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CARE OF THE PROFESSIONAL VOICE Robert T. Sataloff, MD, DMA, Associate Editor Consulting a Voice Doctor: When?

Yolanda D. Heman-Ackah, MD, Robert T. Sataloff, MD, DMA, Mary J. Hawkshaw, BSN, RN, CORLN, Venu Divi, MD

Modified from: Heman-Ackah, Y.D., Sataloff, R.T., Hawkshaw, M.J., Divi, V.D. “Protecting The Vocal Instrument,” in press.

NITIALLY, THE ANSWER TO THE QUESTION “When should I see a voice doctor?” would seem obvious: When you are sick. However, the correct answer is more complex than that. Singing teachers should be familiar with the value of consultation with an expert Ilaryngologist not only during illnesses and crises, but also prior to training, for evaluation, establishing an individual’s “normal” base- line, and for education and advice regarding preventive voice care. Finding the right voice doctor is the subject of another article in Journal of Singing, but this article is to help singing teachers understand bet- Yolanda Heman-Ackah Robert Sataloff ter when a laryngologist (voice specialist) should be consulted, and especially when one should be consulted urgently.

PREVENTIVE VOICE CARE Anyone who relies on one’s voice for his or her profession should have a baseline laryngeal function and videostroboscopic examination with a laryngologist when the voice is functioning optimally and without difficulty. This examination will help to diagnose any potential areas of concern that may contribute, in the long term, to the development of debilitating voice difficulties. Entities such as asymptomatic reflux, Mary Hawkshaw Venu Divi mild asymmetries in vocal fold motion, mild , tonsil enlargement, nasal septal deviation, nasal congestion, nasal polyps, and others that may not be causing any symptoms or difficulties presently, but that may contribute to the development of unhealthy behaviors or voice problems can be identified and recommendations can be made by the laryngologist and voice team on how to prevent these entities from becoming problematic. Additionally, asymptomatic benign lesions such as polyps, , pseudocysts (localized swelling in the vocal fold), areas of stiffness, sulcus vocalis (benign indentations in the vocal fold), and others can be identified. Knowing that these lesions exist when the voice is functioning normally can prevent a misdiagnosis and mis- guided treatment that otherwise may focus on these lesions as the cause of a voice problem that develops in the future. Because everyone is at risk for , trauma, and the need for nonvoice that Journal of Singing, September/October 2008 may require general anesthesia, everyone is at risk for the develop- Volume 65, No. 1, pp. 53–58 Copyright © 2008 ment of voice problems regardless of one’s level of training, technical National Association of Teachers of Singing prowess, or use of proper voice technique.

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Yolanda D. Heman-Ackah, MD, Robert T. Sataloff, MD, DMA, Mary J. Hawkshaw, BSN, RN, CORLN, Venu Divi, MD

SUDDEN HOARSENESS sentence, phrase, or performance, immediately follow- ing surgery, or immediately following a coughing/ Probably the most pressing reason to see a voice clinician vomiting episode. is to evaluate acute voice disorders that may worsen if left untreated. These usually are characterized by the sudden onset of hoarseness and can be precipitated by myriad events, including trauma, voice overuse or mis- a. use, and infection. The sudden onset of hoarseness during or immedi- ately after intense vocal use implies injury to the vocal fold. This may be in the form of hemorrhage (Figure 1), tear (Figure 2), or edema (Figure 3). Hemorrhage oc- curs when there is trauma to one of the blood vessels within the vocal fold and it begins to bleed. Usually the bleeding is beneath the surface of the vocal fold mucosa and the only symptom of the bleeding is the occurrence b. of hoarseness and occasionally soreness or pain in the throat.1 A vocal fold tear occurs when there is disrup- tion of the mucous membrane of the vocal fold, usually from intense yelling, screaming, or forceful singing.2 Edema is swelling in response to vocal fold trauma or infection. Vocal fold tears can also occur during episodes of or other upper respiratory tract or gastroin- testinal , usually as a result of coughing force- fully or from the dry heaves associated with vomiting. The c. placement of an endotracheal (breathing) tube by an anesthesiologist for surgery can also result in vocal fold tears, and whenever possible the smallest (5.0mm to 6.0mm inner diameter) plastic endotracheal tube that will allow adequate ventilation (artificial breathing) dur- ing the general anesthesia is recommended for profes- sional voice users undergoing nonvoice surgery. Each of these entities represents a vocal emergency and should Figure 2. Vocal fold tear (a), with be evaluated immediately, especially if the hoarseness resolution after 1 week (b) and 4 weeks began abruptly enough to interrupt the conclusion of a (c) of voice rest.

