“Alternative medical therapy” use among singers: Prevalence and implications for the medical care of the singer

Singers are extremely conscious of health problems that affect their voices and well-being and often take an active role in seeking care for these problems. They frequently seek treatment from providers or with modalities considered “alternative” to traditional medical care. A survey of singers was completed to elucidate their attitudes and practices regarding “alternative modalities” of medical care. Frequently singers will self-medicate or take advice from people not well versed in the special needs of a professional voice user. They will fail to share this information with the physician when seeking “traditional” medical care. These practices may predispose the singer to suboptimal or even dangerous care. These results are discussed, as well as the implications for the medical physician treating the singer. The possible detrimental pharmacologic effects of “natural therapies” widely used by singers are presented, with special attention to the particular concerns for the professional singer     

Vocal fold hemorrhage associated with coumadin therapy in an opera singer

Vocal fold hemorrhage can represent a disastrous and potentially career ending injury to a singer or professional voice user. The risk factors of vocal fold hemorrhage, including laryngeal trauma, phonotrauma, aspirin and nonsteroidal antiinflammatories, and hormonal imbalances are well known. We present a case of an opera singer who developed recurrent vocal fold hemorrhage associated with coumadin anticoagulation therapy. This case highlights the importance of the risk of vocal fold hemorrhage to professional singers and professional voice users and offers an alternative to long-term coumadin therapy in this select population.     

Airway Considerations for Professional Singers—A Survey of Expert Opinion

The objective of this study was to survey physician experts in voice disorders/treatment to establish consensus guidelines for translaryngeal intubation (TLI) and tracheotomy when treating professional singers or other voice professionals. A written survey was sent to all physician members of the Voice Foundation seeking opinions/recommendations about route of TLI, duration of TLI before tracheotomy, size of endotracheal and tracheotomy tubes, and special interventions during patient care as these might differ between professional singers and nonsingers. Fifty-five percent of the physicians responded, of whom 73% classified their experience in voice care as “extensive.” A strong consensus (76%) favored a smaller endotracheal tube for singers (6–7 mm I.D. for males and 6.0 mm I.D. for females) via the oral (46%) versus nasal (36%) route. Intubation/extubation by the most expert/experienced personnel was emphasized so as to minimize direct trauma to the larynx. While intubated, strong recommendations were made to suppress gastric acid production and to minimize motion of the endotracheal tube, including patient sedation. Preferences for an early tracheotomy (6 days) versus their usual time (10 days) were approximately equal (44% vs. 50%, respectively) and most respondents (69%) recommended the same size tracheotomy tube (8.0 mm I.D. for males and 6.0 mm I.D. for females) for singers and nonsingers. Post extubation/decannulation care emphasized voice rest, retraining, continued gastric acid suppression, and the possibility of direct laryngoscopy to assess post-TLI or tracheotomy injuries.     

Taxonomy of singers used as subjects in scientific research

Criteria for determining the classification of singers in research has posed numerous problems for both researchers and their readership. Previous attempts at creating usable categories have failed because of disagreement within the professions involved in such research. The object of this paper is to explore and suggest a system in which scientific research related to singing is based on a quantifiable singing standard. Use of the systematic categorization set out in this paper will help to alleviate the questions regarding performance abilities of singers used as subjects in scientific projects and lead to more credible results. Nine singer categories have been consolidated and based on proven performance achievement. These categories range from superstar (household name) to local community and amateur singers with comprehensive subcategories under each topic for each type of singer, that is, opera, pop, jazz, etc.     

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.     

Vocal fold microsurgery in singers

Some singers with benign vocal fold mucosal lesions remain unacceptably impaired vocally in spite of compliance with a regimen of medical treatment and voice therapy lasting several months—or even years. I present here my experience with 62 singers who, because of this predicament, chose to undergo vocal fold microsurgery. This series is the second largest reported to date in English literature. Procedures are presented which were used for patient selection, education, and vocal retraining, as well as for surgery itself and postoperative care. Results reported here include (a) comparison of my auditory-perceptual ratings of singing voice impairment before and after surgery, (b) preoperative versus postoperative videostroboscopic findings, (c) postoperative rate of return to public singing, and (d) postoperative patient questionnaires which sought to uncover patient/singer perceptions of the results of vocal fold surgery. Excellent results were achieved overall with a very low incidence of untoward results, and no complications were encountered.     

