Medical Aspects of Voice Teaching

For this issue on voice teaching, I was asked to write on the medical aspects of voice teaching, and as I comment on this controversial topic, I beg forbearance up front. We, all of us, whether teachers, therapists or physicians, basically work in our own little rooms, dealing with vocal problems as we understand them. We may try to talk to one another, but often the only communication is through the student/client/patient. That singer, the focus of all of our efforts, may represent (or misrepresent) us to one another, making us appear as either a shining success or a chronic problem. None of us wants anything but a long and successful career for every singer who passes through our hands. I would like to discuss some of the problems we, as physicians and teachers, share.

I frequently see a certain stereotype, the young voice student. These students are often sent by their new voice teacher, who hears, correctly, that something is wrong with the voice. This is often a female teenager who has been singing “since she can remember.” The child has been the star of high school and summer camp, is the celebrated lead in the annual musical, with no teaching, just the occasional coaching session. And now, at age 15 or 16, it is finally time for voice lessons. She is accompanied by an overly protective parent, who answers every question I direct toward the young patient. The parent is clearly invested in the child’s singing career, not just financially but also emotionally.

Some of these girls already have the posture and demeanor of young prima donnas, a fragile confidence verging on arrogance and lacking only one thing—technique. They also often lack the realization that technique only comes from devoted imitation, practice, and the daily honing of the craft. On physical examination, the larynx is high, the neck and shoulder tense, the voice pleasant and potentially good, but lacking projection, flexibility—in general lacking finesse. If these young students are with a good teacher, and they have the true commitment to learn, they are headed in the right direction. Many, however, become daunted and discouraged once they realize that they now need to address tasks which will not garner immediate adulation and applause.

I take time to reassure such young singers that there is nothing “wrong” in the sense of a physical problem, but they need to learn good technique and perhaps unlearn a few faulty habits. I try to make the point that talent, while essential, is nothing more than potential ability, and it takes daily dedicated work to potentiate that talent.

The other extreme, less common, is the fanatic student. These are again usually girls, at the conservatory level, who practice five or six hours a day and overdo everything. They are single-minded to a fault. Typically they present with early changes suggestive of nodules, or excessive tension in the larynx and the neck. It is rare that I have to tell students to practice less, but that is what is called for here. A combination of innate competitiveness, family pressures, and a degree of social isolation (particularly in foreign students who have come to New York with no significant local support system) may predispose to this problem. Compounding factors include day jobs which require excessive voice use or the self-imposed ambition to try difficult roles too early.

Physical examination often discloses early swellings on the vocal folds, which may presage nodules. This is the sort of singer who will eventually wear out the larynx, develop a wobbly vibrato, or an uncertain pitch, and may become, from a medical standpoint, irremediable.

On a prosaic level, singing is a mechanical feat that involves the anatomy and physiology of the body. For this
reason, I am very supportive of every singer learning as much about the vocal mechanism as possible and using this information to enhance a long and productive career. Teachers are essential in sharing anatomic and technical information with students, who will then integrate this knowledge into improving their technique. There are a few students, however, who become overly concerned in which way the right arytenoid turns, the thinness or thickness of the left vocal fold, etc. While anatomy is an interesting subject, an extreme amount of microanalysis can actually get in the way of good singing. The anatomy is there, but it is asymmetric, inexact, and not always directly relevant to the vocal problems which are being addressed. The photograph or videotape should be used as a teaching aid, but it does not answer all questions related to the voice.

The flip side of the anatomist is the personality of an ostrich, who ignores what is clearly visible and audible in the voice. These are often middle-aged patients who may have had personal and career issues, and all defense mechanisms are already working full tilt. They may not be emotionally able to handle any more “bad news.” A patient once told me that I really should be more sensitive than to point out to her that she has nodules. She knows she has them, and I upset her by pointing out that the huskiness, lack of a top, and other problems with her voice are due to these nodules. If we don’t see them, they are not there. So now we spend our visits talking about everything but the you-know-what. While both teachers and physicians clearly need to be sensitive to the singer’s psychological issues, from the vocal point of view, it is our duty to steer them towards the truth, so the problem can be effectively addressed.

Then there is the Fach issue. This is really a problem for teachers, not physicians, but we both do see the results. There is the baritone who wants to be a tenor, and speaks in a high head voice, the larynx also high, the vocal folds pink, the muscles over-exerted. The bass-baritone who wants to be a basso profundo, speaking in an almost toneless growl. The “mezzo” who is really an underdeveloped soprano, and the misdirected and vocally struggling ugly duckling “soprano” who will grow up to be a beautiful swan of a mezzo. Singers who are struggling in this way will often suffer from excess laryngeal tension, because they are working close to the limits of what their vocal apparatus should optimally do.

The bottom line for both teacher and physician is the singer, the voice. As long as we are all focused on that target, the lines of communication between singer, teacher, physician and therapist are open, the information transmitted honest, unemotional, and untainted by ego, optimal results will follow.

Disclaimer: The suggestions given by Dr. Jahn in these columns are for general information only, and not to be construed as specific treatment, which should be obtained only following a visit and consultation with your own physician.

Anthony Jahn, M.D.

Anthony Jahn M.D. is an otolaryngologist with a subspecialty interest in ear diseases, disorders of hearing and balance, and disorders of the voice. He is a professor of clinical otolaryngology at Mount Sinai School of Medicine and is the noted author of Care of the Professional Voice. For more resources, go to his website