VOLUME 23, ISSUE 1

The Voice

VOICE OF THE

The Voice

EDITOR

Mary Sandage PhD

INJURED SINGERS IN VOCAL CRISISIN THIS ISSUE:
THE VOICE OF
THE EDITOR

1BY EDITORMARY SANDAGE
PHD
NAVIGATING A
VOCAL CRISIS

2, 3, 4BY PAUL E.
KWAK, MD, MM,MSC
PUTTING OUT THE
FIRE

5, 6,7BY JOAN LADER

WORKING WITH
INJURED SINGERS
IN CRISIS

8,9

BY JACKIEGARTNERSCHMIDT, PHD,
CCC-SLPCHAPTER NEWS

47TH ANNUALSYMPOSIUM INFO

1011

BY MARY SANDAGE, PHD

Working with the injured

yngologist, grounds his

singer in vocal crisis is a

medical support for theperfect topic for the Win-injured voice professionalter edition of this newslet-

within an operational

ter. Often during the cold-framework for defining theest months of the year,

special characteristics ofwhen performance spaces

a vocal crisis. Jackie

are even drier than usual

Gartner-Schmidt,

and when flu and upper

Ph.D., CCC-SLP,

respiratory infections

speech language

abound, we are more likely

pathologist, shares ato encounter a singer inclever mnemonic to help

vocal trouble. Helping thescaffold our care of the in-performer meet profession-

jured singer. Last but notal obligations by mitigat-

least, Joan Lader, who is

ing vocal distress is an im-

so well regarded for her

portant role for the singing

work in voice training andor acting teacher, the lar-performance in elite per-yngologist, and the speech

formers, shines a light on

language pathologist.

those aspects of vocal crisis

Once again, we have three
CONTACT

12excellent contributions
from internationally acclaimed voice professionals. Paul Kwak, M.D., lar-

MARY SANDAGE, PHD

care that require our careful attention.
It is a privilege to havethese esteemed authors
share their expertise.

Assistant Professor
Dept. of Communication Disorders
Auburn University

Voice
of
the
Editor

TH E

Page 2V O I C E

N AV I G AT I N G A VO C A L C R I S I S
BY PAUL E. KWAK, MD, MM, MSC

I recently spoke with one of my colleagues in Psychiatry, who wassis as a moment when a singer is in astate in which she is no longer able

treating a patient in the midst of ato cope with or adjust to the recur-

psychiatric crisis. My colleague told

rent stresses of everyday singing in ame that some psychiatrists and psy-functional way, with the tools withchologists define a crisis as a moment when the patient is in a state

which she has been equipped to thatpoint in life. Singing is such an act

in which he is no longer able to copeof courage and vulnerability rooted

with and adjust to the recurrent

in character and spirit, that when astresses of everyday living in asinger loses the ability to sing, how-functional way, with the tools withever momentarily and for whatever

which he has
beenequipped tothat point inlife. I loved“SINGING IS SUCH AN
ACT OF COURAGE AND
VULNERABILITY ROOTEDIN CHARACTER AND
SPIRIT.”reason, it canfeel as though

PAUL E. KWAK, MD, MM,

he is being

MSC

robbed not
simply of his

thinking
about that definition in terms of

livelihood, butof his very identity. Understanding

singers who are in the midst of

the multiple dimensions of this kind

what we often term a vocal crisis –of moment illuminates the reasons I

a term we do not always take thefeel so strongly about a team ap-

time to define or characterize pre-proach to supporting singers during

cisely. Through theacademic lens of psychology, it is helpful tounderstand a vocal cri-

The
Voice
of thethese moments.
In some ways, my role inthis moment is the sim(Continued on page 3)

Lar yngologist

Paul E. Kwak is a laryngologist
and laryngeal surgeon
NYU Voice Center
Assistant Professor
New York University
Department of OtolaryngologyHead and Neck Surgery

V O L U M E

2 3 ,I S S U E

1(Continued from page 2)

Page 3

respiratory infection, a hemorrhage – it can seemplest; I examine the anatomy of the larynx to see

to both patient and clinician that there is a

if there is any acute change, whether that be an
infection, inflammation, hemorrhage, a new mass

