What To Know About Establishing Medical Care for Your Voice
Voice problems can be stressful, and have a huge impact on a person’s quality of life and activities of daily living. Establishing efficient and effective care for your voice is important for all kinds of voice professionals such as singers, teachers, voice actors, and politicians, but is also essential for non-professional voice users.
If you are a voice professional and have the resources, establish care with a laryngologist to obtain a baseline of your laryngeal health and vocal function. Going in to see a laryngologist is necessary if you suspect that something might be wrong with your voice, but it can also be helpful to have a recent exam on file when you are an active voice user, even when you don’t have concerns.
The Voice Care Team:
Receiving efficient and effective care for your voice often involves working with more than just a medical doctor. A voice care team should consist of a laryngologist in addition to a voice-specialized speech-language pathologist (SLP), and/or a clinical singing voice rehabilitation specialist (also referred to as a “singing voice specialist” or “SVS”). Additionally, the non-clinical voice teacher is an important part of the recovery team, as they have known the student’s voice for the longest time. All members of the voice care team should be communicating a consistent plan of care.
The medical doctor: A “laryngologist” is a doctor specializing in diseases and disorders of the larynx (voice box). In the United States, a laryngologist must complete the standard four years of medical school followed by a five year ear, nose, and throat (ENT) residency. Once they’ve completed their ENT residency, they are considered to be an “otolaryngologist”, or ENT doctor. To become a laryngologist, or voice-specialized doctor, they must complete an additional year of training called a fellowship. So, the most specialized doctor you can see for your voice is a fellowship-trained laryngologist. You can ask your provider if they have this certification. While the certifications may have different names in other countries, the requirements of specialty training in the voice are often similar to the U.S. If you are a singer, it is also helpful to ask potential voice centers if they have experience working with singers and performers.
The speech-language pathologist: A “speech-language pathologist” is someone with a master’s degree in communicative sciences and disorders, and is an expert in communication that is trained to assess disorders of speech and language across a variety of settings. Voice is a very small area of SLP specialization. When working with an SLP for your voice, you want to find an SLP that is “voice-specialized”. Often, this means that the SLP completed a voice-specialized fellowship after their graduate program. However, many SLPs become voice-specialized through doing non-voice clinical fellowships, and then completing professional development programs and/or training under other voice SLPs and laryngologists in an outpatient hospital or private clinic setting to gain their voice experience. SLPs that have completed any post-grad, nine month fellowship have the postnominals “CCC-SLP”. CCC stands for “certificate of clinical competence”.
The clinical singing voice rehabilitation specialist: The voice professional qualified to combine the medical and musical areas of the voice is the singing voice specialist (SVS), also called a clinical singing voice rehabilitation specialist, or singing voice therapist. While this title has no certifying body and is a point of much discussion in the field (as it can be claimed by anyone who chooses to), there are agreed-upon qualifications that this professional should hold. These qualifications include but are not limited to a degree in voice performance (often a master’s or doctoral degree focusing on pedagogy), and either a master’s degree in communicative sciences (a licensed SLP) and/or clinical experience working with a laryngologist and voice SLPs that allow the person to develop rehabilitative and medical knowledge of the voice. A skilled singing voice specialist will likely teach non-injured singers for 5-10 years before mentoring under a master singing voice specialist while slowly building their rehabilitative caseload.
When Is My Voice a “Problem”?
Don’t wait for the internet to tell you if your voice problem is “bad enough” to see a doctor. If your voice is concerning or bothering you, see a laryngologist! Voice problems happening after an upper respiratory infection generally resolve within 2-3 weeks. If yours has lasted longer, call in to a local laryngology department for an appointment. Many departments have long waiting lists, so it won’t hurt to put down your name for an appointment. See the link at the bottom of this article for the University of Iowa’s listserv on voice care teams in the U.S.
What classifies as a “voice problem”? A voice problem might look like a change to your vocal quality, such as sounding hoarse (crackly, rough), breathy (air in the sound), or strained, or losing parts of your vocal ability, such as not being able to project the voice. As a singer, this might look like losing parts of your range, changes to where your registers transition, or inability to sing repertoire that you’ve been able to sing in the past.
