Although it is widely understood by singers and voice teachers that many types of vocal fold injuries are caused by excessive voice use, it is less known that vocal disorders can also occur because of vocal underuse. “Disorder” here refers to something that causes a crisis, and not simple deconditioning of the voice.
A person might underuse one’s voice to this point of “disorder” for a variety of reasons: a personality that intrinsically limits voice use—self-imposed voice rest, triggered by a false conclusion one has jumped to about his or her voice; well-intentioned but misguided medical advice to conserve the voice; or a combination of these. A “vocal underdoer” crisis can be chronic and personality-based, or it can be an overlay that causes harm to even a talkative “overdoer” personality.
Background: Vocal Underdoers Versus Vocal Overdoers
If we rate a person’s talkativeness on a seven-point scale, innate vocal underdoers are usually ones and twos, whereas overdoers are sixes and sevens. Likewise, if we ask them to rate their own voice’s conversational loudness, underdoers again tend to sit lower on that scale (that is, they are more soft-spoken) compared with overdoers. Typically, overdoers rate themselves accurately on the talkativeness and loudness scales, but underdoers are sometimes less self-aware, describing themselves as more talkative or louder than what their family or friends report.
In addition, even though overdoers are using the vocal fold muscles more vigorously than underdoers, it is paradoxically the vocal underdoers who much more often complain of general voice fatigue. To be sure, overdoers are the ones who may develop swelling of the vocal fold mucosa and thus will report more mucosal “fatigue” symptoms—for example, a slight huskiness in the voice that leads them to say, “My voice is tired.” But they don’t typically describe the muscle-based fatigue symptoms that bring underdoers in for consultation: a choking sensation, anterior neck awareness or heaviness, a sense of effort, and so forth.
One reason that vocal underdoers experience more fatigue of the larynx and neck muscles may be that their muscles, being under-conditioned, are more easily fatigued. It is as though the professional ballet dancer whose back gets a taxing daily workout rarely feels muscle strain, whereas the attorney who sits at a desk all day needs the chiropractor and massage. In addition, for some vocal underdoers, another cause of fatigue may be their tendency to produce voice with simultaneous over-contraction of antagonistic muscles—driving with the brakes on, as it were.
Because fewer people are aware of vocal underuse disorders, vocal underdoers can suffer through their voice problems much longer without getting a proper diagnosis and treatment. Below are the stories of three different singers who each had a crisis caused by vocal underuse. In the first scenario, the patient was an innate vocal underdoer. In the second and third cases, the patients were not innate underdoers but, through various circumstances, developed a pattern of vocal underuse. Each patient came to harm while he or she went undiagnosed.
Vocal Underdoer #1: Underuse by Nature, Abetted by Time Off
A soprano came for consultation, deeply worried that something was wrong with her voice. She had taken a two-month break from her busy performance schedule to be with her aging parents at their family home. During that time, she did not sing at all. Now, needing to resume her performance schedule in a few weeks, she felt that her voice was markedly abnormal—limited in size, ease, and flexibility. She had been checking in with it daily, but did not feel comfortable doing more than that until she understood what was wrong. Prior evaluations had brought recommendations for acid reflux management and a nasal inhaler trial, as well as the suggestion to be cautious with her voice. Nothing had helped, and the pressure of upcoming performance commitments was mounting.
This person described herself as a “2” on the talkativeness scale. I commented that this was a bit unusual for a premier singer such as her, and she immediately agreed that this had been her observation of the singing world as well. She commented that this was possibly why, alongside a major career in opera, she had also gravitated to more introspective recital events.
Evaluation revealed no deficits of basic vocal capabilities. Specifically, she was in her early 40s, and I could detect no sign of lowered muscular ceiling, register divergence, or other signals of lowered estrogen. The mucosa covering the folds looked to be in perfect condition, including stroboscopically, and “swelling checks” (a short series of vocal tasks I elicit from patients to listen for any voice impairment that might suggest even subtle, hard-to-see mucosal swelling) were normal. I did notice significant vocal fold bowing, however.
My advice was to adopt a regimen of escalating amount and vigor of vocal exercise, such that by the end of two weeks she would be vocalizing for not less than two practice sessions of 45 minutes per day. She needed to ensure that at least 10 minutes of each session was full voice. She seemed surprised at this advice, and relieved. Her voice responded as I predicted, and she resumed singing professionally on schedule.
Vocal Underdoer #2: Jumping to a Wrong Conclusion
I saw a young baritone who was pursuing a voice performance major at a nearby university. Early in the consultation, he told me with an undercurrent of desperation that his voice had been ruined a few months earlier, when he had undergone a tonsillectomy with endotracheal intubation. The surgeon, knowing the patient was a serious singer, had suggested a month should elapse before resuming singing, and he, the patient, had decided that if a month was good, two months might be better yet, and that he would avoid not only singing but also talking.
“I have a different voice than I used to have,” he said. He further stipulated that his new voice had no strength or depth or “body.” He didn’t remember any unusual early postoperative hoarseness, partly because during that time he had written messages instead of speaking. He had used his voice minimally and always gently during the remainder of the two months following the procedure, and when he finally resumed using his voice, he immediately came to believe that the breathing tube must have damaged his vocal folds.
At the time I saw him, he was continuing to rest his voice, but checking it briefly every day for recovery. Now he was about to begin the final month of the fall semester, and without any apparent progress, he was in panic mode.