“straightforward” medical antidote or solution.
Indeed, sometimes singers are “just” sick, andor lesion, or some combination of the above. I be-“just” need medicine and/or time to recover. But

lieve that a laryngoscopic exam is essential as anin a vocal crisis – again, I hearken back to the def-

initial step in the management of a singer in a mo-inition my psychiatrist colleague provided – whenment of crisis, because it provides us with basic
information about the state of the laryngeal anat-a singer is no longer able to cope with or adjust to
the recurrent stresses of everyday singing in aomy. However, in the same way that I do not

functional way, with the tools with which he has

believe that the anatomy of the larynx is solely

been equipped to that point in life – that is theand absolutely determinative about the function

moment when we need all hands on deck, becauseof a healthy and functional voice; so I would not

we are not only rehabilitating the larynx at that

presume that a laryngoscopic assessment of thelarynx is solely and definitively prescriptive in apoint, we are rehabilitating the whole singer. Insofar as singing activates and requires mobiliza-

moment of crisis. Often when there is an acutetion of not simply the tissues and organs of thepathologic process clearly in play – like an upper(Continued on page 4)

T H EVO I C E(Continued from page 3)

Page 4no such thing as too much communication
among members of the singer’s care team, butbody, but the mind and spirit as well, so thethe barriers to communication are most often

support and nurturing of a singer in crisis re-rooted in linguistic differences; we do not always

quires care of the body, mind, and spirit.

know how to speak the same language. It is our

Rehabilitating a voice in crisis, therefore, requires a multidisciplinary team. I firmly believe that this team includes not only the patient’s laryngologist and speech-language
pathologist, but we do well to include in thatteam the singer’s teacher(s), coach(es), houseand stage management, artist management,even family and friends. I feel this deeply, because what I find underlies so much of the anxiety in these situations is fear based on assumptions that are in turn rooted in miscom-

responsibility as members of a multidisciplinary
voice team to learn the lexicons of our teammembers because, unquestionably, this ability
to dialogue seamlessly not only solidifies a unified plan during crisis, but assures the singer
that all members of the team are communicating effectively, which, I believe, remains oneof the most important ways to help a singer feel
fully supported, reassured, and confident about
the ability to recover and make progress forward.

munication or, at times, a total lack of communication between parties who should ultimately be dedicated to the singer’s success. There isPaul E. Kwak is a laryngologist and laryngeal surgeon at the NYU Voice Center, and Assistant Professor in the NYU
Department of Otolaryngology-Head and Neck Surgery, specializing in care of the professional voice and phonomicrosurgical resection of benign vocal fold lesions. He treats patients with vocal cord cancer, vocal fold paralysis, andlaryngeal papilloma, and is experienced in surgical techniques for laryngeal microsurgery and use of the KTP laser. Dr.
Kwak completed his clinical fellowship in laryngeal surgery with Dr. Steven Zeitels at the Massachusetts General Hospital, and his residency in otolaryngology-head and neck surgery at Baylor College of Medicine and MD Anderson Cancer Center. He is also a graduate of The Juilliard School, where he earned a master’s degree in Collaborative Piano
with Margo Garrett, studying vocal accompanying and opera coaching.
In 2003, Kwak graduated magna cum laude from Harvard University, where he studied the history of medicine andmedical ethics and wrote an honors thesis on the history of trust in the physician-patient relationship. Kwak spent a
year abroad at Oxford University, on fellowship from Harvard, where he earned a master’s degree in Comparative
Social Policy, writing an honors dissertation on patients’ rights legislation in the United States and in the United Kingdom. In February 2006, Kwak was awarded the Paul and Daisy Soros Fellowship for New Americans, and in May
2006, the Helen Fay Prize for Outstanding Pianist at Juilliard. He is a graduate of Case Western Reserve University
School of Medicine, where he was named the 2010 Outstanding Graduating Medical Student.
Dr. Kwak’s clinical and research interests center on the care of the professional voice, and his most recent publications
examine physiologic and acoustic effects of opera performance, in ongoing collaborations with The Juilliard School,
The Metropolitan Opera, and the Houston Grand Opera. Additionally, his work focuses on phonomicrosurgical approaches to benign subepithelial vocal fold pathology, paralytic dysphonia, and recurrent respiratory papillomatosis.

V O L U M E

2 3 ,I S S U E

1Page 5BY JOAN LADERFor over 36 years, I have lived

need to develop an under-

in the land of “vocal crisis.” Taking

standing of the individualcare of professional singers is anextremely interesting and challeng-

performer, the limitations

ing, not to mention, emotionallyof the performer at thischarged vocation.

point in time, and the spe-

It has been said that voice isthe barometer of human emotion.

cific demands placed uponthem.

Emotional states can cause a malfunction in the instrument, thereby

The ideal working situation islimiting vocal range and flexibility,

to have the performer in the roomi.e., the voice is out of control. The

with you. Beyond, listening to theemotional state of an individual

vocal production of a singer, it is

may actually cause a vocal pathol-extremely helpful to have bothogy, and medical conditions limit-

your eyes and hands on the per-ing vocal production, may in turn,former. So many problems arise

exacerbate and heighten emotional

due to faulty biomechanics, mus-states, thereby affecting the voice.

cle tension, alignment and airflow.

