clinical voice analysis of carnatic singers

Clinical Voice Analysis of Carnat

*Ravikumar Arunachalam, Prakash Boominathan, and S

Summary: Background and Objective. Carnatic singinrigorous training to produce an open throated loud, predomances in higher pitches. Voice problems in singers are not uncproblems and apply a routine protocol to assess the voice.Methods. Forty-five trained performing singers (females: 3with voice problems underwent voice assessment. The study

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Execution of long musical phrases/notes across varying oc-

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Singing voice is unique and assessment of singing voice

tionalehen-ctionsilitate, andSLP],mak-e.10,11

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Forty-five Carnatic singers (36 females and 9 males) in the ageandard deviation

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MedicalyDepartmPorur, Ch

2014 The Voice Foundation

range of 1874 years (mean: 39.7 years and sthttp://dx.doi.org/10.1016/j.jvoice.2013.08.003ported to a tertiary care hospital with various voice concerns.

MATERIALS AND METHODS

Address correspondence and reprint requests to Prakash Boominathan, Department ofSpeech, Language and Hearing Sciences, Sri Ramachandra University, Porur, Chennai600116, Tamil Nadu, India. E-mail: [email protected] of Voice, Vol. 28, No. 1, pp. 128.e1-128.e90892-1997/$36.00nsonants are essential for Carnatic singing.natic singing emphasizes singing on a right shruthi oritch with correct breathing.2 Along with tonal quality,hroated singing with forward placement of voice ideal-good voice in Carnatic singers.3 Scientific literature de-various aspects of vocal production and ornaments inIndian4 and South Indian classical singers.5,6 The vocals in Carnatic singing are graded with skills on pitching, flexibility of voice across range, and open-throatedted voice with good tone placement.se rigorous training methods and practices pose enor-stress on the vocal apparatus of singers. In addition,s are more prone to develop voice problems due to their

of voice such as structural and behavioral changes, funcimpact of voice disorder, and so forth. Therefore, a comprsive protocol is needed to assess various vocal funin singers. This comprehensive protocol will also faccommunication of results among professionals (ear, nosethroat [ENT] surgeons, speech language pathologist [voice specialist, and so forth). Involving the singers whileing decisions on management will lead to better client carAnalysis of the findings from comprehensive voice assesprotocol will help planning management strategieretrospective analysis was carried out based on docufrom a tertiary care hospital to report inferences on finfrom assessment of voice in Carnatic singers.

AIM OF THE STUDYThe aim of the present study was to report the nature ofproblems and demonstrate the application of a routineprotocol on 45 trained and performing Carnatic singers w

ted for publication August 5, 2013.the *Department of Ear Nose Throat/Head and Neck Surgery, Sri RamachandraCollege and Research Institute, Porur, Chennai, Tamil Nadu, India; and theent of Speech, Language and Hearing Sciences, Sri Ramachandra University,ennai, Tamil Nadu, Indiataves, tempos, and with distinct clear articulation of vowels requires a multidimensional approach that involves all aspectsResults. Voice change, difficulty in singing higher pitcsingers suffered laryngopharyngeal reflux that coexisted wing voices were rated predominantly as moderate devStrain). Maximum phonation time ranged from 4 to 29 sec15.7, SD: 5.79). Singing frequency range was reduced (fenia severity index (DSI) scores ranged from3.5 to 4.91 (DSI did not show significant difference between sex and aoutcome profile revealed overall severity score of 5.1 (Sperspective.Conclusions. Study highlighted the nature of voice proment protocol for Carnatic singers. Need for regular assehealth are emphasized as outcomes.Key Words: Carnatic singingIndian singingSinging f

INTRODUCTIONSingers are frequently compared with athletes due to the de-mands and sophistication involved in using the phonatory appa-ratus. Singers use their voices in special ways to suit particularstyles of music.1 Carnatic singing, the classical music of SouthIndia, is a highly evolved art form, learned from masters (usu-ally called gurus) through rigorous practice. It requires a power-ful voice with emphasis on low-pitched and loud singing.g is a classical South Indian style of music that involvesinantly low-pitched singing, embedded with vocal nu-ommon. The objective was to report the nature of voice

