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Common Medical Diagnoses and Treatments in Professional Voice Users
Updated: Jun 2, 2009
Introduction
Numerous medical conditions adversely affect the voice. Many of these conditions have their origins primarily outside the head and neck. This article is not intended to be all inclusive but rather is intended to highlight some of the more common and important conditions found in professional voice users seeking medical care.
In the 2286 cases of all forms of voice disorders reported by Brodnitz in 1971, 80% of the disorders were attributed to voice abuse or to psychogenic factors resulting in vocal dysfunction.1 Of these patients, 20% had organic voice disorders. Of women with organic problems, approximately 15% had identifiable endocrine causes. In the author's experience, a much higher incidence of organic disorders, particularly reflux laryngitis and acute infectious laryngitis, is found more frequently.
Vocal fold polyp (VFP) found during office videostroboscopy.
Voice Abuse
When voice abuse is suspected or observed in a patient with vocal problems, he or she should be referred to a laryngologist who specializes in voice, preferably a physician affiliated with a voice care team.
Common patterns of voice abuse and misuse are not discussed in detail in this article because they are covered elsewhere in the literature. Voice abuse and/or misuse should be suspected particularly in patients who report voice fatigue associated with voice use, in those whose voices are worse at the end of a working day or week, and in those who are chronically hoarse. Technical errors in voice use may be the primary etiology of a voice problem, or the condition may develop secondarily as a result of a patient's efforts to compensate for voice disturbance from another cause.
Speaking in noisy environments (eg, cars, airplanes) is particularly abusive to the voice. Other activities that are abusive to the voice include backstage greetings, postperformance parties, choral conducting, voice teaching, and cheerleading. All these vocal activities can be done safely with proper training; however, most patients (surprisingly, even singers) have little or no training for their speaking voice. Abuse of the voice during singing is an even more complex problem.
If voice abuse is caused by speaking, treatment should be provided by a licensed, certified speech-language pathologist in the United States or by a phoniatrist in many other countries. In many cases, training the speaking voice will benefit singers greatly, not only by improving speech but also by indirectly helping singing technique. Physicians should not hesitate to recommend such training, but the training should be provided by an expert speech-language pathologist who specializes in voice. Many speech-language pathologists who are well trained in swallowing rehabilitation, articulation therapy, and other techniques are not trained in voice therapy for the speaking voice, and virtually none is trained through speech and language degree programs to work with singers with voice disorders.
Conversely, specialized singing training may be helpful to some voice patients who are not singers, and it is invaluable for patients who are singers. Initial singing training teaches relaxation techniques and develops muscle strength, and it should be symbiotic with standard speech therapy.
Structural Abnormalities
Nodules
Nodules are callous-like masses of the vocal folds caused by vocally abusive behaviors, and they are a dreaded malady of singers. Occasionally, laryngoscopy reveals vocal nodules that do not produce symptoms and do not appear to interfere with voice production; in such cases, the nodules should not be treated. Some famous and successful singers have had untreated vocal nodules throughout their entire careers.
However, in most cases, nodules result in hoarseness, breathiness, loss of range, and vocal fatigue. They may be caused by abusive speaking rather than the singing voice. Voice therapy should always be tried as the initial therapeutic modality; it cures nodules in most patients, even if the nodules look firm and have been present for many months or years. Even apparently large, fibrotic nodules often shrink, disappear, or stop producing symptoms with 6-12 weeks of voice therapy with good patient compliance. Preoperative voice therapy is essential to prevent recurrence, even in patients who eventually need surgical excision of the nodules.
Care must be taken in diagnosing nodules. Consistent and accurate diagnosis is almost impossible without strobovideolaryngoscopy and good optical magnification. Vocal fold cysts are commonly misdiagnosed as nodules, and management strategies are different for the 2 lesions. Vocal nodules are confined to the superficial layer of the lamina propria and are composed primarily of edematous tissue or collagenous fibers. Basement membrane reduplication is common. Vocal nodules are usually bilateral and fairly symmetrical.
Exercise caution in diagnosing small nodules in patients who have been singing actively. In many singers, bilateral symmetrical soft swellings at the junction of the anterior and middle thirds of the vocal folds develop after heavy voice use. No evidence suggests that singers with such physiologic swellings are predisposed to development of vocal nodules. At present, the condition is generally considered to be within normal limits. The physiologic swelling usually disappears with 24-48 hours of rest from heavy voice use. The physician must be careful not to frighten the singer by misdiagnosing physiologic swellings as vocal nodules. Nodules carry a great stigma among singers, and the psychological impact of the diagnosis should not be underestimated. When nodules are present, these patients should be informed with the same gentle caution used in telling a patient that he or she has a life-threatening illness.
Submucosal cysts
Submucosal cysts of the vocal folds are probably traumatic lesions that, in many cases, result from blockage of a mucous gland duct; however, they may also be congenital or occur from other causes. They often cause contact swelling on the contralateral side and are usually initially misdiagnosed as nodules. Typically, submucosal cysts can be differentiated from nodules by strobovideolaryngoscopy when the mass is obviously fluid filled. They may also be suggested when the nodule (contact swelling) on one vocal fold resolves with voice therapy while the mass on the other vocal fold does not resolve.
Cysts may also be discovered on 1 side (occasionally both sides) when surgery is performed for apparent nodules that have not resolved with voice therapy. The surgery should be performed superficially and with minimal trauma (see Surgery in Medical Management for Voice Dysfunction). Cysts are ordinarily lined with thin squamous epithelium. Retention cysts contain mucus. Epidermoid cysts contain caseous material. Generally, cysts are located in the superficial layer of the lamina propria. In some cases, cysts are attached to the vocal ligament.
Polyps
Vocal polyps, another type of vocal fold mass, usually occur on only one vocal fold. They often have a prominent feeding blood vessel coursing along the superior surface of the vocal fold and entering the base of the polyp. In many cases, the pathogenesis of polyps cannot be proven, but the lesions are thought to be traumatic and sometimes start as hemorrhages. Polyps may be sessile or pedunculated. They are typically located in the superficial layer of the lamina propria and do not involve the vocal ligament.
In those polyps arising from an area of hemorrhage, the vocal ligament may be involved with posthemorrhagic fibrosis that is contiguous with the polyp. Histological evaluation most commonly reveals collagenous fibers, hyaline degeneration, edema, thrombosis, and often bleeding within the polypoid tissue. Cellular infiltration may also be present. In some cases, even sizable polyps resolve with relative voice rest and a few weeks of low-dose steroid therapy (eg, 4 mg methylprednisolone twice daily); however, most require surgical removal.
