Rock Band Singer

This case history focuses on a male rock band singer.

Course of Referral:  This performer referred himself to an ENT office for a head and neck evaluation as a result of a long history of chronic laryngitis and throat pain.  He reported not being able to perform effectively with his band and sought out medical attention individually. His condition is related to an increased performance demand described as an “excessive amount” of performing and rehearsing.

Case History: He previously was a drummer in another band that was primarily a country band; he also participated in back-up vocals and special “voice” effects (i.e. growl and grunts) in addition to drumming.  When he was not performing or rehearsing in his current band, he worked as a computer programmer, so his work and home life were fairly quiet.  He reported a long history of cigarette smoking that amounted to at least 1 ½ packs per day.

Time Line and Evaluation. He indicated that he had a “normal” voice until approximately two to three years ago. He recalled frequent episodes where he would lose his voice with the episodes happening more often and for a chronically longer period of time.  In terms of vocal abuse, he demonstrated excessive coughing and throat clearing. He appeared to push his voice to overcome the current dysphonia both during singing and speaking.  

He reported trying to yell and scream to “straighten out” the voice problem but said that this method did not help.  In fact, after engaging in this vocal activity he felt pain and a “stinging” sensation in his throat.  He reported occasional complete loss of voice associated with crying.  He has a history of gastroesophageal reflux (GERD) and currently takes medication (prilosec) to mange the acid indigestion.

He was originally seen On December 30, 1999.  A head and neck exam was performed during this visit and revealed a septal deviation to the right in the patient’s nose.  Also, nasal crusting with irritation and nicotine staining were noted. Examination of the throat revealed very prominent nicotine hypermia.  Results of the mirror examination of the vocal folds revealed polypoid material in the anterior one third of the right vocal fold, far more than the left.  ENT impressions of this exam included chronic laryngitis, polypoid polyps, septal deviation, rhinitis, and dysphonia.

Pharmacological treatment included the antibiotic Cefzil commonly used for sinusitis and pharyngitis; Entex used as a decongestant; SteriPred used as an anti-inflamitory; and daily use of saline nasal spray.  A surgical procedure referred to as a microlaryngoscopy and biopsy was indicated for the lesion on the right true vocal fold.  It was also recommended that he be seen for a complete voice evaluation with video stroboscopy however he was reluctant to pursue any further evaluation or treatment (as well as surgery at this time).

The patient was seen again in the office by an ENT two and a half weeks later on January 18, 2000 and indicated that he thought his voice might be a little better.  However, he was still smoking at least one pack of cigarettes per day, had a stuffy nose and was reporting blowing out “bloody crusts” from his nose.  The ENT performed a flexible nasal laryngoscopy and still found that the polypoid mass was present, more prominent on the right vocal fold also a nodular/polyp like formation on the left vocal fold.  The patient was strongly recommended to be seen for a voice consultation with videostroboscopy.  

His visit to the Voice Care Center for a voice evaluation took place on March 7, 2000.  After topicalization with Pontocaine spray a good view of the larynx was obtained with a 70-degree oral scope. 

Perceptual Impressions: Perceptually, his voice quality was deemed to be moderately breathy with moderate strained voicing segments, frequent hard glottal attacks and intermittent glottal fry.  The pitch was slightly too low (avg. fundamental frequency of 92 Hz) and the voice was too loud with occasional periods of aphonia lasting 1-3 seconds during conversational speech. A maximum sustained phonation time was recorded on the vowel /a/ several times with an average time of eight seconds.

Results of Videostroboscopic Examination:

Vocal fold edge:  A large mass on the right true vocal fold at the junction of the anterior one third and the posterior two thirds was noted.  Generalized polypoid change was present throughout both vocal folds, especially on the glottal edge of the middle one half of the left true vocal fold.

Glottic Closure:  A posterior glottal gap was present.  When the vocal folds closed, the anterior two-thirds of the vocal folds became nonvibratory.

Phase Closure: Open phase predominated. 

Vertical level of Approximation: Equal

Vibratory Amplitude: No visible movement was present in the anterior two thirds of the vocal folds.  The vibratory amplitude of the posterior two thirds was judged as moderately decreased in both vocal folds.

Mucosal Wave: The mucosal wave was judged to be absent in the anterior two thirds of the vocal folds and moderately decreased in the posterior one third of the vocal folds.

Vibratory behavior: Vibratory behavior was judged to be absent in the anterior two thirds of the vocal folds with  partial absence judged for the posterior one third of the vocal folds.  

Phase symmetry: Mostly irregular.

Hyperfunction: Present with some supraglottic press.

Intervention. Following the evaluation, a treatment plan was devised that incorporated immediate implementation of modified voice rest, use of a more therapeutic voice (low impact/no strain), laryngeal relaxation, breath support, vocal hygiene, hydration and elimination of various forms of vocally abusive behaviors.  He continued following through with these strategies for two weeks, then underwent phonosurgery to remove the pathological condition.

Results of Therapy. This therapy regime was completed in order to maximize the benefits of the surgical outcome. Slight changes did occur in the edematous state of the left vocal fold following this short therapy program. 

Surgical Procedure and Result: Following a successful surgery, GIVE ME A BIT MORE HERE

Perceptual Impressions following Surgery. 

Behavioral Voice Therapy Following Surgery.  Five weeks were spent under a modified vocal rest program, gradually regaining the amount of voice use each week. The goal of therapy during this time period was to “re-calibrate” this singer to use both the speaking and singing voice in a more therapeutic manner. Refer to Peggy’s work

It was important for us, as a professional voice team, to understand the voice quality this performer was after and the final product that he desired to have in order for success in his musical career. This performer needed to  set up some point of reference from which he could 

reestablish his stylistic intent.  He did this with the therapist’s help in order to know how to use his voice in a manner that did not create vocal fold damage. The therapist worked hard to develop this performer’s self-monitoring skills and educate him on how to identify the boundaries between vocal style and vocal damage.

Bottom line is that you don’t need to be classicly trained singer in order to have a good singing technique. As long as you understands the basic foundations of the therapy regimens set forth by the therapist, unique modifications can be made that fit the style that is being portrayed during a performance.  For example, this rock singer is going to portray a harsh or raspy voice quality to carry through a desired performance effect. This unique voicing can still be accomplished in a manner that does not require high amounts of laryngeal tension and strain.  

Return to Work/Performance. At five weeks post-surgery his voice quality has progressed without any excessive laryngeal tension, hard glottal attacks and he displayed the ability to self monitor his own “healthy” vocal production.  He was able to return to work without any difficulty due to the nature of his job however, the performance demand was another issue.  Due to the abusive nature that his vocal style demands it was necessary to carefully monitor the frequency of performances and rehersals.  He prioritized the performance schedule based on the most importatant gigs that he didn’t want to miss.  This left him with one vocal perforance with his band approximately every other week.  This schedule was doable.  We began tape recording all of his perforamnces and rehersals so that he could listen back at a later time (with the therapist) and identify and modify un-necessary abusive behaviors.  This method proved to be extremely effective.  At the end of one and a half months he was fully returned to a regular schedule that included one rehersal and one to two performances per week.  He continues to be seen in the office for re-evaluations and “tune-up” therapy sessions.  Overall, his recovery process was successful and he is no longer reported vocal breakdowns.