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Care for the Professional Voice--The Voice Foundation
44 Plays2 years ago
Your voice...perhaps the most underrated and misunderstood human ability. For an ankle sprain, you go see a trainer, a physical therapist, a sports doc, you wear a brace, get taped, do some exercises. For vocal injuries, for vocal dysfunctions, what do you do? How do you make your voice better? How do you improve your performance? Well, just like athletes, vocalists have vocal coaches, speech therapists, and voice doctors whose life’s work is dedicated to keep vocalists performing.
So to learn more about caring for the professional voice, Yasi and Steven talk to Robert Sataloff, MD, world renowned otolaryngologist and the leader of The Voice Foundation, the world’s oldest and leading organization dedicated to voice research, medicine, science, and education. He is joined by Deanna McBroom, AATA liaison to The Voice Foundation, Singing Teacher and Singing Voice Specialist through the Voice Institute at the Medical University of South Carolina in Charleston, SC.
For the Voice Foundation, go to https://voicefoundation.org/
For Athletes and the Arts, go to https://www.athletesandthearts.com/
For more on Dr Sataloff, go to https://drexel.edu/medicine/faculty/profiles/robert-sataloff/
Bios:
Deanna McBroom, MM is a Singing Teacher and works as a Singing Voice Specialist through the Voice Institute at the Medical University of South Carolina in Charleston, SC. She has worked closely with MUSC laryngologist Dr. Lucinda Halstead to treat injured singers since they both attended The Voice Foundation’s annual symposium in 1986. She recently retired from college-level teaching at The College of Charleston, where she led the voice program in providing conservatory-level training in a Liberal Arts & Sciences environment. She’s also maintained a singing career for 40+ years, performing in recitals, orchestral concerts, and operas throughout the US and in Europe.
Ms. McBroom is the Steering Committee representative to Athletes and the Arts from both The Voice Foundation (TVF) and from the National Association of Teachers of Singing (NATS) and currently serves as a member of the Board of Directors for the Performing Arts Medicine Association (PAMA). Her passion for healthy singing led her to assist both NATS and PAMA with their 2019-2021 guidelines and research tools for singers and teachers to deal with Covid-19. She frequently presents research papers and workshops at international meetings; journals with articles published include Journal of Voice and College Music Symposium.
Robert T. Sataloff, MD, DMA, FACS is Professor and Chairman, Department of Otolaryngology-Head and Neck Surgery and Senior Associate Dean for Clinical Academic Specialties, Drexel University College of Medicine. Dr. Sataloff is Director of Otolaryngology and Communication Sciences Research at the Lankenau Institute for Medical Research, and Director of Otolaryngology Education at Lankenau Medical Center. He also holds Adjunct Professorships in the Departments of Otolaryngology – Head and Neck Surgery at Thomas Jefferson University, Temple University and the Philadelphia College of Osteopathic Medicine; and he is on the faculty of the Academy of Vocal Arts. He serves as Conductor of the Thomas Jefferson University Choir. Dr. Sataloff is also a professional singer and singing teacher.
Dr. Sataloff is Chairman of the Boards of Directors of the Voice Foundation and of the American Institute for Voice and Ear Research. He is Editor-in-Chief of the Journal of Voice; Editor Emeritus of Ear, Nose and Throat Journal; Associate E
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Transcript
Introduction and Podcast Overview
00:00:06
Speaker
Welcome to the Athletes in the Arts podcast hosted by Stephen Karaginas and Yasi Ansari. Hello, hello everyone. Welcome to another episode of the Athletes in the Arts podcast along with my co-host Yasi Ansari. I'm Stephen Karaginas. If you're in a good mood today and want to help our show out, please subscribe and leave a review and maybe say a few nice things to us. We love to hear it.
00:00:36
Speaker
But if you want more information on performing arts medicine, latest research, educational resources, please go to athletesandthearts.com.
Exploring the Voice: Importance and Complexity
00:00:46
Speaker
So today we are going to talk about your voice, your actual voice. Now this is perhaps the most underrated and misunderstood human ability. Like for instance, an ankle sprain. If you get an ankle sprain, you go see a trainer, a physical therapist, maybe a sports doc. You wear a brace, you get taped, do some exercises. Most folks understand this.
00:01:08
Speaker
But for vocal strain, other vocal injuries, vocal dysfunctions, what do you do? How do you make your voice better? How do you improve performance with speaking, with singing, with acting?
00:01:20
Speaker
Well, just like athletes, there are vocal coaches, speech therapists, and voice doctors whose life's work is dedicated to keep vocalists performing. So to learn more about caring for the professional voice, we are talking today to two leaders in the Voice Foundation, the world's oldest and leading organization dedicated to voice research, medicine, science, and education.
Meet the Experts: Deanna McBroom and Dr. Robert Sadeloff
00:01:42
Speaker
Yasi?
00:01:43
Speaker
Today we have a wonderful show for all of you. We have Deanna McBroom here with us. She is a singing teacher and works as a singing voice specialist through the Voice Institute at the Medical University of South Carolina in Charleston. Deanna, we're so happy to have you here with us.
00:02:00
Speaker
Thank you, Yasi. It is my pleasure to be here. And anytime I have a chance to talk about singing and singers, I am more than happy to do so. And I'm delighted to also have brought with me today a wonderful guest for us, Dr. Robert Sadeloff, who is an eminent otolaryngologist, but he has many other talents as well. He is
00:02:25
Speaker
a professor and chairman of the Department of Otolaryngology and Head and Neck Surgery, and also senior associate dean for the clinical academic specialties at Drexel University College of Medicine. And he's also director of the Langkinal Institute for Medical Research and the director of Otolaryngology Education at the Langkinal Medical Center.
00:02:53
Speaker
He also teaches in the Department of Otolaryngology and Head and Neck Surgery at Thomas Jefferson University, Temple University in Philadelphia College of Osteopathic Medicine. He's also on the faculty of the Academy of Vocal Arts and Eminent Institution Training Singers. He's the conductor of the Thomas Jefferson University Choir, and he's also a professional singer and singing teacher.