If polyps are not treated, they may produce contact injury on the contralateral vocal fold. Patients should receive voice therapy to ensure good relative voice rest and prevention of abusive behavior before and after surgery. When surgery is performed, care must be taken to not damage the leading edge of the vocal fold, especially if a laser is used (see Surgery in Medical Management For Voice Dysfunction). In all laryngeal surgery, delicate microscopic dissection is now the standard of care. Vocal fold stripping is an out-of-date surgical approach that was used for benign lesions. Vocal fold stripping often resulted in scarring, poor unserviceable voice function, or both; therefore, it is no longer an acceptable surgical technique in most situations.
Granulomas
Granulomas usually develop in the cartilaginous portion of the vocal fold near the vocal process or on the medial surface of the arytenoid. They are composed of collagenous fibers, fibroblasts, proliferated capillaries, and leukocytes. They are usually covered with epithelium. Granulomas are associated with gastroesophageal reflux laryngitis and trauma (eg, voice abuse, intubation). Therapy should include reflux control, voice therapy, and surgery if the granuloma does not resolve promptly.
Reinke's edema
Reinke's edema is characterized by an "elephant ear" floppy vocal fold appearance. It is often observed during examination in many nonprofessional and professional voice users and is accompanied by a low, coarse, gruff voice. In Reinke's edema, the superficial layer of lamina propria (Reinke's space) becomes edematous. The lesion usually does not include hypertrophy, inflammation, or degeneration; however, other terms for the condition include polypoid degeneration, chronic polypoid chorditis, and chronic edematous hypertrophy.
Reinke's edema is often associated with smoking, voice abuse, reflux, and hypothyroidism. Underlying conditions should be treated; however, the condition often requires surgery. Perform surgery only in the presence of justified high suspicion of serious pathology (eg, cancer) or airway obstruction or if the patient is unhappy with personal vocal quality. For some voice professionals, abnormal Reinke's edema is an important component of the vocal signature. Although the condition is usually bilateral, surgery should generally be performed on one side at a time.
Sulcus vocalis
Sulcus vocalis is a groove along the edge of the membranous vocal fold. Most of these lesions are congenital, bilateral, and symmetrical, although posttraumatic acquired lesions occur. When it produces symptoms (it often does not), sulcus vocalis can be treated surgically if sufficient voice improvement is not obtained through voice therapy.
Scar
Vocal fold scarring is a sequela of trauma that results in fibrosis and obliteration of the layered structure of the vocal fold. It may markedly impede vibration and, consequently, may cause profound dysphonia. Recent surgical advances, as described by Sataloff et al, have made this condition much more treatable than in the past; however, restoring voices to normal in the presence of scarring remains rarely possible.2
Hemorrhage
Vocal fold hemorrhage is a potential disaster for singers. Hemorrhages resolve spontaneously in most cases, with restoration of normal voice. However, in some instances, the hematoma organizes and fibroses, resulting in scarring. This alters the vibratory pattern of the vocal fold and can result in permanent hoarseness. In specially selected cases, avoiding this problem through surgical incision and drainage of the hematoma may be best. In all cases, vocal fold hemorrhage should be managed with absolute voice rest until the hemorrhage has resolved (usually about 1 wk) and relative voice rest until normal vascular and mucosal integrity have been restored. This often takes 6 weeks, sometimes longer. Recurrent vocal fold hemorrhages are usually due to weakness in a specific blood vessel, which may require surgical cauterization of the blood vessel using a laser or microscopic resection of the vessel.
Papilloma
Laryngeal papillomas are epithelial lesions caused by the human papilloma virus. Histology reveals neoplastic epithelial cell proliferation in a papillary pattern and viral particles. Presently, symptom-producing papillomas are managed surgically, although alternatives to the usual laser vaporization approach have been recommended by Sataloff and others. At present, the author is also using intralesional injection of cidofovir, as described by Wellens et al.3
Cancer
A detailed discussion of cancer of the larynx is beyond the scope of this article (see Malignant Tumors of the Larynx and Laryngeal Carcinoma). The prognosis for small vocal fold cancers is good, whether they are treated by radiation or surgery. Although perhaps intuitively obvious that radiation therapy provides a better chance of voice conservation than even limited vocal fold surgery, later radiation changes in the vocal fold may produce substantial hoarseness, xerophonia (dry voice), and voice dysfunction.
Consequently, from the standpoint of voice preservation, optimal treatments remain uncertain. Prospective studies using objective voice measures and strobovideolaryngoscopy should answer the relevant questions in the near future. Strobovideolaryngoscopy is also valuable for follow-up of patients who have had laryngeal cancers. It permits detection of vibratory changes associated with infiltration by the cancer long before they can be seen with continuous light. Stroboscopy has been used in Europe and Japan for this purpose for many years. In the United States, the popularity of strobovideolaryngoscopy for follow-up of cancer patients has increased greatly in recent years.
The psychological consequences of vocal fold cancer can be devastating, especially for professional voice users. The consequences can be overwhelming for individuals who are not voice professionals as well. These reactions are understandable and expected. In many patients, however, psychological reactions may be as severe following medically "less significant" vocal fold problems such as hemorrhages, nodules, and other conditions that do not command the sympathy afforded to a person with cancer. In many ways, the management of related psychological problems can be even more difficult for patients with these "lesser" vocal disturbances.4
For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education article Cancer of the Mouth and Throat.
Vocal fold hypomobility or immobility
Vocal fold hypomobility may be caused by laryngeal nerve paralysis or paresis, arytenoid cartilage dislocation, cricoarytenoid joint dysfunction, and laryngeal fracture. Differentiating these conditions is often more complicated than would initially be expected. A comprehensive discussion is beyond the scope of this article, and the reader is referred to other literature. 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 management. Voice therapy should be the first treatment modality in virtually all cases. Even for many patients with recurrent laryngeal nerve paralysis, voice therapy alone is often sufficient to produce a satisfactory voice. When therapy fails to produce adequate voice improvement in the patient's opinion, surgical interventionisappropriate.5
Infection And Inflammation
Upper respiratory tract infection without laryngitis
Although mucosal irritation is usually diffuse, patients sometimes have marked nasal obstruction with little or no sore throat and a seemingly normal voice. If the laryngeal examination shows no abnormality, singers or professional speakers with supposed head colds should be permitted to use their voices but advised not to try to duplicate their usual sound. Instead, they should try to accept the alterations in self-perception caused by the changes in the supraglottic vocal tract and auditory system. The decision as to whether performing under these circumstances is advisable professionally rests with the voice professional and his or her musical associates. The patient should be cautioned against throat clearing, as this is traumatic and may produce laryngitis. If a cough is present, nonnarcotic medications should be used to suppress it. In addition, the patient should be taught to "silent cough," as this is less traumatic.