6 and males: 9) who reported to a tertiary care hospitalanalyzed their problems and the clinical findings.and voice fatigue were major complaints. Most of themuscle tension dysphonia and chronic laryngitis. Speak-n on GRBAS (Grade, Rough, Breathy, Asthenia, and(females: 10.2, standard deviation [SD]: 5.28 and males:s: 21.3 Semitones and males: 23.99 Semitones). Dyspho-les: 0.075 and males: 0.64). Singing frequency range ands clinical diagnosis. Self-perception using voice disorder.7). Findings are discussed from a clinical intervention

s (hyperfunctional) and required modifications in assess-nts and vocal hygiene education to maintain good vocal

ency rangeVocal hyperfunctionVoice analysis.

strenuous schedules, the nature of singing, poor vocal hygiene,and health practices.7 A study7 on vocal and nonvocal habits inCarnatic singers revealed that singers engage in long-durationsinging, irregular eating habits, and frequent throat-clearing.It is well known that professional voice users are at greaterrisk to develop voice problems than the general population.8

A survey on voice problems in professional voice users in India9

revealed a high point prevalence rate of 48% among singers.ic Singers

henbagavalli Mahalingam, *yChennai, Tamil Nadu, India

of e

Ravikumar Arunachalam, et al Clinical Voice Analysis of Carnatic Singers 128.e2[SD]: 13.42) with voice concerns, who reported to a tertiarycare center were included in the study. Number of years of ex-perience of the singers (Figure 1) varied from 8 to 61 years offormal training and performance in Carnatic singing. Meanyears of experience in singing (both training and performance)for females and males were 23.80 (SD: 12.87) and 20.90 (SD:10.55), respectively. In this group of singers, the number ofyears of singing experience between females and males didnot differ significantly (P 0.47). However, because the effectof years of training and practice was high, no attempts weremade to correlate the years of experience with nature ofproblem.All singers were assessed using a comprehensive voice as-

sessment protocol12 developed and followed in the hospital.The protocol consisted of:

1. Structured interviews to elicit symptoms reported by thesingers and obtain relevant information on onset and pro-gression of the voice problem, vocal and nonvocal habits,and so forth.

2. Videostroboscopy: ATMOS media stroboscope was usedfor stroboscopic analysis and involved assessments of

FIGURE 1. Number of yearsparameters such as glottal closure pattern,13 regularity,symmetry of the vocal fold vibration, mucosal wave, am-plitude of vocal fold vibration, nonvibratory portion, andhyperadduction of ventricular folds. The ENT surgeonevaluated for gross laryngeal pathologies. The SLP eval-uated vocal functions and behaviors.

3. Perceptual assessment of speaking voice: GRBAS scale14

was used.4. Aerodynamic measures: Maximum phonation time

(MPT) and s/z ratio were noted.5. Acoustic analysis: Singing frequency range and dys-

phonia severity index (DSI),15 a single weighted multi-parametric measure was calculated using ATMOSlingWAVES Phonetogram Pro and Signal Analysis Mod-ule (version 2.4). Recording was done using a condensermicrophone attached to a sound pressure level meter(Center 322) mounted on a tripod. It enabled adjustmentof height and alignment of the microphone to the singersmouth. The singers were instructed to sit in an upright, re-laxed posture. Mouth to microphone distance was main-tained at approximately 30 cm. Following steps wereused to obtain a phonetogram:a. Phonation/singing profile: The singers were asked to

sing a basic (complete) scale (sampo:rana ra:gam)called the Ma:ya:ma:lavagoulai raagam. This scalehas seven notes (seven consonant-vowel syllables) inits ascending phase (aarohanam) and the same sevennotes in the descending phase (avarohanam). Thesingers were instructed to sing the notes using their com-fortable singing frequency range covering three octaves(stha:yi:) (Lower octave: mandra stha:yi:, mid octave:madhya sthayi:, and upper octave: ta:rasthayi) and atthree speeds (slow tempo: vilambitka:lam, mediumtempo: madhyamaka:lam, and fast tempo: durithaka:-lam). The same was repeated in three different volumeconditions, namely regular, soft, and loud.

b. Speaking profile: Reading a passage (Rainbow pas-sage) or conversational speech sample in three differ-ent intensities (soft, moderate, and high) levels eachfor minimum of 30 seconds was recorded. DSI was cal-

xperience of singers (N 45).culated by the software by using the followingformula:

DSI 0:133MPT 0:00533F0 high 0:263I low 1:183jitter 12:4:

6. Self-evaluation of subject: Voice disorder outcome pro-file (V-DOP)16 was administered for assessing individ-uals perception of voice problems in domains such asphysical, emotional, and functional aspects.

