Care of the Professional 4/22/2020

EVALUATION & CARE Professional Voices OF THE PROFESSIONAL • Educators • Singers VOICE – Teachers – Opera – Lawyers – Pop • Physicians – R & B • Salesman – Country – Church/Gospel • Religious leaders – Rap • Customer service – Mixed

Sanford M. Archer, MD, FACS 1 2

Most speech abnormalities can The mechanics of speech require be diagnosed by simply listening integration of the respiratory, to the equality and frequency of phonatory, resonatory, and the patient’s voice. articulatory musculature.

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Production of speech can be broken down into three categories: Air pressure from the lungs also alters the pitch of the voice. 1. Pulmonary Increasing pressure increases pitch and 2. Laryngeal loudness 3. Oral

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Sanford Archer, MD • University of Kentucky College of Medicine Care of the Professional Voice 4/22/2020

Articulation disorders are produced in Variation in the length, breadth, the oral stage. general outline, degree of Weak / dysphonic voice production elasticity, tension of the vocal occurs in the pulmonary stage. Hoarseness can only be produced folds & the amount of expiratory within the laryngeal stage. force are factors that differentiate vocal frequencies

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VOCAL PARAMETERS: Distinction of Voice (, PITCH: , & ) Perceptual correlate of intensity LOUDNESS: is based on a gradual transition in Perceptual correlate of frequency the length and straightness of each QUALITY: vocal fold Perceptual correlate of complexity FLEXIBILITY: Variations of the above

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Common Medical Voice Problems ASSESSING DYSPHONIA

v Acute Respiratory Infections (URI) v Vocal A buse v Vocal Coach or Teacher assesses the v Acute Laryngitis problem with the performing voice v Chronic Laryngitis v Vocal Nodules v Vocal Polyps v Otolaryngology diagnoses the actual v Smoker’s Vocal Folds v Allergies problem or pathology v Laryngopharyngeal Reflux v False Vocal Fold v Speech Language Pathologist will assess v Hysterical Dysphonia the problem with the speaking voice

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Sanford Archer, MD • University of Kentucky College of Medicine Care of the Professional Voice 4/22/2020

ASSESSING DYSPHONIA (cont.) VOCAL REGISTERS

vThe SLP will use perceptual, physiologic, and acoustic measures to assess vocal vCHEST parameters, e.g., pitch, loudness, range vMIDVOICE vThe Voice Team, with direction from the Otolaryngologist, may use stroboscopic vHEAD images to assist in diagnosis of the vFALSETTO problem and resulting dysphonia

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PITCH BREAK MALE FEMALE v A change in voice quality during the BASS transition between parallel folds from vibrating to damping. BARITONE MEZZO SOPRANO v Neurologic patterns can disturb this TENOR SOPRANO mechanism, creating hoarseness.

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DAMPING Vo c a l F r y

Lowest , produced through a loose Occurs only when the vocal glottal closure which will permit air to bubble folds have reached the through with a popping or rattling sound of a very maximum length and tightness low frequency.

The chief use of vocal fry in is to obtain pitches of very low frequency which are not available in modal voice.

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Sanford Archer, MD • University of Kentucky College of Medicine Care of the Professional Voice 4/22/2020

Modal Voice Register

The usual register for speaking and singing, and the vast The falsetto register lies above the modal voice register and majority of both are done in this register. overlaps the modal register by approximately one octave. Male singers can phonate in the falsetto register. The essential As pitch rises in this register, the vocal folds are difference between the modal and falsetto registers lies in the amount and type of vocal cord involvement. lengthened, tension increases, and their edges become thinner. The falsetto voice is produced by the vibration of the ligamentous edges of the , in whole or in part, and the main body of A well-trained singer or speaker can phonate two octaves the fold is more or less relaxed. In contrast, the modal voice or more in the modal register with consistent production, involves the whole vocal cord with the opening at the bottom first and then at the top. The falsetto voice is also more beauty of tone, dynamic variety, and vocal freedom. limited in dynamic variation and tone quality than the modal voice.

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WORKUP OF A SINGER SINGER EVALUATION WITH HOARSENESS v Age of patient v Date of next important performance v History of voice coaching v Professional singing status and goals vHistory v Amount and nature of vocal training v Type of singing environment v Rehearsing vPhysical examination v Voice abuse in speaking v Voice abuse in singing vLabs v General health v Complaints v URI vRadiographs v Description of hoarseness v Breathiness vOther studies v Fatigue (lose of range, changing , or breaking into different registers) v Vo l u me d i s t u r b a n c e

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Pulmonary LARYNGEAL STROBOSCOPY

1. Breathe Support vSharp, clear view of vocal fold margins at 2. Breathe Support any phase of the vibratory cycle 3. Breathe Support vEvaluation at different pitches & intensities 4. Breathe Support v“Stop-Action” Photography

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Sanford Archer, MD • University of Kentucky College of Medicine Care of the Professional Voice 4/22/2020

VOICE CONVERSATION VOICE CONVERSATION (cont.)

vManaging allergies, colds/flu without OTC vAlso called vocal hygiene vTeaching about the fluid-filled nature of the voice preparations... Following Physician directions vAvoiding “phonotrauma” (yelling, cheering, etc.) vManaging GERD with Physician’s help vAvoiding smoking anything vPlanning your voice on/voice off schedule vAvoiding voice use when you have a cold vAvoiding dry, dusty environments vAvoiding throat clearing and coughing vUsing “alternative therapies”, e.g., massage

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VOICE THERAPY THERAPY APPROACHES

v vMay be as simple as “visiting” the voice conservation Voice conservation measures may be issues to raise awareness sufficient vVoice therapy plan is designed with input from all vDirect therapy approaches which augment members of the team voice conservation may be used, e.g., vVoice therapy requires high level of compliance and reducing forceful adduction motivation. vVoice strengthening or voice building vWith motivation, can be realized quickly procedures may be included, e.g. VFE, vCultural acceptance is a barrier in voice therapy Dynamic Range exercises, etc.

