24 hours prior to curtain

Journal of Voice Vol. 14, No. 1, pp. 92-98 © 2000 Singular Publishing Group, Inc.

24 Hours Prior to Curtain

Suman Mishra, Clark A. Rosen, and Thomas Murry

University of Pittsburgh Voice Center, Department of Otolaryngology--Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Summary: A retrospective review was conducted of 40 singers presenting with acute voice problems prior to performance. The purpose of this study was to determine the reasons for seeking emergent voice treatment, the types of acute voice disorders, and the performance outcome. The patients were assessed by age, singing style, years of experience, chief complaint, laryngovideostrobo- scopic findings, and treatment regimens. The outcomes were classified as full, restricted, or no performance. The majority of patients were classical singers. Laryngovideostroboscopy frequently revealed a pattern of early glottic contact at the mid-portion of the membranous vocal fold in patients with acute laryngitis. Experienced singers uniformly sought treatment many days before their performance compared with inexperienced singers who presented closer in time to performance. Six patients initially withheld information, which had a bearing on their acute management. The results of this study suggest that there is a need to accurately diagnose and treat the singer's emergent problem and educate singers regarding early evaluation of medical problems. With modem evaluation techniques and multi-modality treatment, 85% of the singers proceeded to full performance without negative sequelae. Key Words: Voice disorders--Laryngi- t is-Singers-Treatment outcomes

Acute management of a singer's voice problem car- ries repercussions that may affect his or her career. De- spite the importance of acute voice problems prior to performance, there is little information in the literature

Accepted for publication March 2, 1999. Address correspondence and reprint requests to Clark A.

Rosen, MD, University of Pittsburgh Voice Center, Department of Otolaryngology--Head and Neck Surgery, University of Pittsburgh School of Medicine, Eye and Ear Institute, Suite 500, Pittsburgh, PA 15213

Presented at the 27th Annual Symposium: Care of the Pro- fessional Voice; June 5, 1998; Philadelphia, PA, USA.

regarding the management of these disorders. When a vocal performer develops a voice problem within 24 to 72 hours of a performance, the clinician is required to make a prompt diagnosis, provide treatment, and determine the safety of vocal performance. The ability of the singer to fulfill his or her pending vocal performance without sustaining a vocal injury is of para- mount importance. Therefore, the clinician must un- derstand the presenting complaints and the emergent performance needs of the singer. The purpose of this study was to determine the reasons for 40 singers with acute voice problems seeking emergent voice treatment prior to performance, the types of acute voice disorders, and their performance outcome.

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24 HOURS PRIOR TO CURTAIN 93

METHODS

Subjects The 40 subjects in this study were derived from a

retrospective review of consecutive singers who presented to the University of Pittsburgh Voice Center from 1995 to 1998 with acute voice problems. Pa- tients were included if the laryngovideostroboscopy (LVS) results were available for review and the outcome of their performance was known. Chart notes from the initial presentation and subsequent visits were reviewed in detail to identify any missed medical history during the initial visit. The history fo- cused on presenting voice complaints, previous voice problems, and the use of prescription and nonpre- scription remedies. All of the patients presented with voice complaints. Several subjects also complained of concurrent pharyngeal and sino-nasal symptoms. The patients' ages, singing styles, years of singing experience, chief complaint, treatment regimens, and performance outcome were identified.

The study group was segregated by singing experience: 1 year or less, 1 to 5 years, and greater than 5 years based on years of private voice lessons. The patients were also placed by singing style into popular (pop), musical theater, or opera. The presentation time was designated as emergent (24 hours before performance), acute (more than 24 hours but less than 72 hours before performance), or semi-acute (more than 72 hours before the performance).