Long-Term Horizontal Vocal Directivity of Opera Singers: Effects of Singing Projection and Acoustic Environment

Vocal directivity refers to how directional the sound is that comes from a singer's mouth, that is, whether the sound is focused into a narrow stream of sound projecting in front of the singers or whether it is spread out all around the singer. This study investigates the long-term vocal directivity and acoustic power of professional opera singers and how these vary among subjects, among singing projections, and among vastly different acoustic environments. The vocal sound of eight professional opera singers (six females and two males) was measured in anechoic and reverberant rooms and in a recital hall. Subjects sang in four different ways: (1) paying great attention to intonation; (2) singing as in performance, with all the emotional connection intended by the composer; (3) imagining a large auditorium; and (4) imagining a small theatre. The same song was sung by all singers in all conditions. A head and torso simulator (HATS), radiating sound from its mouth, was used for comparison in all situations. Results show that individual singers have quite consistent long-term average directivity, even across conditions. Directivity varies substantially among singers. Singers are more directional than the standard HATS (which is a physical model of a talking person). The singer's formant region of the spectrum exhibits greater directivity than the lower-frequency range, and results indicate that singers control directivity (at least, incidentally) for different singing conditions as they adjust the spectral emphasis of their voices through their formants.     

Influence of anabolic steroid treatment associated to physical exercise in the ultrasonic vocalization of rats

Unlike humans, who communicate in frequency bands between 250 Hz and 6 kHz, rats can communicate in frequencies above 18 kHz. Their vocalization types depend on the context and are normally associated to subjective or emotional states. It was reported significant vocal changes due to administration of replacement testosterone in a trained tenor singer with hypogonadism. Speech-Language Pathology clinical practices are being sought by singers who sporadically use anabolic steroids associated with physical exercise. They report difficulties in reaching and keeping high notes, "breakage" in the passage of musical notes and post singing vocal fatigue. Those abnormalities could be raised by the association of anabolic steroids and physical exercise. Thus, in order to verify if this association could promote vocal changes, maximum, minimum and fundamental frequencies and call duration in rats treated with anabolic steroids and physically trained (10 weeks duration) were evaluated. The vocalizations were obtained by handling the animals. At the end of that period, rats treated and trained showed significant decrease in call duration, but not in other parameters. The decrease in call duration could be associated to functional alterations in the vocal folds of treated and trained animals due to a synergism between anabolic steroids and physical training.     

Clinical management of country and western singers

The particular problems faced by country and western singers have not often been studied. While making the words of the songs easily understood and creating a desired mood, country and western singers often strain their larynx. Usually, they do not benefit from the guidance of a vocal coach or have the social or economic background to seek early help or to know how to approach and enter the medical care delivery system. Even when they seek help, many speech pathologists, vocal coaches, and physicians are unfamiliar with their specific problems. Therapy for country and western singers depends on an accurate diagnosis and a clear understanding of their unique problems.     

The control of air flow during loud soprano singing

Previous research on the special characteristics of the professional singing voice has at least partially explained how singers can commonly use much higher lung pressures than nonsingers without vocal damage or excessive air flow during the voiced sounds. In this study, the control of air flow during the unvoiced consonants is examined for an operatic-style soprano. It was found that this singer could maintain a low average air flow during the consonants even though the lung pressure reached values over five times those used during normal conversational speech. The air flow was kept low primarily by the use of a number of mechanisms involving rapid, accurate, coordinated valving of the air flow at the point of articulation and at the glottis.     

