Allergic, dietary, chemical, stress, and hormonal influences in voice abnormalities

Allergic, dietary, chemical, biochemical, stress, and hormonal abnormalities have long been recognized as important factors in both abnormalities of the voice and in the general health of the professional vocalist. In recent years objective methods have become available to evaluate and treat allergic, dietary, and chemical abnormalities and to better understand the effects of stress and hormonal variations. Assessment of allergic disease is efficient and cost effective through the use of in vitro testing techniques combined with skin end point titration. This provides highly specific and objective results and leads to accurate planning of desensitization treatment. This form of treatment can be especially beneficial in the prevention of recurrent laryngitis. An accurate nutritional history provides evidence of food sensitivities that can lead to cyclical allergic-like vocal symptoms that can be prevented with the use of elimination diets and the judicious use of desensitization therapy. An adequate knowledge of the potential effects of chemical sensitivities will assist the patient in the avoidance of provocative chemical exposures. An in depth evaluation of biochemical abnormalities and a specific assessment of the nutritional status must be considered to evaluate the underlying causes of long-standing general health problems that can affect the voice. Likewise, hormonal variations are not only important in their direct effects on the vocal mechanism but in their cyclical effects on the patient's basic biochemical balance. Lastly, stress, which has long been related to problems in professional performance, is only now being fully studied to determine its actual biologic influences and these must be related to the causes of voice disturbances. Understanding all these influences and planning a rational and efficient evaluation of these potential problem areas are imperative in the complete care of the patient with voice abnormalities.     

Voice changes in women treated for endometriosis and related conditions: The need for comprehensive vocal assessment

Hormonal treatments which have an androgenic effect have the potential to cause vocal changes. The changes in vocal fold structure and voice quality are considered to be irreversible. To date, studies have documented subjective vocal changes or documented single cases without detailed, baseline voice assessments. The impact on laryngeal function of women taking these androgenic treatments requires further detailed, objective assessment. The need for increased awareness of the actions of androgenic hormones on womns' voices, and the benefits of a thorough voice assessment are discussed.     

Effects of Testosterone Replacement on a Male Professional Singer

Testosterone has been known to play an important role in the development of the postpubertal male voice for many centuries. In fact, the prevention of pubertal development of the voice by castrating young male singers was a well-known practice, especially in Italy beginning in the sixteenth century. The “castrati” were well known for their clear, high-pitched voices. Because of the resulting small larynx and vocal folds, castrati apparently produced a distinctive resonance as well as the high pitch, which cannot be matched even by the counter tenors of today. Busy voice labs occasionally see males with sex hormone deficiencies secondary to chromosomal or gonadal problems. This is a presentation of an unusual patient who was a trained tenor singer and was found to have hypogonadism on a premarital health examination. Administration of replacement testosterone resulted in significant vocal register and voice quality changes.     

Vocal Fatigue—Do Young Speech-Language Pathologists Practice What They Preach?

PurposeSpeech-Language Pathologists can be categorized as Level II professional voice users who play the roles of voice therapist or vocal coach to treat voice problems. SLPs may be at the risk of experiencing vocal fatigue due to vocal loading and other contributing factors. The present study was undertaken to find the percentage of SLPs reporting vocal fatigue, the probable factors resulting in vocal fatigue, the measures that are taken to avoid/reduce the occurrence of vocal fatigue, its effect on their professional and personal life and the measures taken to tackle it.ResultsThe results of this study are based on data collected from 142 SLPs and 50 controls using a questionnaire. 71.13% SLPs reported that they experience vocal fatigue. Some of the contributing factors that are mainly reported are long durations of voice use, voice use for recreational purposes, speaking loudly, frequent throat clearing, lack of adequate hydration and working in noisy or air-conditioned environments. The major symptoms reported were dryness in throat, tightness in neck and shoulder, choking sensation, effortful speech and pain in the throat. 59% SLPs reported that vocal fatigue affected their professional life while 44% SLPs reported that it affects their personal life also to varying degrees. Measures taken to avoid/ reduce the occurrence of vocal fatigue included vocal warm up, break in between sessions, and play activities. Only a few SLPs took intervention measures like ENT consultation, voice therapy, and home remedies.ConclusionSLPs are inevitably at high risk of experiencing vocal fatigue which, if left untreated, will lead to organic voice problems. However, many young SLPs who experience vocal fatigue reported vocal abuse, do not follow vocal hygiene program and do not follow evidence-based preventive or intervention practices to treat vocal fatigue.     

