CARE OF THE OFESSIONAL VOICE
R0bertT. Satal0ff, MD, DMA, Associate Editor
Consulting a Voice Doctor:
Yolanda D. Heman-Ackah, MD, Robert T. Sataloff, MD, DMA,
Mary J. Hawkshaw, BSN, RN, CORLN, Venu Divi, MD
NITIALLY, THE ANSWER TO
a voice doctor?" would seem
the correct answer is more
should be familiar with the va
laryngologist not only during il
training, for evaluation, establish
line, and for education and advice
Finding the right voice doctor is the
of Singing, but this article is to help
Yolanda Heman-Ackah Robert Sataloff ter when a laryngologist (voice
especially when one should be co
PREVENTIVE
Anyone who relies on one's volce
a baseline larymgeal function and vi
a laryngologist when the voice is
difficulty. This examination will h
of concern that may contribute, in t
of debilitating voice difficulties. Ent
mild asyrnmetries in vocal fold moti
nasal septal deviation, nasal conges
may not be causing any symptoms
may contribute to the developmen
problems can be identified and r
laryngologist and voice team on
becoming problematic. Additional
such as pollps, cysts, pseudocysts (
areas of stiffness, sulcus vocalis (ben
and others can be identified. Kno
the voice is functioning normally ca
guided treatment that otherwise
cause ofa voice problem that deve
is at risk for infection, trauma, and t
Journal of Singing, September/October 2008 may require general anesthesia, e
Volume 65, No. I, pp. 53-58
ment of voice problems regardless
Copyright o 2008
National Association ofTeachers of Singing prowess, or use ofproper voice
SsprpraeEn/ O croepn 200 8
hen?
The Vocal lnstrument," in press.
euESrIoN "When should I see
\,\4ren you are sick. However,
c ex than that. Singing teachers
of consultation with an expert
and crises, but also prior to
an individual's "normal" base-
ing preventive voice care.
ject ofanother article in Journal
teachers understand bet-
list) should be consulted, and
ted urgently
ICE CARE
is or her profession should have
troboscopic examination with
tioning optimally and without
to diagnose any potential areas
long term, to the development
such as asymptomatic reflux,
mild allergy, tonsil enlargement,
, nasal polyps, and others that
difficulties presently, but that
unhealthy behaviors or voice
ndations can be made by the
to prevent these entities from
asymptomatic benign lesions
zed swelling in the vocal fold),
indentations in the vocal fold),
g that these lesions exist when
vent a misdiagnosis and mis-
focus on these lesions as the
in the future. Because everyone
need for nonvoice surgery that
is at risk for the develop-
s level of training, technical
que.
53
Yolenda D. Hemqn- Ackah, MD,
SUDDEN HOA
Probably the most pressing
is to evaluate acute voice diso
left untreated. These usually
sudden onset ofhoarseness an lcan be precipitated by
myriad events, including trau af voice overuse or mis-
use, and infection.
The sudden onset of hoarse
atelv after intense vocal use i
fold. This may be in the form o
tear (Figure 2), or edema (Fig
curs when there is trauma to
within the vocal fold and it
bleeding is beneath the surface
and the only symptom of the bl
of hoarseness and occasionall
throat.l A vocal fold tear occ
tion of the mucous membrane
from intense yelling. screami
Edema is swelling in response
infection. Vocal fold tears can al
of laryngitis or other upper r
testinal infections, usually as a
fully or from the dry heaves a
placement of an endotracheal
anesthesiologist for surgery ca
tears, and whenever possible
6.Omm inner diameter) plasti
will allow adequate ventilation (
ing the general anesthesia is re
sional voice users undergoing
ofthese entities represents a voc
be evaluated immediately, es
began abruptly enough to inte
Figure t. Right Vocal
54
rt T. Sataloff, MD, DMA, Mary I. Hawkshaw, BSN, RN, CORIN, Venu Divi, MD
ESS sentence, phrase, or performance, immediately follow-
ing surgery, or immediately following a coughing/
to see a voice clinician
vomiting episode.
rs that may worsen if
characterized by the
ss during or immedi-
ies injury to the vocal
emorrhage (Figure 1),
3). Hemorrhage oc-
e of the blood vessels
to bleed. Usually the
the vocal fold mucosa
ing is the occurrence
or pain in the
when there is disrup-
the vocal fold, usually
or forceful singing.2
vocal fold trauma or
occur during episodes
tory tract or gastroin-
t ofcoughing force-
tedwithvomiting. The
rhing) tube by an
lso result in vocal fold
e smallest (5.0mm to
racheal tube that
tificial breathing) dur-
mmended for profes-
ice surgery. Each
emergency and should Figure 2. Vocal fold tear (a), with
ially if the hoarseness resolution after I week (b) and 4 weeks
pt the conclusion of a (c) ofvoice rest.
hemorrhage. Figure 3. Vocal fold edema.
f ounNer op SrNcrNIc
 Care of the Professional Voice