A data recording sheet was constructed with all componentsof voice assessment and details of all singers were documentedby the investigators. Mann-WhitneyU test was used to comparethe singing frequency range and DSI scores between females

42.2%35.5% 31.1% 26.7% 22.2 % 22.2% 20%

0

20

40

60

80

100

Change in voice Difficulty in "singing higher

octaves"

Difficulty in "singing lower

octaves"

Discomfort & pain while

singing

Difficulty in sustaing voice

for longer duration

Throat tightness and strain while

singing

Dryness of throat and vocal

fatigue

Perc

enta

ge

Symp

ymp

Journal of Voice, Vol. 28, No. 1, 2014128.e3Videostroboscopy findingsENT surgeon and SLP jointly assessed the structural and func-tional aspects of larynx. ENT surgeon evaluated the medicalRESULTS

Symptoms reportedThe percentage analysis (Figure 2) was used to documentsymptoms reported by the Carnatic singers. Change in voicewas reported by 42.2% and 35.5% complained of difficulty insinging higher pitches. Difficulty in reaching lower pitches,dryness of throat, and vocal fatigue were reported in 31.1% ofsingers. Discomfort and pain while singing were reported in26.7% of singers. Difficulty in sustaining voice for a long dura-tion and throat tightness and strain while singing were re-ported in 22.2% of singers. The average duration ofsymptoms (Figure 3) reported by singers was 1.56 months.All singers reported abusive vocal habits such as prolonged

loud singing, practicing in extremes of pitch, and inadequatevoice rest between concerts. Nonvocal unhealthy habits re-ported were improper meal timings, consumption of spicy/oily food, and reduced intake of water in 60% of singers.and males. Significant difference in singing frequency rangeand DSI scores across clinical diagnosis was analyzed usingKruskal-Wallis test.

FIGURE 2. Sstatus and made clinical diagnosis. SLP evaluated vocal func-tion and behavioral factors. Clinical diagnosis and diagnosisbased on functions are tabulated in Table 1.

2.5 2 1.5

0

2

4

6

8

10

12

Change in voice Difficulty in"singing higher

octaves"

Difficulty in"singing lower

octaves"

Discopain wh

Aver

age d

ura

tion

of

sy

mpt

oms (

month

s)

Symp

FIGURE 3. Average durationbe reduced in singers across clinical diagnosis. Singers withvocal fold polyp, edema, presbylarynges, and nodule had sing-ing frequency range lesser than those with laryngopharyngealreflux (LPR), chronic laryngitis, and muscle tension dysphonia(MTD). However, there was no statistically significant differ-ence between singing frequency range among clinical diagnosislimits (females: 1.02 [SD: 0.04] and males: 1.11 [SD: 0.16]).

Acoustic analysis

Singing frequency range. Singing frequency range for fe-males and males across clinical diagnosis is presented inFigure 5. The median singing frequency range for males was23.99 Semitones and for females was 21.3 Semitones. In thisstudy, singing frequency range (in Semitones) was found toPerceptual assessmentPerceptual voice analysis of speaking voice was assessed usingGRBAS scale. The perceptual voice quality ratings ranged be-tween normal and severe deviation. The findings of the percep-tual voice analysis are presented in Figure 4.

Aerodynamic measuresMean and SD of MPT (/a/, /i/, and /u/) and s/z ratio for femalesand males are presented in Table 2. MPT was found to be re-duced than the expected in this group of singers (females:10.2 seconds [SD: 5.28] and males: 15.7 seconds [SD: 5.79]).In this study, the mean values of s/z ratio were within normal

toms

toms reported.(P 0.62). No statistically significant difference was observedin singing frequency range between females and males(P 0.15).

23

2

6

mfort &ile singing

Difficulty insustaing voice forlonger duration

Throat tightnessand strain while

singing

Dryness of throatand vocal fatigue

toms

of symptoms (in months).

