometimes it is about judging the qualifications for voice training, or it is simply an estimation of the person’s ability for specific professional jobs. Both organic and functional test results should be taken into consideration. The principal mistake lies in overvaluing the organic findings and not seeing them in relation to the functional abnormalities, whereby functional findings do not include only the vocal fold movements but most importantly the voice sound. Balancing this relationship is especially necessary for determining the need for surgical intervention and for making far-reaching decisions in regard to actual singing engagements, as well as future professional responsibilities. The flippantly uttered observation ‘Your vocal folds aren’t inflamed – you can sing’ should be a thing of the past.

Inherently, a carefully compiled medical history, a thorough stroboscopic examination and the perceptive auditory assessment of spoken and sung voice all take precedence over instrument-based procedures, which may be of additional importance. However, it would be a serious mistake to send singers first to a voice laboratory in order to obtain an ostensibly objective result and only later to make personal contact with them.

8.5.4 Vocal Medical History

A precise medical history is absolutely necessary for all singers. It should be an insightful consultation without any time pressure that, in addition to answering specific vocal questions, also builds trust. Of course, this goes more quickly in the case of acute complaints than it does with persistent functional disorders (e.g. dysodia) that require a very thorough examination. The vocal development must sometimes even be traced back to childhood (including the age of mutation), and the course of vocal studies must often also be scrutinised. Career-specific questions (choir? solo? career development? career setback? etc.) must include psychological and social particulars. In children with vocal damage, it is especially interesting to note if the hoarseness developed from a possible strain of the voice by excessive singing or through repeated and loud speaking or even screaming. A general medical history, together with an ENT medical history, provides a full picture of the vocal abnormalities. During the consultation, one should pay attention to voice sound, speech and manner of expression, as well as the accompanying movements (facial expressions, gestures).

8.5.5 Laryngostroboscopy

For diagnosing singers, magnifying optics and vibration analysis of the vocal folds, such as with rigid laryngostroboscopy, are indispensible. The simple laryngeal mirror is not sufficient and is only of historical interest in questions involving singers. After all, it is about obtaining a very precise assessment, especially of the moving edges of the vocal folds and of the vocal fold closure in relation to pitch and volume. Discrete changes, such as local or diffuse production of mucus (‘fatigue, catarrh’, noninflammatory), increased vessel visibility and functional phonation-induced vocal fold thickenings (‘functional nodules’, i.e. thickening of the mucous membranes just before vocal fold closure but not in respiratory position), must also be recognised, precisely diagnosed and put into relation with the voice findings. For repeated and comparative assessments, it is advantageous to use the possibilities of a digital image storage system systematically. It is obvious that a careful examination of the vocal tract must also be conducted, since pathological findings in this area could significantly impair singing.

8.5.6 Voice Assessment

The auditory assessment of the voice must take speech (unstressed in common speech or reciting numbers, stressed in a calling voice) as well as singing, both natural (song, aria) and experimental (exercises), into account. The assessment of the speaking voice can follow the RBH system, (roughness, breathiness, hoarseness) whereby additional amounts of stress, sonority and nasality are informative. Assessment of singing and singers needs special knowledge regarding specific singer-related abilities and skills, which might require a consultation with a voice teacher in certain circumstances. The documentation can take place through audio recordings (text, songs or arias) or additionally through the measurement of spoken and sung voice range profiles.

8.5.7 Dysodia

The functional disorder of the singing voice is called dysodia. It can manifest as hoarseness, but also as decreased vocal capacity (quickly fatigued, lengthy recovery), or as a reduction of certain vocal skills. What previously functioned effortlessly in terms of vocal technique now presents problems. Unfortunately, the symptoms are often falsely assessed, since important factors that could interfere with singing are either not acknowledged or taken seriously. Numerous internal and external influences that are often confluent or mutually influential can be the cause of this. Sometimes the decisive factor causing the disorder first comes to light in the course of repeated consultations or in a treatment. Among the more common causes are insufficient constitutional condition, overstress from singing or speaking, psychological factors and general inefficiency or low resistance to infection. Watch for the following: excessive demand from exhausting rehearsals, too many performances with too little rest in between or, what is also common, too short or insufficient training and wrong voice type classification. Singing too much in the upper voice range and forcing a more dramatic sound in particular lead to voice disorders. The symptoms and findings may reflect subtle singing functions. For example, the voice doesn’t respond easily enough, pathological onsets occur more frequently, and piano (soft or quiet) singing is disturbed. The pitch range is reduced, and high, loud notes can only be reached with increased force. Even changes in the voice sound are possible, including a rough or breathy voice. Dullness and paraesthesia in the throat area are symptoms that must be taken seriously. In the case of specific complaints, such as difficulty in changing register, changes in vibrato or intonation problems, a voice teacher with physiological knowledge should be asked to consult. Attempts to compensate for diminished vocal ability are audible and also observable as muscular hyperfunction, especially as hypertension in the neck area, and as reflexive movements and gestures and accompanying physical movements. The treatment should be implemented causally and in certain circumstances must also intervene in the professional situation. The complaints and symptoms can often be traced to a voice technique that has been neglected for a long period of time. In this case, a systematic retraining under the direction of a competent voice teacher is strongly recommended. This also provides the opportunity to check the voice classification and possibly correct it. Speech therapy exercises only seem to make sense when there is already a certain competence in singing and the singer’s voice.

