The term singer applies to any person whose career, avocation or livelihood relies heavily on the use of his or her voice in a musical context rather than ordinary speech. Unlike percussionists, pianists or violinists, the singer is the instrument. Hence, the well-being of a singer depends not only on the health of his or her larynx (where the sound originates) or vocal tract (where the sound is modified), but also on proper functioning and maximal coordination of most mind and body systems.
Of the many styles of singing documented throughout the world, some reflect a unique liturgical, cultural, linguistic, ethnic or geo-political heritage, while others are more universal in nature. Among the common styles of singing in the United States and Western world are: traditional classical (including oratorio, opera, art songs and so on), barbershop, jazz, musical theatre (Broadway), choral, gospel, folk, country (and western), popular, rhythm and blues, rock ’n’ roll (including heavy metal, alternative rock and so on) and others. Each style of delivery has its typical settings, patterns, habits and associated risk factors.
Unlike non-singers, who may not be significantly hindered by vocal problems, for the classical singer, the effect of subtle vocal impairment can be devastating. Even within that category of trained singers, vocal impairment is much more debilitating for the higher voice classifications (sopranos and tenors) than for lower classifications (mezzo sopranos, altos, baritones and basses). On the other hand, some vocal performers (pop, gospel or rock, for example) go to great lengths to achieve a unique trademark and enhance their marketability by inducing vocal pathologies which often yield a breathy, husky, muffled diplophonic (simultaneous multiple pitches) quality. Owing, in part, to their impairment, they tend to sing with great effort, struggling particularly to produce the high notes. To many listeners, this struggle adds a dramatic effect, as if the singer is sacrificing his or her self while engaging in the artistic process.
The prevalence of occupation-related injuries in general, and voice disorders in particular, among singers is not well documented in the literature. This author estimates that on the average, between 10 and 20% of singers in the United States sustain some form of chronic voice disorder. However, the incidence of vocal injury varies significantly with many factors. Because many singers must adhere to specific artistic/aesthetic criteria, performance practices, popular (consumer) demands, financial constraints and social pressures, they often stretch their vocal capabilities and endurance to the limits. Furthermore, singers generally tend to deny, trivialize or ignore warning signs and even diagnoses of vocal injury (Bastian, Keidar and Verdolini-Marston 1990).
The most common problems among singers are benign mucosal disorders. The mucosa is the outer layer, or cover, of the vocal folds (commonly called vocal cords) (Zeitels 1995). Acute problems can include laryngitis and transient vocal fold swelling (oedema). Chronic mucosal lesions include vocal fold swellings, nodules (“calluses”), polyps, cysts, sub-mucosal haemorrhage (bleeding), capillary ectasia (widening), chronic laryngitis, leukoplakia (white spots or patches), mucosal tears and glottic sulci (deep furrows in the tissue). Although these disorders can be exacerbated by smoking and excessive alcohol consumption, it is important to note that these benign mucosal lesions are typically related to the amount and manner of voice use, and are the product of vibratory trauma (Bastian 1993).
Causes of Vocal Problems
In looking at the causes of vocal problems in singers, one should distinguish between intrinsic and extrinsic factors. Intrinsic factors are those related to personality, vocal behaviour (including speaking) on and off stage, vocal technique, and intake habits (primarily if substance abuse, improper medication, malnutrition and/or dehydration is involved). Extrinsic factors are related to environmental pollutants, allergies and so on. Based on clinical experience, intrinsic factors tend to be most important.
Vocal injury is usually a cumulative process of misuse and/or overuse during the singer’s productive (performance-related) and/or non-productive (domestic, social) activities. It is difficult to ascertain how much of the damage is attributable directly to the former versus the latter. Performance risk factors can include unreasonably long dress rehearsals requiring full-voice singing, performing with an upper-respiratory infection in the absence of a replacement and excessive singing. Most vocalists are advised not to sing for more than about 1.5 hours (net) per day. Unfortunately, many singers do not respect the limitations of their apparatus. Some tend to get caught up in the exploratory excitement of new technical skills, new means of artistic expression, new repertoire and so on, and practice 4, 5 or 6 hours daily. Even worse is the beating of the voice into shape when distress signals of injury (such as loss of high notes, inability to sing softly, breathy delay in sound initiation, unstable vibrato and increased phonatory effort) are manifested. The culpability of vocal overtaxing is shared with other taskmasters such as the booking agent who squeezes multiple performances into an impossible time frame, and the recording agent who leases the studio for 12 consecutive hours during which the singer is expected to record a complete CD sound track from start to finish.