On the 7-point scale for innate talkativeness, this man chose “5.” His speaking voice sounded normal—average man-on-the street for his age. He was only slightly tentative when asked to project voice. I did not notice any hypernasality, nor was there any leakage of air when he pretended to blow up a stiff balloon. (Rarely, tonsil surgery can unmask or create a palate deficiency such that it doesn’t fully seal off the nasopharynx during speech, causing hypernasality.) Swelling checks for mucosal injury were normal up into a fairly clear and high falsetto, and laryngeal examination, including stroboscopy, was also normal.
My diagnosis was that this man’s voice was actually normal—that there had been no injury to his vocal folds nor to his resonators at the time of the tonsillectomy, and that he had developed a firm belief in injury when in fact the problem was vocal deconditioning below the threshold needed for good singing.
He was initially dubious. With an eye to his skepticism, I asked him to adopt a new regimen, with a timer as the arbiter. He was to begin having voice practice sessions twice a day, on Day 1 for five minutes per session, and then each day adding another five minutes to each practice session, so that by the end of a week he would be singing 30 minutes twice a day. And so forth. Within a few weeks, the problem vanished.
Vocal Underdoer #3: Panic and Extended Voice Rest from Red Herring Findings
I saw a late-career, classically trained soprano who was quietly distraught. She announced that she had nodules and that her career was on hold waiting for them to resolve. Singing was her livelihood, her sole means of support, and because of this problem, she was now in financial distress.
It all began three months earlier, when she had seen an otolaryngologist for some allergy symptoms of sneezing, runny nose, and itchy eyes. In the course of a complete ear, nose, and throat examination, he had told her that he saw vocal nodules. She had panicked, gone into strict voice rest, and begun canceling performances around the country to try to let her nodules resolve. She was seeing me because, three months of voice rest later, her voice was not improving at all, and in fact seemed to have gotten worse.
I asked her to place herself on the 7-point innate talkativeness scale. Without a second’s thought and with a smile and a shrug, she chose “7.” I then asked if the weeks or months leading up to the allergy symptom consultation had been particularly demanding vocally. She said no. I asked her if the reason for that visit had included any worries about her voice. She said that her voice had seemed fine—it was primarily her nose and eye symptoms that had prompted that appointment.
When I evaluated her voice, I noted that her swelling checks were very impaired, confirming mucosal injury. She began to struggle with onset delays as low as A4, more than an octave below her necessary public singing range. Laryngeal examination confirmed small, pointed, spicule-like vocal nodules.
Nevertheless, my conclusion was that this singer’s main problem was not these nodules, but rather, ironically, her voice rest. After all, I reasoned, she had been a “7” all her life. More importantly, there had been no sense of vocal indisposition or increased voice use prior to being diagnosed with nodules. This soprano had been performing with these nodules for years, most likely; it was the voice rest that made her less able to coexist with them.
I explained that she was like a premier ice skater with a few ounces of lead in her skates. She had indeed been laboring with an impediment, but quite successfully, and she could likely return to doing the same going forward, as these were probably stubborn, chronic nodules that might not resolve without the help of surgery. I predicted that, as long as she stayed in very good shape by vocalizing regularly, she could likely again “skate circles around others.” If I was wrong, or if she became unwilling to adapt to the “lead in the skates,” I explained, there would be an excellent surgical option to restore her voice.
As with cases one and two, I advised her to gradually build up her voice. She departed mostly unconvinced, but promised to “give it a try.” After the first week, she reported by telephone, “Well, it is definitely better, but I can’t return to performing with this voice.” We established together that 50 percent described the state of her voice when I first saw her, and now, she felt she had progressed to 75 percent of her baseline voice. After another week, however, it was up to 85 percent, and within three or four weeks, she stopped canceling performances and returned to her work.
Her nodule problem remained, causing detectable impairment of the swelling checks for the several additional years that I followed her, but her excellent technique and careful choice of repertoire allowed her to continue performing successfully for many more years, in spite of the “lead in her skates.”
Understanding Vocal Underdoers
What is the common thread in these stories? In each case, the person’s voice problem did not arise primarily from a disorder or injury of the voice-making apparatus. Even the nodules in case three were not the main issue. Instead, the main issue for each person was a personality profile or a false conclusion, sometimes supported by misguided advice, which caused that person to inappropriately rest or restrain the voice.
It is important to recognize that, like the soprano in case three, an individual can be a lifelong, innate vocal overdoer and yet abruptly, due to some new life circumstance or belief, dip well below baseline vocal capability by becoming instead a vocal underdoer. Also, as illustrated by case three, one can have a separate vocal disorder (nodules, in her case) that is a red herring alongside the main issue: failing to distinguish between deconditioning and “lead in the skates” and therefore quailing from voice use.
These vocal underdoer stories show that voice rest is not always the answer, and that rest can actually become a hindrance to maintaining or re-gaining a normal voice. Just as vocal overdoers need to learn the skills of voice care and conservation in order to avoid injury to mucosa, vocal underdoers (innate or not) often need to remind themselves of what they already know: the voice, like any other body part, can benefit from and “enjoy” a degree of vigorous use. Even the innate vocal overdoers—a group that includes most vocal performers—should take care. Their typical response to a vocal crisis is voice rest, a response that is usually appropriate, but not always.