The effects of preventive vocal hygiene education on the vocal hygiene habits and perceptual vocal characteristics of training singers

The purpose of the present study was to determine the effects of vocal hygiene education on the vocal hygiene behaviors and perceptual vocal characteristics of untrained singers. Eleven adult untrained singers served as subjects. They attended four 1-hour class sessions on vocal hygiene, including anatomy and physiology of the phonatory mechanism, vocally abusive behaviors, voice disorders commonly seen in singers, and measures to prevent voice disorders. Pre- and postinstruction surveys were used to record subjects' vocal abuses and their perceptions of their speaking and singing voice. They also rated their perceived value of vocal hygiene education. Results revealed minimal changes in vocal hygiene behaviors and perceptual voice characteristics. The subjects did report a high degree of benefit and learning, however.     

Prevalence of voice symptoms and risk factors in teacher students

Teacher students seem to have low awareness of the vocal demands in their future professions, and students with vocal symptoms are at risk for developing voice disorders during their professional careers. The purpose of the present study was to determine the prevalence of voice problems in teacher students at the very beginning of their education at the university. Of 1636 students approached in the first couple of days, 1250 (76%) answered two questionnaires about voice symptoms, Screen6 and Swedish Voice Handicap Index (Sw-VHI), and one questionnaire about potential risk factors. A majority of the students were women, and their mean age was 23 years (range, 18-52 years). The results showed that 208 of 1250 students (17%) had voice problems, defined as at least two symptoms weekly or more often in Screen6. The proportion of women was larger in the group with voice problems than in the group without voice problems. Significant risk factors for voice problems were vocal fold problems in childhood and adulthood, frequent throat infections, airborne allergy, smoking, hearing problems, previous work as teacher or leader, voice demanding hobbies, and previous speech therapy or voice training. There was a clear association between the number of potential vocal risk factors and the number of voice symptoms. There was also a strong association between the scores of the two questionnaires, the Sw-VHI and the Screen6. Students with voice problems according to Screen6 scored 23.1 (mean Sw-VHI) compared with 7.8 for students without voice problems.     

Effect of Hydration and Vocal Rest on the Vocal Fatigue in Amateur Karaoke Singers

Karaoke singing is a very popular entertainment among young people in Asia. It is a leisure singing activity with the singer's voice amplified with special acoustic effects in the backdrop of music. Music video and song captions are shown on television screen to remind the singers during singing. It is not uncommon to find participants singing continuously for four to five hours each time. As most of the karaoke singers have no formal training in singing, these amateur singers are more vulnerable to developing voice problems under these intensive singing activities. This study reports the performance of 20 young amateur singers (10 males and 10 females, aged between 20-25 years) on a series of phonatory function tasks carried out during continuous karaoke singing. Half of the singers were given water to drink and short duration of vocal rests at regular intervals during singing and the other half sang continuously without taking any water or rest. The subjects who were given hydration and vocal rests sang significantly longer than those who did not take any water or rest. The voice quality, as measured by perceptual and acoustic measures, and vocal function, as measured by phonetogram, did not show any significant changes during singing in the subjects who were given water and rest during the singing. However, subjects who sang continuously without drinking water and taking rests showed significant changes in the jitter measure and the highest pitch they could produce during singing. These results suggest that hydration and vocal rests are useful strategies to preserve voice function and quality during karaoke singing. This information is useful educational information for karaoke singers.     

Expanding perspectives in care of the speaking voice

The effective voice clinician has always had to borrow from various disciplines: voice science, otolaryngology, psychology, and speech-language pathology. Such eclecticism requires, however, that the clinician integrate the perspectives of these various disciplines into some kind of theoretical clinical bias. One bias might be that with greater use of instrumentation in voice therapy, the voice clinician must not substitute data collection for attending to the feelings of the patient. By using the clinical input from various disciplines, for example, voice clinicians might develop a useful clinical perspective that vocal hyperfunction is one of the primary causes of many voice disorders. Consequently, from such a clinical view might come a treatment perspective that can clearly define the problem (too much effort while speaking) and offer a rationale for voice remediation.     