Laryngitis with serious vocal fold injury
Hemorrhage in the vocal folds and mucosal disruption associated with acute laryngitis are contraindications to singing. When these are observed, treatment includes strict voice rest and correction of any underlying disease. Vocal fold hemorrhage in skilled singers is most common in premenstrual women who are using aspirin products for dysmenorrhea. Severe hemorrhage or mucosal scarring may result in permanent alterations in vocal fold vibratory function. In rare instances, surgical intervention may be necessary. The potential gravity of these conditions must be stressed, because singers are generally reluctant to cancel an appearance. As von Leden observed, working with "people who are determined that the show must go on when everyone else is determined to goof off" is a pleasure.6 However, patient compliance is essential when serious damage has occurred.
At present, acute treatment of vocal fold hemorrhage is controversial. Most laryngologists allow the hematoma to resolve spontaneously. Because this sometimes results in an organized hematoma and scar formation requiring surgery, some physicians advocate incision along the superior edge of the vocal fold and drainage of the hematoma in selected patients. Further study is needed to determine optimal therapy guidelines.
Laryngitis without serious damage
Mild-to-moderate edema and erythema of the vocal folds may result from either infection or from noninfectious causes. In the absence of mucosal disruption or hemorrhage, edema and erythema are not absolute contraindications to voice use. Noninfectious laryngitis is commonly associated with excessive voice use in preperformance rehearsals. It may also be caused by other forms of voice abuse and by mucosal irritation produced by allergy, smoke inhalation, and other causes. Mucous stranding between the anterior and middle thirds of the vocal folds is commonly observed in inflammatory laryngitis. Laryngitis sicca is associated with dehydration, dry atmosphere, mouth breathing, and antihistamine therapy. Deficiency of mucosal lubrication causes irritation and coughing and results in mild inflammation.
If no pressing professional need for performance exists, inflammatory conditions of the larynx are best managed with relative voice rest in addition to other modalities. However, in some instances, singing may be permitted. The singer should be instructed to avoid all forms of irritation and to rest the voice at all times except during warm-up and performance. Corticosteroids and other medications discussed below may be helpful. If mucosal secretions are copious, low-dose antihistamine therapy may be beneficial, but it must be prescribed with caution and should generally be avoided. Copious, thin secretions are better for a singer than scant, thick secretions or excessive dryness.
A singer with laryngitis must be kept well hydrated to maintain the desired character of mucosal lubrication. The singer should be instructed to consume enough water to keep urine diluted. Psychological support is crucial. For the physician to intercede on the singer's behalf and convey "doctor's orders" directly to agents or theater management is often helpful. Such mitigation of exogenous stress can be highly therapeutic.
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. Indiscriminate use of antibiotics must be avoided; however, when the physician is in doubt as to the cause and when a major performance 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 may result from a course of therapy for an unproven microorganism while culture results are pending. When a major performance is not imminent, indications for therapy are the same as those for nonsinging individuals.
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 because 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 even to whisper, which may be an even more traumatic vocal activity than speaking softly. Whistling through the lips also involves vocal fold activity and should not be permitted. The playing of many musical wind instruments also involves vocal activity.
Absolute voice rest is necessary only for serious vocal fold injury, such as hemorrhage or mucosal disruption. Even then, it is virtually never indicated for more than 7-10 days. Absolute voice rest for 3 days is 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 for 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 reputations 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." This admonition frequently guides the affected singer away from preperformance conversations and backstage greetings and allows a successful series of performances.
Singers 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 for most patients. An urgent session with a speech-language pathologist is extremely helpful for discussing vocal hygiene and for providing guidelines to prevent voice abuse. Nevertheless, the singer must be aware that some risk is associated with performing with laryngitis even when singing 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 performance 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, though 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. Ultrasonic treatments, local massage, psychotherapy, and biofeedback directed at relieving anxiety and decreasing muscle tension may be helpful adjuncts to a broader therapeutic program. Psychotherapy and biofeedback, in particular, must be expertly supervised if used.
Voice lessons given by an expert teacher are invaluable. When technical dysfunction is suggested, the singer should be referred to one. Even when an obvious organic abnormality is present, referral to a voice teacher is appropriate, especially for younger singers. Numerous techniques permit a singer to overcome some of the impairments of mild illness safely. If a singer plans to proceed with a performance during an illness, the singer should not cancel voice lessons as part of the relative voice rest regimen; rather, a short lesson to ensure optimal technique can be 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 adverse effects, particularly mucosal drying, that are unacceptable for professional voice users. When medical management is not satisfactory, functional endoscopic sinus surgery may be appropriate. Acute purulent sinusitis is a different matter. It requires aggressive treatment with antibiotics, surgical drainage (sometimes), treatment of underlying conditions (eg, dental abscess), and surgery (occasionally).
Systemic Conditions
Aging
This subject is so important that it has been covered extensively in other literature. That many of the voice changes commonly associated with aging are not irreversible aging changes but rather consequences of conditioning or other correctable factors must be remembered. Geriatric voice conditions offer exciting possibilities for intervention.
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 be not only because of aesthetic difficulties in matching pitch but also because of the vocal strain that accompanies pitch shifts. In-depth discussion is not presented in this article because this subject is discussed in other literature.
Respiratory dysfunction
Respiratory impairment is especially problematic for professional performers. The importance of the breath has been well recognized in the field of voice pedagogy. Respiratory disorders are discussed at length in other literature. However, recognizing that obstructive pulmonary disease and its treatments may cause difficulty for voice professionals is important. Even mild asthma interferes with expiration, thereby undermining the power source of the voice. This commonly leads to compensatory hyperfunction, voice fatigue, and vocal injury.
Most pulmonologists treat asthma primarily with inhalers, which commonly cause laryngitis; steroid inhalers are also associated with fungal (candidal) laryngitis and possibly with vocal fold muscle atrophy. Whenever possible, singers and other voice professionals with obstructive lung disease should be treated with long-acting oral medications alone, minimizing or eliminating the need for inhalers. Recognizing that asthma can be induced by the exercise of phonation itself is particularly important, and in many cases, a high index of suspicion and a 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. Allergies commonly cause voice problems by altering the mucosa and secretions and causing nasal obstruction. Management of allergies is not covered in depth here, as this subject can be reviewed elsewhere. Patients with mild, intermittent allergies can usually be treated with antihistamines, although antihistamines should never be tried for the first time immediately before a performance. Because antihistamines commonly produce unacceptable adverse effects, trial and error may be needed to find a medication with an acceptable balance between positive effect and adverse effects 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 before an important voice commitment, corticosteroids should be used rather than antihistamines in order to minimize the risks of adverse effects (eg, drying and thickening of secretions) that may make performance difficult or impossible.