Procedure All patients underwent a thorough head and neck

examination and LVS. Each subject's, LVS evaluation was reviewed by two of the authors (CAR and TM) to identify the presence or absence of glottal pathology: edema, vocal fold hemorrhage, prenodn- lar vibratory pattern, and/or vocal fold lesions. Pren- odular vibratory pattern was defined as early mid vocal fold contact as seen during LVS (see Figure 1)

All patients were treated medically at the time of presentation. A discussion of the pathophysiology of the voice disorder accompanied by an explanation of LVS findings preceded medical intervention. The principles of proper voice use and vocal hygiene were reviewed with all patients. Some were encouraged to seek guidance from their voice teachers. Specific medical treatment was individualized based on the

FIG. 1. Prenodular vibratory pattern. Laryngovideostro- boscopy image demonstrates mid-vocal fold swelling to edema (see arrows).

patients' presenting complaints and physical examination findings. Most patients received antibiotics and guaifenesin. These medications were used to treat suspected bacterial infections and the thickened laryngeal mucosa that often occurs with acute infec- tious processes.

The performance outcomes were classified as unrestricted, restricted, or no performance. Unrestricted performances included those in which the singer completed the full performance (or performance se- ties). Restricted performances were those in which the patient was limited in performance participation by either duration or quantity of performances. Pa- tients in the no-performance category were either detained from performing or were vocally unable to perform regardless of clearance. P0stperformance reports were obtained by telephone or at the follow-up

Journal of Voice, Vol. 14, No. 1, 2000

94 SUMAN MISHRA ET AL.

visit to determine the outcome of the vocal performance and to find out if there were any negative vocal sequelae of the performance.

RESULTS

Of the 40 patients studied, 15 were male. The mean age of the subjects was 30 years with an age range of 17 to 57 years. The average age of the females was 26 with an age range of 17 to 45 years. The average age of the males was 35 years with a range from 20 to 57 years. Analysis of singing styles revealed 28 (70%) of the patients to be opera singers. Eleven (27.5%) singers performed musical theater, and 1 (2.5%) was a pop singer. The majority of the popula- tion (92.5%) consisted of intermediately and well- trained singers who possessed between 1 and 5 years of voice training or greater than 5 years of voice training, respectively. Only 3 patients (7.5%) possessed less than 1 y e a r ' o f singing exper ience (Table 1).

Presentation time prior to performance There was variable distribution in the presentation

times with 10 (25%) presenting emergently (<24 hours), 25 (62.5%) urgently (25-71 hours), and 5 (12.5%) semi-urgently (>72 hours). The preponder- ance of patients' chief complaints centered around voice abnormalities (72.5%); however, primary complaints of sinus congestion (15%), pharyngeal irrita- tion (5%), or cough (7.5%) were also revealed.

Analysis of the relationship between performance experience and presentation time prior to performance revealed a trend for the more experienced singers to present to the laryngologist earlier (Figure. 2). The average time of presentation of the less experienced singers was 40 hours prior to performance versus the most experienced singers who presented at an average of 68 hours. When the singers were cate- gorized as having 5 years or less of singing experience or greater than 5 years of singing experience, with 23 and 17 singers respectively in each group, the different presentation times based on singing experience were noted to be statistically significant up- on Chi Square analysis (P<.05).

Singing style also showed a relationship with presentation time. Musical theater singers presented at an average of 38 hours prior to performance time com-

pared with the opera singers who presented at an average of approximately 69 hours (Figure 3).

Undisclosed history Diligent questioning at the initial evaluation and

through follow-up visits revealed undisclosed information at the initial visit in six (15%) of the patients. The missed history included information concerning menstrual cycle changes, previous vocal fold pathology, prescription drug use (coumadin and steroids), and over-the-counter drug use (nonsteroidal anti-inflammatory drugs). The average age of the patients with- holding information was 28 years versus an average age of 31 years in those performers providing complete medical information at the time of initial evaluation. Although the age difference was not statistically significant, there was a trend for the younger performers to withhold vital historical information.

Laryngeal videostroboscopy LVS revealed normal examinations in 16 (40%) of

patients. Edema of the vocal fold was noted in 18 (45%) patients. A prenodular vibratory pattern was noted in 5 (27%) patients. Four (22%) patients had enlarged blood vessels, 3 (16%) had vocal cord nodules, and 1 (2.5%) had a vocal fold hemorrhage (Table 2). The edema of the vocal fold was frequently located within the mid vocal fold region, resulting in a vibratory pattern similar to that seen in the presence of vocal fold nodules. Thus, it was termed prenodular edema. Although this edema mimicked nodules, the inflammatory and temporary nature of the vocal fold edema was confirmed on follow-up LVS examinations (Figure 3). Likewise, the vocal fold nodules of the 3 patients were confirmed on repeat examinations following resolution of the acute inflammation. Of the 10 patients who presented at 24 hours, 7 (70%) exhibited vocal fold edema.