right left

Figure 1. Right Vocal fold hemorrhage. Figure 3. Vocal fold edema.

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The treatment of vocal fold hemorrhage varies de- falling of the neck onto the handlebars of a bicycle, or pending upon the degree of bleeding. In most instances, strangulation or choking injuries to the neck. Injuries a period of absolute voice rest is all that is needed. On oc- from blunt neck trauma can include nerve paresis (weak- casion, the hemorrhage is significant enough to warrant ness), cartilage fracture, joint dislocation, and vocal immediate surgical drainage. In these cases, if left alone, fold hemorrhage, edema, or tear.3 These injuries can be the hemorrhage may organize to form a polyp and/or potentially life threatening, especially if the airway col- scarring of the vocal fold. lapses suddenly or if swelling develops following the Vocal fold tears are treated with a period of voice rest injury. Immediate medical attention, even if mild hoarse- to allow the tear to heal. If the tear is superficial, usu- ness is the only symptom, is recommended in all cases. ally healing will occur without significant sequelae if the Many individuals who suffer a blunt neck injury feel voice is rested. If the tear is deep, there is greater poten- fine initially, and swelling or a sudden shift in the frac- tial for scarring, which can have more significant long- tured cartilages occurs minutes or hours after the trauma term implications. In either case, if one continues to obstructing the airway in a manner that can be life phonate on a vocal fold that is torn, the risk of perma- threatening. nent scarring appears to increase. Once scarring of the During such injuries, the recurrent laryngeal nerve vocal fold has formed, it is difficult to treat and often can become crushed between the spine and the cricoid results in permanent hoarseness and/or difficulty with cartilage, resulting in a nerve paresis. This typically man- register transitions. ifests as hoarseness or breathiness in the voice. Vocal fa- Edema of the vocal fold occurs from several causes, in- tigue and effortful also can occur. The treat- cluding phonotrauma from forceful closure of the vo- ment of vocal fold paresis from neck trauma is usually cal folds. This can occur in an individual who is yelling symptomatic (including voice ), and unless the or screaming, in one who is trying to talk or sing with an nerve is severed, function will usually return over the upper respiratory tract infection, as well as in those who course of weeks to months. are trying to project the voice by increasing pressure in Fracture of the laryngeal cartilages and dislocation of the vocal folds. Edema alone usually requires a period of the cricothyroid and/or cricoarytenoid joints can also relative voice rest or light voice use. Relative voice rest is occur as a result of neck trauma. Symptoms of these in- near complete silence, reserving the voice for urgent juries usually include hoarseness, pain, and occasion- communication only. Light voice use is minimal talk- ally difficulty breathing. Fracture or dislocation is a med- ing, usually no more than five minutes per hour and no ical emergency and warrants evaluation by a laryngologist more than one minute continuously at a time. On oc- or otolaryngologist to determine whether the airway is casion, corticosteroids can be used to speed recovery at risk and whether surgical intervention is necessary. from vocal fold edema, but they should be used cau- There is a high potential for airway compromise, which tiously. Typically, steroids cause one to feel and sound could become life threatening. Even in the absence of much better than the actual health of the vocal folds and airway compromise, the determination as to whether a can predispose to further vocal fold trauma if attention fracture or dislocation should be corrected is best made to good vocal technique is not employed while using within the first 24–48 hours after injury. During this these medications. time frame, attempts at reduction of the fractured or dislocated segments are easiest and are most likely to NECK TRAUMA yield the best long-term results. If too much time is al- External trauma to the neck can result in injury to the lowed to pass before treatment is initiated, scarring and and requires urgent evaluation by a doctor. Such healing of the fragments in abnormal locations may oc- trauma can occur from incidents such as elbow injuries cur, which may limit the success of attempts at reduc- to the neck while playing basketball or during a stage tion and result in permanent hoarseness or problems fight, from automobile accidents in which the neck hits with breathing that is difficult to correct after healing the steering wheel or is caught by the safety belt, the has begun.4