Vocal Tract Resonance Analysis of Aging Voice Using Long-Term Average Spectra

This study is the first to use long-term average spectra (LTAS) to investigate resonance characteristics of dynamic speech in young adulthood and old age. A total of 80 speakers participated, divided equally by age group and gender. All elderly speakers were healthy, active members of the community. Measurement of the first three spectral peaks in LTAS from the first paragraph of the Rainbow Passage revealed significant lowering of peak 1 from young adulthood to old age in both men and women. Peaks 2 and 3 also lowered significantly across the adult lifespan in women and showed a tendency to lower in men. These acoustic findings are consistent with anatomic data suggesting that aging results in lengthening of the supraglottic vocal tract. Findings that women demonstrate more substantial lowering of spectral peaks with aging than men suggest that women may undergo more pronounced age-related lengthening of the supraglottic vocal tract. Alternatively, it is possible that elderly men systematically alter tongue position during vowel articulation while elderly women are less inclined to do so. Taken in conjunction with previous research, these findings suggest a "mixed model" of vocal tract resonance changes with aging in which an interaction exists between gender, the resonance effects of laryngeal lowering, and vowel articulatory patterns.     

Normal strobovideolaryngoscopy: Variability in healthy singers

Strobovideolaryngoscopy has proven essential to accurate diagnosis of voice disorders. Clinical interpretation of stroboscopic images usually follows a standard assessment protocol. Features analyzed typically include symmetry of amplitude, symmetry of phase, regularity of periodicity, amplitudes and wave forms of individual vocal folds, presence or absence of a dynamic segments, and other features. Speed and smoothness of abduction and adduction are also assessed. In order for stroboscopic data to be used meaningfully in a clinical setting, it is essential for the laryngologist to recognize the range of normal variability of these parameters. This may be particularly important when trying to establish diagnoses for subtle voice disorders in professional voice users. This study investigates strobovideolaryngoscopic findings in a population of normal professional singers without voice complaints. “Abnormal” strobovideolaryngoscopic findings occur in this asymptomatic population of “volunteers”. These abnormalities might have been misinterpreted as causing voice complaints if seen for the first time when the singer sought medical care for a voice problem. Physicians must be aware of the range of laryngeal behavior that may be found among normal subjects and must be cautious when interpreting strobovideolaryngoscopic findings. This study also highlights the importance of obtaining “normal” baseline strobovideolaryngoscopic evaluations on professional voice users. The review of strobovideolaryngoscopy performed upon 65 healthy, asymptomatic professional singers revealed an incidence of 58% “abnormal” findings as six clinical entities.     

Relationship between changes in voice pitch and loudness

Changes in mean fundamental frequency accompanying changes in loudness of phonation are analyzed in 9 professional singers, 9 nonsingers, and 10 male and 10 female patients suffering from vocal functional dysfunction. The subjects read discursive texts with noise in earphones, and some also at voluntarily varied vocal loudness. The healthy subjects phonated as softly and as loudly as possible at various fundamental frequencies throughout their pitch ranges, and the resulting mean phonetograms are compared. Mean pitch was found to increase by about half-semitones per decibel sound level. Grossly, the subject groups gave similar results, although the singers changed voice pitch more than the nonsingers. The voice pitch changes may be explained as passive results of changes of subglottal pressure required for the sound level variation.     

Simulated effects of cricothyroid and thyroarytenoid muscle activation on adult-male vocal fold vibration

Adjustments to cricothyroid and thyroarytenoid muscle activation are critical to the control of fundamental frequency and aerodynamic aspects of vocal fold vibration in humans. The aerodynamic and physical effects of these muscles are not well understood and are difficult to study in vivo. Knowledge of the contributions of these two muscles is essential to understanding both normal and disordered voice physiology. In this study, a three-mass model for voice simulation in adult males was used to produce systematic changes to cricothyroid and thyroarytenoid muscle activation levels. Predicted effects on fundamental frequency, aerodynamic quantities, and physical quantities of vocal fold vibration were assessed. Certain combinations of these muscle activations resulted in aerodynamic and physical characteristics of vibration that might increase the mechanical stress placed on the vocal fold tissue.     

Acoustic Measures of Phonatory Improvement Secondary to Treatment by Oral Corticosteroids in a Professional Singer: A Case Report

Short-term administration of corticosteriods is sometimes indicated for professional voice users experiencing laryngeal edema and/or inflammation. Unfortunately, no data are available to document the effectiveness of these medications to improve phonatory parameters. We present a case report of a 32-year-old male professional singer with vocal fold edema experiencing imminent vocal demands who was prescribed a 6-day course (dose-pack) of oral methyl prednisolone. Endoscopic and stroboscopic evaluations were completed premedication and postmedication, and acoustic measures of phonatory function were obtained premedication, 3 days during the dose cycle, 5 days during the dose cycle, and 1 day postmedication. Postmedication results revealed an increase in fundamental frequency (F0) and large decreases in jitter, shimmer, long-term frequency, and amplitude variability. These corresponded with patient and evaluator perceptual measures of improved voice, and with endoscopic observations of reduced edema. The benefits and risks of corticosteroid therapy are discussed, specific to their use in the professional voice population.     