Gastroesophageal reflux laryngitis
Gastroesophageal reflux laryngitis is extremely common among patients, especially singers, with voice conditions. In this condition, the sphincter between the stomach and esophagus is inefficient, and acidic stomach secretions reach the laryngeal tissues, causing inflammation. The most typical symptoms of gastroesophageal reflux laryngitis are hoarseness in the morning, prolonged vocal warm-up time, sore throats, halitosis and a bitter taste in the mouth in the morning, recurrent respiratory tract infections, 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; thus, the diagnosis is often missed. Gastroesophageal reflux laryngitis is associated with the development of Barrett esophagus, esophageal carcinoma, and laryngeal carcinoma.
Physical examination usually reveals erythema and edema of the arytenoid mucosa and interarytenoid pachydermia. A barium swallow radiographic study with water siphonage may provide additional information, but it is not routinely needed. 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 done. This is often advisable for patients who are older than 40 years or who have had reflux symptoms for more than 5 years. Twenty-four hour pH impedance 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 diagnoses when symptoms are refractory to treatment and other physical and psychological 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, medications that decrease or block acid production, and avoidance of eating for 3-4 hours before going to bed. This is often difficult for singers and actors because of their performance schedules, 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.
Recognize 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. During the first 10 or 15 minutes of a performance or lesson, reflux often causes excessive phlegm and throat clearing, as well as other common reflux laryngitis symptoms, all of which may be present, even when acidity has been effectively neutralized. Laparoscopic Nissen fundoplication has proven extremely effective and should be considered a reasonable alternative to life-long treatment with medications in this relatively young patient population.
Endocrine dysfunction
Endocrine (hormonal) problems warrant special attention. The human voice is extremely sensitive to endocrinologic changes, and 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. 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 considered, especially if thyroid-stimulating hormone levels are in the high-normal range or are elevated. Thyrotoxicosis may result in similar voice disturbances.
Voice changes associated with sex hormones are commonly encountered in clinical practice and have been investigated more thoroughly than other hormonal changes. Although a correlation appears to exist between sex hormone levels and the depth of male voices (higher testosterone and lower estradiol levels in basses than in tenors), the most important hormonal considerations in males occur during the maturation process.
When castrato singers were in vogue, castration at approximately age 7-8 years resulted in failure of laryngeal growth during puberty, and voices that stayed in the soprano or alto range boasted a unique quality of sound. Failure of a male voice to change at puberty is uncommon today and is often psychogenic in etiology; however, hormonal deficiencies, such as those seen in cryptorchidism, delayed sexual development, Klinefelter syndrome, or Fröhlich syndrome, may be responsible. In these cases, a persistently high voice may be what causes the patient to seek medical attention.
Voice problems related to sex hormones are more common in female singers than in male singers. Although vocal changes associated with the normal menstrual cycle may be difficult to quantify with current experimental techniques, they unquestionably occur. Most of the ill effects are observed in the immediate premenstrual period and are known as laryngopathia premenstrualis. This common condition is caused by physiologic, anatomic, and psychological 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. The dysfunction is often more apparent to the singer than to the listener. Submucosal hemorrhages in the larynx are common in the premenstrual period. In many European opera houses, singers used to be excused from singing during the premenstrual and early menstrual days (ie, grace days). This practice is not followed in the United States and is no longer the trend in most European countries.
Premenstrual changes cause significant vocal symptoms in approximately one third of singers. Although ovulation inhibitors have been demonstrated to mitigate some of these symptoms, in some women (approximately 5%), oral contraceptives may deleteriously alter voice range and character even after only a few months of use. When oral contraceptives are used, closely monitor the voice. 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 very similar to laryngopathia premenstrualis occur in some women during ovulation.
Pregnancy frequently results in voice alterations known as laryngopathia gravidarum. The changes may be similar to premenstrual symptoms or may be perceived as desirable changes. In some patients, alterations produced by pregnancy are permanent. 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. Uterine muscle cramping associated with menstruation causes pain and compromises abdominal support. Abdominal distension during pregnancy also interferes with abdominal muscle function. Discourage any singer from singing whose abdominal support is substantially compromised until the abdominal function is resolved.
Estrogens are helpful in postmenopausal singers but generally should not be administered alone. Sequential replacement therapy is the most physiologic regimen and should be used under the supervision of a gynecologist. Under no circumstances should androgens, even in small amounts, be given to female singers if any reasonable therapeutic alternative exists. Clinically, these drugs most commonly are used to treat endometriosis. Androgens cause unsteadiness of the voice, rapid changes of timbre, and lowering of the fundamental frequency (ie, masculinization). These changes are usually permanent.
Recently, an increase in the abuse of anabolic steroids has occurred. In addition to their many other hazards, these medications may alter the voice. They are (or are closely related to) male hormones; consequently, anabolic steroids 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 also alter voice. For example, pancreatic dysfunction may cause xerophonia (dry voice), as in diabetes mellitus. Thymic abnormalities can lead to feminization of the voice.
For excellent patient education resources, visit eMedicine's Endocrine System Center. Also, see eMedicine's patient education article Thyroid Problems.
Neurologic disorders
Numerous neurologic conditions exist that may adversely affect the voice. 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 neurolaryngological discussion is beyond the scope of this article. Nevertheless, when evaluating voice dysfunction, laryngologists must consider numerous neurological problems, including Parkinson disease, various other disorders that produce tremor, drug-induced tremor, multiple sclerosis, and dystonias. Spasmodic dysphonia (SD), a laryngeal dystonia, presents particularly challenging problems.
Stuttering also provides unique challenges. Although still poorly understood, this condition is noted for its tendency to affect speech while sparing singing. These conditions are discussed in the literature by Sataloff and others.
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 professional voice user 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.
General illnesses, such as anemia, mononucleosis, autoimmune deficiency disorder (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 be associated with alterations of mucosal secretions. Other systemic illnesses may be responsible for voice problems, 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 (eg, sprained ankle) may alter posture and, therefore, may interfere with customary abdominothoracic support. Patients with voice disorders 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 problems (eg, vocal fatigue, neck pain) that bring the performer to the physician's office for assessment and care.
Anxiety
Good singers are frequently sensitive and communicative people. When the principal cause of vocal dysfunction is anxiety, the physician can often accomplish much by assuring the patient that no organic problem is present and by stating the diagnosis of anxiety reaction. The patient should be counseled that anxiety is normal and that recognition of it as the principal problem frequently allows the performer to overcome it.
Tranquilizers and sedatives are rarely necessary and are undesirable because they may interfere with fine motor control. For example, beta-adrenergic blocking agents (eg, propranolol hydrochloride) have become popular among performers for the treatment of preperformance anxiety.
Beta-blockers are not recommended for regular use; they have significant adverse effects on the cardiovascular system and many potential complications (eg, hypotension, thrombocytopenic purpura, mental depression, agranulocytosis, laryngospasm with respiratory distress, bronchospasm). Beta-blockers impede increases in heart rate, which are needed as physiologic response to the psychological and physical demands of performance.
