Did you know that the Voice, Airway, & Swallowing Center at the University of Pittsburgh Medical Center evaluates and treats people who use their voice professionally? In the Eye & Ear Foundation’s January 27, 2025, webinar, “Professional Voice Management,” two laryngologists from the Center talked about the art of voice production, issues singers can have with their voice, and how they can be helped.
The Art of Voice Production
Chloe Santa Maria, MD, MPH, Assistant Professor in the Department of Otolaryngology-Head & Neck Surgery, began the presentation by explaining the mechanics of voice production:
- Generator
- Vibrator
- Resonator
- Articulator
All four of these are required for singing and speaking.
The generator is the power source, like the driver for our airflow (i.e. lungs, accessory thoracic muscles).
The vibrator refers to the vocal cords/folds, which vibrate hundreds of times per second. The way the vocal folds, or folds of tissue, interact with each other is fundamental to how our voice sounds.
The higher the pitch, the more vibrations will occur. “The only way that we get a nice clear sound is if the white layer, or vibratory layer, is working properly,” Dr. Santa Maria said. “It is absolutely the most important layer for the production of sound.” Interestingly, it is also the most common site for little benign lesions to develop. Unlike other tissues in the body, these don’t regenerate when injured. This area is very sensitive to injury and very difficult to repair.
When we talk, the vocal folds vibrate too fast for the human eye to detect. The Voice, Airway, & Swallowing Center uses high definition stroboscopy cameras to view this. A strobe light syncs into the pitch of the voice, creating a pseudo slow motion to bring it down so human eyes can detect the vibrating cycles very clearly. These cameras are not seen in most ENT offices but are paramount for high-definition views of the vocal folds. A lot of vocal fold lesions cannot be seen without this technology.
The resonator comprises all the structures in the vocal tract, from the bottom of the throat to the tip of the nose. These all affect clarity, color, and sound of the voice. This is why sound will be different if there is nasal congestion, a cold, or sinus infection.
The diaphragm functions in breathing: inhalation and exhalation. Upon inhalation, the diaphragm pulls down and the intercostal muscles move out and the lungs expand. With exhalation, the diaphragm relaxes, as do the intercostal muscles, and air is released through the trachea.
When people undergo singing or voice therapy exercises, they often work on bringing the focus of activation at the level of the chest to take the tension away from the throat.
The articulator is anything from the lips, teeth, tongue, buccal mucosa (inside parts of cheeks), or any part of those interacting that can change the articulation or crispness of a sound that is heard. The tongue is unique as it is a very large structure; its shape not only changes the articulation but also the shape of the vocal tract and resonance.
Basic Musical Terminology
Libby J. Smith, DO, FAOCO, Division Chief of Laryngology, Director of the Voice, Airway, & Swallowing Center and Professor in the Department of Otolaryngology-Head & Neck Surgery, described basic musical terminology.
Pitch – Frequency of a sound
Tone – Timbre of pitch
Note – Musical symbols given to a pitch that have a specific name and frequency
The higher the number of mucosal wave vibrations per second, the higher the pitch. “We think of voice as being generated from different areas,” Dr. Smith said. The lungs are always the power source, but you can almost feel it in different parts. You can hear the difference between a chest and head voice.
Tone is very important; it is the color and feel of the voice you are hearing. It can be described as warm, dark, rich, shrill, or any quality that gives it that color. It is a function of resonating cavities and how we have learned over time to produce our voice qualities. A video was played of a singer who has vocal fold lesions, which gives her color. This is a perfect example of how vocal bumps are not always bad and do not always need to be addressed. “We think of them as a vocal signature, which is part of your tone of voice,” Dr. Smith said. “If she had them taken off, she would not sound as amazing as she does.”
Voice Classification
When looking at vocal range (the notes one can sing), there is tessitura (where your voice feels most comfortable), and passagio, (the transfer of sound from the chest voice up to the head voice). Passagio is difficult for new singers to navigate as it takes a lot of training to make it nice and smooth without cracking in the middle.
These classifications are not based upon gender, but where a voice range sits on a piano keyboard: Typical female roles are soprano (C4-C6), mezzo-soprano (A3-A5), and alto (F3-F5). Typical male roles are tenor (C3-C5), baritone (A2-A4), and bass (E2-E4).