So, what’s the etiology of the prob-

Taking this a step further, obser-

lem, and when the show must go

vation during an actual perfor-

on, what do we do?

mance is advisable whenever pos-

Often the line is blurred be-sible. So, that’s the ideal scenario!

tween the psychological and tech-

However, problems often rear

nical aspects of a problem. Whentheir ugly head during an out of

we sign on to participate in
the rehabilitation or habilitation of these people, wetown performance. Years ago, we
relied on phone sessions. The mostabsurd took place with an opera(Continued on page 6)

JOAN LADER, BFA, SLP

Private Teacher/Coach
Estill Master Teacher
Alexander TechniqueFitzmaurice Voice Work
The work of Arthur Lessac.

VOLUME 23, ISSUE 1

Page 6

PUTTING OUT THE FIRE, CONTINUED(Continued from page 5)

singer calling from a telephone

involved a singer with a vocal

director, director and composer),booth at an airport. We com-

fold polyp. Surgery was indicat-

made the job even easier. Inter-

peted with the sound of air-ed, but there was not enoughestingly enough, the polyp wasplanes, the running announce-

down time following the proce-

actually smaller when he returned

ments, and people interrupting. Today we have the technology to observe via Skype or

T he Voice of the Singing Teacher

FaceTime. Unfortunately,
there is often a delay and wedure before he would have toto New York.

are unable to accompany theperform in a pre-Broadway run

student unless they have a preout of town. The goal was toeffect. A singer with both an un--recorded track or can accom-

get him through this three-dergraduate and graduate degreepany themselves.

month period. Surgery wasin voice was cast in a show inscheduled following the run withwhich she had to belt. Her train-

The [performer's] level ofa month and a half to rest anding had been purely classical. She

anxiety often foreshadows theretrain before Broadway re-was diagnosed with fibrous midoutcome. The presence of thehearsals were to begin. The fact

fold masses. Singing was pressedsmallest “excrescence” canthat he had such a positive atti-

and extremely effortful whensabotage some singers, while

tude made the job easier. He

moving from a legit sound to

Another case had the opposite

thicker vocal folds and mixed"THE PRESENCE OF THE SMALLEST'EXCRESCENCE' CAN SABOTAGE SOMESINGERS, WHILE OTHERS, WITH MORE
SIGNIFICANT PROBLEMS, ARE ABLE TO
COMPENSATE AND EVENTUALLY AFFECTCHANGE."

belt. There was confusion interms of place and space whenaccessing different qualities.
She improved with therapy
and training and within a few
months her vocal folds looked
essentially normal. However,others, with more significant

was placed on a week of voice

she has been unable to return toproblems are able to compen-

rest with a steroid and we slowly

performing. The level of anxiety issate and eventually affectdeveloped a program addressing

too great and vocal quality andchange. Those of us who care

vocal hygiene, vocal exercises,

performance are inconsistent andfor these professionals usuallyand eventually the actual dia-effortful. Many people are psycho-

have an expansive tool box at

logue and music. Cooperation

logically burdened. However, with

our disposal. A recent casefrom the show’s team (musical(Continued on page 7)

VOLUME 23, ISSUE 1

Page 7

PUTTING OUT THE FIRE, CONTINUED

Joan Lader’s more than thirty years of providing

singers it often impacts on their art. In these cas-vocal training and rehabilitation for professionales, we try to be as supportive as possible, but ad-

voice users was commemorated last June when

ditional professional support from psychologists

she was presented with the American theater’sor social workers is advised.
There are as many scenarios as there are talented, but complicated individuals, and there isno single formula for dealing with them. Eachone is sui generis. I like to think of my work as
vocal triage...putting out the fire!

highest honor, a Tony Award for “Excellence in the
Theater.”
Ms. Lader received a BFA from Penn State University in Theatre Arts with a Minor in Music. Trained
as a Master’s level speech pathologist, she specializes in working with singers and actors, and incollaboration with New York’s top otolaryngologists, rehabilitation of injured voices. Her extensive practice includes leading actors and singers
from Broadway, film, opera, R&B, rap, rock andpop.
Ms. Lader is a certified Master Teacher of the Estill
Voice Training System, and has extensive training
in the Alexander Technique, as well as Fitzmaurice
Voice Work and the work of Arthur Lessac.
She has given Master Classes at universities andsummer programs throughout the country, is aconsultant at NYU’s The New Studio and is on theadvisory board of the Voice Foundation and the
Manhattan School of Music. She is particularly
proud to be involved with the National Young Arts

Joan Lader and client Roberta Flackat the 2014 Voice Foundation Voices of Summer Gala

Foundation, whose participants so often become
the stars of tomorrow.

