Managing dysphonia caused by misuse and overuseBMJ 2000; 321 doi: https://doi.org/10.1136/bmj.321.7276.1544 (Published 23 December 2000) Cite this as: BMJ 2000;321:1544
Accurate diagnosis and treatment is essential when the working voice stops working
Actors in the Royal Shakespeare Company are trained to use their voices with consummate skill to express any range of emotions in the most demanding of circumstances.1 Yet the demands of professional performers' lifestyle and work will expose them to many dangers that may jeopardise their most valuable instrument of expression.2 Similar risks may affect teachers, clergy, lawyers, operators at call centres, and others who require the use of their voice to maintain their income. For actors and singers, even a brief period of dysphonia may be artistically or aesthetically devastating. 2 3 For other professional voice users, chronic or recurring dysphonia may have severe career and economic consequences.4
Major risk factors for laryngeal problems include smoking, excessive alcohol consumption, and gastro-oesophageal reflux (often caused by poor dietary habits).3 The main risk factors for non-organic dysphonia include excessive use of the voice, limited vocal recovery time, and stress.5 The effects of overuse of the voice are further compounded by other factors such as background noise, long speaking distance, poor room acoustics, and poor atmospheric humidity.4 These problems are typically reported not only by the actor with a demanding performance schedule but also by the teacher of a large class, the call centre operator working a nine hour shift, the aerobics instructor, and so on.
Accurate laryngological diagnosis is paramount for any patient with dysphonia,6 and especially for professional voice users. 2 3 Inaccurate diagnosis and inappropriate management may result in further laryngeal damage, jeopardising the short term and long term career of the individual 2 6 and increasing the risk of more permanent vocal handicap and disability.7 Along with a detailed case history, examination of the larynx and vocal tract must include videolaryngostroboscopy (a means of examining the vibratory characteristics of the mucosal lining of the vocal folds during phonation)6 and fibreoptic nasendoscopy (a technique to examine the physiology of the whole vocal tract during a range of phonatory tasks). It is also important to understand the vocal tasks expected from the voice user and, wherever possible, to examine the vocal tract during a repeat of these tasks (for example, by examining a teacher using the voice that he or she would usually use in the classroom). 2 3 6 Any patient who has dysphonia for more than two weeks should be referred for otolaryngological examination, especially if they report any high risk factors for organic disease.8 Dysphonic professional voice users should be referred to the voice clinic, run jointly by a laryngologist and a speech and language therapist.9 Most established otolaryngology departments now have specialist voice clinics.
A major challenge to the voice clinic team is the professional voice user who presents with dysphonia during a heavy voice schedule—for example, the actor or singer on a long tour, the teacher in the middle of term. The decision to withdraw them from their work environment is based on an evaluation of the risk of further damage if they continue to use their voice.8 Local anaesthetic sprays are prescribed only in extreme circumstances (for performers an hour before curtain up, for example) and then only as temporary respite. 2 3 8 Accurate diagnosis will enable the specialist speech and language therapist to design a programme of behavioural therapy based on the specific nature of the observed pathophysiology.10 The most common cause of voice problems is vocal hyperfunction or strain and is often the result of overcompensation for an acute laryngeal infection. 9 11 Behavioural therapy techniques to treat this hyperfunction are well documented10 and are known to be effective.11 Prescribing vocal rest alone is unlikely to be effective; the underlying cause must be addressed. 9 11
In advanced societies it is estimated that about a third of the labour force is working in professions in which voice is essential to daily functioning.4 Consequently many specialist speech and language therapists have developed dysphonia prevention programmes targeted at specific groups of professional voice users. Interestingly, the Royal Shakespeare Company is one of the few theatre companies in the world to have a “voice care” programme. Prevention programmes have been shown to reduce the incidence of dysphonia 11 12 and to be cost effective (for both the health service and the economy as a whole). These programmes are based on providing information on how to recognise “early warning signs” of potential vocal damage and how to practise good vocal hygiene. 10 11 Early warning signs include an unintentional change in pitch (the voice getting deeper or squeaking higher), vocal fatigue (getting weaker with increased use), and frequent “sore throats” not associated with other upper respiratory tract symptoms. Good vocal hygiene includes maintaining hydration levels throughout the day; avoiding atmospheric irritants, such as smoke, dust, and fumes; controlling gastro-oesophageal reflux; and maintaining good dietary habits.10