Stroboscopy is not performed during a dynamic voice evaluation. When it is turned on, bumps often pop out during the passaggio, which is helpful to diagnosticians.
Dr. Santa Maria’s Journey
“I think all of these things are nice when there’s a little bit of a personal investment and interest,” Dr. Santa Maria said as a preface to sharing her journey. For the last 10+ years, she knew she was going to go into laryngology. She has always been an enthusiastic singer. As a resident at Stanford, she sang a lot. Even though she was studying to be a laryngologist, her enthusiasm was often greater than her knowledge of vocal hygiene.
When she was a junior resident, Dr. Santa Maria had a bad upper respiratory tract illness with complete voice loss for approximately four months. She was acutely unwell for about a month and had complete voice loss for four months. It took a while to figure out what was going on. Ultimately, her attending at the time, a laryngologist, said she needed to be scoped due to the severity of her voice quality.
A stroboscopy revealed that she had paresis of the vocal folds and vocal fold polyps. “With some good voice therapy, lucky me, the polyps went away, and my voice quality was much better,” Dr. Santa Maria said. Sometimes there will be small lesions on the vocal folds that are important to achieve the sound a singer wants to make. Sometimes a bump will be problematic, and negatively affect the singing quality.
Ballet Analogy
Professional singers are vocal athletes, doing things with their voices that most people do not or cannot do. That places a lot of stress on the instrument, with more potential for lumps and bumps. If a singer is untrained and not singing in the most efficient way, they are more likely to get lumps and bumps.
A ballerina’s feet are the workhorse of the ballerina. They do not always look great without shoes on. The same is true for the vocal folds of professional singers. They may not look fantastic on a scope. “It’s more about what it’s doing for you and whether it’s working for you and is it making the noises that you want to make,” Dr. Santa Maria said.
Phonotrauma
Phonotrauma is when there are nodules, polyps (hemorrhagic vs translucent broad based), fibrous masses, cysts (squamous/ligamentous vs mucosal inclusion/subepithelial), reactive lesions, sulcus, or vocal fold hemorrhage/ectasia. The primary risk factor is vocal overuse and misuse. Histologically, there is inflammation and tissue damage within the vocal fold and remodeling occurring.
Vocal nodules are lesions that affect the epithelial or outermost layer of the vocal folds. The classic archetype is the young female cheer caption in all the musical clubs using her voice a lot. Patients will have air escaping when they are trying to make a sound, because the middle parts are touching but the anterior and posterior parts of the vocal folds are not, which presents as a breathy, weak voice. When they try to increase the pitch of their voice, their vocal folds will elongate and increase in tension,. This will cause the bumps to be more prominent and reduce vocal fold contact. This is a problem that is nearly completely treatable with voice therapy; it is very rare to need any kind of surgical intervention.
A different type of polyp is a hemorrhagic polyp, the result of a small blood vessel rupture, often referred to as a vocal accident. It is a little injury that causes a rapid change in the voice. It usually occurs in a setting such as yelling at a ball game or screaming for something, where a little sharp trigger with a high pressure behind it can cause the vessel rupture, with significant air escape on either side. People with this often have breathy dysphonia and may have a lot of secondary squeeze and muscle tension so they sound strained. Depending on the size, this may respond well to surgery. If it is very small, voice therapy can manage it.
Translucent polyps are a jelly-like edema tissue in the vibrating layer that produces an hourglass shape where it contracts in the middle and air escapes on either side. They respond well to voice therapy, or surgeries can be appropriate, depending on the size.
Vascular lesions are a myriad of things but can be like ectasias or varices. Ectasias and varices are dilated blood vessels on the surface of the vocal fold, whereas a frank hemorrhage is the result of acute bleeding into the vocal folds. This can make the vocal folds very stiff, and the voice is heavily affected. These lesions are typically not visible and can cause real problems if they are. Underlying scar formation and issues with vocal folds can result in potentially lifelong issues with your voice. This is one of the things you do not ever want to sing with. A varix or ectasis without a hemorrhage can happen with repeated voice use, but often does not change the voice quality. Because of the potential for bleeding or acute hemorrhage, sometimes people will prophylactically or preventatively try to remove with a little laser to reduce chances later.
Vocal Fold Pathology
Performers are more likely than the general public to have a vocal fold pathology, Dr. Smith said, with 60-65% of performers with dysphonia having some vocal pathology. There is a heightened worry about vocal lesions in performers, and different singers may be prone to different sorts of lesions.