In addition, the efficacy of beta-blockers is controversial. Although they may have a favorable effect in relieving performance anxiety, beta-blockers may produce a noticeable adverse effect on singing performance, as shown by Gates et al. Because the blood level of the drug established by a given dose of a beta-blocker varies widely among individuals, initial use of these agents before performance may be particularly troublesome. Although these drugs have a purpose under occasional extraordinary circumstances, their routine use for this purpose is potentially hazardous and violates an important therapeutic principle.
Performers have chosen a career that exposes them to the public. If such persons are so incapacitated by anxiety that they are unable to perform the routine functions of their chosen profession without chemical help, this should be considered symptomatic of an important underlying psychological problem. For a performer to depend on drugs to perform is neither routine nor healthy, whether the drug is a benzodiazepine, a barbiturate, a beta-blocker, or alcohol. If such dependence exists, psychological evaluation should be considered by an experienced arts-medicine psychologist or psychiatrist. Obscuring the symptoms by fostering the dependence is insufficient; however, if the singer is on tour and will be under a particular otolaryngologist's care only for a week or two, the physician should not try to make major changes in personal customary regimen. Rather, the physician should communicate with the performer's primary otolaryngologist or family physician to coordinate appropriate long-term care.
Because professional voice users constitute a subset of society, all the psychiatric disorders encountered in the general public are observed in professional voice users from time to time. In some cases, professional voice users require modification of the usual psychological treatment, particularly with regard to psychotropic medications. Detailed discussion of this subject can be found elsewhere in the literature, such as in the book Psychology of Voice Disorders by Rosen and Sataloff.4
When voice professionals, especially singers and actors, have a significant vocal impairment that results in voice loss or the prospect of voice loss, they often experience a psychological process very similar to grieving. In some instances, fear of discovering that the voice is lost forever may unconsciously prevent patients from trying to use their voices optimally following injury or treatment. This can dramatically impede or prevent recovery of function following a perfect surgical result, for example. Otolaryngologists, performers, and their teachers must be familiar with this fairly common scenario, and including an arts-medicine psychologist, psychiatrist, or both as part of the voice team is ideal.
Other psychological problems
Psychogenic voice disorders, incapacitating psychological reactions to organic voice disorders, and other psychological problems are commonly encountered in young voice patients. These disorders are discussed elsewhere in the literature.
Substance abuse
The list of substances ingested, smoked, or snorted is disturbingly long. Whenever possible, patients who care about vocal quality and longevity should be educated by their physicians and teachers about the deleterious effects of such habits upon their voices and on the longevity of their careers. A few specific substances are discussed above in Anxiety.
Other conditions
Numerous other conditions could be included in this article. For a more comprehensive discussion of the subjects covered above, the reader is referred to the related literature.
Medical Management For Voice Dysfunction
Interdisciplinary team
Medical management of many problems affecting the voice involves care prescribed by the otolaryngologist as well as voice therapy, which is provided by an interdisciplinary team. This section provides a brief introduction to the individual team members' roles in the medical milieu.
Speech-language pathologist
An excellent speech-language pathologist is an invaluable asset in caring for professional voice users. However, otolaryngologists and singing teachers should recognize that, like physicians, speech-language pathologists have varied backgrounds and experience in the treatment of voice disorders. In fact, most speech pathology programs teach relatively little about caring for professional speakers and nothing about caring for professional singers. Moreover, few speech-language pathologists have vast experience in this specialized area, and no fellowships in this specialty exist. Speech-language pathologists often subspecialize. A speech-language pathologist who expertly treats patients who have strokes, stutter, have undergone laryngectomy, or have swallowing disorders does not necessarily know how to optimally treat professional voice users.
The otolaryngologist must learn the strengths and weaknesses of the speech-language pathologist with whom he or she works. After identifying a speech-language pathologist who is interested in treating professional voice users, the otolaryngologist should work closely with this person in developing the necessary expertise. Assistance may be found through otolaryngologists who treat large numbers of singers or through educational programs such as the Voice Foundation's Symposium on Care of the Professional Voice. In general, therapy should be directed toward vocal hygiene, relaxation techniques, breath management, and abdominal support.
Speech (voice) therapy may be helpful even when a singer has no obvious problem in the speaking voice but significant technical problems singing. Once a person has been singing for several years, a singing teacher may have difficulty persuading him or her to correct certain technical errors. Singers are much less protective of their speaking voices. However, a speech-language pathologist may be able to teach proper support, relaxation, and voice placement in speaking. Once mastered, these techniques can be carried over fairly easily into singing through cooperation between the speech-language pathologist and the singing teacher. This "back-door" approach has been extremely useful.
For the actor, coordinating speech-language pathology sessions with acting voice lessons and especially with training of the speaking voice provided by the actor's voice teacher or coach is often helpful. In fact, the author has found this combination so helpful that an acting voice trainer has been added to the author's medical staff. Information from the speech-language pathologist, acting voice trainer, and singing teacher should be symbiotic and should not conflict. If major discrepancies exist, poor training from one of the team members should be suspected, and changes should be made.
Singing voice specialist
Singing voice specialists are singing teachers who have acquired extra training to prepare them to work with patients with an injured voice in collaboration with a medical voice team. These specialists are indispensable for singers.
In selected cases, singing lessons may also be extremely helpful to nonsingers with voice problems. The techniques used to develop abdominothoracic strength, breath control, laryngeal and neck muscle strength, and relaxation are similar to those used in speech therapy. Singing lessons often expedite therapy and appear to improve the outcome in some patients.
Otolaryngologists who frequently care for singers are often asked to recommend a voice teacher. This may put them in an uncomfortable position, particularly if the singer is already studying with someone in the community. Most physicians do not have sufficient expertise to criticize a voice teacher, and physicians must be extremely cautious about recommending that a singer change teachers; however, no certifying agency standardizes or ensures the quality of a singing teacher. Although a physician may be slightly more confident of a teacher associated with a major conservatory or music school or one who is a member of the National Association of Teachers of Singing (NATS), neither of these credentials ensures excellence, and many expert teachers have neither affiliation but are excellent teachers. With experience, an otolaryngologist ordinarily can develop valid impressions.
The physician should record the name of the voice teacher of every patient and observe whether the same kinds of voice abuse problems occur with disproportionate frequency in the students of any given teacher. The doctor should note whose students usually have few technical problems and are seen only for acute disease (eg, upper respiratory tract infection). Technical problems can cause organic abnormalities (eg, nodules); therefore, any teacher whose students have a high frequency of nodules should be viewed with cautious concern. The physician should be particularly wary of teachers who are reluctant to allow their students to consult a doctor. The best voice teachers are usually quick to refer their students to an otolaryngologist if they hear anything disturbing in a student's voice.
