Classically Trained Singer
This case study focuses on a female who is a classically trained opera singer.
Course of Referral: Self-Referral. She saw her primary care physician and that physician sent her to an ENT.
Case History and Time Line: She reported singing successfully until approximately October 1995. At that time she had a vocal nodule removed at another medical facility (side unknown). She reported singing successfully for one and a half years follwowing that surgery. As she recalled, her voice problem began with sudden, intermittent periods of “raspy and breathy voice” with episodes of sudden voice breaks. During late 1998 and early 1999, she had an extremely demanding time in terms of vocal use with great deal of vocal abuse.
When she was not singing, she worked as a court interpreter. This required an excessive amount of talking with loud authoritative vocal projection. Often, she reported not having any amplification system and when there was amplification it was not adequate. She described her home environment as a stressful, loud one. She is the mother of two small children that she primarily cares for. Most recently she experienced emotional stress at home that she felt contributed to the current condition.
Her patterns of vocal abuse included: poor hydration, too much caffeine intake (coffee and soda), too much talking, excessively loud talking, talking over noise, strained talking, throat clearing, emotional strain, crying and singing when voice was already fatigued. The crying and emotional strain was related to the emotional stresses at home. This vocal abuse pattern best illustrates a problem in the speaking voice that created ill effects to the vocal folds, however they were not realized until this person engaged in singing.
Evaluation. A mirror examination by the ENT revealed a left vocal fold polypoid type lesion with generalized edema surrounding the lesion side as well as on the opposite vocal fold.
Initial Office Visit. Her voice quality was evaluated during the initial case history interview. Perceptual impressions at the initial visit indicated a moderately breathy voice with compensatory vocal strain and pressed voice. Her voice quality was evaluated during the interview. The pitch of her voice was adequate and conversational voicing was perceived as too loud. The vocal strain was characterized by hard glottal attacks and poor breath support which was indicated by a fast speaking rate observed during conversation. A maximum sustained phonation time was recorded on the vowel /a/ over three trials with an average time of 12 seconds recorded.
Results of Videostroboscopic Examination. A clear view of the larynx was obtained during the videostroboscopic examination using the oral scope. Results indicated the following:
Vocal fold edge: Bilateral vocal prominences at the junction of the anterior one third and the posterior two thirds were noted with generalized edema throughout the vocal folds.
Glottic Closure: Glottic closure was judged as an hourglass configuration.
Phase Closure: Open phase predominated.
Vertical level of Approximation: Equal
Amplitude: Vibratory amplitude was severely decreased in both vocal folds.
Mucosal Wave: The mucosal wave was judged to be severely decreased in both vocal folds.
Vibratory behavior: The vibratory behavior of the vocal fold was judged to be completely absent at times but dod show slight return of movement depending on the pitch that was produced.
Hyperfunction: Occasionally present with anteroposterior squeezing and medial movement of the ventricular folds.
Intervention. Intervention was centered on a behavioral approach just like what has been outlined in the previous case studies. She focused on a modified vocal rest, use of a theraputic voice (low impact), laryngeal relaxation, facilitation of an appropriate tone focus and counseling in hydration and vocal hygiene. In addition, a corticosteriod was perscribed for a controlled period of time in order to facilitate reduction in the generalized edema. She was compliant with this program and extremely motivated to follow through and not undergo additional surgery. The use of a wireless personal amplification device was also a beneficial tool in the therapy room that she will be carrying over to her work location.
Results of Therapy She was an extremely motivated singer. Not only was she not able to sing but not able to work either. She had a tremendous amount of help and support from family and friends so her vocal rest period and rehabiliation of the voice went smoothly. In a matter of seven and a half weeks, she was able to reduce the amount of edema and glottic insufficiency; eliminate vocally abusive behaviors and self monitor her own “healthy” voice production. Additionally, she was pleased with both the singing and speaking voice, which is something she stated that she thought was lost forever.
Surgical Procedure and Result. No surgery was required for this performer as she was able to reduce the pathological condition through voice therapy.
Perceptual Impressions following Intervention. A spontanious conversational speaking sample did not reaveal any breathy, hoarse or harsh vocal features, no episodes of hard glottal attacks or strained pressed voicing. Vocal loudness and pitch was normal.
Videostroboscopic Results following Intervention.
Vocal fold edge: smooth bilaterally
Glottic Closure: complete
Phase Closure: normal
Vertical level of Approximation: equal
Mucosal Wave: normal
Vibratory behavior: fully present
Hyperfunction: not present
Return to Work: This person was able to return to work as a court reporter with effective strategies and the use of amplification following eight weeks of the behavioral voice therapy program. A wireless amplification unit was fitted and used in the courtroom to maximize vocal loudness. Modifications such as reducing speaking rate, which assisted with adequate breath control, and tone placement were focused on in therapy. These regimens were successful and allowed her to begin work in a manner which was less abusive. It was recommended that she return to work to implement these strategies so that a generalization from the therapy setting could happen effectively. Her initial return was three days per week for approximately four hours a day. This schedule occurred the first week back to work. After a certain amount of endurance was built up (within three weeks), she began working full time. At her recheck she reported no problems with the voice. Notably, she sought counseling for her emotional stress and tension in the home environment and reported good success with the counseling program. Additionally, she is seeking training with a vocal coach to optimize her skill levels during singing.