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THERAPY (cont.) Medical Management

vVoice building or strengthening activities are healthy for any voice. They will not harm the voice. Even vProper technique if you don’t have a voice problem you would benefit vHydration from these strategies which stretch the musculature and extend the range. vEarly treatment of medical problems vSuccess in voice therapy is highly dependent upon vAvoidance of certain medications personal motivation!

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Sanford Archer, MD • University of Kentucky College of Medicine Care of the Professional Voice 4/22/2020

ACUTE VOCAL AILMENTS CHRONIC VOCAL AILMENTS

vAcute laryngitis vVo c a l n o d u l e s vLaryngeal hemorrhage vVo c a l p o l y p s vStage fright vVo c a l c y s t s vVocal fold granulomas

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HORMONAL EFFECTS ENVIRONMENTAL FACTORS

vMenstruation vTravel vPregnancy vBirth control vNoise pollution vAnabolic steroids

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SUBSTANCE ABUSE MEDICATIONS

vSmoking Most drugs prescribed for voicing problems are not system-specific and are therefore vAlcohol liable to unwarranted side-effects

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Sanford Archer, MD • University of Kentucky College of Medicine Care of the Professional Voice 4/22/2020

GENERAL RECOMMENDATIONS – GENERAL RECOMMENDATIONS - DRUGS RELATIVELY SAFE TO USE USE ONLY UNDER CAREFUL SUPERVISION

v vAntibiotics Oral inhalers vMucolytic agents vCough suppressants vDecongestants vAcetaminophen vNSAID’s vVasoactive nasal sprays vBeta-Blockers vSteroid nasal sprays vH2-blockers vSedatives and Tranquilizers vPPI’s vAntidepressants

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GENERAL RECOMMENDATIONS – DRUGS TO BE AVOIDED ANTIHISTAMINES

vMost cause dryness, sometimes worse than v Antihistamines the underlying allergy symptoms

v Diuretics vSome may cause drowsiness as well v Aspirin containing compounds vONLY indicated in singers who have used them before without ill effects v Hormonal therapy vMust increase fluid intake at same time (Pee Pale ! )

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COUGH PREPARATIONS HORMONAL THERAPY

vMay contain narcotics, antihistamines v Progesterone - Lowers vocal pitch and/or alcohol v Testosterone - Lowers vocal pitch vCan cause drying of secretions and sedation v Estrogen - May have a negative effect on vMust be used judiciously respiratory mucosa

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Sanford Archer, MD • University of Kentucky College of Medicine Care of the Professional Voice 4/22/2020

BETA-BLOCKERS SEDATIVES AND TRANQUILIZERS

v Can reduce muscle tremors, anxiety and v Used to treat anxiety and insomnia palpitations associated with performance v anxiety May impair mental alertness and fine v May cause asthma, laryngospasm, mental motor control depression, hypotension or bradycardia v Often reduces salivation and produces a dry mouth

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ANTIDEPRESSANTS TONSIL PROBLEMS

v Most commonly treats psychiatric v Scarring of the lateral pharyngeal disorder walls and palatal arches can occur!

v Many of these drugs cause dry v Will voice changes occur? mouth and blurred vision

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NASAL & SINUS SURGERY SLEEP APNEA & SURGERY

v Useful in the management of nasal v CPAP - May dry out airway while in use breathing problems and chronic v Surgery - May affect vibratory sinusitis capabilities of the pharyngeal mucosa v Improves resonance v Weight loss and exercise best option. v May decrease URI’s/allergy symptoms and therefore medications used

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Sanford Archer, MD • University of Kentucky College of Medicine Care of the Professional Voice 4/22/2020

GENERAL ANESTHESIA Treatment v Intubation poses inherent risks to the vocal folds v Issues include: vEducation v Length of operation vMedical management v Experience of anesthesiologist v Size of endotracheal tube vSpeech therapy v Style of extubation (deep) vVo c a l c o a c h i n g v Medications v Steroids v Anti-reflux meds

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DO'S & DON'TS

Do - Drink Plenty of Water – Hydrate!!!! The Speaking Voice Do - Avoid Vocal Irritants (Cigarette smoke) Do - REST Your Voice Periodically is Do - Use a Humidifier Do - Warm-up & Cool-Down Exercises Daily The Singing Voice ! Do - Develop Stress Management Strategies Don't - Whisper Don't - Yell or Scream or Talk Loudly Don't - Clear your Voice (Throat clearing)

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SUMMARY A SINGER’S NEEDS MUST BE INDIVIDUALIZED ! A rapport must exist between the singer and their physician in order to enable management of Partner with their vocal coach most medical voice emergencies and Speech Pathologist on a timely basis.

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Sanford Archer, MD • University of Kentucky College of Medicine