HomeVocal Fold Ailments of Professional Singers and Their Prevention

Hadas Golan's picture

One’s voice is one of the most valuable tools, yet it is often taken for granted and exposed to many damaging factors. These factors may either be environmental or behavioral. Many times, these factors are intrinsic in everyday activities, and thus could be detrimental to someone’s well-being without his or her knowledge. Over time, this exposure could result in various vocal fold complications, ranging from soreness or irritation to hemorrhage. 

Acute laryngitis (Fig. 1) is the inflammation of the larynx or “voice box”, which may last up to three weeks. One usually notices laryngitis by an abnormal speaking voice, which may range from simple hoarseness to a soft whisper. Other signs of laryngitis include coughing, difficulty swallowing, feeling of swelling in the throat, swollen lymph nodes, congestion, and fatigue. Laryngitis is often seen by physicians as reddened swelling of the membrane covering the vocal cords, with little, if any, fluid accumulation. The resulting thickness or stiffness along the entire length of the vocal cords causes a lower pitch in the voices of people suffering from acute laryngitis. This condition may be caused by fungal, viral, or bacterial infections, allergies, air pollutants, vocal trauma (overuse), asthma inhalers, smoking, or alcohol consumption. Gastric reflux disease can also be a cause. In this case, acidic digestive juices from the stomach travel back up the esophagus and cause irritation of the vocal cords.

Treatment of acute laryngitis involves time, avoiding excessive use of the vocal folds, and other irritating factors. Inhaling humid air from a hot shower or bowl of boiling water can cause the upper airway to get some moisture and lessen the intensity of the symptoms. Smoking and alcohol consumption should be avoided completely for a timely recovery. Treatment for gastric reflux may also help through anti-reflux medications or changes in dietary habits. If the laryngitis is caused by bacteria, an antibiotic may help, but this is often a rare cause of laryngitis. Viral laryngitis simply takes time to heal. Acute laryngitis may be prevented altogether by not smoking, avoiding secondhand smoke, drinking plenty of water, and avoiding clearing your throat, which causes excessive mechanical throat irritation.

Vocal fold polyps (Fig. 2) or nodules (Fig. 3) also interfere with the quality of one’s voice. Vocal fold nodules are the result of scar tissue accumulation on both medial edges of the vocal fold. This usually leads to breathiness and hoarseness since the vocal folds cannot close properly. Also, the range and stamina of the voice goes down, while the voice itself gets more fatigued. In many cases, vocal nodules are present since childhood, and it is not necessarily a compromising condition. Some vocalists who have small nodules are not adversely affected. 

Vocal fold polyps are similar to nodules except they are only found on one side of the vocal fold. The symptoms of a polyp are similar to those of a vocal fold nodule; however, diplophonia, a condition in which two simultaneous vocal tones are produced, is also possible with polyps. If the polyp is very large, one may have trouble breathing, but this condition is unlikely in professional vocalists.

Treatment for polyps and nodules is based on the symptoms of the patient. First, gastric reflux is treated if it exists, along with   muscle tension dysphonia, which is the tightening of muscles around the vocal cords. Voice therapy usually treats this condition. In addition, it is used to improve vocal hygiene and reduce any swelling around the nodule or polyp. After therapy, it is possible to have complete recovery. Some singers may still notice vocal limitations, and thus might opt for surgery in which polyps are removed.  Surgery for vocal fold nodules is almost never recommended because of concerns for permanent vocal fold scarring and recurrence of the nodules.

Vocal fold hemorrhage (Fig 4) occurs after intense use of the voice for prolonged period of time or in relation with an upper respiratory tract illness. After strenuous vocal use, a sudden change in the voice is often noted. The condition characterized by the bleeding of the soft tissue of the vocal folds caused by the rupturing of blood vessels on the surface of the vocal cords. Someone who has vocal fold varices, or large dilated veins, on the surface of the vocal fold has a higher risk of suffering from vocal fold hemorrhage. The hemorrhage usually only occurs on one vocal fold, but rarely it can happen in both. This condition is common among females and professional vocalists. This is thought to be because of hormonal imbalances and frequent overuse of the vocal folds and a higher sensitivity to vocal changes, respectively.