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Yolanda D. Heman-Ackah, MD, Robert T. Sataloff, MD, DMA, Mary J. Hawkshaw, BSN, RN, CORLN, Venu Divi, MD

HOARSENESS AFTER SURGERY Hoarseness after a surgical procedure not performed on the larynx warrants special mention. During general anesthesia for most surgical procedures, an endotra- cheal (breathing) tube is placed into the larynx, between the vocal folds, to help maintain respiration while the patient is asleep. Vocal fold trauma (mucosal tear or hemorrhage) is a well recognized complication of anes-

thesia and usually is managed with voice rest. In some Figure 4. Vocal fold . individuals, the placement of the endotracheal tube can result in injury to a vocal fold or even dislocation of the arytenoid cartilage off its location on the cricoid carti- lage. This dislocation may happen occasionally with even the most skilled of anesthesiologists. Usually, the pa- tient awakens from anesthesia with a hoarse voice that does not improve with time. Arytenoid dislocations are best treated as early as possible to prevent permanent scarring around the dislocated cartilage. If scar forms, re- duction can become difficult. As soon as the diagnosis is suspected, consultation with an otolaryngologist should be made.5 Figure 5. Vocal fold papilloma. Another cause of hoarseness after nonlaryngeal sur- gery is injury to the recurrent or superior laryngeal nerves. This may occur during any surgical procedure that and may include corticosteroids, collagen injection, is performed in the vicinity of the nerves and occasion- gelfoam injection, fat injection, or thyroplasty to place ally after intubation for surgery outside of the head and the vocal fold in a favorable position for eating and speak- neck. Because the nerves travel a long route from the ing while it recovers. A nerve that is suspected of having brain, into the neck and chest, and back through the been severed should be repaired as soon as the suspi- neck to enter the larynx, injury may occur with surgery cion is raised to maximize the chances of maintaining 6 in any location along this route. Like arytenoid disloca- good laryngeal tone. tion, patients who experience injury to the laryngeal nerves during surgery usually awaken from surgery with PROLONGED HOARSENESS a hoarse and/or breathy voice. All patients who have hoarseness after nonvoice sur- Anyone who experiences hoarseness or another vocal gery should have their larynx examined immediately by difficulty that persists longer than two weeks should a laryngologist. Differentiation between an arytenoid have his/her larynx evaluated by a laryngologist or oto- dislocation and can be difficult in these in- laryngologist. It is rare for a “laryngitis” alone to persist stances, and diagnosis usually is made with the aid of for more than two weeks, even if the hoarseness began laryngeal examination, laryngeal , and during an upper respiratory tract infection. In such in- computed tomography scanning. stances, the persistent hoarseness may be due to a mild The treatment of laryngeal nerve injury varies de- paresis of the vocal folds, and this should be evaluated.7 pending upon whether the nerve is suspected of having Alternatively, other in the larynx, including been cut or just stretched. A stretched, intact nerve usu- (Figure 4) and human papilloma virus infections ally will recover on its own over the course of weeks to (Figure 5), may begin with a similar presentation and months. Treatment in these instances is symptomatic should be evaluated. If left untreated, these lesions may

