Individuals at Risk for Voice Disorders

The Voice and Swallowing Institute
New York Eye and Ear Infirmary of Mount Sinai
310 E. 14th Street
New York, NY  10003
TEL: (212) 979-4119

About Individuals at Risk

Some people are particularly at risk for developing a voice disorder because of certain health problems, habits or voice use.

Among the most frequently seen professions with voice disorders are teachers, attorneys, sales representatives, receptionists, technical support and customer service personnel.

In addition to these professions which demand a great deal of voice use, there are people who use their voice in noisy environments. These include restaurant workers, factor or machine shop workers, and police officers.

Professional singers and actors form a special category of voice users for whom even minor vocal problems can be devastating. The subtlety of their symptoms and their demanding performance and rehearsal schedules create special challenges in diagnosis and treatment. The Institute is especially interested in working with performing artists to remedy and prevent voice problems.

Vocal Fatigue & Stamina

Vocal fatigue, or impaired vocal stamina, is frequently experienced by individuals with high vocal demands, such as teachers. It is characterized by a sense of increased effort or strain when talking, accompanied by decreased vocal capabilities, such as decreased loudness or quality.

Vocal fatigue occurs when the vocal demands are greater than the individual’s ability to manage those demands. That ability may be due to insufficient training in how to use the voice in challenging conditions (loud voice production, or for prolonged periods of time) for example. Or it may mean the ability of the vocal fold tissue to withstand prolonged micro-trauma. Everyone experiences vocal fatigue on occasion; for example, spending an evening at a noisy party talking with friends can cause vocal fatigue.

When vocal fatigue occurs with increasing frequency, however, it can cause an individual to begin to use muscle activity strategies that promote unhealthy vocal fold tissues, leading to greater voice problems.

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Vocal Performers

Singer's Resource Packet

Extraordinary demands are placed upon the singing and acting voice, well above those of routine voice use. The performer requires a high level of vocal flexibility and agility, the ability to execute rapid maneuvers such as arpeggios, the flexibility to produce a stage shout or whisper, coupled with a clear and resonant tonal quality.

The vocal artist demands fine coordination of considerable range of airflows and air pressures, sensitivity to small maneuvers and considerable endurance. Just as an athlete is at greater risk for knee or shoulder injury, so too the performer is at greater risk of vocal injury simply because of those demands.

At The Voice and Swallowing Institute, we are dedicated to helping performers attain success in their career and joy from their art. 

Our Well-Voice Program for Vocal Artists is designed for baseline check-ups to help prevent vocal injury, and to keep those inevitable small problems from turning into major, career-threatening voice disorders. Bring your vocal coach or singing teacher with you when you come visit us. Or if you prefer, we’ll give you some suggestions of outstanding coaches and teachers in the metropolitan area.

Common causes of vocal problems of performers:

  1. Testing the limits of your voice by requiring it to accommodate the demands of performance as well as other strenuous voice use (perhaps a part-time job, for example) and social voice use, perhaps together with less than desirable health habits (smoking, drinking).

  2. Focusing upon the singing voice and ignoring the speaking voice (including carrying over speech-based habitual excessive tension of the oral articulators into the singing voice).

  3. Professional vocal demands; unstable sleeping and eating patterns, dry air of airplanes and hotel rooms, dusty concert halls, smoke-filled performance venues, risk of fatigue, and gastric reflux.

  4. Hypersensitivity to even the most minor ailments such as a head cold or allergies.
  5. Trying to meet the vocal demands associated with a specific role – perhaps one that is too vocally “heavy” for a voice -- combined with problems in technique.
  6. Technical weaknesses – bad habits that need to be unlearned.

