Street Theater Performer

This case study focuses on a singer/actor who is a street theater performer in a major theme park.  Street theater is a unique setting where the performance site is outside with no covering or barrier walls.  The performers are required to sing and project dialogue with no amplification and typically perform 5 – 9 (30 minute) shows daily.  

Course of Referral

The referral course of this performer to our clinic was by report from the stage manager to the theme park’s First Aid station, an association that was formed by the theme park to protect the performer from injuring themselves and/or refer the performer for evaluation and treatment.  The personnel at First Aid placed the performer on vocal rest for one week.  Following persistence of voice loss, the performer was referred for an evaluation by an ENT. 

Case History

This performer was a 26-year-old female.  She reported a successful history of ten years in street theater within the theme park atmosphere.  She had formal coaching in musical theater and majored in the theater department during her undergraduate schooling in college.  Past medical history was unremarkable. Her schooling included studies in musical theory, music performance and theater training. 

During her interview by the speech language pathologist at the ENT’s medical office, she offered more information about her vocal disturbance and voice condition.  From the interview, we learned that she was unaware of the proper voicing and respiratory strategies used in performance for projecting and maintaining a “good” voice.  She stated,  “I have learned about diaphragmatic support and placement of the head voice from my vocal coaches.”  Our interpretation of the patient’s knowledge of voice production was that it was adequate, but not focused on the physiological mechanisms that are necessary for developing proper breath support, i.e. (subglottal air pressure) for her specific performance style.  The performer was motivated to engage in a therapeutic process that would be focused on remediating her current condition as well as teach her proper mechanisms for generating vocal power as well as eliminating poor vocal techniques developed over the years. 

Time Line

She reported a normal voice until October, 1998.  She experienced one incident of a vocal disturbance occurring in September, 1998 where she reported screaming for about ten minutes at which time she “thinks” strained her voice.  Although she experienced some acute voice difficulties following this incident, she did not perceive any longstanding voice problems.  She continued with her daily activities and performance following this event.  

Early the next year in January of 1999 she recalled a particular performance where she was not warmed up, had “no real support” during loud vocalization, and “pushed through her throat” to perform. During one of nine performances that day she stated that it “felt like a muscle was pulled in my neck”.  She was able to complete all nine shows but experienced a vocal breakdown characterized by periods of complete voice loss and excessive vocal strain.  You may recall similarities between this singer and some you have worked with in your own voice studio.  

She also indicated that at the same time her voice started to “deteriorate.”  She was dealing with severe emotional stress from caring for a family member who was extremely ill.  She stated that she had extensive periods of crying and high amounts of perceived muscle tension in her throat during these crying episodes.  This situation was compounded by an unusual work schedule, which included performing ten days without a day off.


The voice evaluation included an interview as described above, assessment of performance site and demand, videolaryngostroboscopy, perceptual assessment of vocal quality, and acoustic recording and analysis of the voice signal (the acoustic analysis will not be reported, however its data collection is often a standard part of the evaluation protocol).  

Perceptual Impressions

Initial office visit: Perceptually, her speaking voice was characterized as a moderately breathy voice, that was slightly strained with frequent glottal fry (“low pitch gravel sound”) throughout a five-word phrase.  There were frequent episodes of hard glottal attacks (“punching the sounds out when talking”) at the onset of voicing.  Vocal pitch was perceived to be within normal limits and vocal loudness was perceived as excessive.  Occasional voice breaks were observed during conversation, that appeared to be related to the high amount of vocal strain.  Extrinsic laryngeal muscle tension was determined to be moderate based on palpation of the neck muscles.  She reported mild soreness with palpation of the lower neck region (hyoid and mid-thyroid area).  

A maximum phonation time, which is the ability to hold a tone for as long as possible, of twelve seconds was measured during a sustained production of the vowel [a].  Evaluation of her singing voice revealed the highest pitch easily sung was E above middle C and the lowest was C below middle C with a 17 semitone (limited) range; pitch control during this task was fair.

Videolaryngostroboscopy Results Prior to Intervention

She was not able to tolerate the oral endoscopic exam so a topical anesthesia (Ponticaine) was sprayed in the back of the throat, enabling a complete view of the vocal folds to be seen. 

There are specific observations that are made when doing a videolaryngoscopic examination, the following were found for this performer.