00:03:23
Speaker
As I said, he brings many, many talents to his treatment of singers. Dr. Sadoff has also been a real influence on me through the Voice Foundation because that really was where I got a lot of training and
The Voice Foundation: Mission and Interdisciplinary Approach
00:03:41
Speaker
experience and education about being a singing voice specialist. Not all voice teachers seek out that additional education
00:03:51
Speaker
and training in anatomy and physiology and pedagogy of working with injured singers. And the Voice Foundation has been a really important component of my training as a singing voice specialist working with injured singers. So a little bit about the Voice Foundation. The Voice Foundation is a wonderful organization, interdisciplinary organization.
00:04:22
Speaker
It was founded in 1969 by Dr. Wilbur James Gould, an eminent otolaryngologist in New York City. And it really brought together, for the very first time, physicians, scientists, speech-language pathologists, performers, and teachers all sharing their knowledge and expertise about the care of professional voice users.
00:04:51
Speaker
both singers, actors, and other people that use their voice professionally. Amazing. The mission of the Voice Foundation really is to enhance the knowledge and care of training the voice, to publish material for voice care professionals, and to really acquaint the public and professional voice users about the latest research that's going on in the voice world.
00:05:21
Speaker
And in 1989, it was Dr. Sadeloff that took over the leadership of the Voice Foundation. And he has steered that ship for these three plus decades. And we owe a great debt to him for his leadership of the Voice Foundation.
00:05:39
Speaker
They offer an annual symposium as well as publish an eminent journal, The Journal of Voice. And Dr. Sadoff, maybe you can add a little bit to my introduction on that and tell us some things that you think stand out about being in The Voice Foundation and leading The Voice Foundation. Thank you, Deanna. It's a pleasure to be with all of you today. The Voice Foundation is
00:06:08
Speaker
close to the hearts of all of us in the voice world. Jim Gould started it in 1969 and held the first interdisciplinary symposium in New York at the Juilliard School in 1972. I got active and led it with him from 72 until 89 when he turned it over. But his vision was the keystone.
00:06:37
Speaker
The major difference between the Voice Foundation meetings and other meetings that had come before was the true interdisciplinary nature. That is physicians and scientists and speech-language pathologists and singers and actors and teachers didn't just get together and have the doctors pontificate.
00:07:05
Speaker
It was a real discourse. We learned as much from the non-doctors as they learned from us. And the symposia really advanced the field. Singing teachers and performers raised the questions at voice foundation meetings that were pressing to them and practical.
00:07:34
Speaker
scientists and physician researchers designed projects to address those questions. The basic research PhD scientists interacted with the physicians and made our research more rigorous and more evidence-based and more accurate. And questions asked at one symposium
00:08:01
Speaker
led to research projects and one or two symposia later, those questions were answered by evidence-based research and the next week they were in place acting to modify patient care throughout the world. Every year at our symposia at the beginning of June or end of May, we have attendees from between 30 and 40 states
00:08:31
Speaker
and between 30 and 40 countries.
Global Reach and Research Initiatives of the Voice Foundation
00:08:34
Speaker
The 2023 meeting starts on May 31st and runs through Sunday, June 1st. So what people learn there affects voice patients within days, not months for publication, but
00:08:59
Speaker
days and the people who attend the symposium and act with the Voice Foundation talk to each other. The symposium program publishes contact information for all of the faculty and singing teachers know they can be completely comfortable emailing or calling the physicians or the scientists and saying, I have this question. So it's become a real international community.
00:09:28
Speaker
The Voice Foundation also seed funds research. We're particularly proud of the fact that our first $80,000 in small seed grants between five and $10,000 grants led to $13 million in NIH-funded research that has changed the world of voice dramatically. The Voice Foundation is also responsible for the Journal of Voices Deanna mentioned, which is
00:09:58
Speaker
the preeminent peer-reviewed medical scientific and speech language pathology journal. And I'm excited to say with an increasing percentage of very high quality voice pedagogy research from the singing teacher community. Now, Deanna is a singing voice specialist. The first singing voice specialist was Linda Carroll.
00:10:26
Speaker
When I hired her in my office in 1980, she was a secretary in the physiology department. She was my singing student for a decade and we came up with the notion of providing special training to singing teachers to learn how to work in a medical environment and came up with the term singing voice specialist.
Professional Voice Users: Needs and Care Teams
00:10:47
Speaker
And now you can find people with those skills at many major
00:10:55
Speaker
healthcare institutions around the United States and around the world. And I remember well when there was only one, the spread of that information was through the Voice Foundation and meetings that have spun off from the Voice Foundation. And there also now is such a thing as an acting voice specialist who works with the singing voice specialist and speech language pathologists to get voices
00:11:23
Speaker
of performers not merely healthy, but optimal, superior, so that they can do all of the things that they need to do professionally and socially. That's wonderful. And it's really made such an impact on so many singers, professional singers, as well as avocational singers and actors and other professional voice users
00:11:50
Speaker
We probably should define that term. Anyone who uses their voice as a part of their profession is really considered a professional voice user. And so therefore needs specialized treatment in the same way that athletes need specialized medical treatment. Professional voice users have specific needs and problems that they confront that really require
00:12:20
Speaker
all of the interdisciplinary team to know about their special needs. Now, could you could you guys talk a little bit more about that about the interdisciplinary team that is put in place for vocalists? Is it similar to that of the athletic environment? It's very similar. And I agree with Deanna, I have
00:12:46
Speaker
from the beginning of my involvement in this field, defined professional voice user even more broadly. Professional voice users include not only singers, actors, clergy, politicians, although we're not always terribly enthusiastic about getting the politicians' voices back. But they have their moments, I suppose.
