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Vocal Health in the Professional Singer -- Music and Medicine on Monday

Submitted by hoffmanh on Sun, 02/18/2024 - 10:57

Music and Medicine on Monday at the University of Iowa - Schedule of Events

protocol page initiated Feb 2024  Piper Wenzel BS, Henry Hoffman MD

Performance of O Soave Fanciulla (Puccini) with View of Vocal Cords Superimposed:

Explanation of the pharynx as a resonating chamber (60 seconds)

video of full interview and performance:

video identifying technique of transnasal laryngoscopy with discussion of anatomy and physiology:

Definitions

  • Dysphonia:  "Altered vocal quality, pitch, loudness, or vocal effort that imparis communication and/or quality of life" as defined by the AAO -HSN Clinical Practice Guideline Update (Stachler et al 2018)
  • Hoarseness: "A symptom of altered voice quality rerported by patients" (Stachler 2018)
  • Vocal Nodules: "Benign masses located in the lamina propria typically at the midpoint of the membranous vocal folds" (Verdolini 2006)
  • Vocal Fold Hemorrhage the rupture of a submucosal blood vessel of the vocal fold usually associated with internal or external laryngeal trauma and may be associated with impaired coagulation (Lennon, 2013).
  • Vocal range: spectrum of pitches the singer can produce
  • Register: "distinct regions of vocal quality that can be mainteained over some ranges of pitch and loudness" (Titze 1988)
  • Tessitura: the vocal range produced in a comfortable manner   --   Extension: total range that can be vocalized with effort
  • Timber: "the color or tone of the sound" (Rubin and Codino 2019) usually sounds best in the singer's tessitura
  • Passagio: the transition between registers - a sensitive area for vibratory impairment as one 'navigates the passagio"
  • "Straw Phonation" - a form of semioccluded vocal tract exercises are "characterized by a reduction in the cross-sectional area of the distal part of the vocal tract while voicing"  (Kang 2020) see: Teaching Vocal Heath as Music Educator

Background

As per Rubin and Codino (2019) - caring for the professional singer requires a "deeper understanding of the demands, vocabulary, psyche, and economics of the professional singer to provide optimal care". 

Management

  • Voice Rest - Vocal Conservation as a Management Strategy (Non-operative and Post-op)
  • Steroids Side Effects Systemic Corticosteroid Therapy Adverse Effects (balance short term benefit with long term sequelae)
    • Gehling et al (2014) through survey of 135 Broadway singers identified 32% had used steroids to treat voice problems
    • Estes et al (2021) in evaluating management of vocal performers presenting with hoarseness and identified with vocal fold edema on videostroboscopy
      • all counselled about voice rest and oral steroids
      • those that chose steroids were offered enrollment in study
      • treatment with oral glucocorticoids (6-day methylprednisolone taper beginning with 24 mg and decreasing by 4 mg daily)
        • medrol dose pak = 
      • "potential problems identified with steroids: repeated short term use may be associated with effects similar to those of long-term use"
        • osteopenia, hyperglycemia, cataracts, weight gain, cardiac disease
        • 'even a singel methylprednisolone taper pack appears to slightly but increase the risk of osteonecrosis" (citing Dilisio 2014)
        • laryngeal thrush (candida) developed in 5.5% of patients in their study treated with the 6-d steroid course
      • Conclusions from this study evaluating singers with acute vocal fold edema
        • "careful examination of the vocal folds by means of laryngoscopy, prefereably videostroboscopy, is mandatory" and 'should be repeated if symptoms do not improve as expected'
        • recommended treatment is voice rest and treatment of underlying cause
        • "oral steroids may be used to speed the reolution of acute inflammatory changes, with a small possiblity of vocal fold hemorrhage and/or thrush."
        • "repeated need for steroids raises suspicion of overlooked pathology and makes re-evalautionf the larynx advisable"
        • 'serial steroid use should never substitue for a thorough laryngeal evaluation"
    • Estes et al (2022) in a followup article reported on 55 vocal performers treated wtih 6-day methylprednisolone taper
      • prospective evaluation employing the EASE (Evaluation fo the Ability to Sing Easily) questionnaire
      • "significant improvement demonstrated in several facets of performers' sef-perception of function"
      • "appropriate use of these medications appears both safe and effective" -
        • with their study serving to "help debunk myths about singing while on steroids".
        • emphasizing 'steroids be prescirbed carefully, and only following thorough laryngeal examination"
  • ​​​Vocal Fold Hemorrhage, Vocal Cord Bleed, Vocal Varix, Telangiectasia
  • Voice Team: Laryngologist / Speech Pathologist / Singing Teacher or Coach 
  • Warm up
  • Humidification

