36 Special Considerations for the Professional Voice User A professional voice user is anyone whose voice is integral to earning a livelihood. Though singers and actors remain the elite group of professional voice users, teachers, lawyers, physicians, politicians, salespersons, receptionists, and radio jockeys all fall under the umbrella of this increasingly widening group of professional voice users. In today’s world, the importance of the role of our voice, in society, is an undisputed fact. It should be borne in mind that treating or restoring a person’s voice is often in effect changing or restoring their complete personality. A voice professional being a vocal athlete is likely to be affected by even slight changes in voice quality. These vocal changes may be due to a plethora of causes ranging from the obvious polyp, nodules, or subepithelial hemorrhage to the more insidious muscle tension dysphonia or laryngeal paresis. Further confounding matters may be the presence of multiple pathologies, not all responsible for the acute discomfort being experienced by the professional voice user. A case in point is a well-established singer, who may present with vocal nodules and a unilateral subepithelial hemorrhage. It is critical to understand that a singer may sing comfortably with nodules and in fact these nodules may be responsible for the singer’s characteristic voice. A safe mantra to follow while treating this highly sensitive group of professionals is to always tackle the acute changes first and preferably in a conservative manner. Overenthusiastic treatment to let the singer meet pressing singing commitments may damage the longevity of the voice and it is the duty of the treating physician to explain this gently, but firmly, to the professional voice user. Understanding the anatomy and physiology of phonation is the basis underlying the correct management of professional voice users. The correct age to begin serious vocal training is controversial. It was felt that waiting till puberty and voice stabilization was safer; however, many singing prodigies have been training seriously since the age of 6 or 7, with no deleterious effects. It seems reasonable to state that children who have vocal aspirations should be permitted to begin training early with a careful watch on any signs of vocal misuse or abuse, thus avoiding permanent pathological changes. When singer complains of the necessity to warm up for an uncharacteristically long time, laryngopharyngeal reflux or vocal fold pathologies on the vibrating edge should be specifically looked for. A singer usually requires 10 to 30 minutes to warm up the voice. Most singers practice for 1 to 2 hours daily. Cooling down exercises are equally important for singers to maintain a good singing voice. Good abdominal muscle tone, respiratory endurance, optimal weight, and a stress-free mind play a role in the quality of our voice. Adequate hydration of the larynx is of paramount importance, and though eight glasses of water daily has been recommended, the amount may vary in different individuals. A good rule of thumb is to drink adequate water so that the urine is pale. A nonsmoking, dust-free, and humidified environment is ideal. A dry and smoky environment may cause mucosal irritation and edema resulting in a hoarse voice with vocal fatigue referred to as the “Las Vegas Voice.”1 Reflux laryngitis is fairly prevalent in the population of singers probably resultant to late night shows occasionally in a smoky environment. Surprisingly, smoking, overeating, drinking, and sleeping on a full stomach are not habits foreign to the singing population. Good auditory feedback during a show is critical to prevent the singer from the tendency of increasing the vocal intensity of singing in direct response to the background noise. This tendency is referred to as the Lombard effect.1 Cupping ones ear while singing is an effective way to add 6 to 7 dB to ones perception of voice and is useful in a noisy hall. We often see qawali singers (a subgroup in Indian classical singers) cupping one ear and outstretching the other hand. They are attempting to avoid the Lombard effect. For this same reason, hearing loss should not be missed in a singer. Unquestionably, the greatest of all causes of laryngeal disease is the excessive use of one of its normal functions, phonation. —Chevalier Jackson, 1942 Vocal abuse and misuse in both the singing and speaking voice has to be avoided. A technically correct singer who also happens to be an incessant chatterbox may damage the singing voice eventually. Vocal misuse is commonly due to too much tension on the tongue, neck, or larynx while speaking or singing. Vocal fatigue is a common complaint in such a scenario. Antihistamines, given for colds and postnasal drips, are known to cause drying of the mucosa resulting in dryness and laryngeal irritability. Most H1-receptor antagonists have significant anticholinergic effects and need to be avoided before a performance. A good replacement for diphenhydramine is a leukotriene inhibitor such as montelukast.2 Decongestants also need to be used with caution due to the drying effect they have on mucous membranes. However, if guaifenesin is present in the decongestant, it counters the drying effect by thinning and increasing the secretions. Systemic corticosteroids have a huge role in managing many acute emergencies of the singer’s vocal folds. Due to a strong anti-inflammatory action, they help in cases of sudden vocal fold edema. However, inhaled corticosteroids produce dryness and should be avoided. Nonsteroidal anti-inflammatory drugs (NSAIDs) should also be avoided, especially just preceding a singing session as their anticoagulant effect may induce bleeding in the vocal fold.3,4 Diuretics, many antihypertensive agents, and psychoactive drugs cause a resultant dryness of the larynx. The quality of our voice is dependent on the levels of our sex hormones, namely, estrogen, progesterone, and androgen. Females have all the three hormones, though the testosterone is in a low quantity. Although an excess of testosterone will make the female voice masculine, a small amount is essential to give a libido to the female voice.5Males have predominant testosterone, no progesterone, and a low level of estrogen. In the first half of a female’s menstrual cycle, there is abundance of estrogen that helps keep the vocal folds supple, well lubricated with an absence of desquamation of the epithelium. Estrogen promotes the transfer of intravascular fluid to the extra vascular compartment, which gives a better quality to the voice. However, in the second half of the cycle, there is a release of progesterone that causes the vocal folds to get thicker, less lubricated with desquamation of epithelium. Excessive progesterone prevents the return of interstitial fluid to the blood vessels with resultant edema. If the estrogen–progesterone balance is deranged in this second half of the menstrual cycle, some female singers may experience a difficulty in optimal utilization of their performing voice 5 to 6 days before and on the first couple of days of menses. Such singers should be advised to plan stage shows on the 3rd to 20th day of their menstrual cycle. Pregnancy brings with it a surge of hormones that help keep the vocal folds nicely lubricated giving a sparkly quality to the voice. However, reflux, often associated with pregnancy and loss of breath support, toward the third trimester, interferes with the quality of voice. Females nearing menopause or several months after stopping hormone replacement therapy may also experience a change in voice. This is more so in thin and lean women as compared with plump women. The reason for this lies in the fact that estrogen is produced by the ovaries, brain, as well as fat cells. A specific gene in our DNA facilitates the transformation of androgens into estrogen in our adipose cells.5 A correct balance of the thyroid hormones plays an important role in maintaining a healthy voice. Both hypo- and hyperthyroidism may result in voice changes. Hypothyroidism may often result in a Reinke edema picture and the patient is often lethargic. Clinical Pearls •Spend adequate time evaluating a professional voice user. Build a rapport. •Record voice and stroboscopy findings. •Educate regarding vocal hygiene, environmental factors, avoiding reflux, and adequate mental and physical rest. •Female singers may be advised to allocate important singing commitments from 3rd to 20th day of menstrual cycle. •Avoid antihistamines and NSAIDs before shows. •Do not shy away from taking a second opinion when in doubt of diagnosis. •Try to have a basic understanding of various forms of singing and individual artist’s requirements.
Correct Age to Start Professional Training for Singing
Prolonged Warm-up
General Health and Environment
Vocal Abuse and Misuse
Role of Medication
Menstrual and Endocrine Irregularities
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