Musical Theater Performer

This case study focuses on a Musical theater performer, her job location is in a theme park environment.  She performed the leading role in one of the most popular stage productions at this venue.  Her role was extremely demanding. As well, she engaged in social and other occupational activities that occur outside of her regular employment that were equally demanding of the voice.

Course of Referral

She was sent to the theme parks First Aid Station and placed on vocal rest for two weeks.  Re-evaluation at the First Aid Station following this period of vocal rest revealed persistent symptoms of “acute laryngitis,” a referral to an ENT for further evaluation was initiated.

Case History

This thirty year old female performer reported that in the past ten years she has performed in various stage productions of popular musical theater shows. Also, she has done voice-over work for radio advertisements as well as televised commercials. She has traveled with several touring companies and reports a normal and serviceable voice that ensured successful runs of all of her stage productions.  At the time of evaluation, she reported severe pain in throat area, loss of voice and unable to work in her current job location.  Her past medical history is unremarkable.  She currently takes Serzone, 100 mg daily for depression.  She is on no other medications.  She has no known drug allergies.  She denies a history of inhalant allergies.  Family history is remarkable for hypertension.  Social history is remarkable for cigarette smoking, consumes alcohol moderately (approximately three to four nights per week) and drinks caffeine regularly.


She came to our office for consultation regarding symptoms of hoarseness, which have been effecting her performing ability over the last month or more.  She has been working the theme park throughout the duration of these symptoms singing an alto part in a popular show.  She began rehearsals for the role in early March of 1998 and performances started in April.  Her vocal problems began about the time performances started.  She has been singing four shows per day.  She states she lost her voice for about a day one month ago and again this last Friday.  Her voice was normal and serviceable prior to this time.  

She indicated that she is having some difficulty losing breath control, obtaining her highs, and maintaining volume without strain.  She also stated that this style of voicing that she uses is difficult for her to sing.  Although she is a singing in her comfortable range and is amplified much of the time, the “gospel” belting style makes it necessary for her to strain.  So, this certainly is a part of the vocal abuse.  She also has excessive amounts of talking, excited strained talking and hard glottal attacks. She indicated that she has not been on any extended period of vocal rest, but has been resting her voice now since Friday.  Her period of voice rest has consisted of no singing.  She has continued to talk regularly throughout this time.  She states that her voice has not been normal through the last month.  There is a harsh sound to her speaking voice.  Her singing voice fatigues and she develops discomfort in the throat area with singing.  Problems become greater through the course of the week at work, and she begins having problems with her vocal range after two of three days of singing.  She recalls that she has not had any prior problems with hoarseness.  She is not aware of any nasal congestion, paranasal pressure, or allergy symptoms currently.  Her only other complaint has been episodes of choking and coughing which occur in the middle of the night.  She is not aware of any indigestion or heartburn.  

She took Prilosec for stomach acid reduction immediately following her medical evaluation and reported an improvement right away.


Perceptual Impressions

Conversational voicing was observed during he interview.  The following observations were made in regard to frequency and severity of vocal characteristics: a moderately breathy voice with slight strained pressed episodes during conversation, frequent glottal attacks; pitch and loudness level was adequate.  Sustained vowel /a/ was observed for ten seconds the voice quality was breathy.  Her singing evaluation revealed the highest sung tone was E above middle C and the lowest was B two below middle C with an 18 semitone range however she is able to “power her way up” past E.  Any preliminary remediation techniques resulted in extreme hyperfunction.

Initial Office Visit

A mirror examination was performed by the ENT.  This exam revealed mild edematous vocal folds in the mid-membranous area bilaterally.  There were no discrete nodule or polyp formations noted.  To further document these findings she was referred for a complete voice evaluation with videolaryngostroboscopy.

Results of Videostroboscopic Examination:

  • Vocal fold edge: Prenodular swelling in both vocal folds at the junction of the anterior one-third and the posterior two thirds.  
  • Glottic closure: Glottic closure was judged to be a hourglass configuration.
  • Phase closure: Open phase predominated.
  • Vertical level of approximation: Equal 
  • Vibratory amplitude: Vibratory amplitude was judged to be moderately decreased in both vocal folds.
  • Mucusal wave: Mucosal wave was judged to be moderately decreased in both vocal fold
  • Vibratory behavior: Vibratory behavior was partially absent in both vocal folds
  • Phase symmetry: Regular
  • Hyperfunction: Absent

Vocal activity

This performer stated that her vocal activity does not even “nearly” end when work is over.  She reports an active social life where she is typically the “leader” in her social group.  Social gatherings are typically centered around a bar/nightclub environment.  She states that she is active socially approximately four to five nights per week.  In addition, she is performing three nights a week in a lounge setting.  The repitua is a jazz, blues, soul style of music.  Her voice is an extremely “high energy, gospel, beling” type of voice, this matches her personality.