Similarly, voice teachers and voice professionals should compare information on the nature and quality of medical care received and its success. No physician cures every voice problem in every patient, just as no singing teacher produces a premiere star from every student. Nevertheless, voice professionals must be critical, informed consumers and accept nothing less than the best medical care. After seeing a voice patient, the otolaryngologist should write a letter to the voice teacher (with the patient's permission) describing the findings and recommendations.
An otolaryngologist seriously interested in caring for singers should take the trouble to talk with and meet local singing teachers. Taking a lesson or two with each teacher also provides enormous insight. Taking voice lessons regularly is even more helpful. In practice, otolaryngologists usually identify a few teachers in whom they have particular confidence, especially for patients with voice disorders. Otolaryngologists should not hesitate to refer singers to these colleagues, especially singers who are not already in training.
"Pop" singers may be particularly resistant to the suggestion of voice lessons, yet many are in great need of training. The physician should point out that a good voice teacher can teach a pop singer how to protect and expand the voice without changing its quality or making it sound trained or operatic. Pointing out that singing, like other athletic activities, requires exercise, warm-up, and coaching for anyone planning to enter the "big league" and stay there is helpful.
Just as no major league baseball pitcher would play without a pitching coach and warm-up time in the bullpen, no singer should try to build a career without a singing teacher and appropriate strength and agility exercises. This approach has proved palatable and effective. Physicians should also be aware of the difference between a voice teacher and a voice coach. A voice teacher trains a singer in singing technique and is essential. A voice coach is responsible for teaching songs, language, diction, style, and operatic roles but is not responsible for exercise and basic technical development of the voice.
Acting voice trainer
The use of acting voice trainers (drama voice coaches) as members of the medical team is new. This addition to the team has been extremely valuable to patients and other team members. Similar to singing voice specialists, professionals with education in theater arts use numerous vocal and body movement techniques that enhance physical function, release tension, and break down emotional barriers that may impede optimal voice function. Actors often open up to acting voice trainers; therefore, trainers may be able to identify psychological and emotional problems interfering with professional success that have been skillfully hidden from other professionals on the voice team and in the patient's life.
Others
A nurse, physician assistant, medical assistant, psychologist, psychiatrist, neurologist, pulmonologist, and others with special interest and expertise in arts (especially voice performance) medicine are also invaluable to the voice team. Every comprehensive center should seek out such people and collaborate with them, even if some of them are not full-time members of the voice team.
Surgery
A detailed discussion of laryngeal surgery is beyond the scope of this article; however, a few points are worthy of special emphasis.
Surgery for vocal nodules should be avoided whenever possible, and a performance almost never should occur without an adequate trial of expert voice therapy, including patient compliance with therapeutic suggestions. A minimum of 6-12 weeks of observation should be allowed while the patient is using therapeutically modified voice techniques under the supervision of a speech-language pathologist and ideally a singing voice specialist. Proper voice use rather than voice rest (silence) is correct therapy.
The surgeon should not perform surgery prematurely for vocal nodules under pressure from the patient for a quick cure and early return to performance. Permanent destruction of voice quality is a very real complication. Even after expert surgery, voice quality may be diminished by submucosal scarring, resulting in an adynamic segment along the vibratory margin of the vocal fold. This situation produces a hoarse voice with vocal folds that appear normal on indirect examination under routine light, though under stroboscopic light the adynamic segment is obvious.
No reliable cure exists for this complication. Even large, long-standing, apparently fibrotic nodules should be given a chance to resolve without surgery. In some patients, the nodules remain but produce no symptoms, and voice quality is normal. Stroboscopy in such patients usually reveals that the nodules are on the superior surface rather than the leading edge of the vocal folds during proper relaxed phonation (although they may be on the contact surface and produce symptoms when hyperfunctional voice technique is used and the larynx is forced down).
When surgery is indicated for vocal fold lesions, limit it as strictly as possible to the area of abnormality. Virtually no place exists for vocal fold stripping in professional voice users with benign disease. Submucosal resection through a laryngeal microflap was previously advocated; the technique was introduced and first published by this author. Microflap technique involved an incision on the superior surface of the vocal fold, submucosal resection, and preservation of the mucosa along the leading edge of the vocal fold.
The concept that led to this innovation was based on the idea that the intermediate layer of the lamina propria should be protected to prevent fibroblast proliferation. Consequently, preserving the mucosa as a biological dressing seemed reasonable. This technique certainly produced better results than vocal fold stripping; however, close scrutiny of outcomes revealed a small number of patients with poor results and stiffness beyond the limits of the original pathology. Consequently, the technique was abandoned in favor of a mini-microflap or of local resection strictly limited to the region of pathology as described by Sataloff.2
Lesions such as vocal nodules should be removed to a level even with the vibratory margin rather than deep into the submucosa. This minimizes scarring and optimizes return to good vocal function. Naturally, if concern about a serious neoplasm exists, proper treatment takes precedence over voice preservation. Surgery should be performed under microscopic control. Preoperative and postoperative objective voice measures are essential to allow outcome assessment and self-critique. Only through such study can surgical technique improve. Outcome studies are especially important in voice surgery because all technical pronouncements are anecdotal. No experimental model exists for vocal fold surgery; the human adult is the only species with a layered lamina propria.
Lasers are an invaluable adjunct in the laryngologist's armamentarium, but they must be used knowledgeably and with care. Considerable evidence suggests that healing time is prolonged and the frequency of adynamic segment formation is higher with the laser on the vibratory margin than with traditional instruments. In 2 early studies by Abitbol and Tapia et al, serious concerns were raised about dysphonia after laser surgery. Such complications may result from using too low a wattage, causing dissipation of heat deeply into the vocal fold; thus, high-power density for a short duration has been recommended. Small spot size is also helpful. Nevertheless, many laryngologists caring for voice professionals avoid laser surgery in most patients, pending further study.
When biopsy specimens are needed, they should be obtained before destroying the lesion with a laser. If a lesion is to be removed from the leading edge, the laser beam should be centered in the lesion rather than on the vibratory margin so that the beam does not create a divot in the vocal fold. The carbon dioxide laser is particularly valuable for cauterizing isolated blood vessels responsible for recurrent hemorrhage. Such vessels are often found at the base of a hemorrhagic polyp. At the suggestion of Jean Abitbol, MD, the author has been placing a small piece of ice on the vocal fold immediately before and after laser use to dissipate heat and help prevent edema. No studies on the efficacy of this maneuver exist, and more clinical experience is needed before drawing final conclusions, but the technique appears helpful.
Voice rest after vocal fold surgery is controversial. Although some laryngologists do not recognize its necessity at all, most physicians recommend voice rest for approximately 1 week or until the mucosal surface has healed. Even after surgery, absolute voice rest for more than 7-10 days is nearly never necessary and represents a real hardship for many patients.