  • Vocal Fold Edge: In a normal examination the vocal fold edge is seen as straight.  For this performer, a wide-based polyp on the left true vocal fold was identified at the junction of the anterior one-third and the posterior two-thirds of the vocal fold with moderate vascularity.  On the opposite vocal fold a moderate degree of swelling with a small nodular (soft like blister) formation was observed. This formation appeared to be due to irritation from the left vocal fold pathology.
  • Glottic Closure: In a normal examination glottal closure should be complete.  For this performer, glottal closure was an hourglass formation, meaning that a gap existed in the anterior and posterior glottis.
  • Phase Closure: In a normal examination, the phases of vibration are approximately 50% open and 50% close. For this performer, open phase predominated. 
  • Vertical Level: In a normal examination, the vertical level of the superior and inferior portion of the vocal folds should be equal in height.  For this performer vertical level was judged to be equal.
  • Amplitude: In the normal examination, vibratory amplitude correlates to the degree of driving pressure.  For this performer vibratory amplitude was moderately decreased in both vocal folds, slightly more on the left vocal fold.
  • Mucosal Wave: The mucosal wave of the vocal folds is a function of the multiple layers that exist. Specifically, it relates to the movement of the epithelium (most superior layer) relative to the body (the muscle mass of the vocal fold). For this performer, the mucosal wave was moderately decreased in both vocal folds, more on the left.
  • Vibratory Behavior: This characteristic relates to how well the tissues vibrate during voicing.  For this performer, vibratory behavior was partially absent for the right and left, with what appeared to be greater reductions in vibration on the left side. 
  • Phase symmetry: In a normal examination the vocal folds should move symmetrically as they open and close ( the right side should be a mirror image of the left side) For this performer, the phase symmetry was characterized as mostly irregular.
  • Hyperfunction: In a normal examination the accessory structures (false vocal folds, epiglottis) should not participate in assisting with voice production.  For this performer hyperfunction was present characterized by squeezing of the larynx from front to back and false vocal folds moving to midline to assist with glottal closure. 


Treatment for her involved a behavioral approach, which focused initially on modifying maladaptive behaviors associated with her performance and lifestyle. The general strategies at the onset of the behavioral program included identifying and eliminating any form of vocal abuse, initiating a modified voice rest program (no more than 10-15 minutes of talking per day for approximately one week), and light duty at work which meant her performance duties were stopped and she worked in a job that did not require any voicing (filing).

Most individuals are taken out of their performance role when vocal dysfunction arises however, complete voice rest was not recommended due to the nature of this performer’s personality, performance demand etc.  The likelihood of her going back to her performance demand and producing the same abusive behaviors was high without modifications in place and strategies to reduce abusive and strained vocal behavior in the performance.

Within the first therapy session the concept of the therapeutic voice was introduced which was characterized by soft voice (low impact), relaxed voice production (without strain) and use of a breathy voice.  This technique is very similar to one that you may already be using in voice studio as well as the regimin set forth in the “confidential voice” therapy program discussed by Colton & Casper, 19 ?. 

In this program, the concept of a relaxed voice production is described.  For example you might start the program by explaining how to produce voice with a open relaxed throat using the breath stream to initiate and carry the tone, (Clinician: “Begin by taking a big breath in and filling the lungs, then exhale (“feel like your sighing relief”).  Now try that again.  This time as you exhale add soft voice during the sigh.  Once you are feeling comfortable with this open throat, relaxed voicing, begin the same task and as you exhale, count the numbers 1 through 5 aloud during exhalation, making each number sound quite, relaxed and breathy.”  This exercise attempts to reduce over closure of the vocal folds and reduces the collision force during vocal fold closure.  The main goal is to preserve the normal mechanical properties of the vocal folds, prevent more damage to the vocal fold, particularly to the medial edge, as well as restore the vibratory characteristics of the damaged area. 

For modifications of maladaptive behaviors and lifestyle some recommendations were made. These included: providing information to her about hydration, nutrition, sleep and anxiety.

Complete restoration of fluid balance after exercise is an important part of the recovery process for performers in general.  With that said, consider the condition of this particular “high risk performer.” As a street theatre performer she sung in an outside environment that ranged on average from 70-90+ degrees and high humidity.  The recovery process for this type of performance requires  rehydration not only with water, but also electrolyte replacement.  With this performer, water intake was recommended to be approximately 8-10 8 oz glasses of water per day. 