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grow large enough to obstruct the airway, limit breath- 7. G. Dursun, R. T. Sataloff, J. R. Spiegel, S. Mandel, R. J. Heuer, ing, and potentially cause death. and D. C. Rosen, “Superior Laryngeal Nerve Paresis and Paralysis,” Journal of Voice 10, no. 2 (1996): 206–211. CONCLUSION Yolanda D. Heman-Ackah, MD, is a laryngologist who specializes in There are several instances in which the larynx defi- professional voice care. She is board certified by the American Board of nitely should be evaluated promptly. These include Otolaryngology and is a fellow of the American Academy of Otolaryngol- hoarseness that is abrupt in onset, hoarseness that be- ogy—Head and Neck Surgery. She received her Bachelor of Arts degree gins immediately following nonvoice surgery, trauma in Psychology and her Doctor of degree from Northwestern Uni- to the larynx or neck, and hoarseness that persists for versity as part of the Honors Program in . Following longer than two weeks, even if the onset was during the her residency in otolaryngology—head and neck surgery at the Univer- course of an upper respiratory tract infection. The rea- sity of Minnesota, she completed a fellowship in professional voice care sons for evaluation in these instances are the prevention and under the preceptorship of Robert T. Sataloff, MD, DMA, at the American Institute for Voice and Ear Research and Jefferson Med- of long-term sequelae such as permanent hoarseness, ical College of Thomas Jefferson University in Philadelphia. In addition scarring, vocal fold lesions, and the diagnosis and treat- to her medical training, Dr. Heman-Ackah is also a professionally trained ment of potentially life threatening illnesses such as can- dancer, a musician, and a vocalist. cer, tumors, and airway compromise. Having a baseline She founded and directed the Voice Center at the University of Illinois at laryngeal evaluation when vocal production is optimal Chicago upon completion of her fellowship. After a few years in Chicago, is also advocated as a preventive health measure. she joined the practice of Drs. Robert T. Sataloff and Karen M. Lyons in Knowledge of one’s unique anatomy in the “normal” Philadelphia, where she specializes in professional voice care and other state will help to guide diagnosis and treatment should aspects of otolaryngology—head and neck surgery as they pertain to voice difficulties later arise, whether they be from disease, the performing artist and professional voice user. She is an active mem- infection, trauma, or abnormal use patterns. It is also ber of the academic faculties of Drexel University College of Medicine, invaluable for voice teachers to be aware of baseline vo- where she currently holds the position of Associate Professor, and Thomas cal fold abnormalities and to document them prior to Jefferson University. She is the National Medical Advisor for the Voice and Speech Trainer’s Association (VASTA) and is actively involved in starting lessons with a new student, whenever possible. VASTA, The Voice Foundation, the National Association of Teachers of Singing (NATS), the Latin Academy of Recording Arts and Sciences, and NOTES the National Academy of Recording Arts and Sciences (the Grammy Foun- 1. Y. D. Heman-Ackah and R. T. Sataloff, “Blunt Trauma to the dation). She has authored or coauthored numerous publications, includ- Larynx and Trachea: Considerations for the Professional Voice ing award-winning journal articles, book chapters, and several books. User,” Journal of Singing 59, no. 1 (September/October 2002): She is a member of the Editorial Board of the Journal of Voice, and is an 41–47. editorial reviewer for other medical journals. 2. Ibid. 3. Y. D. Heman-Ackah, G. S. Goding, Jr., and V. Rao, “Laryngo- Robert T. Sataloff, MD, DMA is Professor and Chairman of the De- tracheal Trauma,” in J. S. Rubin, R. T. Sataloff, and G. S. Korovin, partment of Otolaryngology—Head and Neck Surgery and Associ- eds., Diagnosis and Treatment of Voice Disorders, 3rd edition ate Dean for Clinical Academic Specialties at Drexel University College (San Diego: Plural Publishing, Inc., 2006). of Medicine. He is also on the faculty at Thomas Jefferson University, the University of Pennsylvania, Temple University, and the Academy 4. R. T. Sataloff, M. Feldman, K. S. Darby, L. M. Carroll, and J. of Vocal Arts. Dr. Sataloff is Conductor of the Thomas Jefferson Uni- R. Spiegel, “Arytenoid Dislocation,” Journal of Voice 1, no. 1 versity Choir and Orchestra and Director of The Voice Foundation’s (1987): 368–377; R. T. Sataloff, I. D. Bough, and J. R. Spiegel, Annual Symposium on Care of the Professional Voice. Dr. Sataloff is “Arytenoid Dislocation: Diagnosis and Treatment,” Laryngoscope also a professional singer and singing teacher. He holds an under- 104 (1994): 1353–1361; R. T. Sataloff, The Science and Art of graduate degree from Haverford College in Music Composition, grad- Clinical Care, 3rd edition (San Diego: Plural Publishing, Inc., uated from Jefferson Medical College, received a DMA in Voice 2005). Performance from Combs College of Music, and completed his Res- 5. Ibid. idency in Otolaryngology—Head and Neck Surgery at the University 6. Y. D. Heman-Ackah and M. Batory, “Determining the Cause of Michigan. He also completed a Fellowship in Otology, Neurotol- of Mild Vocal Fold Hypomobility,” Journal of Voice (in press). ogy, and Skull Base Surgery at the University of Michigan. Dr. Sataloff