5.1 of 10 which indicated that the singers who participated in

TABLE 1.Stroboscopic Findings, Clinical Diagnosis, and Diagnosis Based on Function

No. of Subjects Stroboscopic Findings Clinical Diagnosis Diagnosis Based on Function

13 (11 F and 2 M) Vocal fold edema, interarytenoidband/discoloration, andarytenoid congestion.

LPR Hyperfunctional voice disorder

10 (7 F and 3 M) Excessive muscular tension inlarynx (glottic and supraglottic),normal structures, ventricularband hyperadduction, andstrain.

MTD (grades I, II, and III) Hyperfunctional voice disorder

9 (7 F and 2 M) Soft pliable nodules with mucosalwaves.

Vocal fold nodule Hyperfunctional voice disorder

Ch

Vo

Vo

Pr

Ravikumar Arunachalam, et al Clinical Voice Analysis of Carnatic Singers 128.e4Dysphonia severity index. DSI is a single weighted scoreto calculate the severity of the voice problem.15 In the presentstudy, DSI scores of 45 Carnatic singers ranged from 3.5 to

8 (6 F and 2 M) Inflammation and hypertrophiedlarynx, increased stiffness offold; mucosal wave reduced orabsent.

3 (3 F) Aperiodic and asymmetricalmovements.

1 (1F) Soft pliable polyp; aperiodic andasymmetric movements.

1 (1 F) Atrophy and bowing of vocal fold,compensatory hyperfunction.

Abbreviations: F, female; M, male.4.91 indicating severe deviation to normal voice quality. Themedian of DSI scores for females and males were 0.075 and0.64, respectively. Figure 6 presents the DSI scores for femalesand males across different clinical diagnosis. No statisticallysignificant difference was observed in DSI between femalesand males (P 0.07). Furthermore, it was observed that therewas no statistically significant difference between DSI amongclinical diagnosis (P 0.28).Self-evaluation of subject. The mean and SDs of the eachdomain (physical, emotional, and functional domain) and totalV-DOP scores of singers is presented in Table 3. The results ofself-perceptual evaluation revealed that the overall severity was

3.5

17.2

3.5

10.3

6.9

13.8

48.3

44.9

27.6

20.7

62.1

0 10 20 30 40 50

Grade

Roughness

Breathiness

Asthenia

Strain

Percentage of s

FIGURE 4. Percethe study experienced voice problems.ronic laryngitis Hyperfunctional voice disorder

cal fold edema Hyperfunctional voice disorder

cal fold polyp Hyperfunctional voice disorder

esbylarynges Hyperfunctional voice disorder(compensated)DISCUSSION

Symptoms reportedLiterature from West1719 reveal acute changes in voice,problems in voice projection, and dynamic aspects of voice(pitch range) as the major complaints among singers. In thepresent study, changes in voice quality, difficulty singingin extreme pitches (high and low), fatigue, discomfort, andpain while singing were common symptoms reported bysingers. Voice symptoms exhibited by singers can beassociated with infections and inflammations of phonatoryapparatus. Furthermore, persistence of vocal symptoms maybe associated with inappropriate and excessive use of voice

27.6

31

48.3

65.5

20.7

6.9

20.7

13.8

6.9

60 70 80 90 100ingers

normal

slightdeviationmoderatedeviationseveredeviation

ptual findings.

such as improper singing technique or singing at loud volume

Rosen and Murry18 in Western singers stated that singers

pressure, stress, and inappropriate vocal technique lead toincreased musculoskeletal tension.22

In the present study, 17.7% of singers and 20% of singers hadfindings of laryngitis and vocal fold nodule, respectively. La-ryngeal inflammations, vocal nodules, and polyps are reportedto be common in singers.23

The study had four singers above the age of 60 years; how-ever, only one female singer aged 74 years showed age-related structural changes in larynx such as atrophy, bowing/phonatory gap, and hyperfunction of ventricular folds (compen-sated) with asymmetrical movements of vocal folds and re-duced mucosal wave. Voice problems due to aging process

voice usage and structural changes noticed in vocal folds.Increased musculoskeletal tension of the phonatory apparatus

TABLE 2.Mean and SD of MPT (/a/, /i/, and /u/) and s/z Ratio

Parameters(Unit) Females, Mean (SD) Males, Mean (SD)

/a/ (s) 10.2 (5.28) 15.7 (5.79)/i/(s) 10 (3.8) 20 (3.9)/u/(s) 9.8 (3.5) 20 (4.5)s/z Ratio 1.11 (0.16) 1.02 (0.04)

Journal of Voice, Vol. 28, No. 1, 2014128.e5were more sensitive to subtle voice changes and presentedearly to clinics.