Although every singer may encounter acute episodes of voice problems at some point in his or her career, it is generally believed that those singers who are musically literate and can adjust the musical score to their voice limitations, and those who have had proper voice training, are less likely to encounter severe problems of a chronic nature than their untrained peers, who often learn their repertoire by rote, repeatedly imitating or singing along with demo tapes or recordings of other performers. In doing so, they frequently sing in a key, range or style unsuitable for their voices. Singers who lend themselves to periodic tutelage and maintenance by proficient voice experts are less likely to resort to faulty compensatory vocal manoeuvres if confronted by physical impairment, and are more inclined to establish a reasonable balance between artistic demands and vocal longevity. A good teacher is aware of the normal (expected) capabilities of each instrument, can usually distinguish between technical and physical limitations, and often is the first to detect warning signs of vocal impairment.
Sound amplification can also create problems for singers. Many rock groups, for example, amplify not only the singer, but the entire band. When the noise level interferes with auditory feedback, the singer is often unaware that he or she is singing too loudly and using faulty technique. This may contribute significantly to the development and exacerbation of vocal pathology.
Non-performance factors can also be important. Singers must realize that they do not have separate laryngeal mechanisms for singing and speaking. Although most professional singers spend much more time talking than singing, speaking technique is commonly discarded or rejected, which can adversely affect their singing.
Many of today’s singers must travel regularly from one performance venue to another, on trains, tour buses or airplanes. Ongoing touring requires not only psychological adaptation, but also physical adjustments on many levels. In order for singers to function optimally, they must receive adequate quality and quantity of sleep. Radical rapid changes in time zones causes jet lag, which forces singers to remain awake and alert when their internal clock is cueing various body systems to shut down for sleep, and conversely, to sleep when their brain systems are aroused to plan and execute normal daytime activities. Such interruption may result in a host of debilitating symptoms, including chronic insomnia, headaches, sluggishness, dizziness, irritability and forgetfulness (Monk 1994). Aberrant sleep patterns are also a common problem among those singers who perform late at night. These abnormal sleep patterns are all too often mismanaged with alcohol or recreational, prescription or over-the-counter (OTC) drugs (most of which adversely affect the voice). Frequent and/or prolonged confinement to a closed cabin of a motor vehicle, train or aircraft may create additional problems. Inhalation of poorly filtered (often recycled), contaminated, dehumidified (dry) air (Feder 1984), according to many singers, can cause respiratory discomfort, tracheitis, bronchitis or laryngitis that may linger on for hours or even days following a trip.
Owing to environmental instability and hectic scheduling, many singers develop erratic, unhealthful eating habits. In addition to reliance on restaurant food and unpredictable changes in meal times, many singers eat the main meal of the day after their performance, usually late at night. Particularly for the overweight singer, and especially if spicy, greasy or acidic foods, alcohol or coffee were consumed, lying down soon after having filled the stomach is likely to result in gastroesophageal reflux. Reflux is the retrograde flow of acids from the stomach up the oesophagus and into the throat and larynx. The resulting symptoms can be devastating to the singer. Eating disorders are quite common among singers. In the operatic and classical realm, overeating and obesity are quite common. In the musical theatre and pop domain, particularly among young females, reportedly one-fifth of all singers have encountered some form of eating disorder, such as anorexia or bulimia. The latter involves various purging methods, of which vomiting is thought to be particularly hazardous to the voice.
A detrimental factor to voice production is exposure to pollutants, such as formaldehyde, solvents, paints and dusts, and allergens, such as tree, grass or weed pollens, dust, mould spores, animal danders and perfumes (Sataloff 1996). Such exposure may occur on and off stage. In their work milieu, singers can be exposed to these and other pollutants associated with vocal symptoms, including cigarette smoke and theatrical smoke and fog effects. Singers use a greater percentage of their vital capacity than ordinary speakers. Furthermore, during intense aerobic activity (such as dancing), the number of breathing cycles per minute increases, and mouth breathing prevails. This results in the inhalation of larger amounts of cigarette smoke and fogs during performances.
Treatment of Vocal Problems
Two major issues in the treatment of vocal problems of singers are self-medication and improper treatment by physicians who are not knowledgeable about the voice and its problems. Sataloff (1991, 1995) surveyed the potential side effects associated with medications commonly used by singers. Whether recreational, prescription, over the counter or food supplements, most drugs are likely to have some effect on phonatory function. In an attempt to control “allergies”, “phlegm” or “sinus congestion”, the self-medicating singer will ultimately ingest something that will damage the vocal system. Likewise, the physician who keeps prescribing steroids to reduce chronic inflammation caused by abusive vocal habits and ignores the underlying causes will eventually hurt the singer. Vocal dysfunction resulting from poorly indicated or ill-performed phonosurgery has been documented (Bastian 1996). To avoid injuries secondary to treatment, singers are advised to know their instruments, and consult only with health care professionals who understand and have experience and expertise managing the vocal problems of singers, and who possess the patience to educate and empower singers.