Phonotrauma associated with crying

Vocal fold hemorrhage often results in a sudden change in voice quality. Traumatic use of the voice (phonation or singing) is generally thought to be the cause of the vocal fold hemorrhage. The current report reviews three cases in which the traumatic event was crying. In one case, the patient's voice was only used for crying. All three patients were female and all were professional singers. The treatment of these individuals consisted of voice rest and subsequent phonomicrosurgery for lesions associated with the vocal fold hemorrhage. These case studies suggest that crying as a traumatic vocal behavior may result in vocal fold hemorrhage.     

Sex hormones and the female voice

In the following, the authors examine the relationship between hormonal climate and the female voice through discussion of hormonal biochemistry and physiology and informal reporting on a study of 197 women with either premenstrual or menopausal voice syndrome. These facts are placed in a larger historical and cultural context, which is inextricably bound to the understanding of the female voice. The female voice evolves from childhood to menopause, under the varied influences of estrogens, progesterone, and testosterone. These hormones are the dominant factor in determining voice changes throughout life. For example, a woman's voice always develops masculine characteristics after an injection of testosterone. Such a change is irreversible. Conversely, male castrati had feminine voices because they lacked the physiologic changes associated with testosterone. The vocal instrument is comprised of the vibratory body, the respiratory power source and the oropharyngeal resonating chambers. Voice is characterized by its intensity, frequency, and harmonics. The harmonics are hormonally dependent. This is illustrated by the changes that occur during male and female puberty: In the female, the impact of estrogens at puberty, in concert with progesterone, produces the characteristics of the female voice, with a fundamental frequency one third lower than that of a child. In the male, androgens released at puberty are responsible for the male vocal frequency, an octave lower than that of a child. Premenstrual vocal syndrome is characterized by vocal fatigue, decreased range, a loss of power and loss of certain harmonics. The syndrome usually starts some 4-5 days before menstruation in some 33% of women. Vocal professionals are particularly affected. Dynamic vocal exploration by televideoendoscopy shows congestion, microvarices, edema of the posterior third of the vocal folds and a loss of its vibratory amplitude. The authors studied 97 premenstrual women who were prescribed a treatment of multivitamins, venous tone stimulants (phlebotonics), and anti-edematous drugs. We obtained symptomatic improvement in 84 patients. The menopausal vocal syndrome is characterized by lowered vocal intensity, vocal fatigue, a decreased range with loss of the high tones and a loss of vocal quality. In a study of 100 menopausal women, 17 presented with a menopausal vocal syndrome. To rehabilitate their voices, and thus their professional lives, patients were prescribed hormone replacement therapy and multi-vitamins. All 97 women showed signs of vocal muscle atrophy, reduction in the thickness of the mucosa and reduced mobility in the cricoarytenoid joint. Multi-factorial therapy (hormone replacement therapy and multi-vitamins) has to be individually adjusted to each case depending on body type, vocal needs, and other factors.     

Vocal fold nodules in adult singers: Regional opinions about etiologic factors, career impact, and treatment. A survey of otolaryngologists, speech pathologists, and teachers of singing

This study was undertaken to better understand current regional opinions regarding vocal fold nodules in adult singers. A questionnaire was sent to 298 persons representing the 3 professional groups most involved with the care of singers with vocal nodules: otolaryngologists, speech pathologists, and teachers of singing. The questionnaire queried respondents about their level of experience with this problem, and their beliefs about causative factors, career impact, and optimum treatment. Responses within and between groups were similar, with differences between groups primarily in the magnitude of positive or negative responses, rather than in the polarity of the responses. Prevailing opinions included: recognition of causative factors in both singing and speaking voice practices, optimism about responsiveness to appropriate treatment, enthusiasm for coordinated voice therapy and voice training as first-line treatment, and acceptance of microsurgical management as appropriate treatment if behavioral management fails.     

