Recently, I wrote about the advances in laryngology [December 2007] and how singers are becoming more interested and educated in the anatomy and physiology of the larynx. Almost any visit to a laryngologist will generate a photograph or video of the larynx, in vivid color and magnified detail. The visual image is arresting, seductive, almost addictive. Often patients request a photograph at every visit, even when the examination is normal and they have no vocal complaints, just to see how their larynx looks. Is this useful or a distraction?
Our everyday world has become predominantly visual. Television and computer screens, books, magazines, and PDAs compete for our eyes, trying to attract our attention and move us to action. Reading leads to conscious reflection, thinking, and understanding. Non-verbal visual messages can move us subconsciously, but typically the pathway is between the eyes and the brain. The non-visual world—auditory, olfactory, gustatory, and tactile—is also important but secondary to the world as most of us see it.
For singers, the hierarchy of perceptions is different. The visual still attracts, but much of what a singer learns about the craft is in the realm of the unseen. The voice is an ephemeral phenomenon. We can hear and feel it. It can move us on every level of our nervous systems—we just can’t see it! So for singers, the concept of seeing the larynx, seeing what color the vocal folds are and the appearance of bits of mucus and tiny blood vessels is visually arresting at first glance—but it may not tell the whole story.
I realize that in the current era of videostroboscopy and microphotography I am making a purposely contrarian argument, but bear with me for a bit. I am certainly among the many laryngologists who photograph the vocal folds, pointing out to patients the visual evidence of abnormality, of nodules, or hemorrhage, or of vocal fold malposturing. And visual documentation can be very useful in monitoring a suspicious lesion or the progress of a vocal fold hemorrhage. My point is simply this: when singers look at this information, it must always be in the context of vocal function. These pictures can illustrate conditions, or explanation can link them to vocal problems, but they are not a substitute for the nonvisual perception of the voice that singers must work with.
The impact of the visual is undeniable. Many singers are awestruck when they first look at a picture of their larynx. It is so different from what they had for years imagined. But is that what the voice is about? One of my patients (a well-known opera performer) once told me that he found it confusing more than enlightening to be shown areas of redness, tiny blood vessels, etc. For both the physician and the patient, the visual information is only important if it has explicative and predictive value for the voice (excluding, for the moment, serious medical conditions).
Much of these visually arresting images have no functional significance. Truth can become lost as a patient becomes increasingly attached to wondering, “How do my cords look?” With such a wide range of “normal” in all parts of our anatomy, the image itself can be misleading.
Physicians are also responsible for this situation. We are trained visually, forever looking at X-rays, pathology slides, and specimens. When a singer presents with vocal problems and the photograph is not quite “normal,” doctors feel tempted to link one to the other, even when that cause-effect link is not there. Hoarseness may not always be due to “red cords,” for example. Redness may be unrelated, or due to the color settings on the camera, among other causes.
Since the visual image is so persuasive, singer-patients may feel tempted to share the physician’s bias for the visual, to lose track of their own daily monitoring of the mechanism, which is more sensitive, exquisitely “in the moment,” and nonvisual.
The flip side is equally problematic: the picture looks “normal,” the voice is hoarse, and as the physician points to the picture, the patient is convinced that there is “nothing wrong.”
A “normal” appearance doesn’t always indicate normal function. Any understanding of how things look and how they “should look” is only useful if it can explain and affect function. As Yogi Berra famously said, “In theory, there is no difference between theory and practice, but in practice there is.”
So what knowledge of visual anatomy does a singer need? The short answer is, whatever knowledge that is useful for his or her craft. It is obviously good to know the appearance of your larynx. All singers should have a good photograph of their larynx in its normal state, especially if they are traveling and need to see doctors in different cities. Apart from that “baseline photograph,” however, the visual information should always be in the context of function, not only because in all of nature function generally determines structure, but also because many bits of anatomic information may be irrelevant for the vocal performer.
I am not against knowledge. I am all for learning about many things, but unless a singer, in his or her capacity as a singer (rather than as a collector of minutiae), can integrate that visual information and make it useful for the process of singing, it has no relevance. Understanding how the vocal folds contract is useful, since it can be linked to a physical sensation and put to work in the act of phonation. Knowing that laryngeal muscular contraction involves actin and myosin filaments ratcheting past each other, or that the predominant lubricant in Reinke’s space is hyaluronic acid may be interesting and could be useful to research scientists and some surgeons, but it is irrelevant to the person who drives that larynx daily, the singer.
So what do my colleagues and I need to know as doctors? For physicians, the real advances in managing singers may not be just in the journals of medical research. As a generalization, most singers do not suffer from life-threatening or exotic laryngeal disorders where arcane bits of knowledge hold the key to recovery. Our daily practice depends on gaining a deeper understanding of how the singing larynx (and I use “larynx” to imply the entire vocal mechanism) works. Thus the advances are in the collaboration of voice professionals, singers, teachers, and those of us (physicians and speech therapists) who care for them.
As a “voice doctor” I learn daily from the singers, voice teachers, and voice therapists who are my patients and colleagues. At times singing seems to be such a simple art but such a complex craft, and much remains for all of us to learn at the interface of its various aspects, of which the photographic appearance of the larynx is but one.
DISCLAIMER: The suggestions Dr. Jahn provides in these columns are for general information only, and not to be construed as specific medical advice or advocating specific treatment, which you should obtain only following a visit and consultation with your own physician.