Jackie L. Gartner-Schmidt, Ph.D., CCC-SLP, ASHA Fellow is Co-Director of the University of Pittsburgh Voice Center, Professor of Otolaryngology and Director of Speech-Language Pathology-Voice Division at the University of Pittsburgh Medical
Center. Dr. Gartner-Schmidt’s 25-year clinical and research focus specializes on care of the professional voice, as well as
clinical effectiveness of voice therapy and psychological considerations in the assessment and management of patients withvoice and breathing disorders. Dr. Gartner-Schmidt’s federally funded research as a co-investigator focuses on the development and efficacy of different voice therapy programs. She has published over 35 peer-reviewed papers and presented
over 250 lectures nationally and internationally. Dr. Gartner-Schmidt is the director of the largest voice therapy conferencein the nation occurring biennially. Read her article on the next page!

VOLUME 23, ISSUE 1

Page 8WO R K I N G W I T H I N J U R E D S I N G E R S
IN CRISISBY JACKIE GARTNER-SCHMIDT, PHD

Singers in crisis are a special patient cohort. The best care forsingers with acute voice problems
can be described with the mnemonic BEST, which stands for B:

most performers return to the“spot light” and perform without residual vocal fold injuries.
For singers with recurrent
bleeds, surgery is typically needed.

Blood; E: Emotional support; S:
Schedule, and T: Timing. Let’s

EMOTIONAL SUPPORT: Most

take a look at each element.

their families. Professional sing-

BLOOD: When a singer complainsof a sudden onset of dysphonia,
the fear is that their vocal fold(s)have bled. A vocal fold hemorrhage is an acute phonotraumatic
injury due to broken blood vessel(s) in the lamina propria. To
make matters worse, sometimes
vocal fold bleeds are accompanied
by a “friend,” resulting in a hemorrhagic polyp. Varices, which areuncharacteristically dilated bloodvessels, are generally considered
to cause vessel fragility making
them susceptible to rupture. Voice rest and a discontinued performance schedule with
serial stroboscopic surveillance ofthe resorption of the blood are inorder. The important decision to
be made is whether it is safe forthe singer to sing. Said differently: what is the vocal cost benefit
ratio? After an acute episode,people go to work to support
ers do the same but also indirectly support many others (e.g.,band members, vendors, touring
companies, fans, venues, etc.).
The guilt and emotional toil of
not performing can be burdensome for a singer. Shame andanxiety are also common reactions. The stigma of a pitcher
going for Tommy John Surgery(TJS) on their elbow is not commensurate with a singer being“grounded” from touring because of a vocal injury. Loss ofconfidence and fear of future injury are important discussions tobe had with the interdisciplinary
voice care team. Empathy, patience, non-judgment, and assurance are critical skills.
SCHEDULE: Often there is atruncated treatment window due(Continued on page 9)

JACKIE L. GARTNER-SCHMIDT,
PH.D., CCC-SLP, ASHA FELLOW
Co-Director
University of Pittsburgh
Voice Center
Professor of Otolaryngology andDirector of
Speech-Language Pathology-Voice
Division at the
University of Pittsburgh
Medical Center

The
Voice
of theSpeechLanguage
Pathologist

T H EVO I C E

Page 9WORKING WITH INJURED SINGERS IN CRISIS (CONTINUED)

clinic, at night or on the weekend. The duration of the initial
visit is often long. In addition toa templated History of Present
Illness (HPI), information about
tour schedules, venue locations,genre of music sung, number ofmeet ’n greets, in-ear monitor
use, radio/marketing engagements, importance of performance from a reputation andfinancial stance, etc. are questions asked by the voice careteam. In addition, the(Continued from page 8)

to performance and touringschedules. Performance schedules are immediately canceled
when, for example, a hemorrhagic polyp is diagnosed. It
can take up to three months fora singer to be rehabilitated.
Some professional singers on
tour may want clinical care“back home”, so follow-up evaluation is a rarity. The clinicalprofessionals will have a means

timeframe for performance andfor comparison. Some singers

allowance for vocal rest are also

may only need steroids to “getthrough” a performance if the

crucial to know when considering treatment options.

voice care team is comfortablethat vocal safety will not bethreatened, the singer is confident in their abilities, and subsequent scheduled performances arefew. Professional singers usuallyknow if they capable of performing.

