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11 February, 2019 00:00 00 AM

Professional voice disorder & remedy

Prof. Dr Kamrul Hassan Tarafder
Professional voice disorder & remedy

You may have a voice disorder if you have a problem with pitch, volume, tone, and other qualities of your voice. These problems occur when your vocal cords don't vibrate normally.

Your voice is the sound that air makes when it is forced out of your lungs and passes over your vocal cords. Vocal cords are the 2 folds of tissue inside your voice box (larynx). The vibration of those cords is what makes speech.

Professional voice disorder

Professional voice users as a group have their own special needs, the foremost being that their voices are crucial to their careers. Whereas the voice demanding professions, such as artists, singers, teachers, lawyers, telephonists, telesales, hawkers, salesman, renter, voice performer etc. need a normal voice to function, the performing voice needs to be at an optimum.

Classification

The professional Voice can be divided into three categories:

The singing performing voice

The speaking performing voice

Voice demanding professions

Physiology of voice

The signal emerging from the vocal folds is a simple harmonic wave. 1 This signal is altered as it passes through the vocal tract (the resonator) from the vocal folds to the opening of the lips and the nasal vestibules. Certain frequencies are amplified and these peaks of frequency are called the formants of voice.. Performing artists have certain characteristics of which the laryngologist needs to be aware in the management of their voice disorders.

Personality

Performers are often flamboyant high achievers and everything in life is a drama. Indeed, a performer's life often moves from crisis to crisis.

 Although this personality has perhaps been integral in achieving the performer's status. Performers also have to take on the personality and character of their performing role which involves not only voice abuse, such as screaming and shouting, but also altering the configuration of their vocal tract for different accents and to disguise their age and personality. Prolonged supralaryngeal constriction to give certain emotions such as anger or sadness can, in the long term, lead to secondary structural abnormalities of the larynx

Demands

The phrase 'a starving actor' is, unfortunately, still applicable and performers are in an extremely competitive market. An inexperienced performer may take on roles outside their range and indeed may be under considerable pressure to do this. The hours of rehearsal are frequently demanding, often with eight performances a week. Some roles are beyond the capacity of one performer although, thankfully, musical/theatre directors are now acknowledging this and are beginning to appoint two performers for one extremely challenging role. Performers are now requested to be more versatile and not only singers but also actors and, specifically, dancers. The constricting costumes and physical activity can affect their classical breathing technique.

Environment

Numerous old theatres are dusty, especially in the wings, off stage and in the curtains during change of scenes. A recent performer was seen in the clinic who was found to be allergic to feathers but, unfortunately, for his part of Captain Hook in Peter Pan, was required to wear a large feather in his hat. Artificial smokes and fogs used for special effects are also known to have an irritant and drying effect on the voice.

The acoustics of sound are also important and although modern theatres are built with better acoustics. As a result, many require amplification in the form of a microphone. The microphone should never be placed directly in front of the lips and indeed, should be 20 cm to the side of the mouth. Amplification with microphones has now become such an accepted part of the performer's life that top performers will often bring their own sound mechanics to improve this.

Lifestyle/travel

The normal humidity in a plane is 5 percent but at the end of a transatlantic flight can be up to 28 percent. This comes from incidental loss from the body and stresses the importance of hydration for top professionals during international travel. The ambient noise on an aeroplane can be greater than 60 dB and again it is advisable for professional voice users to use their voice minimally during flight.

Cross-infection is also common during air travel but can occur at any time. Jet lag is equally important and indeed, in a recent survey, general fatigue was one of the main complaints from performing voice users. Changing time zones can affect normal practice hours which is relevant as auditions are frequently carried out in the mornings, completely throwing the performer's body clock. Performers rarely go on stage with a full stomach and tend to eat late at night. As a result, gastrooesophageal reflux is common.

Performance anxiety

The voice is the window of the soul and has an emotional as well as a mechanical and technical component. The larynx has the greatest innervations of any organ of the body (greater than that of the face and also the hand). Its neuromuscular physiology is complex. It also has abundant hormonal receptors. It is known that there is a slight amount of vocal fold oedema immediately before menstruation and female performers were often given grace days because of this. The condition is known as laryngopathia premenstrualis and is now well recognized.  