00:13:16
Speaker
pretty much everybody. You know, I'm a voice doctor. I don't want a secretary to answer my phone and say, hello, Dr. Sadler's office. People are going to say wrong number. Anybody who uses his or her voice in the course of work is a voice professional. And since the eighties, I've defined it even more broadly.
00:13:42
Speaker
anybody who has his or her voice damaged and for whom a good aggressive plaintiff's attorney can come up with a number for damages for a lawsuit related to voice loss is a voice professional. And plaintiff's attorneys are pretty creative. That includes most of us. Certainly salespeople
00:14:10
Speaker
or its coaches who have to yell from the sideline, salespeople who work in noisy environments, stores, street side, in stadiums. It's hard to think of anybody who's not strictly a data input person who's not a professional voice user.
00:14:34
Speaker
And we treat all our voice professionals, whether they're metropolitan opera stars or platinum record stars or school teachers, as if they were Luciano Pavarotti, of course, when he was still alive, or Renee Fleming, as they should be treated. And just as a good sports medicine physician,
00:14:59
Speaker
treats me the same way that he or she would treat an Olympic athlete and is able to do so because of what was learned from treating Olympic athletes. So just as when I sprained my ankle running, I benefit from sports medicine, so too if you get hoarse or have a vocal fold hemorrhage or get hit in the neck with an elbow playing basketball,
00:15:29
Speaker
So you benefit from what we have learned taking care of professionals. The difference between professional performers and it's the same with professional athletes and other people is their definition of normalcy. If I, as a microsurgeon,
00:15:58
Speaker
break a finger, shooting hoops on the weekend, and my hand surgeon gets me back to 95% function. I'm fine. I'm happy. If I'm a concert violinist or pianist, I'm not happy.
00:16:16
Speaker
Arts medicine requires healthcare professionals to recognize, quantify, and restore the last one or two percent of physiologic perfection. Most of medicine doesn't. We have very broad latitude in our definition of normalcy. Not in arts medicine.
00:16:38
Speaker
whether it's hand or foot and ankle or voice. And learning how to really assess the difference between within normal limits and perfect is what makes all of us better doctors caring for everybody.
00:16:57
Speaker
and makes the rest of the members of the team the same. Now, a voice team includes not just a physician, but a speech-language pathologist, a singing voice specialist, ideally an acting voice specialist, often a voice scientist, and an arts medicine team, ideally an arts medicine center, of professionals in other disciplines who collaborate and refer.
00:17:23
Speaker
And that means experts in physical therapy, occupational therapy, nutrition and diet, orthopedics, endocrinology, gastroenterology, psychology and psychiatry, and many other disciplines. We can't take care of people properly with the current standard of care.
00:17:52
Speaker
without the multidisciplinary team approach.
Diagnosing and Evaluating Voice Problems
00:17:57
Speaker
I have singing voice specialists, speech language pathologists, acting voice specialists, and others in the office right next to me, seeing patients with me and looking at my examinations and videos before they ever see the patients. It's critical.
00:18:15
Speaker
Right, and sometimes that involves not just the treatment of the patient, but also being part of the diagnostic team and being relied on to share expertise within the team all the time, everything for the benefit of the patient, to have the patient at the center. We talk about the patient as being the most important part of the voice care team.
00:18:45
Speaker
I don't consider them just the center. I consider them part of the team. I schedule my first visits for new patients for about five hours. They see me, they work with nurses and I can't emphasize enough how important nurses, clinical nurse specialists, specially trained medical assistants are.
00:19:10
Speaker
in helping these patients through their initial histories and through phone calls. But the initial visit in my office ordinarily has a history and examination by me, objective voice measures. My examination includes strobo-videolar endoscopy, flexible and rigid. So we get a really good look at laryngeal function, not just structure.
00:19:34
Speaker
But objective voice measures and evaluation by a speech language pathologist and an evaluation by a singing voice specialist, even in non-singers and perhaps especially. Patients are sometimes a little resistant to that, but I explained it to them as I believe it. If you had trouble walking and we ask you to go out and walk, it's going to take you six months.
00:20:02
Speaker
If you can go out and jog and run, your walking muscles are going to be strong in six weeks. Singing does the same thing for the speaking voice. The singing voice specialists and speech language pathologists work hand in glove. And giving people exercises that take their voices far beyond what they need for speech gets them better, not only faster,
00:20:31
Speaker
but I believe to a higher degree of function. Absolutely, absolutely. Dr. South, we know that singers have lots of complaints about things and
00:20:48
Speaker
They really are not hypochondriacs. They really sometimes are even reluctant to seek medical help for voice problems. What are some of the things that you would consider in making a decision to actually go to a laryngologist? If a professional has a voice problem and it is sudden, for example, you're singing a concert and you get hoarse suddenly,
00:21:19
Speaker
you should see a laryngologist immediately and probably be quiet until you do. That can be a sign of a hemorrhage, a ruptured blood vessel, or a mucosal tear, either of which can leave permanent damage. If the onset is more gradual but persists for more than a few days to a week, it's time and maybe even sooner.
00:21:48
Speaker
especially in a voice professional, but really in anybody. There are people who say off your horse, give it a month or six weeks. There are too many things that can cause those voice problems that are time sensitive for a professional to do that. A voice change benefits from a physical examination. If you're lucky, it may just be
00:22:17
Speaker
You have a little laryngitis. We'll treat it. Don't worry about it. But if it's something more important, the faster it's treated, the less likely it is to leave scar and permanent voice change.
Aging and the Voice: Myths and Treatments
00:22:30
Speaker
And I find that even with older patients, they think that what these voice changes may just be a part of getting older. But most of the time, those voice problems can be treated and improved.
00:22:46
Speaker
Well, you were kind enough to take me knowingly into one of my very favorite areas. As you know, I have co-edited the standard textbook on geriatric otolaryngology in general, but I've been so interested in aging that if you take a look at the Journal of Voice more than 30 years ago, volume one, number one, the launch issue was a special issue on aging.