Assessment of the Larynx:
When visiting a laryngologist for the first time, it’s good to know what type of exam to expect. Your laryngologist will likely use either a flexible or rigid scope to perform a procedure called “laryngoscopy”.
Flexible scope: The flexible scope is a camera that is passed through the nasal cavity and down into the throat after the nose is sprayed with numbing and decongestant. Being relaxed and knowing how to breathe easily is important during this exam, so that the doctor can get a close up and thorough video of your vocal folds. They will ask you to sustain sounds, perform pitch glides (moving the voice low to high), and perform other tasks for assessment, such as sniffing, talking, and singing. Flexible scopes are a great option for seeing a lot of vocal tasks. See an example of a flexible scope exam below:
Rigid scope: A rigid scope is a long metal rod with a camera at the end, and gives a very clear and close up image of the vocal folds. This scope gently slides over your tongue to the back of your throat. Easy mouth breathing and staying relaxed are important for this exam, again to give a clear and thorough video of the vocal folds. Patients with an extremely strong gag reflex might struggle with this exam, but it’s a great option for the clearest image of the vocal folds. While rigid scopes often give a more clear image than flexible scopes, it’s only possible to make vowel sounds (no speech or singing with words) while using this scope. See an example of rigid scoping below.
Stroboscopy: All laryngoscopies should be performed with videostroboscopy, which means that the light source at the end of the camera “flickers” or “strobes”, so that the vocal folds can be seen in slow motion (the vocal folds vibrate hundreds to thousands of times per second!). There are many things that cannot be assessed in the vocal folds without videostroboscopy, such as mucosal wave (the rate and consistency of how the vocal folds vibrate), vertical phase difference (the balance of the level of the vocal folds alignment with each other), amplitude of vocal fold vibration (how far the vocal folds move away from the midline during vibration), non-vibrating or “stiff” portions of the vocal folds, phase closure (how often the vocal folds are closed vs open), phase symmetry (whether the vocal folds close and open at the same time), and glottal closure (can display lesions, weakness, and other disorders/pathologies of the vocal folds impacting closure).
Pictures or video?: Be sure to obtain a copy of your laryngeal exam immediately after the appointment. Some patients will record a close up, high quality phone video. Let the doctor or residents help center your phone so that you get everything you need from the image. Many centers will also be able to burn your exam onto a CD or USB drive. Photos do not provide thorough information about a laryngeal exam. Make sure to obtain a video.
To recap, a thorough voice examination includes a fellowship-trained laryngologist performing (or analyzing, if done by an SLP/laryngology fellow/resident) flexible and/or rigid laryngoscopy with stroboscopy. Obtain a video of your exam at the conclusion, to provide to anyone on your voice care team that needs it.
Voice Assessment:
Assessment of your voice is often provided by the voice-specialized speech-language pathologist, and includes a subjective assessment of the sound of your voice, such as how “rough”, “breathy”, “strained”, loud, or weak your voice sounds, in addition to other perceptual descriptors. Your SLP may also perform objective assessment using acoustic analysis. Acoustic analysis is a process in which software and audio recording equipment are used to determine the quality of the voice signal. Both subjective and objective voice data are useful in developing a plan of care for your voice. Your SLP will likely need to see you for a longer assessment outside of the meeting with the laryngologist to collect information about your vocal health and medical history.
Conclusions:
Voice problems can onset suddenly and cause concern and stress for the professional and non-professional voice user alike. Managing a voice problem should be done with an interdisciplinary care team comprised of a fellowship-trained laryngologist and voice-specialized SLP. For singers, the care team should also include a clinical singing voice rehabilitation specialist, and/or non-clinical voice teacher. Obtain a laryngeal exam with videostroboscopy prior to starting voice therapy, and save the video at the end of the exam for easy communication between professionals regarding your case.
Written by Brittani Farrell, MS CF-SLP, MM, BME
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