8.5.8 Voices at Different Ages

Singing disorders in childhood, during puberty, in menopause and in advanced age require special diagnostic and therapeutic tools. For example, vocal rest for set periods of time is no longer recommended during voice change, since the effects of puberty can be mitigated or shortened through gentle voice use under the supervision of an experienced voice teacher. Menopause-induced voice problems often occur less frequently when vocal technique and a healthy lifestyle are maintained. Phoniatricians should also be able to help older people to sustain choir singing as an important part of their life.

8.5.9 Emergency Treatments for Singers

Phoniatric emergency treatments are almost exclusively provided to professional singers and require a basic knowledge about the upcoming artistic performance. The most common causes are head cold infections and vocal overuse (e.g. dysodia, which can lead to sudden stress-related weakness or even loss of certain vocal abilities). The earlier the treatment can begin, the less ‘drastic’ the measures required—in which case a close collaboration with the artistic institutions involved (e.g. theatres, arts presenters, agents, etc.) can be helpful.

Regarding the medical history, the patients themselves can be quite helpful, since they know their own abilities and available resources better than anyone and seldom exaggerate. On the other hand, they usually want to sing and rather tend to underestimate the problem and overestimate their ability. The current work situation, the difficulty of the role to be sung and the singer’s current condition should all be considered in the therapeutic diagnosis.

In addition to a careful physical assessment, which is required for a complete ENT status and which cannot be limited to the larynx, it is essential to analyse briefly the sound of the speaking and singing voice. Even when a magnifying laryngostroboscopy must be performed in order to achieve an exact diagnosis of the vocal folds, the condition of the mucous membranes in the nasal and oral cavity must also be assessed, since swelling, excess mucus, paraesthesia and the after-effects thereof can also significantly restrict singing or even render it impossible. Non-inflamed vocal folds are not sufficient for professional singing! After all, distinct abnormalities in vocal fold oscillation or dry mucous membranes can cause significant discomfort. In the case of secondary organic alterations to the vocal folds (‘nodules’) or menstruation-related changes, larger roles should not be sung. It is especially dangerous to sing a large and heavy role when there are signs of inflammation, however insignificant.

When considering possible therapies, one must consider whether the singer will be able to sing the role in its entirety, if the performance would potentially have to be interrupted and whether or not performing is likely to cause long-term vocal damage. Ultimately, our medical responsibility is for the singer’s vocal health and not for a theatre’s performance schedule! An expert consultation, possibly with the participation of an experienced vocal pedagogue, together with an intense but mild anti-inflammatory treatment, vocal rest (without silent participation in rehearsals!) as well as agreements with the artistic administration are more important than the (mostly questionable) use of antibiotics or intravenous/oral corticoid applied as a ‘safety chute’. These injections are certainly overrated and are usually an expression of helplessness when faced with acute singing-related problems. The exception proves the rule. The well-known laryngeal injection, by which an anti-inflammatory substance (usually an essential oil) is suddenly injected into the interior of the larynx by means of a blunt cannula, can only be valued as a kind of ‘psychotherapeutic’ surprise attack. The precipitously applied medicine is usually roughly coughed up, whereby no therapeutically significant dose actually reaches the vocal folds. If it is not possible to save a performance despite medical treatment, it is sometimes possible and even acceptable to use a double as an emergency solution. The role can be sung from the orchestra pit or the side stage by a vocally healthy singer, while the sick singer performs silently on the stage.

More information can be found in the books by Seidner and Wendler (2010), Dayme (2009), Nair (2007), Richter (2013), Sataloff (2005) and Sundberg and Mecke (2015).

8.6.1 Introduction

In such cases, the attending physician is usually and optimally a phoniatrician, as the voice specialist assumes a high degree of responsibility (Seidner 2004; Flach 1992).