The treatment of vocal fold hemorrhage varies de- falling of the neck on the handlebars ofa bicycle, or
pending upon the degree of bleeding. In most instances, strangulation or injuries to the neck. Injuries
a period of abrolute voice rest is all that is needed. On oc- from blunt neck trau an include nerve paresis (weak-
casion, the hemorrhage is significant enough to warrant ness), cartilage frac , joint djslocation, and vocal
immediate surgical drainage. In these cases, if left alone, fold hemorrhage, ede , or tear.3 These injuries can be
the hemorrhage may organize to form a polyp and/or potentially life threa ng, especially if the airway col-
scarring ofthe vocal fold. lapses suddenly or if elling develops following the
Vocal fold tears are treated with a period of voice rest injury. Immediate I attention, even if mild hoarse-
to allow the tear to heal. If the tear is superficial, usu- ness is the only symp , is recommended in all cases.
ally healing will occur without significant sequelae if the Manv individuals w suffer a blunt neck injury feel
voice is rested. Ifthe tear is deep, there is greater poten- fine initially, and swe g or a sudden shift in the frac-
tial for scarring, which can have more significant long- tured cartilages occurs inutes or hours after the trauma
term implications. In either case, if one continues to obstructing the air in a manner that can be life
phonate on a vocal fold that is torn, the risk of perma- threatening.
nent scarring appears to increase. Once scarring of the During such injuri , the recurrent laryngeal nerve
vocal fold has formed, it is difficult to treat and often can become crushed ween the spine and the cricoid
results in permanent hoarseness and/or difficulty with cartilage, resulting in a paresis. This tlpically man-
register transitions. ifests as hoarseness or iness in the voice. Vocal fa-
Edema of the vocal fold occurs from several causes, in- tigue and effortful p ation also can occur. The treat-
cluding phonotrauma from forceful closure of the vo- ment of vocal fold pa is from neck trauma is usually
cal folds. This can occur in an individualwho is yelling symptomatic (includ voice therapl), and unless the
or screaming, in one who is trying to talk or sing with an nerve is severed, fu will usually return over the
upper respiratory tract infection, as well as in those who course of weeks to m hs.
are trying to project the voice by increasing pressure in Fracture ofthe lar cartilages and dislocation of
the vocal folds. Edema alone usually requires a period of the cricothyroid and/ cricoarytenoid joints can also
relative voice rest or light voice use. Relative voice rest is occur as a result ofn trauma. Symptoms of these in-
near complete silence, reserving the voice for urgent juries usually include rseness, pain, and occasion-
communication only. Light voice use is minimal talk- ally difficulty breathin racture or dislocation is a med-
ing, usually no more than five minutes per hour and no ical emergency and wa evaluation by a larlngologist
more than one minute continuously at a time. On oc- or otolaryngologist termine whether the airway is
casion, corticosteroids can be used to speed recovery at risk and whether s ical intervention is necessary.
from vocal fold edema, but they should be used cau- There is a high potent for airway compromise, which
tiously. Typically, steroids cause one to feel and sound could become life th ning. Even in the absence of
much better than the actual health of the vocal folds and determination as to whether a
airway compromise,
can predispose to further vocal fold trauma if attention fracture or dislocatio be corrected is best made
to good vocal technique is not employed while using within the first 24- urs after injury. During this
these medications. reduction ofthe fractured or
time frame, attempts
dislocated segments easiest and are most likely to
NECK TRAUMA results. If too much time is al-
yield the best long-
External trauma to the neck can result in injury to the lowed to pass before t tment is initiated, scarring and
larynx and requires urgent evaluation by a doctor. Such healing of the fragme in abnormal locations may oc-
trauma can occur from incidents such as elbow injuries cur, which may limit e success of attempts at reduc-
to the neck while playing basketball or during a stage tion and result in per nent hoarseness or problems
fight, from automobile accidents in which the neck hits with breathing that is ifficult to correct after healing
the steering wheel or is caught by the safety belt, the has begun.a