Too often, the laryngologist is confronted with a desperate singer whose voice has been ruined by vocal fold surgery, recurrent or superior laryngeal nerve paralysis, trauma, or some other event or condition. Occasionally, the cause is as simple as a dislocated arytenoid that can be reduced. If the problem is an adynamic segment, decreased bulk of one vocal fold after stripping, bowing caused by superior laryngeal nerve paralysis, or some other serious complication in a mobile vocal fold, exercise great conservatism. None of the available surgical procedures for these conditions is consistently effective. If surgery is considered, the procedure and prognosis should be realistically explained to the patient. The patient must understand that the chances of returning the voice to professional quality are slim and that the voice may be worsened.
Zyderm collagen (Xomed) injection has been studied and is helpful in some difficult cases. More recent experience with human collagen shows even greater promise. Presently, collagen is not approved by the United States Food and Drug Administration (FDA) for use in the vocal fold. If used at all, the material should be used under protocol with institutional review board approval. Collagen may be particularly helpful for small, adynamic segments. In the author's opinion, the best technique for extensive vocal fold scarring is the recently introduced method of autologous fat implantation into the vibratory margin. Occasionally, voice professionals inquire about surgery for pitch alteration. Such procedures have been successful in specially selected patients (such as those undergoing sex-change surgery), but they do not consistently provide good enough voice quality and range to be performed in a professional voice user.
Discretion
The excitement and glamour associated with caring for a famous performer may naturally tempt the physician to talk about a distinguished patient; however, this tendency must be tempered. The knowledge that a voice professional has consulted a laryngologist, particularly for treatment of a significant vocal problem, is not always in the voice professional's best interest. Famous singers and actors are ethically and legally entitled to the same confidentiality ensured for other patients.
Voice maintenance
Prevention of vocal dysfunction should be the goal of all professionals involved in the care of professional voice users. Encourage good vocal health habits in childhood. Discourage screaming, particularly outdoors at athletic events. Promising young singers who join choirs should be educated to compensate for the Lombard effect. Young persons interested in singing should receive enough training to prevent voice abuse and should receive enthusiastic support for singing works suitable for the appropriate age and voice. Training should be continued during or after puberty, and the voice should be allowed to develop naturally without pressure to perform operatic roles prematurely.
Excellent regular training and practice are essential. Stress the importance of avoiding irritants, particularly smoke, early on. Educating the singer with regard to hormonal and anatomic alterations that may influence the voice allows him or her to recognize and analyze vocal dysfunction, compensating for it intelligently when it occurs. The body is dynamic, changing over a lifetime; the voice is no exception.
Continued vocal education, training, and monitoring are necessary throughout a lifetime, even in the most successful and well-established singers. Vocal problems in premiere singers are commonly caused by cessation of lessons, excessive schedule demands, and other correctable problems rather than by irreversible ravages of aging. Anatomic, physiologic, and serious medical problems may affect the voices of singers of any age. Cooperation among the laryngologist, speech-language pathologist, acting teacher, singing teacher, and conductor provides an optimal environment for cultivation and protection of the vocal artist.
Multimedia
 | Media file 1: Vocal fold polyp (VFP) found during office videostroboscopy. |
Keywords
voice professional, vocal artist, voice abuse, nodules, submucosal cysts, polyps, granulomas, Reinke's edema, polypoid degeneration, chronic polypoid chorditis, chronic edematous hypertrophy, sulcus vocalis, vocal fold scar, vocal fold hemorrhage, laryngeal papilloma, vocal fold hypomobility, laryngitis, sinusitis, upper respiratory tract infection, URTI, gastroesophageal reflux laryngitis, postnasal drip, arts-medicine, professional singers, vocal fold immobility, laryngeal cancer
More on Common Medical Diagnoses and Treatments in Professional Voice Users |
| References |
References
Brodnitz FS. Hormones and the human voice. Bull N Y Acad Med. Feb 1971;47(2):183-91. [Medline].
Sataloff RT, Spiegel JR, Heuer RJ. Laryngeal mini-microflap: a new technique and reassessment of the microflap saga. J Voice. Jun 1995;9(2):198-204. [Medline].
Wellens W, Snoek R, Desloovere C, et al. Treatment of severe laryngeal papillomatosis with intralesional injections of cidofovir. In: McGrafferty G, Coman W, Carroll R, eds. Sydney 1997, Proceeding XVI World Congress of Otorhinolaryngology Head and Neck Surgery. Bologna, Italy:. 1997:455-459.
Rosen DC, Sataloff RT. Psychology of Voice Disorders. San Diego, Calif: Singular Publishing Group; 1997:1-261.
Chijiwa H, Chitose S, Umeno H, Ueda Y, Nakashima T. [Voice reconstruction of the recurrent laryngeal nerve after nerve resection]. Nippon Jibiinkoka Gakkai Kaiho. Mar 2009;112(3):116-21. [Medline].
Brodnitz F. Medical care preventive therapy. In: Lawrence V, ed. Transcripts of the Seventh Annual Symposium, Care of the Professional Voice. NY:. The Voice Foundation;1978:3-86.
Abitbol J. Limitations of the LASER in microsurgery of the larynx. Transactions of the 12th Symposium: Care of the Professional Voice. 1984;297-301.
Abitbol J. Limitations of the laser in microsurgery of the larynx. In: Lawrence VL. Transactions of the Twelfth Symposium: Care of the Professional Voice. New York, NY: he Voice Foundation; 1984.
Blitzer A, Brin M, Saski C, et al. Neurologic Disorders of the Voice. Thieme; 1992:3-285.
Bourdial J. [Voice disorders caused by androgen hormonal therapy]. Ann Otolaryngol Chir Cervicofac. Dec 1970;87(12):725-34. [Medline].
Brodnitz FS. The age of the castrato voice. J Speech Hear Disord. Aug 1975;40(3):291-5. [Medline].
Carroll C. Personal communication with von Leden D. Arizona State University at Tempe.
Damaste PH. Virilization of the Voice due to Anabolic Stereoids. Folia Phoniatr (Basel). 1964;16:10-8. [Medline].
Damste PH. Voice change in adult women caused by virilizing agents. J Speech Hear Disord. May 1967;32(2):126-32. [Medline].
Dordain M. [Statistical study on the influence of hormonal contraceptives on the voice. Preliminary results]. Folia Phoniatr (Basel). 1972;24(2):86-96. [Medline].
Flach M, Schwickardi H, Simen R. Welchen Einfluss haben Menstruation and Schwangerschaft auf die augsgebildete Gesangsstimme?. Folia Phoniatr. 1968;21:199-210.