Videostroboscopy findingsReflux laryngitis was the most common findings in Carnaticsingers. A study on vocal and nonvocal habits in Carnaticsingers by Boominathan et al7 had revealed that singers re-ported irregular dietary patterns, prolonged loud singing prac-tice, enormous work stress, and insufficient rest betweenconcerts. Earlier survey reports7 and current findings relate as-sociation of dietary habits, life style changes, and workpressure.Around 33% of singers were diagnosed to have primary

MTD (grades I, II, and III). It is reported in literature that laryn-geal musculoskeletal problems are very common in profes-sional voice users, especially in singers.20,21 Effects of workduring rehearsals or performance.17 Increase in laryngeal mus-cle tension is another common problem in singers leading tovoice disorders.20 Throat tightness and strain while singing re-ported in this study may be associated with increased musculo-skeletal tension in the larynx and perilaryngeal area.In this study, the average duration of symptoms reported

varied from 1.5 to 6 months. A survey on Carnatic singers7

in India revealed that long-lasting voice problems (lastingmore than a week) were more common among singers. Thiswas assumed to be related to apprehension and reluctance insingers to seek professional/medical treatment for problemsat an early stage. Singers prefer trying ancient home reme-dies/practices for voice-related concerns before consultingprofessionals for help in India. On contrary, study done by22.7 21.6 21.3518

22.95 23.04 23.2

0

5

10

15

20

25

30

LPR Vocal fold nodule

Chronic laryngitis

Voe

Med

ian

Sin

gin

g fr

equ

ecny

ra

nge

(Sem

iton

es)

Clinica

FIGURE 5. Singing frequency range for femmay lead to increased effort while speaking resulting in phys-ical perceptible strain. This study was limited to analyzingspeaking voice only as it was routinely followed as partof the protocol. However, perceptual voice quality ratings dif-fer with speaking and singing voices.27 Auditory perceptualrating of singing voice requires standard tool that accommo-dates different aspect of singing voice. In addition, incor-porating a rating scale for singing voice may be ideal incomprehensive assessment of professional voice users suchas singers.

.7

13.9

18.9

23.7526.5

cal fold dema

Vocal fold polyp

Presbylarynges Muscle Tension Dysphonia

l diagnosis

Females Malesare common24 resulting in structural alterations and functionallimitations25 in voice production.All subjects had hyperfunctional voice disorder in this study,

irrespective of their age, sex, and singing career length. Al-though one would assume more a singing techniquerelatedreason for MTD among singers, the findings in this study alertsto other possible reasons for functional voice disorders. Culturerelevant variations in work style (and possibly pressure), dietand food habits, and life style cannot be neglected to causestructural and functional changes in the larynx.

Perceptual assessmentPerceptual voice evaluation is regarded as the gold standardfor documenting voice disorder severity.26 In this study, voicequality of the speaking voice was rated using GRBAS scale.The overall grade rating (G) revealed moderate deviation inmost of the singers in speaking voice. The perceptual voicechange in speaking could be attributed to the hyperfunctionalales and males across clinical diagnosis.

Singing requires a highly coordinated breathing and phonation.In this study, MPT was reduced than expected in both females

0.5

0.17 0.09 0.0

1.59

0.640.38

-1

-0.5

0

0.5

1

1.5

2

Voced

Med

ian

DS

I sco

res

icalles an

Ravikumar Arunachalam, et al Clinical Voice Analysis of Carnatic Singers 128.e6and males. Carnatic singing emphasizes the importance ofbreathing for singing and improving breath support and control.However, no formal training or exercises are taught to achievethe required breath support and control for singing.7 ReducedMPT can be due to the poor coordination between breathingand phonation. These could be attributed to underlying vocalpathology or improper technique used for singing.

