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A 23 year old female singer, well-known to the practice, presented with new onset of vocal symptoms. She noted that things had been going well since her last screening visit, which did not demonstrate any abnormalities. However, over the past month she had been having increasing vocal difficulty. She noted pain when she tried to sing, rapid onset of vocal fatigue while singing, and decreased vocal range. She stated her voice would crack and break when she tried to reach notes that were normally comfortable for her.
She denied any precipitating factors and noted no change in her general health since the onset of symptoms.
Videostroboscopy was performed and is as follows:
Stroboscopy appeared normal and comparable to prior strobe exams. However, this patient has been evaluated here before and immediately upon performing the scope, it was apparent that something had changed. Her tongue tension was palpable, although not grossly visible on the scope. She had a stronger gag reflex and had a more difficult time being scoped, requiring several attempts.
It was at this point that I realized her voice was being affected by something outside the instrument itself. I knew this patient well enough to recognize the difference in her comfort with the exam.
I asked her again what had been happening since she noted onset of symptoms and she finally came forward with the full story. She had just gotten out of an abusive relationship. She had not attributed her voice symptoms to this because she did not think that the emotional stress of this could impact her voice in such an audible way. She had assumed the vocal fatigue was due to this, as she was not sleeping, but could not imagine her decreased range, voice cracking, and pain were stress-related.
I advised she take some time off performing while she worked with a few available resources. At this time her symptoms have not completely resolved but she is aware of the source of her problem and has improved. She struggles still when working with my vocal therapist, as the hands-on approach is not readily feasible due to her past. However, through alternative techniques, the most severe symptoms have been ameliorated.
This case ably demonstrates the incredibly profound impact that emotions and trauma may have on the voice. Audible changes, including cracking and breaks in the voice, may be completely unrelated to the vocal folds themselves. This occurs with all types of stressors, including death or illness in the family, job loss, starting a new school, signing with a label, etc.
Aside from recognizing this, what helped in this case was having an established relationship with this patient. Recognizing that something as subtle as a stronger gag reflex was abnormal for her, and being comfortable talking about serious issues, allowed accurate diagnosis and implementation of a treatment plan.
To learn more about Dr. Reena Gupta or proper voice evaluation, please visit www.voicedoctorla.com.