Almost all performers have a certain amount of stage fright due to the effects of adrenaline. Standing on the podium with a dry mouth, sweaty hands and heavy legs is a normal reaction of the body to stre'ss and adrenaline production. Indeed, in some cases, this small amount of adrenaline is beneficial as it primes the performer for action.

If this performance anxiety becomes a greater problem then there are three recognized management strategies; deep breathing exercises, an emotional support (the 'magic feather'), or cognitive psychotherapy. Beta blockers have been used by musicians and athletes to prevent tremor but they have had no benefit for the voice. Anxiety can help produce a world class performance and beta blockers have no role in the management of anxiety in the performing voice.

Confidence

Many of the best phonosurgeons are either musically trained or have a musical background themselves. This not only reflects their interest in this area but also allows them to be more compassionate and understanding to the performer. To the scientist, the use of modal voice with falsetto at the upper range and vocal fry at the lower range will mean very little to a performer who would rather discuss head and chest voices and persaggio.

A laryngologist who understands these terms will inspire confidence in his or her diagnosis, which is essential for the performer. Many performers now also demand a record of their voice either from a video or a video print and also a quantitative record. It may be the recommendation from the voice clinic that the performer returns to his theatre and asks to sing a less demanding part or a different range and it will require a great deal of confidence in the voice clinic for the performer to be able to do this and not feel that their career is threatened in any way.

Tips on voice care

Avoid clearing your throat.

Avoid coughing whenever possible.

Speak in a clear tone.

Avoid talking above loud noise.

Keep volume level low on audio sets.

Wear earplugs at music concerts.

Keep airflow smooth during exercise (especially weight lifting)

Drink plenty of water to avoid vocal cord dehydration (at least 8 glasses per day)

Do not smoke and avoid smoky environments.

If your voice quality changes suddenly, rest your voice and consult your physician or laryngologist.

If your voice loss is gradual, but does not improve within 2 weeks, consult your physician or laryngologist.

If you are speaking or singing in a way that makes you hoarse or causes discomfort, STOP!

Additional tips for the performer

Always warm-up before a performance.

Rest the voice when you do not need to use it.

Get formal voice training if you have not already.

Be careful with “character” voices and “emotional” releases. Always  use good technique.

Career longevity is dependent on maintaining a healthy voice. Make wish decisions and protect yourself.

Come in early to be evaluated for any voice problems.

Treatment of Voice Disorders

Three Main Treatments

The three main treatments for voice disorders are:

Medical treatments

Voice therapy

Surgical treatments

Medical Therapy

New anti-reflux medicines provide effective medical treatment of reflux laryngitis

Effective monitoring and treatment of low thyroid hormone levels help patients with voice disorders caused by hypothyroidism.

Advances in the use of botulinum toxin A as an injected medicine for muscle disorders provides a key treatment option for voice disorders caused by muscle spasm (spasmodic dysphonia)

Voice therapy

Laryngologists often recommend voice therapy as first-line treatment for voice disorders in which voice misuse or abuse has contributed to long-term irritating injury to the vocal folds, resulting in lesions (such as vocal fold nodule, cyst or polyp).

Surgical therapy

Surgical treatments of voice disorders have improved dramatically in recent years.

The main surgical approaches to voice disorders are:

Phonomicrosurgery: Surgical techniques that are performed with a microscope for viewing (microsurgical techniques) and are used to remove vocal fold lesions or abnormalities that hamper vocal fold vibration.

Laryngeal framework surgery: Surgical manipulation of voice box framework that improves vocal fold closure, which is important for vocal fold vibration during speaking and singing.

Injection Laryngoplasty 

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Editor : M. Shamsur Rahman

Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

Editor : M. Shamsur Rahman
Published by the Editor on behalf of Independent Publications Limited at Media Printers, 446/H, Tejgaon I/A, Dhaka-1215.
Editorial, News & Commercial Offices : Beximco Media Complex, 149-150 Tejgaon I/A, Dhaka-1208, Bangladesh. GPO Box No. 934, Dhaka-1000.

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