Hearing myself with others: Sound levels in choral performance measured with separation of one's own voice from the rest of the choir

The choir singer has two acoustic signals to attend to: the sound of his or her own voice (feedback), and the sound of the rest of the choir (reference). The balance in loudness between feedback and reference is governed mainly by the room acoustics. Although earlier experiments have shown that singers have a fairly large tolerance for imbalance, with references ranging from −23 to +5 dB, experience suggests that, when singers are given control over this parameter, their preferences are much narrower. A quantification of the optimum balance would be useful in the design of concert stages and rehearsal halls. A method is described for measuring the feedback and reference levels as experienced by singers under live performance conditions. Recordings were made using binaural microphones worn by choir singer subjects. With the given combination of choir and room, it was possible to achieve adequate separation of the feedback and reference signals with simple signal processing. The feedback-to-reference ratio averaged over the 12 singers was found to be +3.9 dB, with extremes of +1.5 and +7.3 dB.     

Speaking fundamental frequency characteristics as a function of age and professional singing

The purposes of this project were to discover (1) if the speaking fundamental frequency (SFF) levels of professional singers differ significantly from those of nonsingers and (2) if the age-related SFF patterns are similar for these two classes of individuals. Sixty professional singers and 94 nonsingers were recorded reading the first paragraph of the “Rainbow Passage;” both males and females were included. Three paired groups (young, middle, and old age) were studied; they were selected on the basis of health and age. The professional singer groups were further divided by a binary voice classification system, specifically that of soprano/alto for women and tenor/baritone for men. It was found that the sopranos and tenors exhibited significantly higher SFF levels then did the age-matched nonsingers, whereas the altos and baritones did not differ significantly from the controls. Relationships within the performer groups were mixed. For example, there appeared to be a systemic trend for the sopranos and tenors to exhibit higher SFF levels than the altos and baritones. Finally, although the nonsinger SFF levels varied significantly as a function of age, those for the professional singers did not.     

Discrimination Functions: Can They Be Used to Classify Singing Voices?

Researchers long have searched for invariant acoustic features that can be used to identify singing voice categories or even individual singers. Few researchers have examined how listeners perceive singing voice categories or individual voices. Timbre, the most studied perceptual dimension of the singing voice, is generally believed to vary systematically between singing voice categories but is often assumed to be invariant with an individual singer. To test this assumption, 2 mezzo-sopranos and 2 sopranos were recorded singing the vowel /a/ on the pitches A3, C4, G4, B4, F5, and A5. Trials of three stimuli were constructed. Two of the three stimuli in each trial were produced by the same singer at two different pitches (X₁ and X₂), while the third stimulus was produced by a different singer (Y). Three X₁X₂ conditions were created: (1) G4, B4; (2) C4, F5; and (3) A3, A5. For each singer and each condition, Y was varied across the three remaining singers and across all six pitches. Experienced and inexperienced listeners were asked to identify which stimulus was produced by the “odd” person. The ability to correctly choose the odd person varied greatly depending on pitch factors, suggesting that the traditional concept of an invariant timbre associated with a singer is inaccurate and that vocal timbre must be conceptualized in terms of transformations in perceived quality that occur across an individual singer's range and/or registers.     

Effects of Topical Anesthetic and Flexible Fiberoptic Laryngoscopy on Professional Sopranos

This study examined the acoustic and perceptual effects of topical anesthetic and flexible fiberoptic laryngoscopy (FFL) against a control condition on the singing voices of ten professional sopranos. Recordings of a section of an aria, various scales, and a messa di voce exercise were obtained in the three experimental conditions. Acoustic analyses of the same aria section recorded during the three conditions were similar with respect to the distribution of energy across the spectrum (LTAS) and vibrato rate and extent. The ability of the participants to achieve their highest and lowest notes or to complete the messa di voce was also not affected by the anesthetic or FFL. Perceptual ratings of a variety of parameters by experienced singing teachers also revealed little difference across conditions with only "appropriate velopharyngeal closure" found to differ in one comparison. These results indicate that highly experienced operatic sopranos are either not affected by or appear to have the ability to compensate for the presence of anesthetic and the FFL. The most likely explanation is that this group of singers relied on a solid vocal technique. Results will need to be replicated on less accomplished singers before concluding that this medical procedure does not affect the operatic singing voice.     

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.     