It is the specialist’s duty to protect the singer affected by a disorder from additional damage that could have a serious impact on the singer’s further career. The specialist must also devise an effective treatment concept that will enable the patient to make full use of his voice within the shortest possible time (Seidner 2004; Schlömicher-Thier and Weikert 2003).

Unduly prolonging vocal rest as a matter of precaution risks unnecessary cancellations, involving potential sizable financial loss and even possible loss of future contracts for the singer. On the other hand, inadequate vocal rest can constitute a great danger. Finding the optimum variables in such cases requires considerable sensitivity and composure. The primary focus of this section is to report and discuss the general situation of singers and speakers in opera houses (from Regensburg and Salzburg). The data were obtained from two retrospective studies by the authors in the Austrian Voice Institute. These investigated the occupational situation of singers and actors in the theatres/festival house and music academies of Salzburg (Austria) and Regensburg (Germany). In this section we have used the masculine form of address to include both sexes but regard both female and male singers and voice users with the same degree of respect and appreciation.

8.6.2 Voice Problems

Vocal problems hinder professional training or have consequences in the leisure time activity of choir singing; absence from choir rehearsals and choir performances results in personal distress. It does not, however, result in any financial loss.

This section of cancellation policy will focus on the professional voice user in Level I.

During the examinations 1–4, a comprehensive auditory and kinaesthetic assessment of the artist’s speaking and singing voice was undertaken (Richter 2013; Sataloff 2005; Wendler et al. 2005; Rubin et al. 2006; Schneider-Stickler and Bigenzahn 2013).

8.6.3 Evaluation of Professional Singers and Speakers

In an examination period extending from 1996 to 2001, we evaluated 512 singers and speakers of both genders according to the vocal usage classification system by Koufman and Isaacson (1991). Figure 8.5 represents Level I elite vocal performers, and Level II represents semi-professional voice users, i.e. singing and acting students (Level I, see yellow bar; Level II, see blue bar).

The data were split into six categories of complaints: acute, chronic, functional, psychogenic, reflux and organic. This terminology follows Sect. 4.​2 by using terms which, while they may not coincide with other modern usages of the respective vocabulary, reflect the terminology used for malregulative dysphonia. It should further be noted that for reasons of data availability, in this evaluation (see Fig. 8.5), ‘psychogenic dysphonia’ denotes an independent entity on the same level as, and not constituting, a subgroup of regulatory dysphonia.

8.6.4 Interpretation

The diagnoses were evaluated according to the classification system by Koufman and Isaacson (1991). In these comparisons, the singers and speakers are listed without distinguishing by gender. The statistical evaluation sought to address whether there is a difference in vocal fold dysfunction complaints between the four levels of the vocal usage classification system.

In conclusion, it can be stated that elite performers do not have problems in the categories ‘functional’ or ‘psychogenic’, thanks to their competence developed by consistent professional voice training. They may, however, suffer from other types of occasionally severe complaints, especially of acute problems such as laryngitis caused by the common cold, vocal fold bleeding and oedema caused by allergic rhinitis or by premenstrual voice syndrome and phonation thickenings caused by overuse of the voice. These can have serious consequences, even including the cancellation of the performance.

8.6.5 Cancellation Policy: What Should It Achieve?

Good cancellation policy should ensure that the audience, the artist/singer and the directorship enjoy a successful performance. The vocal specialist serves as a mediator between the singer and the directorship of the opera house or festival. In a circumspect approach, he needs both sides, the artist and the directorship, to trust him, in order to apply his medical expertise and protect the singer’s well-being. Only if the vocal specialist and the directorship collaborate with the singer’s well-being in mind will it be possible to achieve an individualised, tailored solution suitable for the stage as a workplace and, finally, to satisfy the audience optimally.

Case Study 8.1

During a rehearsal, a 47-year-old mezzo-soprano suddenly lost her voice and sought consultation. She was cast in two roles during the summer festival, one in a Mozart opera and the other in a modern opera (Le Grand Macabre) by Ligeti. Rehearsals were just starting for the premieres 3 weeks later. She had been taking about 1000 mg of aspirin daily for repeated migraine attacks. A  video-stroboscopic examination showed a vocal fold haematoma with a polypoid swelling on the left side (Fig. 8.6). The singer agreed that her manager should be informed. The therapy consisted of prednisolone in decreasing doses, Bromelain POS and inhalations. After a vocal rest of 10 days, the haematoma disappeared, but the polyp was still visible on the left side. The question was then whether the singer would have to cancel her appearances in both operas or whether she could still sing the Ligeti. It was recommended that the patient should try some cautious warm-up exercises over a few hours and then an aria from the Ligeti opera. That afternoon, she sang the Ligeti aria, which required nothing above the middle register. She managed it beautifully. It was decided by the vocal specialist that she should sing the Ligeti role, but not the Mozart, which had a much higher tessitura. Thus, at least half the fee was saved.

