Most of my voice patients do not come to me from a primary care doctor. They either refer each other, or have been sent by their teacher, who has noticed something wrong with the voice—and I applaud their acumen and pro-active attitude.
Teachers are in an excellent position to diagnose voice problems, much more so than even the best laryngologist. First, the teacher is also a singer, and knows “from the inside” what goes into producing a good singing voice. Second, she monitors the student’s voice regularly. Subtle changes that may escape the student’s own attention are more obvious to the trained ear of the teacher, and hearing the student at weekly or biweekly intervals makes these changes (and their progressive development) more apparent. Finally, the long-term psychological relationship between student and teacher often reveals the key to an otherwise puzzling problem.
The voice teacher is a mentor and advisor, who can correctly put a vocal problem into the context of a student’s personal life. Even the most empathetic physician cannot duplicate this in a 15-minute visit.
On the other hand, physicians should also be teachers. It is part of our vocation not only to fix what’s gone wrong, but also to educate the singer as to why it happened, and how to prevent it in the future. The very word “doctor” comes from the Latin verb docere, which means “to teach.” A physician who doesn’t teach is doing only part of his job, especially when dealing with singers, many of whose problems are functionally and occupationally induced.
I normally see students from teachers for two reasons. First, a new student who seems to have vocal issues is referred for a “pre-employment physical” of the larynx. Some of these students have had either misdirected training or no training at all, and before a teacher begins, she needs to know that the vocal apparatus is healthy. Others are students who have been doing well, but now have encountered new and persistent vocal problems that vocal pedagogy can’t readily correct.
When should students be referred? From the teacher’s point of view, when any vocal problem arises that can’t be explained in the context of what the student is doing with the voice. From the laryngologist’s point of view, the following problems justify an examination of the larynx:
1) A voice that is difficult on top. The singer is unable to float unstrained top notes, and needs to grab and “muscle” the voice to squeeze out notes that normally come easily. This usually indicates a swelling, and may progress in severity to a total loss of notes on the top.
2) A voice that is breathy throughout the range. This often begins with difficulty in the passaggio but may progress to involve the entire vocal range, both head and chest voice.
3) A voice that is good one day, bad the next. This vocal “roller coaster” means the voice is unpredictable, and hence unserviceable in a professional setting. It is often a manifestation of more than one problem.
4) A sudden loss of voice, either complete or partial. One of the causes of this, vocal hemorrhage, requires that the singer go on immediate voice rest until the larynx has been examined.
5) Recurrent or persistent pain in the throat, whether this is related to singing or not.
Of course, both teacher and student want things to be all right, and at times there is a curious blind spot that is borne not out of neglect, but out of affection and the shared wish to work things out without the trauma of a medical visit and a “dreaded” diagnosis. When faced with unresolved vocal difficulties, however, both teacher and student should be able to distance themselves emotionally from the voice so they can make the decision to have the vocal apparatus examined by a sympathetic but objective physician.
Disclaimer: The suggestions given by Dr. Jahn in the columns are for general information only, and are not to be construed as specific medical advice or advocating specific treatment which should be obtained only following a visit and consultation with your own physician.