It is the delicate mixture of patient vulnerability, urgency ofevaluation and treatment, andemotional support that makesingers in crisis a special patient
cohort. The BEST care for asinger in crisis isn’t an option.
It’s proven approaches thatcare team often recommends

TIMING: By definition, a crisis is

move singers from crisis back totrusted voice care colleagues
around the country and abroad,not planned and consequently
seldom is an evaluation scheduled

the stage and studio.

if needed. Singers are given dig-for a singer in vocal crisis. The

ital records of all their laryngeal

timing of a voice evaluation is

exams, so that other voice care

usually either in the middle of a

CHAPTER NEWSDr. Brian Galante presented at the NW Chapter
Click HERE to listen to his presentation

Mara Behlau, Déborah Feijó, Maria Russo, Claudia Eckley,
Beth Amin, Glaucya Madazio, Thays Viano

The Brazilian Chapter
had it's inaugural meeting on November. Paulo Pontes,
MD, contributed prize money to be used to attend the Annual Symposium in a competition for best research.
Their second meeting, with presentations by Dr. Mara Behlau, Dr. Glaucya Madazio, Dr. Claudia Eckley, SLP,-CCCsDéborah Feijó, Beth Amin, and Thays Viano drew 78
audience members

North Carolina Chapter
Will have their first meeting on ….World Voice Day,
April 16!

Mexico Chapter
Dr. Fermin Zubiar and Dr. Carlos Manzano are planning
Dr. Paulo Pontes, Dr. Luciano Neves, Dr. Mara Behlau

their very first meeting in Mexico City.

Houston Chapter
Had the first meeting for 2018 in March

Northwest/Seattle Chapter
Dr Brian Galante, Associate Professor of Music and Associate Director of Choral Studies at Pacific Lutheran
University in Tacoma, WA, presented "The Acoustical,
Physiological and Perceptual Characteristics of Vocal
Mara Behlau, Paulo Pontes,
1st Prize winner Leonardo Lopes, PhD,Maria Russo, Leonardo Lopes

Vibrato".
Send your chapter pictures and event reports!

V O L U M E

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1Page 11

VOICE FOUNDATION NEWS4 7 TH A N N U A L S Y M P O S I U M :CARE OF THE PROFESSIONAL VOICECHAIRMAN, ROBERT T. SATALOFF

MAY 30—JUNE 3, 2018 PHILADELPHIA PENNSYLVANIA

Wednesday, May 30

Saturday, June 2

Basic Science Tutorials

Medical, SLP Session

Presentation Coaching

PanelsAccent Reduction Coaching

G. Paul Moore Lecture: Nicholas Maragos, MD
Vocal Master Class

Thursday, May 31
Science Sessions
Quintana Awardee: Luc Mongeau, PhD
Keynote Speech - Boris Alexander Klebe,

Sing Along with
Grant Uhle

PhD

Friday, June 1
Special Session: Exercise and the Voice
Nancy P. Solomon, PhD

Sunday, June 3
Medical Session
PanelsYoung Laryngologists Study Group
Vocal Workshops*Voices of Summer Gala*

The Brazilian
Chapter inaugural
meeting inNovember 2017

Voice Pedagogy Session

THE VOICE FOUNDATION BOARD OF DIRECTORSCHAIRMAN
DIRECTORS
Robert Thayer Sataloff, MD, Martina Arroyo
DMA, FACS
Harolyn Blackwell
Claudia Catania
Jennifer CreedPRESIDENT
Stuart Orsher, MD
Abdul-Latif Hamdan, MD
Walt Hunter
Gwen S. Korovin, MD
VICE-PRESIDENT
Michael S. Benninger, MD
Justice Sandra Newman
Renata ScottoMichael Sheehan
SECRETARY
Mary Hawkshaw
George Shirley
Caren J. Sokolow
TREASURER AND
GENERAL COUNSELBrian P. Flaherty, Esq.
ADVISORY BOARD CHAIRMAN
Michael M. Johns III, MD

THE VOICE FOUNDATION
STAFF

THE VOICE FOUNDATIONEXECUTIVE DIRECTOR,
THE VOICE FOUNDATIONMaria Russo, MM

219 N. Broad St. 10FLEXECUTIVE COORDINATORMANAGING EDITOR,
JOURNAL OF VOICE
Katie Erikson, MM

Philadelphia, PA 19107(215) 735-7999
fax: (215) 762-5572
voicefoundation.org
office@voicefoundation.org
journal@voicefoundation.org
abstracts@voicefoundation.org
symposium@voicefoundation.org

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