SEPTEMtsI,R/OCTODER 2OO8 55
Yolanda D. Heman-Ackah, MD,
HOARSENESS A
Hoarseness after a surgical
the larynx warrants special
anesthesia for most surgical
cheal (breathing) tube is
the vocal folds, to help main
patient is asleep. Vocal fold t uma (mucosal tear or
hemorrhage) is a well recogni complication of anes-
thesia and usually is managed ith voice rest. In some
individuals, the placement of t endotracheal tube can
result in injury to a vocal lold
arytenoid cartilage offits loca
lage. This dislocation may h
even the most skilled of anest
tient awakens from anesthesia
does not improve with time. A
best treated as early as possi
scarring around the dislocated
duction can become difficult.
is suspected, consultation with a
be made.s
Another cause ofhoar
gery is injury to the recurre
nerves. This may occur during
is performed in the vicinity of
ally after intubation for surger
neck. Because the nerves tr
brain, into the neck and ches
neck to enter the larynx, inju
in anylocation along this route
tion, patients who experienc
nerves during surgery usually
a hoarse andlor breathyvoice.
All patients who have hoa
gery should have their larynx
a laryngologist. Differentiati
dislocation and nerve injury
stances, and diagnosis usual
laryngeal examination, lary
computed tomography scanni
The treatment of laryngeal
pending upon whether the n
been cut or just stretched. A str
ally will recover on its own
months. Treatment in these i
rt T. Satalffi MD, DMA, Mary I. Hawkshaw, BS L RN, CORLN, Venu Divi, MD
SURGERY
ure not performed on
tion. During general
cedures, an endotra-
to the larynx, between
respiration while the
4.
Figure Vocal fold carcinoma.
dislocation of the
on the cricoid carti-
n occasionally with
logists. Usually, the pa-
h a hoarse voice that
oid dislocations are
to prevent permanent
ilage. If scar forms, re-
soon as the diagnosis
arlmgologist should
Figure 5. Vocal fold papilloma.
ter nonlaryngeal sur-
r superior laryngeal
surgical procedure that and may include corticosteroids, collagen injection,
nerves and occasion- gelfoam injection, fat injection, or thyroplasty to place
utside of the head and the vocal fold in a favorable position for eating and speak-
a long route from the ing while it recovers. A nerve that is suspected of having
back through the been severed should be repaired as soon as the suspi-
occur with surgery cion is raised to maximize the chances of maintaining
arltenoid disloca- good laryngeal tone.
jury to the laryngeal
n from surgerywith
PROLONGED HOARSENESS
after nonvoice sur- Anyone who experiences hoarseness or another vocal
mined immediately by difficulty that persists longer than two weeks should
tween an arytenoid have his/her larynx evaluated by a laryngologist or oto-
difficult in these in- laryngologist. It is rare for a "laryngitis" alone to persist
made with the aid of for more than two weeks, even if the hoarseness began
lectromyography, and during an upper respiratory tract infection. In such in-
stances, the persistent hoarseness may be due to a mild
ve injury varies de- paresis of the vocal folds, and this should be evaluated.T
is suspected ofhaving Alternatively, other pathologies in the larynx, including
:hed, intact nerve usu- cancer (Figure 4) and human papilloma virus infections
he course of weeks to (Figure 5), may begin with a similar presentation and
ances is symptomatic should be evaluated. If left untreated, these lesions may
)ouRNar or SrNcrNc
 Care of the Professional Voice