Despite the extent of vocal fold pathology seen in this group, 34 (85%) of the patients proceeded to full performances. Only 3 (7.5%) patients in this group were restricted in their performance, whereas another 3 (7.5%) did not perform. The patients who were restricted in their performance were instructed to limit their voice to only absolutely necessary use and to avoid 2 performances within a 24-hour period. The reasons for the lack of performance varied. One patient with vocal fold hemorrhage was detained to prevent further vocal

Journal of Voice, Vol. 14, No.l, 2000


TABLE 1. Demographic Data, Singing Experience and Style, Presentation Time Prior to Performance and Chief Complaint.

Singing Singing Time Chief Subjects Age Experience Style Prior Complaint

Male 1 29 1 MT 24 Male 2 38 1-5 MT 24 Male 3 42 >5 MT 24 Male 4 46 1-5 Opera 24 Male 5 25 >5 Opera 36 Male 6 57 1-5 Opera 48 Male 7 28 >5 Opera 72 Male 8 29 1-5 Opera 72 Male 9 32 >5 Opera 72 Male 10 38 1-5 Opera 72 Male 11 49 >5 Opera 72 Male 12 27 >5 Opera >72 Male 13 31 >5 Opera >72 Male 14 40 >5 Opera 72 Male 15 20 1-5 Opera 24 X=15 X=35

Female 1 31 >5 Opera <24 Female 2 25 1-5 MT 24 Female 3 45 1-5 MT 24 Female 4 20 1 MT 48 Female 5 20 1-5 MT 48 Female 6 20 1-5 Opera 48 Female 7 21 1-5 Opera 48 Female 8 23 1-5 MT 48 Female 9 25 1-5 Pop 48 Female 10 27 1 Opera 48 Female 11 29 >5 MT 48 Female 12 23 >5 Opera 72 Female 13 26 >5 Opera 72 Female 14 28 1-5 Opera 72 Female 15 28 >5 Opera 72 Female 16 29 1-5 Opera 72 Female 17 29 1-5 Opera 72 Female 18 31 1-5 Opera 72 Female 19 26 >5 Opera >72 Female 20 29 >5 Opera >72 Female 21 31 >5 Opera >72 Female 22 1 1-5 MT 72 Female 23 22 1-5 Opera 24 Female 24 22 1-5 MT 24 Female 25 31 >5 Opera 72 X=25 X=26

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trauma. Another patient displayed significant vocal fold edema, unresponsive to systemic steroids. This patient later revealed a history of coumadin use, and therefore was instructed to decline performance participation to prevent a potential hemorrhagic disaster,

especially given the significant vocal fold edema present. The third patient with an incomplete performance was actually cleared for his performance; however, he could not complete the performance secondary to voice loss during the performance.



8O 70 I n=17 1

60 s o

40

o 30

20

10

0

<1 1-5 >5 Years of Singing Experience

FIG. 2. Average presentation time versus singing experience.

Pharmacologic treatment Fifteen of the patients with vocal fold inflamma-

tion or prenodular edema were treated with steroids. Usually a methyl prednisone dose pack was pre- scribed. The decision to use steroids was based on the amount of edema of the vocal folds, the time to presentation, and the demands and experience of the singer. These decisions were not made based on strict criteria but the following guidelines were set. When significant vocal fold edema was present and the singer reported a significant reduction in vocal ability (often decreased range and strength) steroids were offered to the patient. This decision to use steroids and the form of steroids (IM or PO) was also made using the time to performance information. Thus, for

patients with significant vocal fold edema, reduction of vocal capability, and a short time period before performance, IM steroids were suggested. In con- trast, if singers had several days prior to performance, significant vocal fold edema, and reduced voice ability, they were offered per oral steroid treatment. No untoward side effects of steroid administration were found during follow-up evaluation with the singers. Thirty (75%) patients were placed on antibiotics, usually cefuroxime, unless known allergies to this drug ex- isted. Throat cultures were not obtained in most patients; however, the risk of selection of antibiotic resistant organisms outweighed the potential to treat an evolving and potentially disabling laryngitis. In ad- dition to antibiotics, nearly 60% of the patients were treated with 600 mg of guaifenesin and 30 mg of dex- tromethorphan hydrobromide twice a day.