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is Chairman of the Board of Directors of The Voice Foundation and received a Bachelor of Science degree in Nursing from Thomas Jeffer- of the American Institute for Voice and Ear Research. He is Editor-in- son University in Philadelphia. In collaboration with Dr. Sataloff, she has Chief of the Journal of Voice, Editor-in-Chief of the Ear, Nose and coauthored more than 60 book chapters, 130 articles, and four text- Throat Journal, an Associate Editor of the Journal of Singing, and books. She is on the Editorial Board of the Journal of Voice, Ear, Nose on the Editorial Board of Medical Problems of Performing Artists and and Throat Journal, and the Journal of the Society of Otorhinolaryngol- numerous major otolaryngology journals in the United States. Dr. ogy and Head—Neck Nurses since 1998. She is recognized nationally and Sataloff has written over 650 publications, including thirty-eight internationally for her extensive involvement in care of the professional voice. books. Dr. Sataloff’s medical practice is limited to care of the profes- sional voice and to otology/neurotology/skull base surgery. Venu Divi, MD is Assistant Professor in the Department of Otolaryngol- ogy—Head and Neck Surgery at Drexel University College of Medicine. Mary J. Hawkshaw, BSN, RN, CORLN, is Research Associate Professor in the Department of Otolaryngology—Head and Neck Surgery at Drexel He received his undergraduate education at Kent State University and University College of Medicine. She has been associated with Dr. Robert his medical training at Northeastern Ohio University College of Medicine. Sataloff, Philadelphia Ear, Nose, and Throat Associates, and the American In 2006, he finished his residency in otolaryngology at Henry Ford Hos- Institute for Voice and Ear Research (AIVER) since 1986. She has served pital in Detroit, Michigan. In 2007, he completed his fellowship in pro- as Secretary-Treasurer of AIVER since 1988, and was named Executive fessional voice and laryngology with Dr. Robert Thayer Sataloff. His interests Director of AIVER in January 2000. She has served on the Board of Direc- include care of performing artists, including singers and emcees. He is tors of The Voice Foundation since 1990. Ms. Hawkshaw graduated from also passionate about investigating the utility of yoga and ayurvedic med- Shadyside Hospital School of Nursing in Pittsburgh, Pennsylvania, and icine (the of India) in the care of the voice patients.

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