Vocal health: What to do if you have a problem

Guidance produced by Mr. Declan Costello (ENT), Mr. Nick Gibbins (ENT), Ms. Tori Burnay (SLT), Ms. Linda Hutchison (VRC), Mr Dane Chalfin (VRC), Mr Ed Blake, (Physiotherapist)

The literature on dysphonia demonstrates that singers and elite voice users who present with voice disorders are most likely to have Muscle Tension Imbalance (MTI) rather than organic pathology or structural abnormality, and this is not always picked up in general ENT clinics, or even in all Voice Clinics. Ideally, MTI in singers is assessed via nasendoscopy by a Multidisciplinary Team (MDT) including a Vocal Rehabilitation Coach with experience/training in the assessment of the larynx and vocal tract in a wide range of singing styles. Such MDTs are available in the NHS in certain Specialist Voice Clinics, which have access to equipment including high definition cameras with stroboscopic or high-speed videos. The team in these clinics would normally include:

• Voice Specialist Laryngologist*
• Voice Specialist Speech and Language Therapist
• Vocal Coach (Singing Voice Specialist)
• Performance Specialist Osteopath/Physiotherapist (in some clinics)

*Some Specialist Clinics are SLT-led with Laryngologist review.

Referral

There are many Voice Clinics in the NHS nationwide, but we recommend that, whenever possible, professional voice users, including singers, are seen in Specialist Voice Clinics as described above, where there is stroboscopy and access to a Multidisciplinary Team, or in a clinic that is led by clinicians who are highly experienced in caring for the professional voice and are knowledgeable about the multidisciplinary approach and optimal care pathways.

For all professional voice users, referral to an NHS Specialist Voice Clinic  (or privately if waitings time are long and if funding is available),  should be made for any vocal symptom lasting more than 2-3 weeks, or persisting for more than 2 weeks after the resolution of a viral or bacterial upper respiratory infection.

Direct referral can be made by the patient’s NHS GP to one of a list of NHS Specialist Voice Clinics (so that diagnostic tests can rule out any pathology and a multidisciplinary assessment can be made and appropriate treatment recommended). Recommended management might include rehabilitation by a speech and language therapist, a physiotherapist or osteopath, a psychotherapist or a vocal coach working as part of the clinic team under clinical supervision.

Recommended NHS specialist Voice Clinics include:

• Birmingham, Queen Elizabeth Hospital (Anita Sonsale ENT)
• Cardiff, Royal Glamorgan Hospital (Huw Williams ENT)
• Cardiff, University Hospital of Wales (Gareth Williams ENT)
• Doncaster, Royal Infirmary (Mark Watson ENT, Jane Shaw SLT)
• Dublin, St Vincent’s Hospital, Mark Rafferty (cross border referrals from Northern Ireland accepted)
• Fife, Victoria Hospital (Richard Steven ENT)
• Liverpool, Royal Liverpool and Broadgreen University Hospitals (Mr Webb ENT, Sally Dennis SLT, Jo Clayton SLT)
• London, Charing Cross Hospital (Guri Sandhu ENT, Aphrodite Iacovidou ENT, Abi Simpson SLT)
• London, Guy’s/St Thomas’ Hospital (Natalie Watson ENT, Yakubu Karagama ENT, Tori Burnay SLT)
• London, Lewisham Hospital (Nick Gibbins ENT, Rehab Awad SLT)
• London, Royal National ENT and Eastman Dental Hospitals (John Rubin ENT, Jonathan Fishman ENT)
• Manchester, Wythenshawe Hospital (Sadie Khwaja ENT, Paul John McKenna SLT, James Smithson SLT)
• Newcastle, Freeman Hospital (Ben Cosway ENT, Natalie Eastwood SLT)
• Nottingham University Hospitals (Julian McGlashan ENT)
• Slough, Wexham Park Hospital (Declan Costello ENT)

Who to refer

BAPAM recommends that the following groups of patients presenting with voice problems should be referred to NHS Specialist Voice Clinics:

• Elite Performers (professional singers, actors, broadcasters, etc.)
• Studying Performers (FE, Undergraduate and Postgraduate singers and actors)
• Quality of Life Performers (amateur singers for whom singing is their primary means of socialising, such as older local choir members)

Examples of Relevant Presenting Voice Problems

• Loss of range, power, flexibility
• Pain, fatigue, hoarseness
• Gaps in range, delayed onset of phonation
• Increased recovery or warm-up time
• Chronic throat-clearing, sensation of lump in throat (globus).

Patient Outcomes

• Faster recovery times due to accurate diagnosis and specialist treatment, saving time and money in the long run
• If organic lesions are present the patient can be listed for surgery immediately or referred for Speech Therapy and then reviewed
• Functional disorders will be referred for Speech and Language Therapy and/or Vocal Rehabilitation
• Laryngologists and/or Speech and Language Therapists may suggest that vocal coaches can help with rehabilitation
• Musculoskeletal disorder will be referred for Osteopathy/Physiotherapy
• Psychogenic disorders will be referred to Speech and Language Therapy and onwards to Psychology/Talking therapies as appropriate
• Most patients will be referred to more than one of the above.

Vocal Coaches

A suitably experienced vocal coach is agreed by vocal health experts to be an important part of the rehabilitation team. This should be a highly specialist singing coach who works with patients as part of a clinical team within a Voice Clinic and/or has a significant relationship with a Voice Clinic and receives referrals from a clinician. A project run with BAPAM developed competencies which may be useful for referring clinicians.

Vocal coaches do not as yet, have a professional body and we recommend that Laryngologists and Speech and Language Therapists refer to a named coach and provide clinical oversight of the rehabilitation phase of the work.