Treating Professional Voice in the Community
Objective findings need to be weighed alongside the singer’s lived experience so that expectations are realistic and responsibility is shared.
Mark R. Gilbert, MD, on behalf of the Laryngology and Bronchoesophagology Education Committee
Mark R. Gilbert, MD
What is your singing background, training, and style? How does someone who sings this genre differ from someone who sings other genres?
Sarah Quintana, CCC-SLP
Singing styles differ in jazz and contemporary commercial music (CCM), as do our sound environments. I think the most challenging aspect of being a gigging musician in New Orleans and touring the festival circuit is the variability in sound environments and technicians. Jazz is diplomatic music with a culture of listening to each player. It is very challenging to hear each other and one’s own voice in most venues in New Orleans.
Alex Schenck, CCC-SLP
One major distinction between opera and CCM is amplification. Opera singers perform unamplified, often over a full orchestra, requiring efficient vocal projection and stamina. Classical singing has a long and highly codified pedagogical tradition. Training is intensive and individualized, typically involving a primary voice teacher, collaborative pianists, and language coaches. Voice types are categorized—often through the Fach system—based on range, tessitura (where the voice most comfortably sits), timbre (tone color), and vocal weight (heft and carrying power). These classifications influence repertoire and career trajectory.
In contrast, CCM historically placed less emphasis on rigid categorization, though training in this area continues to evolve with growing interest in evidence-informed approaches and genre-specific aesthetics.
Did you ever see an otolaryngologist prior to becoming an SLP? Was it a voice specialist? What was your experience? Did you undergo stroboscopy? Did you feel they understood your needs? Are there questions you wished they had asked?
SQ: Yes, once. I had been touring internationally and saw an otolaryngologist in France. They put me on reflux medication and steroids. I had never seen an otolaryngologist other than that one time, even though I had been performing for a decade. Most working musicians do not know what a clinical voice care team is. My first laryngeal videostroboscopy exam was as a fellow at the Ochsner Voice Center in New Orleans.
AS: Yes. During my college training and early professional career, I saw approximately 10 otolaryngologists (most of whom were voice specialists) and three SLPs. I underwent stroboscopy at several visits. I was not referred to an SLP until after my fifth otolaryngology consultation, and in retrospect, that referral would have been helpful sooner. I saw only one SLP in an interdisciplinary setting alongside my 10th otolaryngologist, but that joint visit and subsequent therapy were the most influential in my care.
I benefited from prior providers, but the interdisciplinary model addressed my needs more comprehensively. Given the vocal demands I was under at the time, I needed not only information about my laryngeal findings but also education on phonotrauma, strategies for self-monitoring and managing vocal load, and evidence-based therapeutic techniques to meet performance demands. I received that support through interdisciplinary care and subsequent voice therapy.
While singers experience a wide range of voice disorders, I reference phonotrauma here and in subsequent answers because of its prevalence in high-demand professional singing and the unique management challenges it presents.
Some of the earlier visits felt perfunctory. I do not recall specific missed questions, but the broader impact on my training, finances, and professional identity was not always explored. For singers, voice concerns are rarely just physical; they are vocational and deeply tied to identity. Understanding that broader context is something I try to bring to my practice.
What do you think otolaryngologists who do not specialize in voice need to know about the needs of a singer? Are there particular requirements for a professional singer?
SQ: Most ENT specialists think that voice is niche, boutique, or "Lagniappe," as we say in Louisiana. Working musicians in my state perform for their livelihoods, keep our oral traditions and languages alive, and support our cultural tourism economy. Voices of Louisiana are important to the rich history of jazz and rock and roll—Lead Belly, Mahalia Jackson, Fats Domino, Louis Armstrong, and the list goes on. Could you imagine what Louis Armstrong’s laryngeal videostroboscopy exam might have looked like? There has been an enormous output of music from Louisiana, but also a huge gap in healthcare.
AS: Professional singers function much like elite athletes. Given the intensity and frequency of their vocal demands, some degree of phonotrauma over the course of a career is not uncommon. That does not make it insignificant, but for a professional singer, effective management often focuses on load regulation and sustainability rather than on the complete avoidance of vocal strain.
What may be less apparent is the level of external pressure singers operate under. The field is highly competitive, and declining work due to vocal health concerns can feel professionally risky. As a result, singers may continue performing despite symptoms. Recommendations such as voice rest or workload reduction may be medically appropriate, but they carry financial and career implications. I have occasionally heard colleagues express frustration when singers do not appear to follow recommendations to reduce vocal load, interpreting that as a lack of commitment to recovery.
While singers may need meaningful adjustments to protect their vocal health, clinicians should recognize the professional pressures influencing those decisions. Load modification is rarely a straightforward choice. Ongoing counseling, repetition of recommendations, and collaborative problem-solving are often necessary to help singers find a sustainable balance.
What do you think the general otolaryngologist does not know about professional singers that they should?
SQ: They should connect with their state-based laryngology teams, consider partnering with a community-based SLP who can strobe and has voice experience, and know when to refer to laryngology. At a minimum, singers with complaints need a laryngeal videostroboscopy exam.
AS: Prolonged, complete voice rest or extreme load reduction is not always ideal if it can be safely avoided. While short-term relative rest or vocal budgeting often has a role, extended inactivity may lead to deconditioning, similar to what is observed in other neuromuscular systems. Professional singing requires sustained coordination, efficiency, and endurance, and loss of conditioning can make returning to prior performance levels challenging.