Ford CN, Bless DM. Collagen injected in the scarred vocal fold. J Voice. 1988;1(1):116-118.
Gates GA, Saegert J, Wilson N, et al. Effect of beta blockade on singing performance. Ann Otol Rhinol Laryngol. Nov-Dec 1985;94(6 Pt 1):570-4. [Medline].
Gupta OP, Bhatia PL, Agarwal MK, et al. Nasal, pharyngeal, and laryngeal manifestations of hypothyroidism. Ear Nose Throat J. Sep 1977;56(9):349-56. [Medline].
Hochman I, Sataloff RT, Hillman RE, Zeitels SM. Ectasias and varices of the vocal fold: clearing the striking zone. Ann Otol Rhinol Laryngol. Jan 1999;108(1):10-6. [Medline].
Imre V. [Hormone induced voice disorders]. Folia Phoniatr (Basel). 1968;20(6):394-404. [Medline].
Lacina O. [The influence of menstruation on the voice of female singers. Premenstrual laryngopathy]. Folia Phoniatr (Basel). 1968;20(1):13-24. [Medline].
Malinsky M, Chevrie-Muller, Cerceau N. [Clinical and electrophysiological study of voice changes in thyrotoxicosis (author's transl)]. Ann Endocrinol (Paris). Mar-Apr 1977;38(2):171-2. [Medline].
Meuser W, Nieschlag. [Sex hormones and depth of voice in the male (author''s transl)]. Dtsch Med Wochenschr. Feb 25 1977;102(8):261-4. [Medline].
Michelsson K, Sirvio P. Cry analysis in congenital hypothyroidism. Folia Phoniatr (Basel). 1976;28(1):40-7. [Medline].
Pahn J, Goretzlehner G. [Voice disorders following the use of hormonal contraceptives]. Zentralbl Gynakol. 1978;100(6):341-6. [Medline].
Punt NA. Vocal disabilities of singers. Applied laryngology--singers and actors. Proc R Soc Med. Nov 1968;61(11 Part 1):1152-5. [Medline].
Ritter FN. Endocrinology. In: Paparella M, Shumrick D. Otolaryngology. Philadelphia, Pa: WB Saunders Co; 1973:727-734.
RITTER FN. THE EFFECT OF HYPOTHYROIDISM ON THE LARYNX OF THE RAT. AN EXPLANATION FOR HOARSENESS ASSOCIATED WITH HYPOTHYROIDISM IN THE HUMAN. Ann Otol Rhinol Laryngol. Jun 1964;73:404-16. [Medline].
Rubin J, Sataloff RT, Korovin G. Diagnosis and treatment of voice disorders. San Diego, Calif. 3rd ed. San Diego, Calif: Plural Publishing, Inc; 2006.
Saez S, Sakai F. [Androgen receptors in the cytosol of normal mucosa and of pharyngo- laryngeal epitheliomas in humans]. C R Acad Sci Hebd Seances Acad Sci D. Feb 17 1975;280(7):935-8. [Medline].
Sataloff RT. Professional Voice: Science and Art of Clinical Care. 3rd ed. San Diego, Calif: Plural Publishing, Inc.; 2006.
Sataloff RT. Professional voice: the science and art of clinical care, 3rd ed. San Diego, Calif:Plural Publishing, Inc.; 2005.
Sataloff RT, Bough ID Jr, Spiegel JR. Arytenoid dislocation: diagnosis and treatment. Laryngoscope. Nov 1994;104(11 Pt 1):1353-61. [Medline].
Sataloff RT, Castell DO, Katz PO, Sataloff DM. Reflux Laryngitis and Related Disorders. San Diego, Calif:. Singular Publishing Group;1999:1-112.
Sataloff RT, Castell DO, Katz, PO, Sataloff DM. Reflux Laryngitis, 3rd ed. San Diego, Calif:Plural Publishing, Inc.; 2006 [in press].
Sataloff RT, Feldman M, Darby KS, Carroll LM. Arytenoid dislocation. J Voice. 1988;1(4):368-377.
Sataloff RT, Spiegel JR, Hawkshaw M, et al. Autologous fat implantation for vocal fold scar: a preliminary report. J Voice. Jun 1997;11(2):238-46. [Medline].
Schiff M. The "pill" in otolaryngology. Trans Am Acad Ophthalmol Otolaryngol. Jan-Feb 1968;72(1):76-84. [Medline].
Schiff M. The influence of estrogens on connective tissue. In: Asboe-Hansen G, ed. Hormones and Connective Tissue. Munksgaard Press;1967:282-341.
Sundberg J, Prame E, Iwarsson J. Replicability and accuracy of pitch patterns in professional singers. In: Vocal Fold Physiology: Controlling Chaos and Complexity. Sydney, Australia:. Singular Publishing Group;1995:291-306.
Tapia RG. Effects of the LASER upon Reinke's space and the neural system of the vocalis muscle. Transactions of the 12th Symposium: Care of the Professoinal Voice. 1984;289-291.
Tapia RG, Pardo J, Marigil M, Pacio A. Effects of the laser upon Reinke's space and the neural system of the vocalis muscle. In: Lawrence VL, ed. Transactions of the Twelfth Symposium: Care of the Professional Voice. New York, NY: The Voice Foundation;1984:289-291.
van Gelder L. Psychosomatic aspects of endocrine disorders of the voice. J Commun Disord. Sep 1974;7(3):257-62. [Medline].
von Deuster C. [Irreversible vocal changes in pregnancy (author''s transl)]. HNO. Dec 1977;25(12):430-2. [Medline].
von Leden H. Presentation at the Seventh Symposium on Care of the Professional Voice. New York, NY:. The Juilliard School;1978.
Vuorenkoski V, Lenko HL, Tjernlund P, et al. Fundamental voice frequence during normal and abnormal growth, and after androgen treatment. Arch Dis Child. Mar 1978;53(3):201-9. [Medline].
Wendler J. [Cyclicly dependent variations in efficiency of the voice and its influencing by ovulation inhibitors]. Folia Phoniatr (Basel). 1972;24(4):259-77. [Medline].
Zeitels SM, Sataloff RT. Phonomicrosurgical resection of glottal papillomatosis. J Voice. Mar 1999;13(1):123-7. [Medline].
Further Reading
Keywords
voice professional, vocal artist, voice abuse, nodules, submucosal cysts, polyps, granulomas, Reinke's edema, polypoid degeneration, chronic polypoid chorditis, chronic edematous hypertrophy, sulcus vocalis, vocal fold scar, vocal fold hemorrhage, laryngeal papilloma, vocal fold hypomobility, laryngitis, sinusitis, upper respiratory tract infection, URTI, gastroesophageal reflux laryngitis, postnasal drip, arts-medicine, professional singers, vocal fold immobility, laryngeal cancer