grow large enough to obstruct the airway, limit breath- 7. G. Dursun, R. T. Satal
ing, and potentially cause death. and D. C. Rosen, "S
Paralysisl' Journal of
CONCLUSION
Yolanda D. Heman-Ackah
There are several instances in which the larynx defi-
professional voice care, She
nitely should be evaluated promptly. These include Otolaryngology and is a
hoarseness that is abrupt in onset, hoarseness that be- ogy-Head and Neck
gins immediately following nonvoice surgery, trauma in Psychology and her Doctor
to the larynx or neck, and hoarseness that persists for versity as part of the
longer than two weeks, even if the onset was during the her residency in otolar
course ofan upper respiratory tract infection. The rea- sity of Minnesota, she
and laryngology under the
sons for evaluation in these instances are the prevention
at the American lnstitute for
of long-term sequelae such as permanent hoarseness,
ical College of Thomas
scarring, vocal fold lesions, and the diagnosis and treat-
to her medical training, Dr
ment of potentially life threatening illnesses such as can- dancer, a musician, and a
cer, tumors, and airway compromise. Having a baseline
She founded and directed
laryngeal evaluation when vocal production is optimal
Chicaqo upon completion
is also advocated as a preventive health measure.
she yoined the practice of
Knowledge of one's unique anatomy in the "normal" Philadelphia where she
state will help to guide diagnosis and treatment should aspects of otolaryngology
voice difficulties later arise, whether they be from disease, the performing artist and
infection, trauma, or abnormal use patterns. It is also ber of the academic faculties
, |. R. Spiegel, S. Mandel, R. J. Heuer,
ior Laryngeal Nerve Paresis and
10, no. 2 (1996): 206-211,
is a laryng0l0gist whO specializes in
ceftified by the American Board of
the American Academy of Otolaryngol-
received her Bachelor ofAfts degree
Medicine degree from Northwestern Uni-
in Medical Education, Followinq
and neck surgery at the Univer-
a fellowship in professional voice care
ip of Robert T. Sataloff , MD, DIVA,
and Ear Research and Jefferson Med-
University in Philadelphia. ln addition
-Ackah is also a professionally trained
Center at the University of lllinois at
o1 lowship. After a few years in Chicago,
T. Sataloff and Karen M. Lyons in
in professional voice care and other
and neck surgery as they pertain to
al voice user. She is an active mem-
Drexel University College of Medicine,

invaluable for voice teachers to be aware of baseline vo- where she currently holds the of Associate Professor, and Thomas
Jefferson University. She is National Medical Advisor for the Voice
cal fold abnormalities and to document them prior to 1

and Speech Trainer's n (VASTA) and is actively involved in

starting lessons with a new student, whenever possible.
VASTA The Voice Foundation National Association of Teachers of
Singing (NATS), the Latin Ac of Recording Arts and Sciences, and
NOTES the National Academy ol Arts and Sciences (the Grammy Foun-

l. Y. D. Heman-Ackah and R. T. Sataloff, "Blunt Trauma to the dation). She has authored or thored numerous publications, includ-

Larynx and Trachea: Considerations for the Professional Voice ing award-winning lournal , book chapters, and several books

Userl' Journal of Singing59,no. I (Septemberi October 2002): She is a member of the Editor ol lhe Journal of Voice, and is an
4r-47. editorial reviewer for other journals

2. Ibid.
3. Y D. Heman-Ackah, G. S. Goding, Jr., and V. Rao, "Laryngo- RobertT. Sataloff, MD D Professor and Chairman of the De'
partment of Otolaryngolog and Neck Surgery and Associ-
tracheal Traumal'in Rubin, R. T. Sataloff, and G. S. Korovin,
J. S.

eds., Diagnosis and Treatment of Voice Disorders,3rd edition ate Dean for Clinical Acad ies at Drexel University College