00:23:15
Speaker
Most of what we hear that we associate with aging is not caused by irreversible aging change. We have all been to religious services with volunteers in the choir. They all have a tenor or a soprano who's been there for decades, who hasn't sung on pitch for 10 years, who has a wobble wider than your spread arms,
00:23:44
Speaker
But nobody wants to throw that person out of the choir that's been a devoted singer. Those are not aging changes. Those are conditioning changes. There are aging changes. The lungs lose and thorax lose elasticity and distensibility, which affects support. The mucosa on the vocal folds changes. The nerve endings change.
00:24:10
Speaker
People tend to lose a half step or two or three in some voice efficiency. And sometimes they can't get their vocal folds to close as well as they used to. So their voices get a little breathy and they strain to compensate. All of those things can be fixed, often by good therapy alone, sometimes by bringing the vocal folds closer together,
00:24:37
Speaker
But the first thing that has to be done for those patients is to perform a comprehensive evaluation and work them up to see what else is contributing. Often there's weakness in a vocal fold. And when the voice team knows that there's a 30% weakness in the left superior laryngeal nerve, they use different exercises than they would if that were not the case
00:25:06
Speaker
And treatment is much more directed, expeditious, and successful. So most of what we hear and interpret is the aging voice.
00:25:19
Speaker
is deconditioning. And we also include physical reconditioning under medical supervision as part of the process. Because if you can't run or at least walk quickly up a flight of stairs without getting short of breath, how are you going to create the air pressure that you need to support
00:25:43
Speaker
to sing correctly without damaging your vocal folds. You can't. So it's a systemic rehabilitation system guided by the voice team, but including others. If you have a singer who can't do a sit-up or a leg lift, he or she probably doesn't have the back muscle and abdominal muscle strength needed to sing or speak in a projected acting fashion.
00:26:13
Speaker
safely without compensatory hyperfunction and potentially damage in the laryngeal tissues. And I can attest to the response to some of these older patients being able to return to conditioned singing. And it's something that is so much a part of their life, not just professionals, but even avocational church choir singers, for instance, that
00:26:41
Speaker
It really helps them maintain their quality of life and do the things that are really important, the things that they love to do. On my website, there is a video recording that chronicles two patients, one of whom is a minister, certainly a professional voice user who goes through the diagnostic process.
00:27:10
Speaker
The video includes segments of the speech language pathologist and singing voice specialist, surgery, and the final result with the minister being able to lead hymns and get through a service again. If people are looking for not a metropolitan opera star type example, but a practical everyday explanation
00:27:39
Speaker
of what we're talking about with Team Care. Yeah, that's great and I encourage people to check that out. Let's shift gears a little bit and talk about some of the common things that you see of singers and actors that
00:28:00
Speaker
a peer at your office, it might be something acute, it might be something that's been going on for a long time. But what are the most common disorders that you see? I know disorders can have an organic cause and they can have a behavioral cause, but tell us about some of those things.
Vocal Disorders and Physical Influences
00:28:18
Speaker
Sure. We'll see if we can reduce that three hour lecture to five or 10 minutes. Sure. Of course, infections are extremely common. People who have upper respiratory tract infections without laryngitis.
00:28:34
Speaker
can sing, perform, provided they are good enough voice technicians that they don't change their technique to try to sound to themselves as they usually do. If your ears are stuffy from a cold, no matter how hard you try, you're not going to sound right to yourself. It's the same as if the crown is gone on the sounding board on your piano. It doesn't matter how hard you bang on the keys.
00:29:02
Speaker
So if a singer with a cold has no vocal fold involvement, has good enough technique to be able to sing the usual way, and has not taken blood thinners, and that includes aspirin and lots of cold medicines that contain aspirin, performing usually is safe.
00:29:23
Speaker
If there's a vocal fold, hemorrhage or a tear, performing generally is not safe. Most people fall in between and we can find ways to get them on stage. But we see bacterial infections, we see viral infections, we have seen people for years with partial vocal fold paralysis, weakness after viruses, after Lyme disease,
00:29:50
Speaker
and recently in very troublesome ways after COVID infection. And it doesn't even have to be full-blown long COVID. COVID can affect any of the nerves. We have reported actually early on, Peek Woo and I combined some cases on which we'd done laryngeal EMGs, but it's not rare for us to see people who have weakness in all six of the muscles we test in the larynx.
00:30:19
Speaker
electrically with EMG. And the ones who have too long COVID and have respiratory problems are really in trouble. There are lots of other things, of course, substance abuse, not very common in the classical world, but more common among some genres of pop singing and among the students.
00:30:45
Speaker
Lots of systemic conditions. We talked about aging, but respiratory dysfunction, including asthma, especially unrecognized asthma, allergies, inhalation, which can be anything from dust and sawdust from people building sets in a rehearsal space, to dry air on noisy airplanes, to fumes from
00:31:15
Speaker
Other artsy things like making ceramics and jewelry can also be from stage fogs and smokes. You don't often think of musculoskeletal problems as affecting the voice, but proper posture is important. It's hard to stand on one foot and have appropriate abdominal and back muscle support, contraction and function.
00:31:45
Speaker
to drive the air stream between the vocal folds. Real good professionals can. Opera singers do death scenes, dying, lying down, leaning over stages all the time, but they're pros. They've studied for years. A sprained ankle can be enough to cause a voice problem. GI disorders are extremely common, particularly reflux, which is a serious concern and which usually is missed because when
00:32:15
Speaker
Because when people hear the word reflux, they think about heartburn. When reflux is bad enough to affect the larynx, most patients don't have heartburn. The sensors in their esophagus that cause heartburn are numb. They may have nothing, silent reflux, but most have
00:32:34
Speaker
What they think of is post-nasal drip, excessive phlegm, throat clearing, morning hoarseness, bad breath, prolonged warmup time. If they're singing a morning church service, they have to warm up for an hour and a half or two hours instead of 10 or 20 minutes. The reason reflux is so important is that it really affects the vocal folds. If you cut your hand
00:33:00
Speaker
and poured acid on it 18 times a day, you wouldn't expect the cut to heal very well. We traumatize our vocal folds all the time. Usually they recover perfectly well. When you pour acid on them, they don't. Acid and pepsin also are chronic irritants and over years, they cause cancers of the esophagus and the larynx. So this is not just an inconvenience, it's a health problem.
