Non-Surgical Musical Theatre

Course of Referral

This performer was referred by the stage manager to First Aid Station within the theme park (see description above).  First Aid Station placed the performer on vocal rest for a period of one week. She was referred by First Aid Station for an ENT evaluation. 

Case History

This case history is also a musical theater performer.  Her current work location is at a Major theme park.  Prior to the current performance location she toured throughout the United States with a musical theater show and then spent the last month of her contract performing in New York City.  She left New York City and relocated to her current stage on June 21, 1998 where she began performing the lead in a brand new stage production.  She recalls that her voice was “normal and serviceable” for her current performance role for approximately one month then, the voice became “raspy and deep.”  She reports losing her top octave and added some bottom notes and recalls having to push a great deal to produce any volume and variability in her voice.  As time went on and her performance demand increased, the problem became worse. 

In terms of vocal abuse, she clears her throat and coughs an excessive amount, she is a loud enthusiastic talker, with poor hydration and nutrition, and she does not get enough sleep and typically reports general body fatigue. 

Evaluation of her performance site revealed inadequate amplification used during performance, this was just in terms of the sound technicians as well as her vocal demand in her current role revealed a great deal of hyperfunction during vocal performance.  She has a hyperfunctional show voice, as well as a speaking voice.  Her social and emotional activites also create a great deal of tension in her life.

Initial Evaluation

Perceptual Impressions:  This singer had moderate-to-severe hoarse voice characterized by excessive strain in quiet and loud voicing, hard glottal attacks were present and the tendency to posture her body as if she was running out of air in a short phrase(three to four words).  A maximum phonation time (MPT) was averaged from three trials of sustaining the vowel /a/ and was seven seconds.

Videostroboscopic examination

The use of a topical numbing spray was used in order to view her vocal folds with the rigid scope due to a hyper gag reflex.

  • Vocal fold edge:  Moderately rough in both vocal folds.  Generalized in both vocal folds, more on the right vocal fold.  The mid-half of both vocal folds were gently swollen and produced hourglass closure.
  • Glottic Closure:  Hourglass
  • Phase Closure: Open phase predominates always.
  • Vertical level of Approximation: Equal
  • Amplitude: Moderately decreased in both vocal folds.
  • Mucosal Wave: Moderately decreased in both vocal folds
  • Vibratory behavior: Partial absence always in both vocal folds.
  • Phase symmetry: irregular
  • Periodicity: irregular
  • Hyperfunction: Present


After this evaluation, she was put on vocal rest for one week.  During this time she only performed “light duty” work that involved absolutely NO vocal demand.

She was involved in weekly check up and treatment sessions to continue with elimination of vocal abuse, good vocal hygiene and to develop a more theraputic speaking voice (See case one for full description).

Pharmacological therapy was used in this case; an anti-inflammatory was prescribed for a controlled amount of time.  The vocal use during this time was monitored and was extremely minimal.  The use of this one time only pharmacological treatment is occasionally used to speed up the process of decreasing swelling in the vocal folds.  The dosage is a six or twelve day treatment. 

Result of Intervention

After four weeks of this type of treatment a re-evaluation with videostroboscopy revealed a slight reduction in the generalized edema however, the vibratory behavior, amplitude and mucosal wave was still limited.  Another four weeks of modified voice rest and vocal rehabilitation was reccommended.  The next few weeks were focused on continuing to reduce the edema by vocal rest, relaxation and breathing techniques (see case 1).  She was stimulable for with all of these strategies and even more motivated to follow through so that she could quickly return to work.  During this time window she was asked to participate in a very important audition.  Although she was not fully ready (vocally) she was extremely motivated to take part in this audition and ultimately made the decision to go.  The audition was in New York City so it was necessary for her fly.  Counseling in air travel strategies for good nutirion, sleep and hydration were covered (see the section on travel).  

And the treatment sessions became an outlet for her to reherse her selections for the audition in a safe and controlled environment.  This also gave us the opportunity to implement the modifications strategies for healthier vocal performance that she would be using as she begins her return to work.  She began to gain great insight into the ease of vocal production and that she did not have to “power-up” her voice to make every performance effective.

In essence, this was a good change of event because she was beginning to loose interest in the treatment program and was less hopeful that she would ever recover.  Although ultimately she did not get casted for the new part, it however, gave her great confidence that she could have an effective performance voice once again.

Following two more weeks of light duty, her re-evalution with the oral scope revealed a siginficant reduction in edema of the vocal folds with no observed hyperfunction thoughout the entire examination.  Her voice quality was beginning to return back to normal, with only a slightly breathy voice and no vocal strain or hard attacks.

Surgical Treatment

Surgery was not recommended for her due to the effectiveness of the voice therapy program.

Return to Work

Again, like the other case studies the return to work was gradual.  She began one show a day for the first three days and then was comfortable taking on two shows a day.  She performed two show per day for the remainder of the week and into the next three days of the next week.  Her re-evaluation with videostroboscopy did not reveal any adverse reactions or negative changes in vibratory behavior.  She began work the next week by performing three shows per day and then increased to four the week after.  She is currently in good vocal health, sill performing in the original show and has not experienced an exagerated period of a vocal breakdown.