Voice rest A form of voice rest was instituted in 33 (82.5%)

of the patients following the examination. Thirty-two patients (80%) were placed on relative voice rest, with only one patient placed on absolute voice rest. Those on relative voice rest were instructed to use their voices only when absolutely necessary and to refrain from rehearsal until show time. The importance of vocal hygiene was reviewed with each patient and each was asked to increase rest and hydration. The patients on relative voice rest were encouraged to eliminate or minimize the preperformance demands on their voice, including rehearsals,

TABLE 2. Videostroboscopic Examination Findings With Performance Outcome

Laryngovideostroboscopy Performance Findings N Outcome

Normal

Edema

Prominent vessels

Vocal fold nodules

Vocal fold hemorrhage

Prenodular edema

16 Full performance

18 Full performance

4 Full performance

3 Full performance

1 No performance

5

3 Full performance

1 Restricted performance

1 No performance

Journal of Voice, Vol. 14, No.I, 2000


68.7 Hours

70

60

50

40

e 30

20

10

0 Musical Theater Opera

FIG. 3. Average presentation time versus singing style.

interviews, and family gatherings. They were instructed to conserve their voices with the axiom of Dr. Punt in mind, "Don't say a single word for which you are not being paid. ''1

DISCUSSION

Intramuscular and oral steroids comprised front- line treatment for vocal fold inflammation in the singer who presented in the hours preceding a performance. The steroids were always used several hours prior to performance to ensure the patient did not develop an allergic response. The purpose of steroids would indeed be defeated and ironically detrimental with an allergic response.

Of the patients who presented at 24 hours prior to performance, 70% demonstrated prenodular edema. Many of the patients with severe edema were treated with steroids. Although there are no definitive studies on the efficacy of steroids, inferences based on sub- jective improvement and infant laryngotracheobron- chitis studies indicate a positive effect. 2 The patients were also treated with an antibiotic and guaifenesin. The latter, a mucolytic agent, is relatively safe and ef- ficacious for thick nasopharyngeal and bronchial se- cretions. The number of singers treated with a cough suppressant was too small to evaluate the outcome of this treatment.

The high incidence of edema in this group is most likely related to the increased vocal demands on singers immediately before performance time and the acute inflammation of infection. Rehearsals, preperformance interviews, and excessive conversations

with visiting family and friends are only a few of sources for the increased voice use in the singer pri- or to curtain.

The authors have found that voice teachers and speech-language pathologists may particularly assist the inexperienced singer with acute vocal problems. Proper warm up, vocal hygiene, and treatment of specific vocal habits should be introduced as preven- tative measures. Voice exercises before performances can be an integral part of the treatment regimen that should not be dismissed.

The patients in the present study were encouraged to adequately hydrate themselves by drinking 6-8 glasses of water and humidifying their living space. The adage of "pee pale" was incorporated for the self-monitoring of hydration status. 1 Patients were educated on the potentially compounding negative effects of preperformance stress, poor nutrition, lack of sleep, and the potential for increased voice abuse preceding a performance. Throat clearing, whisper- ing, and inordinate voice use were also discouraged.

