Figure 4–1. Video print obtained from a strobovideolaryngoscopic examination shows diffuse erythema from acute laryngitis. Additionally, there is a left sulcus vocalis. Also visible is an ecstatic vessel on the superior surface of the left vocal fold (straight arrow). (Figure 40–1 from Sataloff RT et al.⁴)

Infectious laryngitis may be caused by bacteria or viruses. Subglottic involvement frequently indicates a more severe infection, which may be difficult to control in a short period of time. Indiscriminate use of antibiotics must be avoided; however, when the physician is in doubt as to the cause and when a major voice commitment is imminent, vigorous antibiotic treatment is warranted. In this circumstance, the damage caused by allowing progression of a curable condition is greater than the damage that might result from a course of therapy for an unproven microorganism while culture results are pending. When a major concert or speech is not imminent, indications for therapy are the same as for the nonsinger or nonprofessional speaker.

Voice rest (absolute or relative) is an important therapeutic consideration in any case of laryngitis. When no professional commitments are pending, a short course of absolute voice rest may be considered, as it is the safest and most conservative therapeutic intervention. This means absolute silence and communication with a writing pad. The patient must be instructed not to whisper, as this may be an even more traumatic vocal activity than speaking softly. Whispering through the lips also involves vocal fold activity and should not be permitted. The playing of many musical wind instruments also should not be permitted. Absolute voice rest is necessary only for serious vocal fold injury such as hemorrhage or mucosal disruption (Figure 4–3). Even then, it is virtually never indicated for more than 7 to 10 days. Three days are often sufficient. Some excellent laryngologists do not believe voice rest should be used at all. However, absolute voice rest for a few days may be helpful in patients with laryngitis, especially those gregarious, verbal singers who find it difficult to moderate their voice use to comply with relative voice rest instructions. In many instances, considerations of finances and reputation mitigate against a recommendation of voice rest. In advising performers to minimize vocal use, Punt counseled, “Don’t say a single word for which you are not being paid.”⁴ This admonition frequently guides the ailing singer or speaker away from preperformance conversations and backstage greetings and allows a successful series of performances. Patients should also be instructed to speak softly and as infrequently as possible, often at a slightly higher pitch than usual; to avoid excessive telephone use; and to speak with abdominal support as they would in singing. This is relative voice rest, and it is helpful in most cases. An urgent session with a speech-language pathologist is extremely helpful for discussing vocal hygiene and in providing guidelines to prevent voice abuse. Nevertheless, the patient must be aware that some risk is associated with performing with laryngitis even when performance is possible. Inflammation of the vocal folds is associated with increased capillary fragility and increased risk of vocal fold injury or hemorrhage. Many factors must be considered in determining whether a given speech or concert is important enough to justify the potential consequences.

Steam inhalations deliver moisture and heat to the vocal folds and tracheobronchial tree and may be useful. Some people use nasal irrigations, although these have little proven value. Gargling has no proven efficacy, but it is probably harmful only if it involves loud, abusive vocalization as part of the gargling process. Some physicians and patients believe it to be helpful in “moistening the throat,” and it may have some relaxing or placebo effect. Ultrasonic treatments, local massage, psychotherapy, and biofeedback directed at relieving anxiety and decreasing muscle tension may be helpful adjuncts to a broader therapeutic program. However, psychotherapy and biofeedback, in particular, must be expertly supervised if used at all.

Voice lessons given by an expert teacher are invaluable. When technical dysfunction is suggested, the singer or actor should be referred to his or her teacher. Even when an obvious organic abnormality is present, referral to a voice teacher is appropriate, especially for younger actors and singers. Numerous “tricks of the trade” permit a voice professional to overcome some of the impairments of mild illness safely. If a singer plans to proceed with a performance during an illness, he or she should not cancel voice lessons as part of the relative voice rest regimen; rather, a short lesson to ensure optimal technique is extremely useful.