Following the recommendation regarding hydration a general overview of her nutrition was reviewed in order to identify any potential contributions to vocal fold irritation or diminished drive.  Discussion occurred with her about her overall general body health and its relationship to the health of her larynx (see section on Effects of Diet and Nutrition for the Voice).   

Additionally, external sources of stress/tension that may be contributing to the voice problem were discussed with the her.  For this performer, this included discussing performance demand, her financial reliance on her job, and her coping strategies in dealing with her ill family member, her difficulties with sleeping and her motivation for participating in the voice therapy program. Her awareness of these factors was noted to be elevated based on her compliance with recommendations for change as well as her observed ability to learn how to monitor her vocally abusive behaviors. 

In order to relax the laryngeal musculature and reduce laryngeal height and stiffness, the circumlaryngeal massage techniques were employed (Roy, 1998).  You may already be implementing something similar with your studio students.  This procedure is similar to the use of massage used on other parts of the body and is geared at reducing muscle tension and maximizing the movement of the larynx. 

In order to facilitate a lower laryngeal position, an open mouth posture was demonstrated during voicing whenever possible (Iwarsson & Sundberg, 1998).  This also took advantage of facilitating a full oral resonance.  This is done by again taking in a large breath (inhale), filling the lungs and then, during exhalation, loosening and lowering the jaw so that there is no tension pulling up (as in keeping the lips closed) or pulling down (like opening the mouth too wide).  Some visual pointers for you to consider is to think of the blank face a child may form when they are bored or tired  (the “duh” look) or visualize seeing a skeleton hanging in your fifth grade science classroom and the jaw is just dangling down.  This is the most relaxed position, where the muscles are not contracted both in the neck, face, and laryngeal region. 

Although we were unable to measure her lung volume levels used to initiate and produce voice it has been demonstrated that taking an adequate breath prior to initiating voice production forces you to breathe to higher lung volumes, assisting in lowering the position of the larynx  (Iwarsson & Sundberg, 1998). This technique is similar to Boone and McFarlane’s (1994) yawn sigh technique that concentrated on the inspiratory and expiratory phases of the breathing cycle and slow and controlled expirations that corresponded with the onset of voice production. 

Another behavioral technique that was incorporated into this program was use of a forward tone focus. Performers spend many hours in rehearsal perfecting the show voice and placing it properly, however when the rehearsal or performance is over, a forward focus tends to fall to the back of the throat, the breathing techniques become more lax and little attention is paid to the amount of vocal use. Forward placement of the voice is focused on relaxing the tongue musculature, using nasal resonance to “move” the tone to the upper vocal tract rather than the lower vocal tract and paying close attention to the relationship between what is being produced and what is being heard.  Therapy is focused on tuning the patient into the voice quality that is being produced, contrasting the forward focus production to the back focus production, where there is a great degree of tongue tension.  Back focus has been described as if the voice were deep in the throat and focused on the anatomical site of the problem (Boone & McFarlane, 1994).

This exercise may be easiest to practice with nasal sounds such as m,n,ng with vowel prolongations.  Further explanation and an example of these exercises can be found in the section called Focus of Therapy.  

Results of Therapy

The performer was considered compliant with therapy, in that she attended all sessions regularly.  After seven weeks of voice therapy the vocal folds were re-examined with the oral endoscope.  Review of the videostroboscopic examination revealed improvement in the movement of the right vocal fold, increased mucosal wave on the left side and a decrease in the overall edema and vascularity of both vocal folds.  Unfortunately, tissue changes on the left side still persisted.  Surgery was recommended.  

Surgical Procedure and Result

The patient was brought to the operating room and put under general anesthesia brought about by oral endotracheal intubation.  Bilateral vocal fold polyps were noted at the junction of the anterior and middle thirds of the vocal folds. The polypoid change was more pronounced on the right side.  An apparatus with an operating microscope was used to magnify the vocal folds and both polyps were removed. The left vocal fold was characterized by more generalized and diffuse thickening of the mucosa along its entire length in comparison to the right. There were no intraoperative complications. 

Perceptual Impressions of Voice following Surgery

Recall, that the perceptual impressions during the initial evaluation characterized the performer’s voice as a moderately breathy, slightly strained voice with glottal fry and frequent episodes of hard glottal attacks. There were occasional voice breaks and a vocal loudness perceived as excessive.  Post-treatment, perceptual impressions of the performer’s voice were characterized as a voice without a breathy quality, no longer any strained voice production, infrequent glottal fry, and no observed  episodes of hard glottal attacks or voice breaks.  The vocal loudness was adequate.