Cancellation means that the affected artist does not perform on a particular day/evening or perhaps even on subsequent days. The artist needs an official confirmation of work disability for both the employer and the insurance company. The theatre management must prove that the financial damage was caused as a side effect by the cancellation of performances in each individual case.

Often a cancellation is the result of anxiety and uncertainty. If decisions are made in haste and without proper vocal medical assessment, considerable financial loss can result for both the opera house and the artist. This is the reality in many opera houses in the world because the staff and management do not have the courage to explore other options of changing or maintaining a performance. Often the reason is simply that there is no vocal specialist and no phoniatrician in the opera house. The aim of this section is to show a useful arrangement for cancellation, with the goal of not burning out the artist.

A cancellation policy needs the mutual appreciation of artists and theatre management by using vocal medical procedures (Schlömicher-Thier and Weikert 2015).

8.6.6 Absolute Indications for Cancellation

Furthermore, there are indications without direct laryngeal-phoniatric causes that have a negative impact on voicing and voice control, forcing the artist/singer to cancel the performance. These include:

• 
  

  Acute intravertebral disc prolapse with pain and moving problems such as knee or hip pain because of a sloping stage (Fig. 8.7).

  
  
• 
  

  Acute gynaecological illness with haemorrhage, problems of pregnancy and urogenital inflammations, such as adnexitis with pain, fever and strong restriction of movement. These patients need bed rest.

8.6.7 Relative Indications of a Possible Cancellation, Perhaps with Alteration of Performance

These include:

• 
  

  Slight irritations after recovery time of 1 week

  
  
• 
  

  Successful anti-allergic treatment, i.e. decrease of oedema of the vocal folds

  
  
• 
  

  Tonsillitis and pharyngitis without irritation of the vocal folds, by successful treatment with antibiotics

  
  
• 
  

  Subacute reflux laryngitis LPR: laryngopharyngeal reflux can trigger a severe laryngitis and should be treated by proton-pump inhibitors and dietary restrictions

  
  
• 
  

  Prenodal condition (a tendency to thickening of the vocal folds) of female singers, e.g. at the time of premenstruation, when there is the beginning of acute vocal fold oedema, causing glissando to be restricted (Fig. 8.8)

Case Study 8.2

A professional soprano, with a marginal oedema on the left vocal fold (Fig. 8.9), could get through the concert. The messa di voce (a singing technique using crescendo and decrescendo—louder and quieter—singing of a tone) was possible, but the glissando (smooth change in pitch over the individual’s pitch range) was restricted. Nonetheless, her voice functioned reliably during the performance time of 4 weeks. After the production, she was treated by subsequent voice rest, medication and MLS—phonosurgery was scheduled.

What are the criteria for the final decision of relative to absolute indication of a cancellation?

Absolute indication causes the definite cancellation of performance as a rule. Relative indication means that additional time must pass before a final decision, typically 2–3 days of vocal rest. Changes to the rehearsal schedule and the modalities of the performance can and should be considered, even at an earlier stage.

8.6.8 Responsibility of Vocal and Performing Arts Medicine in the Opera and Stage

The case studies above reinforce the important function of the voice specialist. It is the specialist’s primary concern to protect his patients as well as retain their trust. He must also act as a mediator between singers and management of the opera house or festival, striving to gain the confidence of both sides. Thus, he has to make as precise an estimate as possible of the patient’s condition and the amount of vocal rest needed before the next performance. Overprotective ‘safety advice’ at every incipient infection (‘Better stay at home for a week, and then we’ll see how you’re doing’) only causes both sides to lose out: the singer loses his fee and the festival has to pay for a replacement. Only if both sides—doctor and management—collaborate in the best interests of the indisposed singer is it possible to rearrange rehearsal schedules. One possibility is for a ‘standby’ to sing from the orchestra pit while the indisposed singer acts out the complicated movements on stage. It is also important for the doctor to inform the artistic director as soon as possible—even if it is midnight—that a standby may be required. The burden of responsibility no longer rests with the singers, and the management gains time. In such cases, the physician in attendance assumes a high degree of responsibility: it is the specialist’s duty to protect the singer affected by the disorder from additional harm, which might endanger the singer’s further career (Seidner 2004; Flach 1992). He must also devise an effective concept of treatment that will enable the patient to make full use of his voice again within the shortest possible time. Any unduly prolonged precautionary vocal rest results in unnecessary cancellations, involving the risk of financial loss for the singer and endangering further contracts.