Sinusitis

Chronic inflammation of the mucosa lining the sinus cavities commonly produces thick secretions known as postnasal drip. Postnasal drip can be particularly problematic because it causes excessive phlegm, which interferes with phonation, and because it leads to frequent throat clearing, which may inflame the vocal folds. Sometimes chronic sinusitis is caused by allergies and can be treated with medications. However, many medications used for this condition cause side effects that are unacceptable in professional voice users, particularly mucosal drying. When medication management is not satisfactory, functional endoscopic sinus surgery may be appropriate.⁵ Acute purulent sinusitis is a different matter. It requires aggressive treatment with antibiotics, sometimes surgical drainage, treatment of underlying conditions (such as dental abscess), and occasionally surgery.⁵

Lower Respiratory Tract Infection

Lower respiratory tract infection may be almost as disruptive to a voice as upper respiratory tract infection. Bronchitis, pneumonitis, pneumonia, and especially reactive airway disease impair the power source of the voice and lead to vocal strain and sometimes injury. Lower respiratory tract infections should be treated aggressively, pulmonary function tests should be considered, and bronchodilators (preferably oral) should be used as necessary. Coughing is also a very traumatic vocal activity, and careful attention should be paid to cough suppression. If extensive voice use is anticipated, nonnarcotic antitussive agents are preferable because narcotics may dull the sensorium and lead to potentially damaging voice technique.

Tonsillitis

Tonsillitis also impairs the voice through alterations of the resonator system and through technical changes secondary to pain. Although there is a tendency to avoid tonsillectomy, especially in professional voice users, the operation should not be withheld when clear indications for tonsillectomy are present. These include, for example, documented severe bacterial tonsillitis 6 times per year. However, patients must be warned that tonsillectomy may alter the sound of the voice, even though there is no change at the vocal fold (oscillator) level.

Lyme Disease

Lyme disease, as it is known today, has been reported for over a hundred years, but the bacteria responsible for the disease was not identified until 1982. It was discovered in Lyme, Connecticut, when a group of children contracted arthritis inexplicably, and research was initiated to identify the cause.⁶ Due to its ability to appear similar to many other diseases and its wide range of nonspecific symptoms, Lyme disease often goes undiagnosed. If not recognized and treated, this condition can have profound consequences including damage to the inner ear, the 8th cranial nerve, and the facial nerve as reviewed by Sataloff and Sataloff (from which a portion of this section has been modified, with permission)⁷. It can also affect laryngeal mewes.

Lyme disease is one of many common illnesses that can cause special problems for singers and other voice professionals. Lyme disease is an increasingly prevalent infection in many parts of the United States and elsewhere. It can affect the larynx directly by causing unilateral or bilateral vocal fold paresis/paralysis or interfere with other parts of the vocal tract by causing joint pains that impair posture and support, temporomandibular joint pain that leads to technical changes, and in other ways.⁸ It is important for singing teachers and singers to be familiar with this common problem in order to improve the chances of prompt diagnosis and treatment.

Epidemiology

In the United States, Lyme disease is known to be endemic particularly in northeastern, mid-Atlantic, and north-central states, with recent expansion into some parts of the southwest.⁹ Approximately 60% of initial infections occur during the summer, when it’s warm and people are outside.¹⁰ Lyme disease has no sex or age predilection.

Etiology

Lyme disease is an illness caused by a spirochete infection. Like syphilis, another spirochete infectious process, the clinical presentations may vary. Sir William Osler once termed syphilis “the great imitator,” and likewise, Lyme disease has a broad clinical spectrum.

Lyme disease had many different names given to it until Steere, in 1977, recognized it as a multistage systemic disease.¹¹ In 1982, Burgdorfer et al isolated the infectious organism from the belly of a tick, while studying a group of children in Lyme, Connecticut, with unexplained arthritis.¹² He named this spirochete Borrelia burgdorferi. Borrelia burgdorferi is the primary cause of Lyme disease. However, Borrelia garinii and Borrelia afzelii also had been implicated and reported as common causes of Lyme neuroborreliosis in Europe.¹³ Many different vectors have been listed as contributors to this disease. However, the tick seems to be the main culprit transmitting the spirochete. In the Northeast, the tick Ixodes dammini is the most common, and in the West, Ixodes pacificus has been named.⁹ The ticks carry the disease in their stomachs and transmit it while feeding on the blood of their victims which can take up to 2 days. In many cases, the ticks are noticed and removed or washed away before the disease can be spread; but sometimes a tick is small enough to avoid notice. Even when definitive symptoms occur, the tick often is not found, and the classic target rash may have been absent or gone unnoticed, as well. Therefore, the opportunity for early diagnosis often is missed, and many people carry Lyme disease into later stages of the disorder, during which nerve and vascular problems can occur, before the condition is diagnosed.⁷