00:33:28
Speaker
There also are numerous endocrine disorders and endocrine problems that range from low thyroid, which can be just slightly low, to birth control pills, pregnancy, menopause, and lots of other conditions. And those are in addition to neurological disorders and psychological conditions.
00:33:56
Speaker
Deanna mentioned that hypochondriasis is rare among professional singers. It is. I wrote the first paper in the modern era, Teaching Doctors How to Take Care of Singers. It was published in 1981.
00:34:14
Speaker
It has a sentence in it that says hypochondriasis is rare, and in general, failure to reach a diagnosis in a serious singer with a voice complaint is due to lack of expertise on the part of the doctor, not an imaginary complaint on the part of the singer. Incidentally, just so the arts medicine world knows that they're not alone with the more recent things,
00:34:41
Speaker
That paper helped launch our current field. It was published in 81, but I started submitting it in 1977. And it was turned down in every major journal until it was published in the American Journal of Otolaryngology. And pretty much everybody said that this is not otolaryngology.
00:35:06
Speaker
Now it's mainstream, their fellowships, every academic department needs a laryngologist. But in the late seventies and early eighties, there was considerable resistance and it took me four years to get that paper published. And it took a lot of people, including speech pathologists like Diane bless.
00:35:31
Speaker
and many of us working together to get the field established, the need for better technology like stroboscopy and high speed and laryngeal EMG established and accepted, and even the importance of reflux.
Challenges in Voice Medicine and Treatment Approaches
00:35:51
Speaker
I will tell you a story because he was a good friend when he was alive and he told this in public many times and gave me permission to,
00:36:01
Speaker
But many of you know that Jack Klugman, who was on the board of directors of the Voice Foundation, had laryngeal cancer. And I had seen him and told him he had reflux and put him on reflux treatment. And he saw another eminent otolaryngologist in New York who said, oh, that's nonsense. You don't need to take all that medicine.
00:36:24
Speaker
So he stopped. And 10 years later, he went back and saw the same otolaryngologist in New York and said, yeah, you have cancer. You have reflux. No wonder you have cancer. And that was the same person who 10 years before hadn't believed there was any significance to the diagnosis.
00:36:43
Speaker
So it takes a long time to get the field established, just like it took a long time to get people in the hand world to know that they needed
00:36:55
Speaker
piano, they needed a rehearsal room, they needed to collaborate with teachers, so somebody could watch people play the piano and see if their ergonomics were wrong, if the bench was at the wrong height, if violinists were not holding the instrument correctly, same with flautists, same with cellists, and that that was not peripheral. That was all central to medical care and often revealed the cause of
00:37:26
Speaker
of the problem. Now, sometimes behavioral problems are technique alone. We never make that assumption. Very often when we see people with voice strain, muscle tension, dysphonia, they are compensating for a physical problem, whether it's parasis, partial paralysis, or scar, or atrophy, wasting of the vocal folds from aging,
00:37:54
Speaker
They are doing something unconsciously to try to be heard. And we need to find out what that is. See if we can fix it behaviorally with Deanna and
00:38:07
Speaker
our other colleagues, and if we can't, address the underlying problem surgically. Most of the surgery we do even for aging involves bringing the vocal folds closer together. It's outpatient surgery done under sedated local anesthesia. It doesn't even require patients to go to sleep or stay in the hospital overnight. So it's always a last resort, but it's not a frightening last resort.
00:38:35
Speaker
And it's restored more than a few careers. There are very few of my voice professionals about whom I can talk, but there's some who've talked about this in public. Shania Twain is one. She talked about it in the AARP magazine, which unfortunately I get.
00:38:55
Speaker
And she talked about what happened, bringing her vocal folds closer together so she didn't have to work so hard and could continue performing. And there are hundreds and hundreds of people like that who have not been kind enough to talk about that in public so that other performers know that it's not
00:39:22
Speaker
a shame. It's an appropriate artistic thing to do, just as it's appropriate for an NFL football player to get his knee fixed if it's damaged. Is the training different between a voice professional who's younger versus someone who has an aging voice? Interesting question.
00:39:49
Speaker
Yes and no. Most of the younger people that we see who are performers these days are in reasonably good aerobic physical condition. So we mention it, but we don't necessarily have to put them in a medically supervised physical training program. Many of our aging people are as well. The general exercise health of the population is a lot better than it was 20 years ago, but some are not.
00:40:18
Speaker
The other differences are that the younger people respond faster for the most part. It takes longer to make the same amount of progress in many of the older patients. And finally, the older patients are more likely to have an underlying physical problem, such as vocal fold thinning and inability of the vocal folds to meet firmly
00:40:46
Speaker
without using muscles that you're not supposed to use. Sometimes the voice team can build up enough muscle bulk to compensate for that. And sometimes there's just too much physical change and that can't be done without some surgical help.
00:41:04
Speaker
So the basic approach is the same. The basic approach also is largely the same in classical singers versus pop singers, including rock singers and even rappers. If you are taught how to pitch correctly, it doesn't matter whether you throw a hardball, a softball or a wiffle ball, you understand the mechanics of throwing and you can adopt your style.