Vocal cord hemorrhage is considered an emergency and calls for immediate and complete vocal rest for one to two weeks. During this time, the vocal cord usually flattens and the blood diminishes. If the condition persists, surgery may be required to fix the bleeding. Voice therapy and medical follow up is required to reach and confirm a full recovery. In some cases, hemorrhage can reoccur. Prevention of vocal cord hemorrhage involves avoiding prolonged vocal strain.

As devastating as these conditions are, they can be prevented by taking proper precautions, starting with good oral hygiene and general health. Good diet, exercise, and an adequate amount of physical rest are necessary to maintain optimal vocal health. In  certain situations, one may be exposed to detrimental environmental factors. Vocal students are often at high risk for the vocal fold damage because of the drugs or alcohol involved in the partying scene on college campuses. In addition, yelling at sporting events contributes a great deal to adverse vocal strain. Although singers make an effort to be cautious with their singing voices, they often forget to apply the same care to their regular speaking voices. Adverse vocal strain from everyday activities is often the cause of laryngitis and other vocal illnesses.

Professional singers often have to handle frequent changes in environment. Smoke-filled concert venues or clubs take a huge toll on vocal hygiene by causing irritation, and at times, infection. In addition, those who travel frequently are exposed to the dry air of airplanes, as well as, the noisy sound of the engine. One should avoid talking on airplanes for these reasons. Talking loudly over the noise and the drying of the vocal cords will cause unwanted or unnecessary irritation. The burden to perform when ill is also very high for professional singers. Singing when suffering from allergies, cold, or swollen cords would result in devastating vocal conditions that last months.

Proper vocal training also prevents vocal cord damage by teaching singers techniques to avoid unnecessary strain and promote better voice quality. Good posture and body alignment are crucial in creating a healthy work environment where respiration, phonation, resonance, and articulatory systems can work together efficiently. Complementary therapies such as Yoga, Pilates, Alexander technique, and Feldenkrais help to develop awareness and are very useful in the development of core stability and strength, balance, and flexibility.

Breathing for singing is simply an extension of the natural functioning of the respiratory system. The system is designed to meet our basic needs for sufficient air. Ironically, not content with “sufficient”, singers struggle to take in more breath than they actually need,  locking tension in the respiratory muscles, and actually restricting air intake and blocking the natural flow of vocal energy.

Well-balanced phonation requires coordination between the vocal folds and the flow of breath. The vocal folds function as a valve on top of the airway. For optimal vibration, they must position themselves in a nearly closed position, where minimal breath will set them into vibration. Pushing too much breath will blow the vocal folds too much apart, weakening the tone and resulting in excessive laryngeal muscle tension, as the singer tries to bring them together again. Holding back with the breath will result in laryngeal strain as well. For good phonation a balance is required, not holding back with the breath and not forcing it forward.

The articulatory system has a major and sometimes unrecognized impact on voice quality and resonance. The tongue and jaw must be very strong to assist in chewing and swallowing but both can have a very negative effect on singing. Singers who habitually constrict the jaw and base of the tongue often complain of vocal fatigue, restricted range, and loss of pitch flexibility. For optimal resonance a maximum pharyngeal space with lifted soft palate is required. The jaw should hang nicely in place with a flexible ready tongue.

When everything is working in balance the singer will experience active posture, natural abdominal movements as breath flows in and out, no strain at the laryngeal level, vibrations in the head, and feelings of ease and pleasure in singing.

A performer’s vocal health may be taken for granted until one of the above common maladies develops.  Fortunately, most common vocal fold ailments are reversible.  More importantly, many are preventable if the above guidelines for vocal health are followed.

Formerly submitted at Choral Director Magazine, November, 2008.

Authors are: Pieter Noordzij, Harini, Naidu and Hadas Golan.

Pieter Nooedzij, MD is associate professor of Otolaryngology-Head & Neck Surgery at Boston University School of Medicine, Boston Medical Center. Harini Naidu is a BS medical student at Boston University, and Hadas Golan, B.Ed. Mus. MS/CCC-SLP is a speech pathologist specialized in the professional voice at Boston Medical Center.


I've translated this article

I've translated this article in Chinese and put it in my blog:  http://blog.sina.com.cn/s/blog_61e0dffa0100hsep.html


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