The tick life cycle has 3 stages: larva, nymph, and adult.¹¹ In each stage the tick acquires a blood meal and may obtain the spirochete from an infected host such as the white-tailed deer or white-footed mouse.

The exact nature of injury to the human is not known, but evidence exists for 3 possible mechanisms. These theories include direct invasion, immunological attack, and vasculitis.¹⁴

Otolaryngologic Findings

The clinical spectrum of Lyme disease is broken down into 3 stages. In stage 1, a rash named erythema chronicum migrans follows the tick bite in 6% to 80% of cases.¹⁵ The rash has an outer red circular or oval border with a clear central area. These lesions have led to the term “target rash.” The outer red zone is felt to represent the best area for biopsy when trying to isolate the organism for culture. This rash may follow or precede cold or flu-like symptoms. The rash usually occurs within a few days of the tick bite but may show up as long as a month later.¹⁶

Other symptoms during this stage include fatigue, fever, chills, sore throat, headache, cough, chest pain, abdominal pain, muscle aches, loss of appetite, dizziness, lymphadenopathy, backache, conjunctivitis, enlarged liver and spleen, arthritis, and low-grade fever.

The patient usually calls on an otolaryngologist during stage 2 of Lyme disease. Although facial paralysis is the most common complaint in these patients, other symptoms may occur.^10,17 Patients may have symptoms such as hoarseness from involvement of the recurrent laryngeal nerve or inability to sustain a high note or project the voice due to injury to the superior laryngeal nerve. In 1988, Schroeter reported a case of a 45-year-old singer who developed a left vocal fold paralysis and had positive antibodies to Borrelia burgdorferi.¹⁸ The patient was treated with antibiotics for 6 weeks, during which time there was resolution of the vocal fold paralysis and dramatic reduction of the Lyme titers.

Stage 2 also may include a skin lesion called lymphadenosis benigna cutis. This lesion has another name, Borrelia lymphocytoma, and is characterized by lymphocytic infiltration of the dermis or subcutaneous tissue.¹⁹ The lesion has a blue-red color with gross swelling.

Patients may have involvement of the temporomandibular joint and complain of ear pain or pain when chewing. Other joints may be involved, such as the neck, knees, hips, shoulders, ankles, or elbows.

Patients also may have involvement of the cardiovascular system and may develop arrhythmias and/or lightheadedness. Failure to recognize any of these lesions may lead to increased morbidity and possible death.

Another skin lesion is seen in stage 3 of Lyme disease. It is termed acrodermatitis chronic atrophicans.¹⁹ This lesion usually is seen in elderly patients and is often misdiagnosed as scleroderma or vascular insufficiency.

Diagnosis and Treatment

The ELISA test is the most sensitive and is used widely for Lyme disease.¹⁴ Western blot technique is used to confirm the diagnosis. Other assays such as immunofluorescence antibody and cultures have been utilized with varying success. Results of all of these studies vary from lab to lab, and blood samples should be sent to labs that do large volumes of testing and have experience. The IgM antibody is seen early and is less specific. However, it is useful when reinfection or reactivation is suspected. The IgG may take 6 weeks to appear and is good for assessing stages 2 and 3. False-positive tests occur in patients with mononucleosis, syphilis, or rheumatic fever.^9,14 False-negatives may be seen in patients on antibiotics or patients who are immunocompromised by diseases such as cancer or AIDS.

