Academic journal article Journal of Singing

Singers: What Is Normal?

Academic journal article Journal of Singing

Singers: What Is Normal?

Article excerpt

PEOPLE HAVE KIDDED FOR CENTURIES about singers being something other than "normal." In fact, many of the best singers aren't normal: they are exceptional. However, most of these observations have been good-natured anecdotes about personality and disposition, not scientific observations. From a medical standpoint, it has turned out that many of us are not "normal" physically even when we have no symptoms. A great many singers have baseline physical findings that most otolaryngologists would interpret as pathologic. So long as such abnormalities do not affect voice technique or quality, they need not be treated. However, singers should know about them. If they are discovered for the first time when a singer seeks medical care for a voice problem, a physician is likely to ascribe the voice problem to the abnormality seen. This common and understandable error is hard to avoid unless the singer has had a baseline comprehensive voice evaluation and knows his or her laryngeal findings when "healthy." We have been performing such examinations for students at the Academy of Vocal Arts since 1980; and there are many outstanding graduates performing at the Metropolitan Opera and elsewhere who have small cysts, mild vocal fold weakness, reflux, and other findings that have not interfered with their singing careers and success. However, if they were misdiagnosed as causing a new voice problem and were treated, especially by surgery, the unnecessary treatment certainly could affect a career adversely. This problem has been avoided by arming these singers with knowledge of their baseline "normal" vocal fold condition, and, if abnormalities are seen, by way of photographs and sometimes videos with which they travel so that doctors in other states and countries can know what they look like when they are healthy.

A few studies have looked at this issue more formally than our anecdotal observations summarized above. In 1996, Elias et al. reported on strobovideolaryngoscopy findings performed on 65 healthy, asymptomatic professional singers.1 Fifty-eight percent of them had abnormal findings: 42% had laryngopharyngeal reflux, 6% had vocal fold asymmetries, 3% had nodules, 3% had cysts, 3% had varicosities, and 1.5% had vocal fold paresis (weakness).

A 1999 study by Lundy et al. on 65 singing students reported that 73.4% had laryngopharyngeal reflux, and 8.3% had vocal fold masses (two with nodules, three with cysts).2

In 2001, Heman-Ackah et al. published a preliminary study of strobovideolaryngoscopic examinations in singing teachers.3 The study included 20 volunteers at a convention of the National Association of Teachers of Singing (NATS), 13 of whom were reportedly normal, and several of whom had voice complaints. Most of the subjects in this study were women (13 sopranos, 3 mezzo sopranos, 1 alto). All 20 sang classical music. In the group with no vocal complaints, all had reflux, 62% had a vocal fold cyst, 8% had a vocal fold polyp, 77% had varices, 23% had sulcus vocalis, 8% had Reinke's edema, 8% had vocal fold scar, 8% had a saccular cyst (an abnormality above the vocal fold that did not affect voice), and 23% had vocal fold paresis.

Reulbach et al. published an interesting study in 2001.4 They assessed 100 adults (not singers) over the age of 40. None had a history of voice problems. Still, 64% had laryngopharyngeal reflux, 72% had vocal fold bowing, and only 12% had "normal" laryngeal examinations.

The most recent study involving singing teachers was carried out at a NATS conference in 2008,5 and involved 72 volunteers (60 females, 12 males), all of whom were trained singers without significant voice complaints that were found to have vocal fold pathology during strobovideolaryngoscopy in 86.1% (62 of 72 subjects), many of whom had more than one abnormality. Using criteria used in previous papers, 72% were found to have signs suggesting laryngopharyngeal reflux. Using the Reflux Finding Score (RFS), an instrument that has become used fairly widely, the number was substantially lower (16. …

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