Good vocal management for performers includes:

  1. Reducing the quantity of singing; more use of instrumental arrangements, featuring other members of the group.

  2. Using monitor speakers facing the stage.

  3. Marking rehearsals when feeling vocally fatigued.

  4. Discussing your vocal needs with the sound technician.

  5. Avoiding use of chest voice at high pitch levels, in general.

  6. Resting the voice on performance days.

  7. Resting the voice between sets or scenes.

  8. Arranging the music to suit your voice; change keys if necessary.

  9. Pacing your practicing.

  10. Warming up the voice. (See our suggestions for Vocal Warm Ups PDF)

  11. Studying with a singing teacher.

And finally,

  1. Don’t ignore persistent voice problems, even small ones. Discuss them with your singing teacher or voice coach. Consider having your vocal folds assessed by a  laryngologist  who further specializes in performance voice.

See our page on Vocal Performers' Frequently Asked Questions and Presentation Skills (PDF) for more suggestions about using your voice to lecture to groups of people.

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Teachers

Teaching is one of the most vocally-demanding professions. It demands long periods of speaking. Often added to that is environmental noise competing with your voice for the students’ attention, inadequate ventilation, few opportunities for resting the voice, extra vocal burdens such as tutoring, lunchroom monitoring, parent-teacher conferences, to say nothing of your own personal vocal demands if you yourself have children, sing in religious services, or socialize in noisy environments on the weekends.

For these reasons, teachers are among the highest risk group for voice problems. To help you prevent minor vocal irritation from becoming a major problem, take a look at our vocal hygiene tips (PDF), where you’ll find information about the benefits of drinking lots of water and maintaining a healthy lifestyle.

Here are some additional suggestions for teachers:

  1. Personal microphones can help a lot. They aren’t very expensive and will help your voice carry to the back of the classroom. 

  2. Your voice should be warmed up before teaching. Just as a singer or actor warms up their voice before a performance to maintain a healthy voice, the teacher should similarly get his or her voice ready for the classroom “performance” demands. Read about many types of exercises that you can perform from our Vocal Warm Ups (PDF) page.

  3. Balance the vocal demands of teaching with vocal rest. You would not expect yourself to be able to participate in a sport every day without some rest periods in between. So too, your voice production system needs rest. If possible, schedule one to two hours of complete voice rest after you finish teaching for the day. Limit extraneous voice use on those days when your voice is feeling particularly tired. That means no singing to the radio, limiting telephone calls, avoiding noisy social environments, and generally concentrating more on listening than speaking during conversations. (See our tips on voice rest.)

  4. Quiet the class environment as much as possible. Speaking against background noise is quite difficult, and puts a significant added strain on your voice production system. We know, of course, that many aspects about the physical classroom and location are beyond your control – noisy ventilation systems, street noise, and the challenge of managing students, to name just a few of the factors. Get together with other teachers in your school to brainstorm ideas for managing environmental noise. 

  5. Enlist student participation as much as possible. We recognize that class participation is dependent upon the age of the students, among other factors. But it can help to have a discussion with the class about your voice problem. Explain that you cannot shout. Tell students that talking amongst themselves while you are teaching is not only distracting to other students, it’s hard on your voice.

  6. Use non-vocal signals to gain attention of the students, whenever possible. Flashing room lights, clapping hands or ringing a bell are easy alternatives to yelling for attention. Sometimes even standing quietly is enough to get a few of the students’ attention and then those students will quiet the rest of the class.

  7. Move about the room to avoid rigid posture. Standing in one place for the whole class encourages stiffness, which is counter-productive to healthy voice production. Movement helps keep the muscle of the throat and upper body relaxed, and helps engage all of the students in the room.

For additional suggestions about talking to groups of people in a vocally-healthy way, take a look at Presentation Skills (PDF).

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Personal Amplification Systems

Using a microphone can be very helpful for people with voice problems, especially those who must talk loud enough to be heard by groups of people, in large rooms, or within background noise.

For this reason, many teachers have found personal amplification systems a necessary tool. Using a microphone to amplify the voice may help prevent trauma to the vocal fold mucosa by reducing the need to speak loudly and forcefully. Therefore, microphones can be beneficial in both the prevention of voice disorders and as part of the treatment plan for patients with existing voice disorders.