Antibiotics are the recommended treatment. For adults, doxycycline or tetracycline is effective. When intolerance to these medications is encountered, amoxicillin is used. Amoxicillin is preferred in children. Chloramphenicol may be used with allergy to cephalosporin or penicillin. When resistance to these medications is found, intravenous medication such as ceftriaxone is used. Lyme disease is complex; with proper recognition it is treatable and has an excellent prognosis.

Autoimmune Deficiency Syndrome (AIDS)

AIDS is a lethal disease that is becoming more and more common. Its incidence in the artistic community is probably somewhat higher than in the general public. Physicians should consider this diagnosis along with other causes of chronic debilitation and recurrent infections in the proper clinical setting in professional voice users. Dry mouth and hoarseness are common complaints in patients with HIV infection. Candida infection of the oral cavity or tracheobronchial tree should make the clinician particularly suspicious. When fungal infections are encountered, particularly fungal laryngitis, it is important not only to treat the infection, but also to rule out serious predisposing causes such as HIV infection and other conditions that suppress the immune system. Recurrent respiratory tract infection and infection with unusual organisms also raise one’s suspicions, but it should be remembered that infections with Haemophilus influenza, Streptococcus pneumonia, and common viruses are the most frequent pathogens in HIV-infected patients, just as they are in patients without HIV. Acute infectious laryngitis and epiglottis may occur in AIDS patients, but they are less common than mild chronic laryngitis, dry mouth, and frequent or persistent symptoms of a “cold.”

Other Diseases That May Affect the Voice

The larynx is subject to numerous acute and chronic infections. Some of them may be mistaken for malignancy and may be biopsied unnecessarily, exposing the patient (and sometimes the physician) to unnecessary risk. Tuberculosis, for example, is still seen in modern practice. Although laryngeal lesions used to be associated with extensive pulmonary infection, they are now usually associated with much less virulent disease, often only a mild cough. Laryngeal tuberculosis lesions usually are localized.^20,21 Sarcoidosis, another granulomatous disease, causes laryngeal symptoms in roughly 3% to 5% of cases.²² Noncaseating granulomas are found in the larynx, and the false vocal folds are frequently involved, producing airway obstruction rather than dysphonia. Less common diseases including leprosy,^23,24 syphilis,²⁵ scleroderma,²⁶ typhoid,²⁷ typhus, anthrax, and other conditions, can produce laryngeal lesions that might lead the laryngologist to obtain an unnecessary biopsy. Confusing lesions also may be caused by a variety of mycotic infections including histoplasmosis,^28–30 coccidioidomycosis,³¹ cryptococcosis,³² blastomycosis,^30–34 actinomycosis,^35,36 candidiasis,³⁷ aspergillosis,^38–40 mucormycosis,⁴¹ rhinosporidiosis,⁴² and sporotrichosis.⁴³ Parasitic diseases may also produce laryngeal masses. The most prominent example is leishmaniasis.⁴⁴ More detailed information about most of the conditions discussed above is available in a text by Michaels⁴⁵ and elsewhere in this book.

Collagen vascular diseases and other unusual problems may produce laryngeal masses. Rheumatoid arthritis may produce not only disease of the cricoarytenoid and cricothyroid joints, but also consequent neuropathic muscle atrophy⁴⁶ and rheumatoid nodules of the larynx.⁴⁷ Rheumatoid arthritis with or without nodules may produce respiratory obstruction. Gout may cause laryngeal arthritis. In addition, gouty tophi may appear as white submucosal masses of the true vocal fold. They consist of sodium urate crystals in fibrous tissue and have been documented well.^48,49 Amyloidosis of the larynx is rare but well recognized,^50–53 as discussed in other chapters. Urbach-Wiethe disease (lipoid proteinosis)⁵⁴ often involves the mucous membrane of the larynx, usually the vocal folds, aryepiglottic fold, and epiglottis. Other conditions, such as granulomatosis with polyangiitis (Wegener granulomatosis) and relapsing polychondritis, also may involve the larynx. They are less likely to produce discrete nodules, but the diffuse edema associated with chondritis and necrotizing granulomas may produce substantial laryngeal and voice abnormalities. Unusual laryngeal masses also may be caused by trauma. Trauma is discussed in detail elsewhere in this book, but the physician must be careful to inquire about laryngeal trauma, the consequences of which may not be recognized until months or years after the injury.