A maximum phonation time of 23 seconds was measured during sustained vowel production of [a]. Evaluation of the singing voice revealed the highest note sung without strain was A one octave above middle C and the lowest was G, one octave below middle C with a 27 semitone range, which is considered to be wider and more normal range for this singer. 

Videolaryngostroboscopy Following Surgery

  • Vocal Fold Edge: Smooth bilaterally; free of laryngeal lesion and no edema present
  • Glottic closure:  Complete
  • Phase Closure: Normal
  • Vertical Level: Equal
  • Amplitude: Normal
  • Mucosal Wave: Normal
  • Vibratory Behavior: Fully present
  • Phase Symmetry: Normal 
  • Hyperfunction: Not present

Behavioral Voice Therapy Post Surgery

After the pathology was surgically removed and the vocal fold structure and function were observed to be returning back to normal, the therapy focused on retraining, strengthening and balancing the three systems responsible for voice production and quality.  These three systems are: 1. Respiration, 2. Phonation, and 3. Resonance.  Principles of vocal exercise physiology as well as breathing physiology were used to help the patient maintain an optimum vocal performance. The patient was taught to understand that the muscles in the respiratory and laryngeal system can be trained similarly to the way athletes train the muscles that govern movement during a particular type of athletic task.   An analogy that we often used is that “A runner would not enter in a track meet without proper training in endurance, strength, flexibility and muscle toning”, neither should a singer return to a high performance work demand without considering these same physical training principles.  

We consider singers and actors (or any professional voice user) as “vocal athletes” with the premise that working with respiratory and vocal exercise addresses the issues of strength, flexibility and endurance as they apply to the voice.  The application of the therapy that we did with this performer involved training the laryngeal muscles and avoiding the misuse of the larynx.  A secondary effect of this method was to train the proper mechanics of breathing in order to utilize the natural forces of the respiratory system to facilitate voice production.  This provided her with the ability of producing her voice in an efficient, low-risk manner for meeting her performance and lifestyle demand.


The performance schedule for this patient included a return to work on a gradual basis.  It is important to note that although her vocal pathology was eliminated and her vocal function restored, the training strategies needed to be learned and maintained prior to returning to the performance environment.  The patient also engaged in practicing these strategies in order to build a certain level of endurance.  This was a critical step that gave her a confidence that she would not harm the vocal mechanism again. In our opinion, it is most helpful for your student to work through current performance material prior to the return to work.  The voice therapist and/or the singing specialist will be helpful in this process.

This performer understood that vocal warm-ups and cool-downs were mandatory prior to and following a performance.  It is important to note again, that vocal these exercises were tailored to fit the performer’s individual need. 

Return to Work

Because of financial constraints, this patient was eager to return to work as early as possible. Her gradual return to work after six weeks post-surgery was the following:

She completed one show per day in a five-day work week incorporating vocal modification strategies and carrying out various laryngeal-strengthening exercises to increase vocal endurance throughout this week.  She was seen in the clinic three times during this first week for a re-evaluation and voice therapy.  

The results of the videostroboscopic evaluation, performed after her first day back to work, revealed straight vocal fold edges, slight edema bilaterally and slight limitations in vibratory amplitude. Slight vocal strain was present as would be expected.  She continued incorporating her therapy strategies outside of the clinic. For the second and third week, she completed two shows per day for the first five days and three shows for the remainder.  She reported that she did not experience any straining or overcompensation to produce voicing for her performance and was feeling stronger and more confident with her voice production both on and off the stage.  Results of videostroboscopy after week three revealed a good closed phase and intact vibratory function.  At week four the patient began feeling comfortable with her performance and was able to incorporate modification strategies (such as …) to meet the demand of her performance schedule.  At this point, upon re-evaluation, the vocal fold structure and function was deemed to within normal limits.  The vocal fold edges were straight with an absence of the edema.   

It was recommended that she be able to return the next week to produce four-five shows per day. Intervention continued throughout this time period, on a fairly regular basis, two times per week. As she moved into her regular work schedule, therapy focused on maintaining the training strategies outlined above with her actual script.