There are many different types of personal amplification systems. They range in price, portability and level of amplification. Therefore, there is no overall “best” system. Listed below, in alphabetical order, are some of the more popular sources for personal amplification systems, along with phone numbers, where available, and website addresses.

PERSONAL AMPLIFICATION SYSTEMS

Light Speed Technologies markets infrared wireless microphone systems and personal voice amplifiers.
800.732.8999
http://www.lightspeed-tek.com/proaudio/index.html

Luminaud makes the very popular Chattervox, as well as other types of personal amplification systems.
800.255.3408
http://www.luminaud.com/luminaud_main.htm

Moffitt Audio-Visual distributes voice amplification systems produced by a number of different companies.
http://eshop.actworld.net/moffittco/PA.html

Portable Voice Amplification Systems
Apollo Boone
800-777-3750
http://www.apolloavproducts.com   

Radio Shack carries a variety of wireless microphones. 
Investigate the local stores in your area or review their website.
http://www.radioshack.com

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Vocal Performer FAQs

Can I perform when I am sick or experiencing vocal problems?

The best answer is – it depends. If the vocal problem is minor, if it’s a temporary voice problem, and if you can perform without pain, then probably yes -- it’s okay. Rarely will you make your voice problem seriously worse with just one performance. If your voice is not up to the level of performance you know you are capable of producing, do you want to perform? Only you can determine whether you want to take public (artistic) responsibility for your voice. However, if you continue to perform repeatedly while you are experiencing vocal problems, then you may be inviting more serious laryngeal damage that will require you to miss a large block of performance time. We recognize that sometimes you can avoid performing, and other times it is extraordinarily difficult to cancel an engagement.

There are a range of secondary problems that can occur when a performer suspects laryngeal damage, from “guarding” (trying to protect the voice and in the process, using incorrect muscle activation patterns that actually make it worse), to trying to “sing through” the problem with adjustments in vocal tract posture. If you are unsure about whether you should be performing, come to The Voice and Swallowing Institute for an examination. We’ll be able to give you more specific information about your larynx that will help you make an informed decision about whether or not to perform.

I get hoarse when I perform and my doctor/voice coach/agent told me to rest my voice. Is this appropriate?

Complete voice rest (not using your voice at all) is a great way to reduce any swelling of the vocal folds, since the mucosa of the vocal folds is not vibrating and the vocal folds are not coming into contact with one another frequently. In instances where you have minor, short term hoarseness that you know is due to an infection or dehydration or the like, voice rest can be used to help your vocal folds recover more quickly. If you find, however, that you have to follow performance with voice rest frequently or consistently, then obviously voice rest is not curing an underlying problem, and you should seek a medical voice evaluation.

Furthermore, voice rest is de-conditioning. Just like an athlete who stops working out for a time, going from complete voice rest to full performance is risking injury. Voice rest should be followed by warm up and rehearsal until your voice has returned to performance level.

Is it okay to use steroids to get through a performance when I am sick or experiencing voice problems?

The steroids reduce inflammation, allowing improved contact of the vocal fold mucosa during vibration, and better voice production. Very occasionally, we recommend steroid use for that reason. The danger of relying on steroids is that you may become over-confident with the improved sound, and use your voice to the fullest performance extent. The underlying damage to the vocal fold mucosa is still present, despite the use of steroids, and you may be risking further injure to the tissues.

Like voice rest, the consistent and repeated need for steroids should alert you to an underlying problem that requires medical evaluation. Steroids have many side effects, some of which can be serious. They should not be used lightly.

Singing lessons were recommended, but I like my singing voice and I don’t want to sound like an opera singer. Can I preserve my own sound?

Contrary to popular belief, singing is not a natural process. Be it commercial pop, rock, rhythm & blues, reggae or classical, it requires not muscle strength but fine motor coordination that must be learned and practiced. There are a small handful of performers who achieveed greatness without lessons. They are the unusual and extraordinarily talented. The great majority of performers are very talented but need to develop their artistry with expert guidance. A good singing teacher will respect your craft and your personal sound, and will provide you with increased vocal flexibility to extend your abilities and enhance your performance.

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