A few rare skin lesions also may involve the larynx producing symptomatic lesions, and sometimes airway obstruction. These include pemphigus vulgaris, seen in adults between 40 and 60 years of age. Pemphigus lesions may involve the mucosa, including the epiglottis.⁵⁵ Epidermolysis bullosa describes a group of congenital vesicular disorders usually seen at birth or shortly thereafter. This condition may cause laryngeal stenosis, or large, bleb-like vocal fold masses. Some viral conditions may cause laryngeal structural pathology, most notably papillomata. However, herpes, variola, and other organisms also have been implicated in laryngeal infection.

There are numerous other conditions, many of which are not covered comprehensively in this book, that may affect voices adversely. Most of them are not common problems among professional voice users. However, the laryngologist should remember that laryngeal manifestations of many systemic diseases may cause voice changes that bring the patient to medical attention for the first time. We must remain alert for their presence and think of them particularly when more common, obvious etiologies are not identified, or when patients do not respond to treatment as expected. The voice may be affected by the following problems not discussed above (among others): acromegaly, Arnold-Chiari malformations, blood dyscrasias, neurologic disease (vocal fold paralysis), collagen vascular disease (including rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Sjögren’s syndrome, and others), deafness, gout, Hodgkin’s disease, leprosy, lymphoma, Madelung’s disease, malignancies, myopathies, a myriad of infectious diseases (bacterial, viral, granulomatous, and fungal), mononucleosis, numerous syndromes (Basedow’s, adrenogenital syndrome, Down’s syndrome, hereditary angioedema, Kleinfelter’s syndrome, Melkersson-Rosenthal syndrome, pachyonychia congenita, short stature syndromes, Shy-Drager syndrome, and many others), syphilis, sarcoidosis, tuberculosis, Crohn’s disease, Wilson’s disease, and other chronic diseases.

Systemic Conditions

Aging

This subject is so important that is has been covered extensively in other literature.⁵⁶ Many characteristics associated with vocal aging are actually deficits in conditioning, rather than irreversible aging changes. For example, in singers, such problems as a “wobble,” pitch inaccuracies (singing flat), and inability to sing softly are rarely caused by irreversible aging changes, and these problems can usually be managed easily through voice therapy and training.

Hearing Loss

Hearing loss is often overlooked as a source of vocal problems. Auditory feedback is fundamental to speaking and singing. Interference with this control mechanism may result in altered vocal production, particularly if the person is unaware of the hearing loss. Distortion, particularly pitch distortion (diplacusis), may also pose serious problems for the singer. This appears to cause not only aesthetic difficulties in matching pitch but also vocal strain, which accompanies pitch shifts.⁵⁷ Hearing impairment can cause vocal strain, particularly if a person has sensorineural hearing loss (involving the nerve or inner ear) and is unaware of it. This condition may lead people to speak or sing more loudly than they realize.

Respiratory Dysfunction

The importance of “the breath” has been well recognized in the field of voice pedagogy. Respiratory disorders are discussed at length in other literature.⁵⁸ Even a mild degree of obstructive pulmonary disease can result in substantial voice problems. Unrecognized exercise-induced asthma is especially problematic in singers and actors, because bronchospasm may be precipitated by the exercise and airway drying that occurs during voice performance. In such cases, the bronchospastic obstruction on exhalation impairs support. This commonly results in compensatory hyperfunction.

Treatment requires skilled management and collaboration with a pulmonologist and a voice team.⁵⁹ Whenever possible, patients should be managed primarily with oral medications; the use of inhalers should be minimized. Steroid inhalers should be avoided altogether whenever possible. It is particularly important to recognize that asthma can be induced by the exercise of phonation itself,⁶⁰ and in many cases a high index of suspicion and methacholine challenge test are needed to avoid missing this important diagnosis.