(San Diego: Plural Publishing, Inc., 2006). of Medicine. He is also on 1 at Thomas Jefferson University,
the University of Pennsylvan Temple University and the Academy
4. R. T. Sataloff, M. Feldman, K. S. Darby, L. M. Carroll, and J.
of VocalArts. Dr. Sataloff is tor of the Thomas Jefferson Uni-
R. Spiegel, 'Arytenoid Dislocation," lournal of Voice l, no. I
versity Choir and 0rchestra Dlrector of The Voice Foundation's
(1987): 368-377; R. T. Sataloff, I. D. Bough, and J. R. Spiegel,
Annual Symposium on Care Professional Voice, Dr, Sataloff is
'Arytenoid Dislocation: Diagnosis and Tr eatment:' L ary ngo s co p e
also a professional singer inging teacher. He holds an under
10a (199a): 1353 1361; R. T. Satalofl The Science andArt of
graduate degree from Haverl College in Music Composition, grad-
Clinical Care,3rd edition (San Diego: Plural Publishing, Inc.,
uated from Jefferson Medi College, received a DMA in Voice
200s).
Performance from Combs Col of Music, and completed his Res-
s. Ibid. idency in Otolaryngology and Neck Surgery at the University
6. Y. D. Heman-Ackah and M. Batory, "Determining the Cause of Michigan, He also comple a Fellowship in Otoloqy, Neurotol-
of Mild Vocal Fold Hypomobilityi' lournal of Voice (in press). ogy and Skull Base Surgery at University of Michigan. Dr. Satalofl

Ssprr,rler.n/OcroBER 2008 57
Yolanda D. Heman-Ackah, MD,
is Chairman of the Board of Directors
of the American lnstitute for Voice and
Chief of Ihe Journal of Voice. Edilor-t
Throat Journal, an Associate Editor
on the Editorial Board of Medical
numerous malor otolaryngology
Sataloff has written over 650
books. Dr. Sataloff 's medical practice
sional voice and to otolo
Mary J. Hawkshaw, BSN, RN, C0RLN,
in the Department of 0 and Neck Surgery at Drexel
University College of Medicine. She has
Sataloff, Philadelphia Ear, Nose, and T
lnstitute for Voice and Ear Research
as Secretary-Treasurer of AIVER since
Director of AIVER in January 2000. She
tors of The Voice Foundation since 1 Hawkshaw graduated f rom
Shadyside Hospi12l School of Nursing
The School of M
58
T. Satalffi MD, DMA, Mary I. Hawkshaw,
The Voice Foundation and
Research, He is Editor-in-
ief of the Ear, Nose and
Journal of Singing, and
of Performing Arlisls and
s in the United States. Dr.
ns, including thirty-eight
ited to care of the profes-
ll base surgery.
h Associate Professor
associated with Dr. Roberl
and the American
,
since 1 986. She has served
1 and was named Executive
served on the Board of Direc-
, Pennsylvania, and
c & Dance Proudly Announces the 2oo8 Appointments of
ianakas
BSI'I, RN, CORTN; Venu Divi, MD
received a Bachelor of Science degree in Nursing from Thomas Jeffer-
son University in Philadelphia. ln collaboration with Dr, Sataloff, she has
coauthored more than 60 book chapters, 130 articles, and four text-
books. She is on the Editorial Board of Ihe Journal of Vorce, Ear, Nose
and Throat Journal, and Ihe Journal of the Society of Otorhinolaryngol-
ogy and Head-NecklVursessince 1998. She is recognized nationally and
internationally for her extensive involvement in care of the professional voice.
Venu Divi, MD is Assistant Professor in the Department of Otolaryngol-
ogy-Head and Neck Surgery at Drexel University College of Medicine.
He received his undergraduate education at Kent State University and
his medical training at Northeastern Ohio University College of Medicine.
ln 2006 he finished his residency in otolaryngology at Henry Ford Hos-
pital in Detroit, Michigan. |n2007, he completed his fellowship in pro-
fessional voice and laryngology wlth Dr RobeftThayer Sataloff His interests
include care of performing artists, including singers and emcees. He is
also passionate about investigating the utility of yoga and ayurvedic med-
icine (the traditional medicine of lndia) in the care of the voice patients.
Amanda Quist
Director of Choral Activities
't,''+
='t-?:
SCHOOL OF
SAN JOSE STATE
UNIVERSITY
MUSIC & DANCE
/ouRNAr oF SINGt.r!G