24 Hours prior to curtain

A retrospective review was conducted of 40 singers presenting with acute voice problems prior to performance. The purpose of this study was to determine the reasons for seeking emergent voice treatment, the types of acute voice disorders, and the performance outcome. The patients were assessed by age, singing style, years of experience, chief complaint, laryngovideostroboscopic findings, and treatment regimens. The outcomes were classified as full, restricted, or no performance. The majority of patients were classical singers. Laryngovideostroboscopy frequently revealed a pattern of early glottic contact at the mid-portion of the membranous vocal fold in patients with acute laryngitis. Experienced singers uniformly sought treatment many days before their performance compared with inexperienced singers who presented closer in time to performance. Six patients initially withheld information, which had a bearing on their acute management. The results of this study suggest that there is a need to accurately diagnose and treat the singer's emergent problem and educate singers regarding early evaluation of medical problems. With modern evaluation techniques and multi-modality treatment, 85% of the singers proceeded to full performance without negative sequelae.     

Nonconscious control of fundamental voice frequency

The aim of this paper is to answer the question whether "perception-action" dissociation, which is well documented in vision, may also be found in auditory information processing. Trained singers were asked to produce vowel sounds into a microphone. The sound that each singer produced was fed back to their ears via headphones. Two seconds after the sound production had begun, the auditory feedback was shifted in pitch by a certain degree (9, 19, 50, or 99 cents in either direction). In every set of sounds, instances without any pitch shifts also appeared. After each trial, participants reported whether they were aware of a pitch change or not. It was found that even though the participants were unaware of subtle pitch changes, the fundamental frequency of their vowel production was found to shift slightly in the opposite direction to the pitch shift. These results show that auditory information is processed by two separate systems: one for perception and one for action. They also show that the function of the auditory control system differs from the visual control system. The latter is used to control bodily movements while the function of the former is a nonconscious, instant control of vocalization.     

Comparing historical and contemporary opera singers with historical and contemporary Jewish cantors

This study is an attempt to ascertain if singers from different traditions and milieus follow similar aesthetic trends regardless of training and/or background. Cantors who sang the Jewish synagogue liturgy during the Golden Age of cantorial singing prior to World War II came from Eastern and Central Europe. For the most part, they were not trained in the classical Western opera tradition. They received training from choir leaders and other cantors and the training was primarily in the modes of synagogue chant. Cantors today receive the same kinds of training that opera singers receive, often from the same teachers. Four groups of singers, consisting of four singers in each group, were utilized in this study. The four groups are: historical opera singers, contemporary opera singers, historical cantors, and contemporary cantors. The historical opera singer recordings date from as early as 1909 to as late as 1939. It was not possible to determine the dates of the historical cantor recordings. However, the four cantors chosen for this group were active only to the 1940s. Contemporary samples were taken from CDs and/or live recordings and all the singers from the contemporary groups are either still active or were active in the 1960s through the 1980s and all of them are considered to be premier-level singers in their respective areas. The variables analyzed were: vibrato pulse rate, frequency variation of the vibrato pulse above and below the mean sustained sung frequency in percent, the mean amplitude variation of the amplitude vibrato pulse above and below the mean sustained amplitude in percent and the fast Fourier transform (FFT) power spectrum of the sustained samples. Results indicate that most of the significant differences were found between eras and not between groups within a time period.     

Phonational profiles of female professional singers and nonsingers

Measures of the SFF, vocal intensity, phonational range, and habitualpitch level are reported for 39 professional singer and 39 nonsinger females, who were divided into three age groups (young, middle, and old age), with the professionals further divided into sopranos and altos. Each read the “Rainbow Passage” and spoke extemporaneously, from which measures of the SFF and vocal intensity were calculated; phonational range and habitual pitch levels were also determined. No significant differences were noted between the reading and speaking tasks. The SFF and intensity levels were significantly higher for the professionals in comparison to the nonsingers, but only for certain age groups. Moreover, whereas the nonsinger SFF levels varied significantly as a function of age, those for the professional singers did not. Although trends occurred, no significant differences were found for the mean phonational range or habitual pitch levels when the professionals and nonsingers were compared.