Efficacy of a Behaviorally Based Voice Therapy Protocol for Vocal Nodules

The aim of this study was to assess the effects on vocal function of voice therapy for vocal nodules. Perceptual and physiological progressive changes were examined during a strictly structured, behaviorally based voice therapy protocol in which 11 women with vocal nodules participated. Randomized audio recordings from pretherapy and from each of the therapy approaches (vocal hygiene, respiration, direct facilitation, carryover) were used for perceptual evaluations. Six speech-language pathologists rated ten voice quality parameters. Two evaluation procedures were performed and compared. Interlistener reliability was sufficiently high in both tests. Significant effects of therapy were found for decreased overall dysphonia, press, instability, gratings, roughness, vocal fry, and "scrape." Nonsignificant group effects were found for breathiness, aphonic instances, and lack of sonority. No significant parameter changes occurred between baseline assessment and the completion of the initial (vocal hygiene) phase of therapy. Significant changes were found following the direct facilitation and respiration phases of therapy. Videostroboscopic evaluations made by two laryngologists showed that in no case were the nodules completely resolved. However, the nodules had decreased in size and edema was reduced after therapy for all clients, but one. Combined results suggest: (1) Alterations in vocal function were reflected in perceptual parameters, and (2) the voice therapy had a positive effect on voice quality, vocal status, and vocal function for the majority of the vocal nodule clients.     

Vocal aging and the impact on daily life: a longitudinal study

Longitudinal studies on vocal aging are scarce, and information on the impact of age-related voice changes on daily life is lacking. This longitudinal study reports on age-related voice changes and the impact on daily life over a time period of 5 years on 11 healthy male speakers, age ranging from 50 to 81 years. All males completed a questionnaire on vocal performance in daily life, and perceptual and acoustical analyses of vocal quality and analyses of maximum performance tasks of vocal function (voice range profile) were performed. Results showed a significant deterioration of the acoustic voice signal as well as increased ratings on vocal roughness judged by experts after the time period of 5 years. An increase of self-reported voice instability and the tendency to avoid social parties supported these findings. Smoking males had a lower speaking fundamental frequency compared with nonsmoking males, and this seemed reversible for males who stop smoking. This study suggests a normal gradual vocal aging process with clear consequences in daily life, which should be taken into consideration in clinical practice as well as in studies concerning communication in social life.     

Effects of environmental noise on computer-derived voice estimates from female speakers

The purpose of this study was to examine the influence of noise on voice profile statistics from female samples. Six young adult females served as subjects. Five had normal voices; one had a pathological voice with accompanying bilateral vocal nodules. Each female subject was required to match a generated 235 Hz tone (+/- 2 Hz) while maintaining a constant output level of 70 dB SPL (+/- 5 dB). Data collected from a previous study involving a normal male subject were included for comparative purposes. Noise was generated from a personal computer fan which had a strong center frequency component at 235 Hz. Six different A-weighted signal-to-noise [S/N(A)] conditions were created, ranging in 5 dB increments from 25 to 0 dB. Results revealed that fundamental frequency was reasonably resistant to the effects of noise and to the effects of the noisy (pathological) voice signal. Jitter and shimmer estimates generally increased as noise floors elevated. The greatest amount of measurement error was found for the pathological female voice when captured in the presence of environmental noise. Findings are discussed relative to clinical issues surrounding measurement error.     

Influence of glottal closure configuration on vocal efficacy in young normal-speaking women

Posterior closure insufficiency of the glottis is often mentioned in connection with permanent voice disorders. Recently published studies have revealed that an incomplete closure of the glottis can be found also in normal-speaking voices, especially in women. However, the effect of glottal closure configuration on vocal efficacy is not sufficiently clarified. The purpose of this study was to determine the effect of glottal closure configuration on singing and speaking voice characteristics. Overall, 520 young female normal-speaking subjects were examined by videostroboscopy for different phonation conditions in the combination of soft, loud, low, and/or high phonation and by voice range profile measurements. According to the videostroboscopic analysis, the subjects were subdivided into four groups: complete closure of the vocal folds already in soft phonation (group 1), closure of the vocal fold with increasing intensity (group 2), persistent closure insufficiencies despite increasing intensity (group 3), and hourglass-shaped closure in subjects with vocal nodules (group 4). Subjects in which the glottal closure could not be evaluated sufficiently were subclassified into group 5 (missing values).

Selected criteria of the singing and speaking voice were evaluated and statistically processed according to the mentioned subclassification. Group 1 reached significantly the highest sound pressure levels (SPL_max) for the singing voice as well as for the shouting voice. Group 3 showed a limited capacity to increase the intensity of the singing and speaking voice. The results gathered in this study objectify the relationship of insufficient glottal closure and reduced vocal capabilities. As long as no conclusive data on long-term consequences of insufficient glottal closure are available, a prophylactic improvement of the laryngeal situation especially in female professional voice users by voice therapy should be recommended.