Reported Symptoms

Her reported vocal symptoms at the onset of this evaluation was a loss of vocal range, a hoarse and breathy voice with extreme amounts of laryngeal tension and strain.  She complains of a stinging sensation in the thyroid notch area coupled with excessive neck and jaw tension.  In addition to the vocal symptoms, she reports an inability to perform at her current work location.  Currently she has taken two and a half weeks off of work.  Also, she is depressed that she is unable to socialize with friends and family and reports that “she feels locked up and unable to effectively be in contact with others without straining herself more.”


The initial goal in intervention was geared towards eliminating abusive vocal behavior both in the singing voice and in the speaking voice.  She was counseled on elimination of cigarette smoking, the effects of alcohol on voice production as well as general vocal hygiene as stated previously.  Additionally, due to the amount of social interaction that was centered around abusive vocal behavior, special focus in the treatment sessions was placed on elimination of these factors gradually.  Recall, in an earlier section of this book, discussion focused on the importance that a “social life” has on some performers.  This serves as a theraputic outlet.  When you counsel your students on these issues you should be extremely carefully so that you do not offend your student and cast judgement. But, at the same time, be stern and educate her on the cause and effect of this type of lifestyle.  Remember, this is a gradual process, she should be cautioned not to draw back from all interaction, otherwise she may become withdrawn and loose focus of the treatment program and be turned off from you.

The treatment strategies implemented were again similar to the cases presented above.  She began a modified voice rest, used a low impact voice during any vocal production, elimination of vocal abuse, good breath support and control strategies, laryngeal relaxation and refocusing the placement of the voice into the frontal mask.

Results of Therapy

Her carryover of these strategies was gradual, she was determined to avoid surgery however, the healing process was somewhat slow.  She was perscribed a corticosteroid for a controlled amount of time to help reduce the generalized edema in both vocal folds.

Surgical Procedure and Result

Perceptual Impressions following Surgery

Videolaryngostroboscopic Results following Surgery

  • Vocal fold edge: smooth bilaterally
  • Glottic closure: complete
  • Phase closure: normal
  • Vertical level of approximation: Equal 
  • Vibratory amplitude: Vibratory amplitude was just slightly limited in the surgically affected area. 
  • Mucusal wave: Mucosal wave was slightly limited in the surgically affected area. 
  • Vibratory behavior: Vibratory behavior had slight limitations but generally increased.
  • Phase symmetry: Regular
  • Hyperfunction: Absent

Behavioral Voice Therapy Following Surgery 

This post-surgery behavioral program was similar to that of case one in terms of outlining the program and goals.  She was an active person both socially and occupationally so follow up treatment again was centered on counseling in elimination of vocal abuse and coping strategies when faced with certain situations that are difficult to maintain healthy voice in.  She complied very well and the voice therapy regimen was successful.  She began her training to return to work initially in the office.  We worked initially on protecting the voice in terms of vocal power in performance, she was re-educated in her use of the amplification system and continued to modify the vocal performance and eliminate as much of the abuse as possible.  She was comfortable and understood these ideas.

Return to Work

Her return to work was gradual, similar to the return in case one.  She began performing one show a day for the first week with followup evaluations and treatment sessions throughout.  On the second week she was able to perform two shows per day for the first three days and then finished the last two days of her work week singing three shows per day. This schedule of three shows per day was followed for the next week and a half followed by a complete return on the fifth week.  She felt that her gradual return to work was successful.  

Re-Occurrence of Vocal disturbance After eight months of successful voice production, she returned to our office for another evaluation due to episodes of hoarseness.  She reported a history of chronic sinus infections that  were characterized by excessive coughing, throat clearing and persistent mucous drainage.  She was placed on antibiotics and vocal rest until the symptoms were diminished.  Voice therapy sessions resumed and careful monitoring of the speaking and singing voice.  Her vocal disturbance was detected early and so progressions of the voice problem was limited.  She was able to make a full recovery within a three and a half week time window and return back to her normal work and social schedule.

Expiratory Pressure Threshold Training

In the section the program for pressure threshold training is discussed.  Due to her work demand and style of voicing, she was issued a training device and participated in the treatment program.  She was seen for a baseline evaluation two times before the training began and her Maximum Expiratroy Pressure (MEP) was averaged at 72 centimeters of water.  After the four weeks of training, her MEP averaged at 156 centimeters of water.  Her perception of her voice quality and support for singing was phenomenal.  She reports that her performance is better than it has ever been, she has a better control of breathing during singing and has not had any bouts of vocal fatigue.  She reported that she is performing more now than ever and her voice is the best it has ever been.

She is routinely re-evaluated every four to six months.  Since the last training program and treatment sessions, she has not had any vocal disturbances to report and is currently auditioning for other musical productions.