The motto here is ‘Save the singer’s fee, but avoid health risks’.

8.7.1 Introduction

People suffering from voice disorders are also very often affected by musculoskeletal disturbances, especially those of the muscular-fascial-ligamentous system. Therefore, to address dysphonia-related disorders and dysfunctions in the region of the musculoskeletal system effectively, a particular stress should be placed on the role of the physiotherapist and osteopath in a specialised team delivering diagnosis and therapy of vocal disorders.

When treating voice disorders, special emphasis is placed on relieving musculoskeletal tension, which particularly occurs with hyperfunctional dysphonia. Excessive extrinsic laryngeal musculature causes a pathological elevation of the larynx by shifting it upwards towards the hyoid bone. This changes phonation within the vocal tract, especially the length, tension and flexibility of the vocal folds. The tension disturbs phonatory vibration adversely, affecting the quality and capacity of voice (Marszałek et al. 2012; Van Houtte et al. 2011). For this reason a local and global pathology needs to be assessed in the cervical soft tissue, particular joints of the cervical spine and the larynx, so that a customised therapy may be applied aimed mainly to relieve musculoskeletal tension.

It needs to be underlined that a physiotherapist/osteopath should be trained in the aetio-pathogenesis and management of occupational voice disorders and cooperate closely with other specialists in the voice disorder therapy team. Physiotherapeutic treatment is more general, based mainly on local and global exercises and on motor learning. Osteopathic treatment is based on precise palpatory skills and on precise manual treatment.

8.7.2 Physiotherapeutic and Osteopathic Diagnosis in Patients with Voice Disorders

8.7.3 Physiotherapeutic and Osteopathic Therapy of the Vocal Organ

Physical therapy involves manual therapy of the muscles and fascial structures of the neck and nape and is complementary to phoniatric treatment and voice therapy. Correct measures taken by a properly trained physiotherapist/osteopath will allow the normalisation of function of the cervical spine, muscles of the trunk, neck and larynx, thus improving the quality of voice in patients affected with vocal disorders, especially those with hyperfunctional dysphonia.

8.7.4 Basic Tenets of Therapy for People with Voice Disorders Resulting from Oncological Treatment

Following cancer treatment, the musculoskeletal system is heavily affected by postsurgical or postradiation scars, tissue adhesions and radiotherapy-related tissue fibrosis. These can directly or indirectly affect the phonatory function. This usually occurs following a cancer treatment in the head and neck region involving surgery with adjuvant radiotherapy or primary radiotherapy and particularly so if the treatment is directly related to the larynx (total or partial removal of the larynx) or to the cervical lymph system, maxillary-ethmoidal massive region, mouth or salivary glands. Physiotherapy should take into account the resulting structural disorders and related dysfunctions, which tend to reduce the phonatory capabilities of the larynx and muscles responsible for phonation and articulation. Respiratory disorders, increased muscular tension and limited physical performance are often observed after a long-lasting cancer therapy associated with strong pain and restricted physical activity. These factors are significant contributors to the development of voice disorders. Physiotherapy in such cases is aimed at restoring the lost mobility and activity of particular anatomical structures directly associated with phonation and articulation. Such therapy is designed to improve the disturbed mobility and fitness of the tongue muscles, mouth floor (oral cancer), facial muscles (cancers of the parotid gland) and muscles of mastication responsible for trismus (cancers of the maxillary-ethmoidal massive). In the case of patients who have had their larynx entirely removed and who do not use any voice prosthesis, a physiotherapist should reduce the increased soft tissue tension in the region of the surgical field and the nape. This will allow the superior pharyngeal constrictor muscle and inferior constrictor muscle of pharynx to be released while facilitating the aspiration of air into the oesophagus and production of oesophageal speech.

Physiotherapy in cancer patients with voice disorders should be conducted in parallel with voice therapy.

8.8.1 Drug Treatment in Dysphonia

8.8.1.8 Medical Treatment in Neurological Conditions

Spasmodic Dysphonia

This is an idiopathic focal dystonia of the larynx that affects the fluency of connected speech. The standard treatment of spasmodic dysphonia (SD) is intramuscular injections of botulinum toxin. The thyroarytenoid-lateral cricoarytenoid muscle complex is injected in adductor SD, while the posterior cricoarytenoid muscle is the target for abductor SD. Botulinum toxin causes a temporary paralysis of the injected muscle (Blumin and Berke 2007; Rosen and Simpson 2008a; Sulica 2004).

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