Allergy

Even mild allergies are more incapacitating to professional voice users than to others. This subject can be reviewed elsewhere.⁶¹ Briefly, patients with mild intermittent allergies can usually be managed with antihistamines, although they should never be tried for the first time immediately prior to a voice performance. Because antihistamines commonly produce unacceptable side effects, trial and error may be needed in order to find a medication with an acceptable balance between effect and side effect for any individual patient, especially a voice professional. Patients with allergy-related voice disturbances may find hyposensitization a more effective approach than antihistamine use, if they are candidates for such treatment. For voice patients with unexpected allergic symptoms immediately prior to an important voice commitment, corticosteroids should be used rather than antihistamines, in order to minimize the risks of side effects (such as drying and thickening of secretions) that might make voice performance difficult or impossible. Allergies commonly cause voice problems by altering the mucosa and secretions and causing nasal obstruction. Management is not covered in depth in this brief chapter. However, it should be recognized that many of the medicines commonly used to treat allergies have side effects deleterious to voice function, particularly dryness and thickening of secretions. Consequently, when voice disturbance is causally related to these conditions, more definitive treatment through allergic immunotherapy should be considered. This is especially important to professional voice users.

Gastroesophageal Reflux Laryngitis

Gastroesophageal reflux laryngitis is extremely common among voice patients, especially singers.⁶² This is a condition in which the sphincter between the stomach and esophagus is inefficient, and acidic stomach secretions reflux (reach the laryngeal tissues), causing inflammation. The most typical symptoms are hoarseness in the morning, prolonged vocal warm-up time, halitosis and a bitter taste in the morning, a feeling of a “lump in the throat,” frequent throat clearing, chronic irritative cough, and frequent tracheitis or tracheobronchitis. Any or all of these symptoms may be present. Heartburn is not common in these patients, so the diagnosis is often missed. Prolonged reflux also is associated with the development of Barrett esophagus, esophageal carcinoma, and laryngeal carcinoma.^62,63

Physical examination usually reveals erythema (redness) of the arytenoids mucosa. A barium swallow radiographic study with water siphonage may provide additional information but is not needed routinely. However, if a patient complies strictly with treatment recommendations and does not show marked improvement within a month, or if there is a reason to suspect more serious pathology, complete evaluation by a gastroenterologist should be carried out. This is often advisable in patients who are older than 40 years or who have had reflux symptoms for more than 5 years. Twenty-four-hour pH monitoring of the esophagus is often effective in establishing a diagnosis. The results are correlated with a diary of the patient’s activities and symptoms. Bulimia should also be considered in the differential diagnosis when symptoms are refractory to treatment and other physical and psychologic signs are suggestive.

The mainstays of treatment for reflux laryngitis are elevation of the head of the bed (not just sleeping on pillows), antacids, H2 blockers or proton pump inhibitors, and avoidance of eating for 3 to 4 hours before going to sleep. This is often difficult for singers and actors because of their performance schedule, but if they are counseled about minor changes in eating habits (such as eating larger meals at breakfast and lunch), they can usually comply. Avoidance of alcohol, caffeine, and specific foods is beneficial. Medications that decrease or block acid production may be necessary. It must be recognized that control of acidity is not the same as control of reflux. In many cases, reflux is provoked during singing because of the increased abdominal pressure associated with support. In these instances, it often causes excessive phlegm and throat clearing during the first 10 or 15 minutes of a performance or lesson, as well as other common reflux laryngitis symptoms, even when acidity has been neutralized effectively. Laparoscopic Nissen fundoplication has proven extremely effective and should be considered a reasonable alternative to lifelong medication in this relatively young patient population.⁶³

Endocrine Dysfunction

Endocrine (hormonal) problems warrant special attention. The human voice is extremely sensitive to endocrinologic changes. Many of these are reflected in alterations of fluid content of the lamina propria just beneath the laryngeal mucosa. This causes alterations in the bulk and shape of the vocal folds and results in voice change. Hypothyroidism is a well-recognized cause of such voice disorders, although the mechanism is not fully understood.^64–67 Hoarseness, vocal fatigue, muffling of the voice, loss of range, and a sensation of a lump in the throat may be present even with mild hypothyroidism. Even when thyroid function tests results are within the low-normal range, this diagnosis should be entertained, especially if thyroid-stimulating hormone levels are in the high-normal range or are elevated. Thyrotoxicosis may result in similar voice disturbances.⁶⁸

Voice changes associated with sex hormones are encountered commonly in clinical practice and have been investigated more thoroughly than have other hormonal changes. Although a correlation appears to exist between sex hormone levels and depth of male voices (higher testosterone and lower estradiol levels in basses than in tenors),⁶⁹ the most important hormonal considerations in males occur during the maturation process.