For that reason, vocal budgeting is often preferable to complete silence when medically appropriate. Collaboration with a voice-specialized SLP can promote tissue recovery while maintaining coordination and efficient vocal patterns.
As a personal example, I had prenodular edema for much of my singing career and was still able to meet high vocal demands, albeit with some difficulty. When I stopped singing professionally, the edema resolved, but my singing quality and stamina declined due to loss of conditioning. That experience reinforced the idea that tissue appearance and functional capacity are not always directly correlated, and that both recovery and ongoing conditioning are central to the care of professional voice users.
As SLPs who treat singers, what insight from your background allows you to better treat singers? Is it easier to make connections with them?
SQ: I rely a great deal on my performance background, my singing voice training, and my musical ear to meet that need. I can accompany my singers on piano or guitar and guide them through technical exercises or songs. They can continue with their voice teachers once their voices are rehabilitated. It's a lot of fun to work with singing teachers and singers. I have performed and still sing at most of the places where my patients work. It is very rewarding to serve my community as a voice SLP and to provide access to much-needed otolaryngology resources and laryngology networking in Louisiana.
AS: In part, I became an SLP because I wanted a better understanding of my own vocal challenges. Having navigated a professional singing career myself, I understand the difficulty of setting boundaries around voice use. I experienced negative reactions from directors and management when I marked (did not sing full voice) in rehearsals, and may have lost later opportunities as a result. Accepting those reactions to protect recovery time was difficult but necessary.
That experience informs how I counsel singers, and shared experience can make those conversations easier. Hearing guidance about load management and long-term sustainability from someone who has faced similar decisions can make it feel more achievable and less abstract.
What misconceptions might singers feel about otolaryngologists and/or SLPs? How have you been able to address those issues?
SQ: Everyone is afraid of doctors and big bills. We provide reassurance and resources. Among singers, it is very taboo to have a voice disorder, and people tend to feel ashamed. The first thing to do is normalize not singing perfectly all the time. The more you get to know your instrument, the more you understand what you need to sing your best.
We offer free in-services, have worked with MusiCares and the Grammy Foundation to get singers’ exams covered, partner with voice care teams across the state to ensure our singers have access to care, and invite our local undergraduate opera students to the clinic for baseline laryngeal videostroboscopy exams. There is a lot to do.
AS: One misconception I occasionally see is that singers assume otolaryngologists and SLPs can give definitive answers about readiness to perform following a vocal injury. We can provide essential information about tissue health and vibratory function and identify clear contraindications to performance, such as vocal hemorrhage. Determining readiness to perform, however, involves more than laryngeal appearance alone.
There are situations where stroboscopic findings improve and a singer is medically cleared, yet the singer does not feel their instrument is fully reliable. The reverse also occurs. A singer may report meaningful functional improvement while exam findings appear relatively unchanged. Thus, while stroboscopy is invaluable, professional-level singers also possess a highly developed insight into their voice, so conversation around both exam findings and personal experience is most effective.
In counseling, I emphasize that medical findings provide essential guardrails, but readiness to perform is a shared decision-making process. We weigh objective findings alongside the singer’s lived experience so that expectations are realistic and responsibility is shared rather than assumed to be solely medical.
Are there persistent myths in the professional singing population that you routinely must address?
SQ: There are a lot of myths about coffee, reflux, remedies, etc. I saw a wonderful presentation on this that Michael Johns, MD, and Edie Hapner, PhD, CCC-SLP, prepared for the Vanderbilt Professional Voice Conference in 2023. I would never tell someone not to drink coffee.
AS: One of the most persistent and harmful myths is that developing a voice disorder, such as vocal fold nodules, necessarily reflects poor technique. That belief can create significant shame.
While inefficient technique can contribute, voice disorders of phonotraumatic etiology are often better understood as a mismatch between vocal demand and tissue capacity. Even technically skilled singers can exceed physiologic limits during intense periods of rehearsal, performance, travel, or illness.
Many singers do not openly share when they experience a vocal injury, which creates the perception that they are rare and reflect individual failure rather than occupational risk. I routinely address this when counseling singers with phonotraumatic lesions. Reframing the issue around load management and vocal efficiency helps remove blame and supports sustainable change.
Is there anything else you would like to add or anything we didn’t discuss?
AS: Singers often seek multiple opinions, particularly when they travel for training or performance. I have worked with singers who report confusion after hearing a range of diagnostic terminology from prior providers, and I can relate to that experience.
Within a two-year period, I received the following diagnoses from different otolaryngologists:
- Vocal fold nodules
- “The most pristine vocal folds I’ve seen in a while”
- Laryngopharyngeal reflux disease (LPRD)
- Prenodular swelling
- A left vocal fold cyst with a contralateral reactive lesion
- Pseudocysts
- A left vocal fold paresis
Some variability likely reflected evolving findings and interpretive differences. But, for me, the experience of conflicting diagnoses was disorienting.
From a clinician’s perspective, distinctions such as nodules, prenodular swelling, and mid-membranous edema may represent differences in presentation or clinical interpretation. In some cases, terminology also stems from differing communication approaches. Some providers avoid the term “nodules” because of its emotional impact, while others prefer precise labeling to support informed decision-making.
Providers should be aware that singers may have been given different diagnostic labels in prior evaluations, and proactively addressing that variability can reduce confusion and build trust. Greater consistency in terminology would be beneficial. More importantly, singers need more than a diagnostic label—they need clear education about what that label means, how it fits within a spectrum of phonotraumatic change, and what actionable steps can support recovery and sustainability. Contextualizing the diagnosis may ultimately matter more than the specific term itself.
