There are few ENT surgeons who have as much insight into singers’ problems as Nick Gibbins. A good knowledge of working patterns, repertoire and the physiology of ‘vocal athletes’ is essential. He shares a few thoughts with us.
When deciding how to start this article about treating voice disorders in singers, I struggled with how to open. Should I remark that the famous singer is just a person like ourselves with their own anxieties, hopes and fears, nervous about seeing the doctor and worried about examinations or treatments?
Perhaps I should point out some obvious differences between your routine dysphonia patient and the international soprano with mounting concern over a perceived change in her voice and the catastrophising that occasionally comes with it? With so many aspects that need to be considered when treating singers, and especially those that make their living from their voice, I will simply start with this: treating the professional singer can be interesting.
“The professional singer is the thoroughbred of the vocal athlete. No sportsperson goes through a career uninjured, and it is extremely unlikely that a singer will either”
First and foremost, the singer in front of you is a patient with a problem with which they are coming to you for help. An important skill for the clinician to have with any patient is to be able to connect with them and to make them feel at ease. This is usually amplified with the singer for a number of reasons. It is not usually because of the traditional and outdated view of the prima donna (although they do exist, they are few and far between) but is more likely to be because they have spent a long time trying to find the right person to see – someone that understands their work, their language and their life pressures. It is not uncommon for a singer to have seen their GP, paid privately for speech therapy and singing teachers, and yet still have an issue with their voice before finally stumbling into your voice clinic. A friendly welcome and the reassuring atmosphere of professionals at work can help put the singer at ease.
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Like almost any area of medicine that you are not familiar with, you may think that the approach to the singer differs but, of course, it does not. History, examination and investigation are golden, with the history usually telling you the diagnosis before you reach the examination. With singers, and especially with famous ones, you might feel unnerved by seeing stars in the inauspicious surroundings of your NHS clinic, but you can be sure that they feel it more so. Put them at ease. Once they are comfortable that they are in a safe place, they will confide in you things that they may not have revealed to their friends, family or manager.
Having said all of the above, it is important to note that there are some extra considerations that need to be taken in to account. The patient may have a normal speaking voice but be struggling with one small area – classically the passaggio (roughly the change between chest and head voice). There are not many places that are used to dealing with professional singers regularly. They may have been going ‘around the houses’ for some time, maybe years, trying to be taken seriously or just to be seen by someone with an interest in voice. Patients are regularly referred to urgent assessment clinics for a change in voice, not because their GP thinks they have cancer but because they do not know where else to refer them for a specialist review.
“History, examination and investigation are golden, with the history usually telling you the diagnosis before you reach the examination”
The singer’s income, even in the lofty realms of the international stars, is often a hand-to-mouth existence. Singers struggle to get mortgages due to the lack of regular work. Dysphonia may have serious financial implications. Waiting for months for a routine appointment or surgery may have long-lasting ramifications on their career.
Once you have taken your history and listened to them well, performed your examination and made a diagnosis, you need to plunge into the minefield of treatment and/or management. I would suggest that treating the professional singer like a professional sportsperson would be the right mindset. Consider you are treating the refined right shoulder of Jimmy Anderson or the World Championship-winning legs of Dina Asher-Smith. The professional singer is the thoroughbred of the vocal athlete. No sportsperson goes through a career uninjured, and it is extremely unlikely that a singer will either. Encourage them to involve their team – manager, friends, family, and have a good team around yourself as well. Have a network of contacts you can refer to, both in the hospital setting (SLT, gastro, neuro, psychological) and out (teachers, vocal rehabilitation coaches, osteopath/physio).
“The most common finding from our unpublished data is equally muscle tension imbalance and inflammatory laryngeal changes, usually from reflux”
Finally, once you are prepared to approach the patient and discuss treatments, the pathology can be dealt with (see how late into the article pathology appears?). The most common finding from our unpublished data from almost 8000 patient contacts is equally muscle tension imbalance and inflammatory laryngeal changes, usually from reflux. The former can be primary due to technical issues or secondary due to pathology (cysts etc) or inflammatory changes. The latter is usually lifestyle related, especially if the singer is performing in the evenings. This can be followed with food and drink late at night followed by a sore, dry throat the following morning. A one-off can be mitigated but if they are performing eight shows a week in the West End, this will rapidly become a problem.
If, and this is usually a last resort, the time comes to operate, you and the patient need to be completely clear about the reasons for doing it, what their voice will be without the procedure, and an honest recovery period estimate. All of my patients will have had expert speech therapy and usually a combination of laryngeal manipulation (specialist osteopath or physio) and vocal rehabilitation coaching or teaching. If they are still unable to do what they need to do with their voice, that is the time to consider surgery, in full and open discussion with them and their managers. Time your intervention well, between shows, recording contracts or term times, to allow maximum recovery, and ensure this is lead by your expert speech therapist. If you have built a strong rapport with your patient, they will trust you to make the right decision. Good luck!