The Voice, Airway, & Swallowing Center meets with local singing communities, as it is imperative that they get help when needed. If someone is identified as having a lesion and is worried about a bleed, or their voice acutely changes, call the Center and be seen that day. If the call is made late in the evening, the appointment will be the next morning. “This is our emergency area,” Dr. Smith said.
For singers, using their voice is their livelihood. They probably still speak more than they sing, but performing is a high intensity activity. Often vocal fold pathology is part of their vocal signature, what makes them sound the way they do, and why they potentially get the gigs instead of someone else. Turns out, in certain genres of music, vocal fold bumps are more prevalent, like in country music, folk, gospel, musical theatre, and jazz. On the contrary, classical and opera singers usually have pristine vocal folds, because that is what the music requires. Belting music, like in musical theatre, is always traumatic and is often the precursor to unwanted vocal fold bumps. Singers can be trained to sing in a healthier way.
When people come to the Voice, Airway, & Swallowing Center, they are asked about their range and training, and what genre they are in. Since gospel singers have a higher rate of vocal fold polyps, they may be exceptionally unhappy if they are removed. The Center works with patients on what they need. When singers come in, the only thing they want to know is if they have nodules, but what they really mean are bumps. Until they are told yes or no, they do not hear anything else, so the Center tries to alleviate that concern as fast as possible. If they have bumps, it becomes an opportunity for education. The bumps may not actually be new. “When these bumps prevent you from doing what you want or can do, then that’s something we need to take care of,” Dr. Smith said.
Often voice therapy is extremely helpful, because if you do not fix what got to the problem, then it does not matter what you do. If you have surgery that does not fix how it got there, then it will happen again.
Vocal Hygiene
Prevention is ideal but not everything. Efficient vocal use is key – do not give your voice more than what it needs. If you are always at 100%, that is too much. Talking over loud music or in smoky environments are not good.
Avoid misuse. Yelling is bad except in case of emergency.
Conserve your vocal dollars. Think about it this way – you have X amount of credit you can use to vocalize. Think about how you want to use it. If it is a performance day, maybe you do not do a lot of extra talking and save it for the performance. Often people will not realize that how they use their voice throughout the day takes away from their total bucket of voice use.
Hydration is absolutely critical. Your voice will work better if it is hydrated. If you pound coffee, sodas, and cappuccinos all day without hydrating, your voice gets desiccated. Several medications also have drying side effects.
Irritants should be avoided. Smoke and good vocal quality do not run hand in hand. Avoid caffeine, which dehydrates.
The Hoarse Performer
Taking care of a hoarse performer is a team sport, involving a laryngologist, speech language pathologist, and a singing voice specialist. The patient’s well-being is the first priority. Lots of questions are asked: What are the consequences to not performing? Is there an understudy? What is the role size? Touring? Cancelled performances/ financial/reputational consequences? Is this a potentially career ending pathology if they were to keep singing with it? Any singing modifications available?
In the end, Dr. Smith always tells her patients, “I’m your vocal fold advocate.” No one else is the vocal fold advocate; this is her job. She will provide the information, like, “You had that hemorrhage with the polyp. It is not smart to sing on that.” She works with the performer and sometimes, with their permission, the director.
Medical Therapy and Voice Therapy
Glucocorticoids – either a shot or oral – are prescribed to decrease any inflammation. Anti-acids and antihistamines may also be prescribed, but the sedating side effects are a concern. Avoid drowsy side effects as they will not help.
Voice rest, low impact/voiceless, and vocal fold vibrations are used as part of therapy. Surgery is the last resort and an option in extreme or severe cases. Recovery is long. Patients must be quiet for a week and are usually not allowed to sing for a whole month. It probably takes around three months until they can return. A lot of it is timing – when can they get off and when does the next gig start?
Upcoming Collaborations
Dr. Santa Maria has been the lead on collaborating with resident artists in the Pittsburgh Opera in the Vocal Injury Prevention (VIP) Program. The Center goes to them and provides a half day of education about vocal health and hygiene and down the line performs a full laryngeal exam (which they can have for themselves when they move on to the next tour or gig). The goal is to help them avoid injury so they can keep doing what they love as long as they want.
“It takes an entire village to raise a performer,” Dr. Smith said. “We are fortunate to have such a wonderful team.”