00:41:32
Speaker
The same is true in the voice world. So the fundamental approaches and techniques are the same throughout ages, throughout genders, and throughout genres. Of course, with stylistic modifications. And there are differences in the level of training that we see in different styles as well. If someone has
00:41:58
Speaker
good vocal training and they are working with a vocal coach regularly, doesn't matter what style they're singing, they're going to have more tools to work with. But it's not uncommon to work with, to find people that have just begun singing because they love it and they don't have any other training. And so even then retraining and learning things that
00:42:26
Speaker
They've never studied before, never worked on before, becomes part of their treatment. I agree with what Diana said, and we'll add a few things. First of all, there are more pop and rock singers who have training than people realize they are because for the most part, they don't advertise it. Their fans want them to be all natural.
00:42:55
Speaker
But a lot of the ones who are and have remained successful, especially into their older years, have plenty of good voice training. It is also true that what Diana said is absolutely right, provided they're getting good training. There are a lot of singing teachers out there who do not necessarily provide good training. And there's an important reason for that.
00:43:23
Speaker
If you're a speech-language pathologist in the majority of states, you have to be licensed, you have to go through school, you have to go through a clinical fellowship, which is supervision, it's like an internship for a doctor, and you have to have a license. Unfortunately, to be a singing teacher, you don't have to do a thing. I haven't checked recently, so I'm probably 20 years out of date, but at that time,
00:43:52
Speaker
There were 25,000 singing teachers listed in New York City. Now, if you think about the fact that it's hard to pay rent in New York City and teaching singing for the most part is a cash business, you can see how tempting it would be. But there's no certificate. There's no certification. There's a National Association of Teachers of Singing, which I've been a member of forever.
00:44:20
Speaker
But you don't have to pass a teaching quality examination even to become a member of NETs, unfortunately. It's been discussed. It's not practical as things stand now. So anybody can say, I'm a singing teacher and go teach. So, Wendy Anna and I see people who are taking lessons from a voice teacher
00:44:47
Speaker
We want to know exactly what the voice teacher is doing, what's being taught, what's being trained in posture, in support, in appropriate use of neck muscles, in tongue relaxation and jaw opening, and lots and lots of other things before we know whether we can rely on that community voice teacher
00:45:12
Speaker
to participate productively as part of the team. And I'll tell you over the years when the answer has been not really, we have often asked the patients to bring their teachers in with them to sit through the sessions with the voice team, the speech pathologist and singing voice specialist. Some have been resistant, but some very gratifying voice teachers
00:45:41
Speaker
have recognized immediately that the team was doing something different from what they were doing and it was working and have learned and become better teachers. So that provides another opportunity for us to influence the quality of voice training in the community.
00:45:59
Speaker
And the Voice Foundation has partnered with National Association of Teachers of Singing in many instances to provide educational opportunities and training about voice disorders and about how to manage singing problems. Both organizations have a strong commitment to that. And that was very profitable for the singing world recently.
00:46:28
Speaker
NATS has a Voice Science Advisory Committee. Pretty much all of us on the Voice Science Advisory Committee also have been active with the Voice Foundation. And when the COVID pandemic hit, the guidance that came out from NATS to singers and singing teachers was rational, conservative, and scientifically based.
00:46:58
Speaker
There is another organization that I have also been a member of for a long time and that I won't name, but that has to do with voices and conducting of voices and other things that also came out with the statement that was purely an advocacy statement and that intentionally avoided
00:47:27
Speaker
getting opinions from physicians and speech-language pathologists and voice scientists and was very disappointing to those of us who have been long-time members. And that organization has not had a similar partnership with the Voice Foundation or other professionals, although we wish it would.
Voice Health Amid COVID-19: Research and Guidance
00:47:50
Speaker
So those partnerships between organizations like NATS and the Voice Foundation have gone a long way
00:47:58
Speaker
toward maintaining health and safety for singing teachers and their students. And both organizations were sponsoring agencies for the landmark research studies that were done on the contribution of aerosols to infectious disease, et cetera, that helped to really gather information that
00:48:28
Speaker
We didn't have, we didn't have research on how aerosols behaved with singers and infection. And so this landmark research study was extremely important. It involved well over a hundred arts organizations around the world supporting that. And Voice Foundation and NATS were both, as well as athletes and the arts were all part of that.
00:48:55
Speaker
It's worth mentioning that there are more components of the team than Meet the Eye. For example, we've mentioned Journal of Voice. The publisher of Journal of Voice is Elsevier, which is a very major publisher. When the pandemic
00:49:15
Speaker
arrived, we talked with Elsevier about expediting publication. It often takes 18 months, sometimes two years, from the time a paper is accepted to the time it gets into print. Publication online in advance of print is faster. During COVID, Elsevier set up a special division so that as soon as the editorial board accepted a COVID paper,
00:49:44
Speaker
It was made available online and we could publish it in print as quickly as we want. And we actually had papers that were submitted, revised, and published in under four weeks. Unheard of, but that's what partnership with a publisher that appreciates all of the organizations that converge to make a journal like Journal of Voice definitive
00:50:15
Speaker
can do to help the world.
00:50:27
Speaker
As of recent, I've heard stories of certain musical artists canceling their shows when they're on stage and something happens and they're not able to sing, or someone who may have something that comes up right before they're about to get on stage.
Managing Vocal Issues and Performance Risks
00:50:45
Speaker
How do you manage issues like those? Another interesting question.
00:50:50
Speaker
to having written about that since the early 80s. There is a course that we give at the American Academy of Otolaryngology that's been going on for more than 40 years called the Actor and Singer is Patients of the Otolaryngologist. There are specific guidelines that require cancellation. If someone has a vocal fold hemorrhage or a mucosal tear, it is almost never worth the risk to go on stage.
00:51:20
Speaker
I did say almost, and I meant that. There are always rare exceptions. But judgments in other circumstances require a full understanding of the factors. For example, anybody who has a mild to moderate laryngitis is at increased risk of hemorrhage from singing. The reason you have laryngitis, itis means inflammation. The reason that your vocal folds are red is because the capillaries are dilated.
