Voice medicine: arts medicine for otolaryngologists

Ear, Nose & Throat Journal, Nov, 2005 by Robert Thayer Sataloff

The developing speciality of arts medicine has been extremely valuable for voice professionals and otolaryngologists. Arts medicine was described in a previous editorial (1) and in other sources. (2) Through the Voice Foundation, the American Laryngological Association, the American Academy of Otolaryngology-Head and Neck Surgery, the American Speech-Language-Hearing Association, the National Association of Teachers of Singing, the Voice and Speech Trainers Association, the Journal of Voice, the Journal of Singing, and many other sources, otolaryngologists, our patients, and singing and acting teachers have become familiar with recent advances in the care of professional singers and other professional voice users. Many of these advances arose out of interdisciplinary teamwork. New insights have resulted in better methods of history taking and wider access to educational information about the voice. These have produced better-informed, healthier singers, actors, and others.

In addition to voice medicine, several related arts medicine specialties may be helpful during a singer's career. Singers and actors often must also dance, play piano and/or other instruments, and participate in other, nonperformance employment that may affect their vocal condition. Analogous considerations apply for practitioners in most artistic endeavors.

The history of voice medicine can be traced back to the time of Hippocrates. After 1854, however, when singing teacher Manuel Garcia invented indirect mirror laryngoscopy, physicians began examining the vocal folds routinely, substantially improving the care of voice disorders. Surprisingly, little else happened until well into the 20th century.

Although a few noteworthy collaborations between laryngologists and speech-language pathologists occurred as early as the 1950s and 1960s, voice medicine did not really develop as an accepted subspecialty of otolaryngology until the 1980s. Its establishment and acceptance were due to advances in the understanding of vocal fold anatomy and physiology, the development of new technologies for voice analysis and quantification (permitting outcomes assessment), and increased awareness of vocal problems and their complex solutions within the fields of medicine, speech/language pathology, music, acting, and related areas. Many of these advances were direct results of intense interdisciplinary collaboration fostered through the annual five-day Voice Foundation symposia that began in 1972. Because of the extraordinary, open dialogue among world-class experts in various fields, voice medicine has evolved remarkably quickly and has dramatically improved the standard of care for all voice patients. Speech-language pathologists have developed new skills to address singers' and actors' subtle voice problems. A select group of singing teachers have acquired training in special approaches to vocal injuries. Recently, acting-voice coaches have developed similar techniques to address the special needs of vocally injured professional speakers within the medical milieu. Strikingly, the secrecy, mystique, and fear of doctors common among singing teachers 25 years ago have all but disappeared, especially among academically trained musicians. Similar collaboration and trust are developing in other areas of arts medicine, albeit slowly in some instances.

The practice of voice medicine is grounded in an understanding of the anatomy and physiology of the voice. Vocal anatomy encompasses the larynx, throat, oral cavity, chest, and abdomen, but virtually all body systems may affect voice production. (3) Consequently, laryngologists caring for voice patients have learned to take histories that investigate all body functions. Mild endocrine disorders, gastroesophageal reflux, early neurologic dysfunction, alterations in balance or posture following a sprained ankle, and many other seemingly unrelated problems may be responsible for a voice complaint and may disable a voice professional.

Professional voice users include not only singers and actors but also clergy, politicians, teachers, sales personnel, telephone operators, and anyone else whose ability to function in the workplace suffers if vocal quality, volume, or endurance is impaired. Voice problems may present as hoarseness, loss of control, decreased vocal endurance, pitch inaccuracies, loss of agility, a "wobble," pain while speaking or singing, and in several other ways. In professional performers, such problems are almost always physical in origin; accurate diagnosis can be achieved through systematic inquiry grounded in an understanding of anatomy, physiology, and the patient's special professional needs and activities. Psychological factors are common as well; even if psychological factors did not cause the voice problem, it is important for physicians to recognize and address them in a systematic fashion. (4) Physicians also must be aware of special problems encountered in theaters, where singers and actors may be exposed not only to overwork but also to hazardous substances such as pyrotechnics, soundstage fogs, and smokes.