Acoustic analysisAerodynamic measures

-2.5

-2

-1.5

LPR Vocal fold nodule

Chronic laryngitis

ClinFIGURE 6. DSI scores for femaSinging frequency range. Study done on frequency rangein trained Carnatic singing5 revealed that singers traversed 22.5 octaves comfortably when compared with historic expecta-tions of three octave singing. The average frequency range formales was 23.99 Semitones and in females, it was 21.3 Semi-tones.5 In Carnatic singing, overall range is lesser (26 ST)5

compared with Western classical singing (38.4 ST).28 In thepresent study, the singers showed a reduced singing frequencyrange than expected. Most of the singers in this study reporteddifficulty in reaching higher and lower octaves as their majorconcern. Mean singing frequency range was observed to be re-

TABLE 3.Mean and SD of Each Domain and Total V-DOP Score ofSubjects

Domains Mean SD

Severity 5.1 2.7Physical 40.4 21.5Emotional 39 23.1Functional 31 24.2Total 110.24 73.20stricted for singers with mass lesions such as nodules, polyps,and edema. Presence of extra mass in vocal fold may lead to dif-ficulty in reaching higher pitches.29 However, no statisticallysignificant difference in mean singing frequency range was ob-tained across different pathologies. Flexibility in reaching dif-ferent pitches is an essential component for good singing.Also reduced flexibility and restricted range could be attributedto excessive and inappropriate use of vocal mechanism result-ing in or from structural abnormalities.

Dysphonia severity index. DSI is a sensitive and objectivemeasure to analyze voice quality.15 In the present study, DSIscores of the singers revealed normal to severe deviation. Devi-ant values noticed in DSI are due to abnormal values in I-low,

9

-2.09

-0.96

0.87

1.68

al fold ema

Vocal fold polyp Presbylarynges Muscle Tension Dysphonia

diagnosis

Females Males

d males across clinical diagnosis.jitter, and MPT. Despite perceptible problems reported bysingers, a few of them showed normal DSI values. This directsthe need for clinicians to correlate laboratory-based measuresand clinical findings with patient feelings to arrive at appropri-ate management strategies. Normal DSI values also may indi-cate that singers can modify the functional capacity of theirphonatory apparatus to provide a serviceable voice linkedto psychophysical effort (difficult to quantify) despite structurallimitations.

Self-evaluation of subject. In overall severity of the voiceproblem, the average score was 5.1 of 10. This revealed self-perceived severity in overall voice quality. Furthermore,V-DOP scores revealed concerns in all domains predominantlyrelated to physical and emotional aspects of voice production.Functional domain scores were lesser than physical and emo-tional domain. This could be because the questions in V-DOPfocused on speaking voice and it did not address any specificissues to singing voice. In the study by Rosen and Murry,18

while determining the degree of handicap reported by singers,voice handicap index (VHI) scores were lower than the generalvoice patients. They concluded that a low score did not neces-sarily indicate a weak handicap and rather pointed out that

TABLE 4.Clinical Diagnosis and Management Decisions

No. of Subjects Clinical Diagnosis Diagnosis Based on Function

Management

Medical Therapy

13 (11 F and 2 M) LPR Hyperfunctional voice disorder Antireflux medications: protonpump inhibitorswith/without

prokinetics for 6 wk

Vocal hygiene instructions,conservative voice use, andpostural correction

9 (7 F and 2 M) Vocal fold nodule Hyperfunctional voice disorder Vocal hygiene instructions,conservative voice use, andpostural correction

Voice therapybreathing andvocal function exercises31

8 (6 F and 2 M) Chronic laryngitis Hyperfunctional voice disorder Anti-inflammatorymedicationswith/without steroids

Vocal hygiene instructions,conservative voice use, andpostural correction

Voice therapy to unlearnhyperfunctional behaviors

3 (3 F) Vocal fold edema Hyperfunctional voice disorder Anti-inflammatorymedications Vocal hygiene instructions,conservative voice use, andpostural correction.


1 (1 F) Vocal fold polyp Hyperfunctional voice disorder Microlaryngeal surgery Vocal hygiene instructions,conservative voice use, andpostural correction.


after surgery1 (1 F) Presbylarynges Hyperfunctional voice disorder

(compensated) Vocal hygiene instructions,

conservative voice use, andpostural correction.


10 (7 F and 3 M) Muscle tension dysphonia(grades I, II, and III)

Hyperfunctional voice disorder Vocal hygiene instructions,conservative voice use, andpostural correction.