00:51:50
Speaker
and tissues are more fragile because of the inflammatory mediators. So if it's your weekly church job, it's probably not worth it. If it's your last year of eligibility for the med auditions and you stand a chance of winning, maybe it is worth it. So those kinds of judgments come into place in everybody. Now the touring artists,
00:52:19
Speaker
are a special concern, but it also depends what kind of touring artist. If you have a touring musical theater singer, that person may be on stage eight shows a week, may have Mondays dark, but not much break, and maybe in the middle of a tour that's going to go on for 18 months.
00:52:45
Speaker
So that's different from an opera singer who's on tour, who's singing once a week or twice a week. And it's different and who also, if it's a recital tour, has the option to change repertoire or to change keys. And that's different from
00:53:14
Speaker
rock singers, big league rock singers who also have the ability to make some modifications. The fundamental rule is the long-term safety of the voice and helping the patient understand the risks and benefits, and then when necessary, running interference with artistic management, which doesn't always get it. The best of management does.
00:53:44
Speaker
So if we need to pull somebody off stage, we talk to management and we talk to the theater more often than not. It's not necessary. However, through the voice foundation, most of the voice specialists in the world know each other, the physicians, the speech language, pathologists, the singing voice specialists. So if somebody is in Philadelphia today and New York next week and
00:54:12
Speaker
Charlotte or Charleston the week after and Cleveland a few days after that and Madison and then Los Angeles. I know the people to send them to in all those cities and we communicate with each other and take joint care of patients all the time. So you can maintain continuity of care.
00:54:34
Speaker
through the community of laryngologists and speech-language pathologists and singing voice specialists very easily. It was not like that when I got started. When I got started counting mine, there were three voice laboratories in the country and that included Bell Labs. Now they are everywhere and they're attached to voice teams with knowledgeable professionals.
00:54:58
Speaker
We also all know each other well enough that when people come in and say, oh, I need a prescription for steroids, Dr. Benninger at the Cleveland Clinic gives me steroids every time I perform. We know that's not true. And we pick up the phone with the patient there and call Dr. Benninger and find out what the real story is. So touring artists are part of the everyday business of taking care of voice professionals.
00:55:27
Speaker
and with a large international community of caregivers, it's not that hard. Now, for people who are seeing you in voice therapy or other professionals, what do you tell them when it comes to encouraging them to persevere in their treatment? I can imagine it's really challenging for them. It's hard to take a break from something they love so much. In certain patients, they might not even be able to sing or perform for a longer period of time.
00:55:56
Speaker
What is the guidance you give to them then to keep encouraging them? First of all, whenever it's medically safe, we keep them performing. More often than not, it's not necessary to take people completely off performance. Sometimes it is, especially an acute injury like a hemorrhage, but then they're back on stage in six weeks, give or take, sometimes less, sometimes a little more.
00:56:26
Speaker
For the most part, we try to keep them performing. We may make them modify performance, change repertoire, change keys. If they're classical singers who have no training and use of amplification, sometimes getting them appropriate training makes a difference. Microphones also amplify
00:56:49
Speaker
subtle breathiness and other problems with the voice that may not be audible without amplification. And most classical singers have no training in how to use microphones. Pop singers do. We may have them decrease if somebody is singing five nights a week. We may have them cut it down to two nights a week for a few weeks and get help. On those rare occasions when it's necessary to interrupt performance completely,
00:57:19
Speaker
They understand. And in truth, we use the athlete analogy. If somebody needs Tommy John surgery, if he wants to continue his pitching career, he's not just going to try and pitch through it. He's going to get taken care of. So singers are professional athletes.
00:57:46
Speaker
And there are good parts of that and the bad parts of that. The bad parts are that just like other athletes, they get injured. And just like other athletes, when they get injured, they may have to rest for a little while so they can heal. Most performers are smart enough to understand that. And those that aren't, you know, they, they suffer the consequences. Um, performing injured is not uncommon.
00:58:14
Speaker
And with the voice team guiding, it can be done in a very healthy way. But a lot of people will just try to do it on their own, and they can really make their voice problem worse. That's correct, of course. They can also make their career worse. Even in the classical world, if someone's
00:58:42
Speaker
A pure performer, the show must go on. I don't have an understudy. I can't do it to them. I'm going to sing. When they go on stage, the critics don't say, Oh, what a trooper. She was really sick, but she performed anyway. They just say she sounded terrible and people read those reviews. And we have singers who've had contracts canceled when they performed against advice or before they ever saw us sick.
00:59:11
Speaker
and didn't get work for two years because of a bad review from eminent reviewers. So there's an artistic portion of the decision that goes into whether or not people should sing. Of course, it's easier when there's an understudy or a substitute or a rock singer can only sing one or two numbers instead of 20 numbers and do instrumentals and have other members of the band sing.
00:59:43
Speaker
They're, you know, it's the same thing. Audiences and especially critics are not forgiving of people who try not to disappoint their fans. They just rate them on what they sound like. And that's a hazard.
01:00:01
Speaker
It's so true, I never actually thought about it in that perspective, but that is extremely, it's good insight because I think it's important for musicians to take the time they need to rest and recover and take care of their one, you know, this is like the biggest instrument that they have. So coming out and performing their best is more important than trying to just please people, right, in their audience. The other thing that we remind them in that category
01:00:31
Speaker
is that these days, everything gets recorded. So if they do a bad performance, it's gonna be on YouTube forever. Right, or on every other social media.
Mental Health and Emotional Support in Voice Care
01:00:43
Speaker
When it comes to mental health resources for this population, are there a lot of resources on your website, on the Voice Foundation's website?