When castrato singers were in vogue, castration at about age 7 or 8 years resulted in failure of laryngeal growth during puberty, and voices that stayed in the soprano or alto range and boasted a unique quality of sound.⁷⁰ Failure of a male voice to change at puberty is uncommon today and is often psychogenic in etiology.¹ However, hormonal deficiencies such as those seen in cryptorchidism, delayed sexual development, Klinefelter syndrome, or Fröhlich syndrome may be responsible. In these cases, the persistently high voice may be the complaint that causes the patient to seek medical attention.

Voice problems related to sex hormones are most common in female singers.⁷¹ Although vocal changes associated with the normal menstrual cycle may be difficult to quantify with current experimental techniques, unquestionably they occur.^2,71–75 Most of the ill effects seen in the immediate premenstrual period are known as laryngopathia premenstrualis. This common condition is caused by physiologic, anatomic, and psychologic alterations secondary to endocrine changes. The vocal dysfunction is characterized by decreased vocal efficiency, loss of the highest notes in the voice, vocal fatigue, slight hoarseness, and some muffling of the voice. It is often more apparent to the singer than to the listener. Submucosal hemorrhages in the larynx are more common in the premenstrual period.⁷³ In many European opera houses, singers used to be excused from singing during the premenstrual and early menstrual days (“grace days”). This practice is not followed in the United States and is no longer in vogue in most European countries. Premenstrual changes cause significant vocal symptoms in approximately one-third of singers. Although ovulation inhibitors have been shown to mitigate some of these symptoms,⁷⁴ but in some women (about 5%),⁷⁶ birth control pills used to deleteriously alter voice range and character even after only a few months of therapy.^76–80 However, modern oral contraceptives usually do not produce such problems. Under crucial performance circumstances, oral contraceptives may be used to alter the time of menstruation, but this practice is justified only in unusual situations. Symptoms similar to laryngopathia premenstrualis occur in some women at the time of ovulation.

Pregnancy results frequently in voice alterations known as laryngopathia gravidarum. The changes may be similar to premenstrual symptoms or may be perceived as desirable changes. In some cases, alterations produced by pregnancy are permanent.^81–82 Although hormonally induced changes in the larynx and respiratory mucosa secondary to menstruation and pregnancy are discussed widely in the literature, the author has found no reference to the important alterations in abdominal support. Abdominal distention during pregnancy also interferes with abdominal muscle function. Any singer whose abdominal support is compromised substantially should be discouraged from singing until the abdominal impairment is resolved.

Estrogens are helpful in postmenopausal singers but generally should not be given alone. Sequential replacement therapy is the most physiologic regimen and should be used under the supervision of a gynecologist as potential systemic side effects have been described. Under no circumstances should androgens be given to female singers even in small amounts if any reasonable therapeutic alternative exists. Clinically, these drugs are most commonly used to treat endometriosis or postmenopausal loss of libido. Androgens cause unsteadiness of the voice, rapid changes of timbre, and lowering of the fundamental frequency (masculinization).^83–87 These changes are usually permanent.

Recently, we have seen increasing abuse of anabolic steroids among bodybuilders and other athletes. In addition to their many other hazards, these medications may alter the voice. They are (or are closely related to) male hormones; consequently, they are capable of producing masculinization of the voice. Lowering of the fundamental frequency and coarsening of the voice produced in this fashion are generally irreversible.