Voice therapylaryngealmassage, breathing andvocal function exercises31

Abbreviations: F, female; M, male.Notes: Discussing specifics of every subject is beyond the scope of this article, and so most observable signs are documented in the above table.

JournalofVoice

,Vol.28,No.1,2014

128.e7

hygiene and conservative voice use. Vocal hygiene tips in-cluded aspects on hydration, diet modification to reduce reflux

perception questionnaire focusing on singing voice may be1998;98:493498.

21. Jahn FA.Medical management of the professional singer: an overview.Med

Ravikumar Arunachalam, et al Clinical Voice Analysis of Carnatic Singers 128.e8ideal to be included in a comprehensive voice assessment forsingers. Importance of periodic voice assessment in Carnaticsingers can be emphasized as an outcome from this study.Changes in traditional voice training method, need for in-

cluding conservative voice use, and dietary modification ad-vises in Indian context are highlighted as other areas to probedisease, emphasis on regular consumption food/eating habits,singing at comfortable pitch, use of amplification during con-certs, and adequate rest before concert. The singers were coun-seled on refraining from intake of coffee/tea/carbonated drinks,spicy food/sour foods, smoking/alcohol consumption, singingwith compromised breathing posture (neck tightening), yell-ing/screaming/mimicry/throat clearing, singing in extremepitches, and singing with strain. Table 4 summarizes the clinicaldiagnosis and management decision of the singers.

CONCLUSIONThis studys finding that all Carnatic singers (considering thenature and style of performance) presented with hyperfunc-tional voice disorders is alarming. Structural and functionalchanges in the larynx of a Carnatic singer may be due to exces-sive and inappropriate use of the vocal mechanism. Exploringsimilar types of singing done elsewhere and comparing the find-ings (drawing parallels) with that reported here might be inter-esting and multiculturally relevant.This study also highlighted the limitations in routine compre-

hensive voice assessment when applied with Carnatic singers.However, visualization of larynx has helped singers to under-stand the mechanism of vocal function and hence aided in coun-seling to improve compliance in treatment. Furthermore, theuse of standardized auditory perceptual evaluation and self-questions should address the specific needs of this group. As theprimary focus of VHI was on speaking voice, the questionnairewas less sensitive in identifying voice problems in singers.18,30

This indicates the need to develop a PROM (patient-reportedoutcome measures) tool to assess this group of singers.

Clinical diagnosis and management decisionsBased on the information from history, behavioral observation,and visual analysis, clinical diagnosis was made. The clinicaldiagnosis and treatment decisions of singers are given inTable 4. All singers presented with varied symptoms and com-plaints with varying degrees of severity. Acoustic and aerody-namic analysis allowed documentation of vocal function(allowing scope for comparisons during/after treatment). Self-assessment provided scope to understand the self-percept ofthe voice change in the subjects life. It gave indication of dis-crepancies between the singers his/her own voice with the cli-nicians perception of voice problem.The management protocol for the Carnatic singers included

vocal hygiene, diet modification advises, voice therapy, andpharmacologic treatment. All singers were counseled on vocalfurther. These findings will help to educate professionals in-Probl Perform Art. 2009;24:39.

22. DietrichM, Verdolini AK, Gartner-Schmidt J, Rosen CA. The frequency of

perceived stress, anxiety, and depression in patients with common patholo-

gies affecting voice. J Voice. 2008;22:472488.

23. Houtte EV, Van Lierde K, DHaeseleer E, Claeys S. The prevalence of la-

ryngeal pathology in a treatment-seeking population with dysphonia. La-volved in this field, including speech pathologists, laryngolo-gists, and singers/performers, and singing teachers regardingprevention, early identification, and treatment of individualswith voice concerns.

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Journal of Voice, Vol. 28, No. 1, 2014128.e9

Clinical Voice Analysis of Carnatic SingersIntroductionAim of the studyMaterials and methodsResultsSymptoms reportedVideostroboscopy findingsPerceptual assessmentAerodynamic measuresAcoustic analysisSinging frequency rangeDysphonia severity indexSelf-evaluation of subject

DiscussionSymptoms reportedVideostroboscopy findingsPerceptual assessmentAerodynamic measuresAcoustic analysisSinging frequency rangeDysphonia severity indexSelf-evaluation of subject

Clinical diagnosis and management decisions

ConclusionReferences

clinical voice analysis of carnatic singers

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