01:00:56
Speaker
No, maybe we should put some more up there, but on our website, we don't do any referrals to individuals. It's strictly scientific and educational, so there's not even a link to me on the Voice Foundation website. However,
01:01:20
Speaker
It's an important question. I was fortunate enough to co-author the first book called Psychology of Voice Disorders 20 years ago. And the second edition came out just a couple of years ago. And that book was to help fill a gap in the field. There are
01:01:48
Speaker
Psychological problems that go along with voice problems and they need to be expected and understood. It's relatively uncommon for voice problems to turn up in professional voice users, especially singers and actors caused by psychological or psychiatric issues. They can sometimes, we see them much more in other people.
01:02:19
Speaker
where people will come in whispering with psychogenic dysphonia and there are ways to treat that. But there are psychological consequences to any professional who has a voice problem. If as a microsurgeon, I injure my hand and I'm not sure whether I'm ever going to be able to operate again, there's going to be psychological impact. If I'm a singer and I injure my voice,
01:02:48
Speaker
And I'm not sure whether I'll ever be able to sing again. There needs to be a population of healthcare professionals who understand that. And that's just one set. We, we discovered, I noticed early on that there were some singers who had injuries, needed surgery. I operated on them and got perfect results and they still weren't getting better.
01:03:19
Speaker
and realized that it was because psychologically they were so afraid that they weren't going to be able to get better that they couldn't allow themselves to try to get better. And that led me to work with a psychological professional. Fortunately, I found one who is an old friend who was a nurse, PhD, psychologist and singer.
01:03:42
Speaker
who was full-time in my practice for seven years while we were sorting all this out and who's the first author in the psychology of voice disorders book. But there are those problems, there's pre-performance anxiety, and there are many others. The problem is most of these performing artists are not crazy enough for most psychologists. Psychologists and psychiatrists
01:04:09
Speaker
are accustomed to treating people with major mental health disorders and the performing arts and also the athletic population.
01:04:25
Speaker
has equally important and equally serious problems. But in the grand scheme of mental health disorders, they don't seem quite so severe compared to somebody with schizophrenia or major depression. So you need specialized arts medicine psychologists. And the reason we wrote the book is to help other health care teams find them. We have them.
01:04:53
Speaker
But my advice was to go find psychologists who sing in choirs, get them to read the book, come to the Voice Foundation meetings, talk to our psychologists, and figure out what needs to be done and how to do it for people in the voice world. So there is a growing substantial population of psychological professionals
01:05:18
Speaker
who understand the subtle but critical mental health issues for performing artists and for performing athletes. And all members of the voice team include
01:05:32
Speaker
that mental health support and emotional support. Because when a singer is not able to perform and not able to sing the way they are used to doing it, it really is a very emotionally draining problem. And I always tell my patients, don't disregard the emotional component of what you're dealing with.
01:05:58
Speaker
that if you can't do what you usually do, you are disabled and acknowledge that and deal with the feelings that go with it. And I have often referred people to mental health professionals to help them deal with those problems. In the old days, like 30, 40 years ago,
01:06:22
Speaker
What Deanna does, which we do and which is entirely appropriate, wasn't possible because there weren't mental health professionals to refer to. Exactly. And some wonderful speech language pathologists, including good friends of mine like Janina Kasper, tried to take care of the psychological problems as well as they could themselves. But remembering the team concept
01:06:47
Speaker
We provide psychological support, but speech language pathologists and singing voice specialists and laryngologists are not psychological professionals any more than psychiatrists should be operating on the voice. So we need them psychological professionals as part of our team so that it can be done right
01:07:09
Speaker
rather than trying to do it ourselves as we had to in the old days. Although, I'll tell you, we often kid among ourselves in the office about practicing psycholaryngology for a living. Deanna and Dr. Saddelof, from all the information that you've shared with us, what is the most important thing that you'd like for listeners to know when it comes to taking care of the voice? Ladies first. OK.
01:07:38
Speaker
My best advice would be not to disregard what seems like a small voice problem. If there is something that has changed your voice and you are noticing it for two to three weeks, maybe up to a month, it's time to go
01:07:57
Speaker
Get that looked at, have your voice visualized by a laryngologist and really get in contact with somebody who can get you involved with a voice team. Don't wait.
01:08:14
Speaker
I agree, and it's important for the public to understand that the level of expertise, the state of the art in voice care has advanced dramatically, but recently. That means that there are many superb otolaryngologists who take care of ears and sinuses and head and neck cancer and lots of other things who don't know much about the voice.
01:08:42
Speaker
and who don't necessarily know that they don't know much about the voice. So performers need to be educated consumers. I lecture the students at the Academy of Vocal Arts, the freshmen, every year.
01:08:56
Speaker
about voice health, voice care, voice pedagogy, so they know when somebody tells them, oh, you have a nodule, you need emergency surgery, that they need to go someplace else. So in addition to what Deanna said, people need to look for and understand expertise. And they can find it through the Voice Foundation. They can find it through NATS and the Journal of Singing. They can find it through Good Teachers.
01:09:26
Speaker
including many who are members of NATS, but just like there are good singing teachers and great singing teachers and other singing teachers, there are good and great and behind the times physicians who see voice patients.
01:09:49
Speaker
Be choosy. Correct. And know that you can be choosy. There is good help available. And when necessary, it's worth traveling for.
01:10:01
Speaker
Yes, yes, absolutely. Dr. Saddeloff, Deanna, thank you so much for your time and expertise and joining us today. I want to remind everyone that the Voice Foundation is the largest organization that supports voice professionals worldwide, not just in the United States. For more information, where can listeners go to? Voicefoundation.org.
01:10:28
Speaker
And if they want to see the video to see how a voice team works, that's www.phillyent.com. P-H-I-L-L-Y-E-N-T, as in your nose, throat in the media section. Wonderful. Thank you both so, so much. It's been a pleasure. Thank you, Yasi. Likewise. Thank you.
01:10:51
Speaker
And that wraps up our show. I want to thank all of our guests today, as well as Yasi. Remember, if you like what you hear, please click subscribe and leave a nice review for us. For Yasi Ansari, this is Stephen Karaginas, and this has been the Athletes in the Arts Podcast.