Other hormonal disturbances may also produce vocal dysfunction. In addition to the thyroid gland and the gonads, the parathyroid, adrenal, pineal, and pituitary glands are included in this system. Other endocrine disturbances may alter voice as well. For example, pancreatic dysfunction may cause xerophonia (dry voice), as in diabetes mellitus. Thymic abnormalities can lead to feminization of the voice.⁸⁸

Neurologic Disorders

Numerous neurologic conditions may adversely affect the voice. They are discussed in other literature² and elsewhere in this book. Some of them, such as myasthenia gravis, are amenable to medical therapy with drugs such as pyridostigmine (Mestinon). Such therapy frequently restores the voice to normal. An exhaustive neurolaryngologic discussion is beyond the scope of this chapter. Nevertheless, when evaluating voice dysfunction, laryngologists must consider numerous neurologic problems, including Parkinson disease, various other disorders that produce tremor, drug-induced tremor, multiple sclerosis, dystonias, and many other conditions. Spasmodic dysphonia (SD), a laryngeal dystonia, presents particularly challenging problems. This subject is covered in detail in another chapter. Stuttering also provides unique challenges. Although still poorly understood, this condition is noted for its tendency to affect speech while sparing singing.

Vocal Fold Hypomobility

Vocal fold hypomobility may be caused by paralysis (no movement), paresis (partial movement), arytenoid dislocation, cricoarytenoid joint dysfunction, and laryngeal fracture. Differentiating among these conditions is often more complicated than it appears at first glance. A comprehensive discussion is beyond the scope of this chapter, and the reader is referred to other chapters in this book.⁹ However, in addition to a comprehensive history and physical examination, evaluation commonly includes strobovideolaryngoscopy, objective voice assessment, laryngeal electromyography, and high-resolution computed tomography (CT) of the larynx. Most vocal fold motion disorders are amenable to treatment. Voice therapy should be used first in virtually all cases. Even in many patients with recurrent laryngeal nerve paralysis, voice therapy alone is often sufficient. When therapy fails to produce adequate voice improvement in the patient’s opinion, surgical intervention is appropriate.

General Health

As with any other athletic activity, optimal voice use requires reasonably good general health and physical conditioning. Abdominal and respiratory strength and endurance are particularly important. If a person becomes short of breath from climbing 2 flights of stairs, he or she certainly does not have the physical stamina necessary for proper respiratory support for a speech, let alone a strenuous musical production. This deficiency usually results in abusive vocal habits used in vain attempts to compensate for the deficiencies.

Systemic illnesses, such as anemia, Lyme disease, mononucleosis, AIDS, chronic fatigue syndrome, or other diseases associated with malaise and weakness, may impair the ability of vocal musculature to recover rapidly from heavy use and may also be associated with alterations of mucosal secretions. Other systemic illnesses may be responsible for voice complaints, particularly if they impair the abdominal muscles necessary for breath support. For example, diarrhea and constipation that prohibit sustained abdominal contraction may be reasons for the physician to prohibit a strenuous singing or acting engagement.

Any extremity injury, such as a sprained ankle, may alter posture and therefore interfere with customary abdominothoracic support. Voice patients are often unaware of this problem and develop abusive, hyperfunctional compensatory maneuvers in the neck and tongue musculature as a result. These technical flaws may produce voice complaints, such as vocal fatigue and neck pain, that bring the performer to the physician’s office for assessment and care.

Obesity

Singers, actors, and many other professional voice users are verbal, oral people. Most of us enjoy singing, talking, and a good bowl of pasta after the show. However, before indulging our passions for culinary excess, it is important to understand the impact of obesity not only on singing performance, but also on general health and longevity.

For medical reasons, when obesity becomes extreme, serious measures may be necessary to accomplish weight loss. The most severely overweight patients have an entity called “morbid obesity.” This condition is diagnosed when a person is more than 100 pounds or 100% over ideal body weight (Table 4–1). Morbid obesity is a disease that is extremely common in our society. It is estimated that 34 million adult Americans (1 of every 5 people over the age of 19) have significant obesity. As little as 20% excess over desirable body weight may be enough to constitute a health hazard. Doctors have long been aware of the difficulty in controlling weight problems with medical treatment alone. Of all patients who lose weight, 90% regain it at some point in their lives, and many even exceed their original weight. This led doctors to consider surgery as an option in treating this problem in selected cases.

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