The patient who presented with vocal fold hemorrhage possessed several vocal fold risk factors that included hormonal changes (premenstrual) and vocal abuse. The mechanism for the occurrence of vocal cord hemorrhages is postulated to be multi-factorial with an emphasis on hormonal influences and phonotrauma. In performers with repeated voice abuse, these hemorrhagic events have been suggested to result in vocal fold lesions. 3

Three patients presented with vocal cord nodules at the initial evaluation. Unlike a previous study in which singers with nodules were found to have smaller nodules, less impairment of vibratory func- tion, and less severe vocal symptoms than their non- singing counterparts, 4 the performers with vocal fold nodules in our study subjectively demonstrated vari- ably sized nodules. Previous reports indicated that singers who develop vocal cord nodules should stop singing until the nodules resolve, then start singing with a different technique. 5 Recent literature sug- gests more aggressive treatment including proper voice therapy and vocal hygiene as the primary treatment modality. 6

Two (5%) of the patients had histories of cigarette smoking; however, at the time of evaluation these patients had quit smoking. Smoking should emphati- cally be discouraged, because it leads to vocal cord



thickening with potential changes in pitch and inter- ference with voice quality. 7

The 15% incidence of initially missed history rep- resents an important issue regarding the care of acute voice problems. Often singers are nervous and pre- occupied. This may explain some of the undisclosed medical history in this series. The voice team may be partly at fault in not reviewing key information suffi- ciently to elicit important details that the singers have not associated with their current problem.

Voice changes can often be recognized by singers in advance of clinical laryngeal findings, which ex- plains the high incidence of normal LVS in this study. Mild edema of the vocal fold and increased vascularity were generally related to the singer's concerns of voice changes. The finding of prominent blood vessels on the vocal folds, noted in 3 patients, may be an indicator of excessive or improper voice use. The increased vascularity may be a clinical harbinger of potentially serious complications if the singer is not cognizant of recent habits.

The most obvious difference in the treatment of singers before presentation is the lack of time available to allow adequate efficacy of their treatment regimen. The lack of time may justify the use of antibiotics despite suspected viral infections or uncon- firmed cultures. Sometimes, the use of steroids may also be indicated. The decision of whether to allow performers to proceed is a judgment call based on the patient's risk of vocal fold hemorrhage, time to performance, and the demands of the performance. The voice care specialist must always keep long-term goals in mind, especially for the novice singer who may present immediately prior to performance and not appreciate the risk of "singing sick."

The trend of inexperienced singers presenting late identifies a need for the voice care community to increase education and awareness among singers of available resources and proper management of acute voice problems prior to performance. This study

demonstrates the need for careful evaluation and treatment of a singer with an acute voice problem.

CONCLUSIONS

The 40 patients in this review underwent a thorough history, head and neck examination, and LVS. This study revealed a tendency for less experienced and musical theater singers to present for treatment closer to performance time. LVS revealed a 45% incidence of vocal fold edema, which mimicked vocal fold nodules. With modem evaluation techniques and multi-modality treatment options, 85% of the singers proceeded to an unrestricted performance. The authors recommend an increased effort on behalf of the voice care community to educate performers about potential vocal problems before they occur. The authors have a high success rate for allowing the singer to perform despite acute voice problems prior to performance.

REFERENCES

1. Sataloff RT. Professional Voice: The Science and Art of Clin- ical Care. 2nd ed. San Diego, Calif." Singular Publishing Group; 1996:429-555.

2. Cruz M, Stewart G, Rosenberg N. Use of Dexamethasone in the outpatient management of acute laryngotracheitis. Pedi- atrics. 1995;96(2 pt 1):220-223.

3. Lin P, Stern J, Gould W. Risk factors and management of vocal cord hemorrhages: an experience with 44 cases. J Voice. 1991;5:74-77.

4. Peppard R, Bless D, Milenkovic P. Comparison of young adult singers and nonsingers with vocal nodules. J Voice. 1988;2:250-260.

5. Baker D. Laryngeal problems in singers. Laryngoscope. 1962;72:902-908.

6. Murry T, Woodson GE. A comparison of three methods for the management of vocal fold nodules. J Voice. 1992;6:271-276.

7. Shapshay SM, Rebeiz EE, Bohigian RK, Hybels RL. Benign lesions of the larynx: should the laser be used? Laryngoscope. 1990; 100:953-957.

Journal of Voice, Vol. 14, No.l, 2000

24 hours prior to curtain

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