References

Childs LF, Mau T. Combining Voice Rest and Steroids to Improve Diagnostic Clarity in Phonotraumatic Vocal Fold Injury. J Voice. 2022 May;36(3):403-409. doi: 10.1016/j.jvoice.2020.06.003. Epub 2020 Jul 9. PMID: 32654865.

Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, McCoy SJ, Ouellette DR, Patel RR, Reavis CCW, Smith LJ, Smith M, Strode SW, Woo P, Nnacheta LC. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngol Head Neck Surg. 2018 Mar;158(1_suppl):S1-S42. doi: 10.1177/0194599817751030. Erratum in: Otolaryngol Head Neck Surg. 2018 Aug;159(2):403. PMID: 29494321.

Verdolini K, Rosen CA, Branaski RC. Classification manula for voice disorders I. Special interest division 3, Voice and voice disorders American Speech - Language-Hearing Association. Mahwah, NJ: Lawrence Erbaum Associates, Inc.; 2006

Rubin AD, Codino J. The Art of Caring for the Professional Singer. Otolaryngol Clin North Am. 2019 Aug;52(4):769-778. doi: 10.1016/j.otc.2019.03.019. Epub 2019 May 13. PMID: 31097334.

Titze I.R.: A framework for the study of vocal registers. J Voice 1988; 2: pp. 183-194.

Murphy Estes C, Chadwick K, Sadoughi B, Andreadis K, Sussman S, Sulica L. Prospective Evaluation of Safety of Singing on Steroids: Testing the Truth of Received Wisdom. Laryngoscope. 2021 Oct;131(10):2298-2304. doi: 10.1002/lary.29437. Epub 2021 Feb 19. PMID: 33605442.

Dilisio MF. Osteonecrosis following short-term, low-dose oral corticosteroids: a population-based study of 24 million patients. Orthopedics. 2014 Jul;37(7):e631-6. doi: 10.3928/01477447-20140626-54. PMID: 24992058.

Murphy Estes C, Chadwick K, Sadoughi B, Andreadis K, Sussman S, Sulica L. Performers' Perceptions of Vocal Function During Oral Steroid Treatment of Vocal Fold Edema. Laryngoscope. 2022 Dec;132(12):2434-2441. doi: 10.1002/lary.30072. Epub 2022 Feb 25. PMID: 35218020.

Gehling D, Sridharan S, Fritz M, et al. Backstage at Broadway: a demo-graphic study.J Voice2014;28:311–315

SchneiderSL,Sataloff RT.Voicetherapyfortheprofessionalvoice. Otolar yngol Clin North Am. 2007;40:1133–1149. ix. http://dx.doi.org/10.1016/j. otc.2007.05.013.

Kang J, Xue C, Lou Z, Scholp A, Zhang Y, Jiang JJ. The Therapeutic Effects of Straw Phonation on Vocal Fatigue. Laryngoscope. 2020 Nov;130(11):E674-E679. doi: 10.1002/lary.28498. Epub 2020 Jan 23. PMID: 31971264.

Lennon CJ, Murry T, Sulica L. Vocal fold hemorrhage: factors predicting recurrence. Laryngoscope. 2014 Jan;124(1):227-32. doi: 10.1002/lary.24242. Epub 2013 Jul 19. PMID: 23754508