Vocal Fold Microsurgery and Postoperative Rehabilitation – Part 1

Post Operative Posture Memory Rehabilitation using Speech Level Singing Exercises and Balanced Onsets

In 2002 I had the opportunity to publish a study I took part in regarding Vocal Fold Microsurgery for the Journal of Singing magazine.  Here is the first part of that article.

The landmark report of Cornut and Bouchayer(1) along with Bastian’s classic paper titled “Vocal Fold Microsurgery in Singers(2)” and other writings(3-5) validate the of vocal fold microsurgery in singers with otherwise irreversible mucosal lesions.  These sources, along with many other publications, deal with the subject comprehensively, including the kinds of lesions involved, indications for surgery, surgical techniques, results, and patient perceptions of results.  Especially important for the voice teacher is information found here not only about pre- but also postoperative voice care and self monitoring for recurrence of lesions.

A particular comment Bastian makes, that he has illustrated by clear photographs in the above-mentioned work, serves as the focus of this paper(2):

One “non-surgical” postoperative laryngeal finding deserves mention.  A number of female singers manifested a slightly abducted phonatory posture in the postoperative period.  It may be that this was simple a continuing manifestations of the patient’s muscular tension dysphonia…another view that may also be valid is that the patient had “learned” to hold the folds at an appropriate distance apart to compensate for early contact of the nodules, and that this habitual vocal fold positioning persisted even after the nodules were removed.

Posture Memory

Bastian has subsequently dubbed this postoperative phenomenon “posture, or gap memory.”  It has been the subject of numerous conversations with him, during and after extensive clinical observation at the Loyola Voice Institute, and also in the course of our collaborations in the re- and postoperative care of surgical patients.  In his clinic, I have observed singers who have undergone successful surgery to remove mucosal lesions.  In these singers, the lesions are gone and the margins of the folds are straight.  During stroboscopic viewing, mucosal oscillation is normalized, without signs of stiffness.  Nevertheless, under continuous illumination, at the prephonatory instant (just before the blur of vibration), the folds are positioned with a significant gap of essentially the same size observed when the nodules were present.  Under strobe light, there may be an “infinitely long” open phase of vibration.  In other words, especially at mid- and upper-voice, the mucosa swings laterally with god amplitude, flexibility, and wave, then swings medially with equally good function, but never quite coming to a true closed phase.  Therefore, the folds always seem to be postured in an open position.  In these instances, the voice always has improved capabilities, but may retain a sense of breathiness along with onset delays.

Bastian has stated that “this type of postoperative difficulty supports the need for careful postoperative care by a singing-voice-qualified speech pathologist, laryngologist, and voice teacher, not only before but often also after surgery.(6)”  He has suggested in his paper, as well as in subsequent conversations, a variety of rehabilitative techniques that had seemed to help some of his patients overcome the “posture memory” problem:

  • Use of a slightly lower laryngeal position.
  • Use a pianissimo and piano dynamics during vocal exercises, so that breathiness can be readily heard and targeted for elimination.
  • Employment of staccato exercises, again at a soft dynamic levels.
  • Training of reinforced, non-breathy head voice in the low falsetto range.
  • Beginning phonation in fry or creaky voice and moving from there to normal phonation as a means of re-establishing efficient and “stingy” use of air (a temporary training antidote, to be sure).
  • Use of laryngeal image biofeedback, for stubborn cases.

In conversation with a variety of voice professional, it has become clear that the phenomenon of “posture memory” is often unknown, under diagnosed, or not understood at all.  Thus, the purpose of this article is first, to increase general awareness of this problem in the postoperative singer, and second, to outline and test the efficiency of a codified behavioral program using Speech Level Singing exercises and balanced onsets designed to correct posture memory.  This way, voice teachers will have an effective method of dealing with this phenomenon when it presents itself.  Without awareness of posture memory and an effective method of dealing with it, postoperative rehabilitation can prove to be frustrating and potentially misdirected.

Although a singer subject study, this rehabilitation program has been used by this writer on numerous singers with great success.  This single subject study presents an opportunity to document its success and to outline the exercises and procedures used in the program.

The photographs used in this study show the folds at the prephonatory instant before mucosal oscillation obscures the degree to which closure is real versus apparent.  This gives the clearest possible picture of the phenomenon.  Photographs f the phenomenon can be seen later in the article.

The Subject and Objectives

The subject is a thirty seven year old professional singer.  Employed by various bands and agencies, and a professional speaker as well, her living is earned entirely through voice use.  After successful surgery to remove bilateral mucosal lesions, a postoperative stroboscopic exam revealed incomplete closure due to posture memory.

The long-term objective of the program is to create efficient closure of the vocal folds as determined under stroboscopic examination using a battery of standardized tasks to evaluate behavior on a vocal fold level.  The subject will be allowed to return to work following findings that reflect the desired results and will be examined sometime soon after the fourth session.

The short-term objective of the program is an eighty percent successful completion rate of the exercises, in successive trials, through a range of predetermined pitches, singing in a connected manner through all registers while the larynx maintains a neutral “speech level” posture.

Speech Level Singing

The majority of the exercises are used in the Speech Level Singing (SLS).  Developed by Seth Riggs(7), SLS emphasizes a neutral laryngeal position (speech level) as in the position one would find when he or she speaks comfortably.  Riggs’s exercises are designed to create pitch and/or register adjustments using intrinsic laryngeal musculature only.  Adduction is so efficient that very little air is needed to engage the Bernouli effect, therefore ensuring that the folds always close along the whole length.  The exercises are sequenced – in the order presented here – to shape behavior towards the goal of connected singing, without interference of outside muscles, regardless of pitch and/or register.  Audio examples for the ensuing exercises can be found in Riggs’s book, Singing for the Stars.(7)

Lip Trills

In this exercise the lips are put into vibration in addition to the vocal folds.  The purpose is to balance out airflow and resistance to it in order to create favorable subglottal pressure.  Less pressure ensures that extrinsic musculature will not be needed to bring the folds to the midline and help adjust pitch.  To keep the folds and lips vibrating simultaneously, the right balance must be present or the whole process will break down and the folds and/or the lips will cease vibrating.  Titze also notes that, because of the secondary compression created by the lips, supraglottal pressure is created, assisting the closure of the superior portion of the folds as cricothyroid involvement is introduced(8).  This exercise was used in each session.  In addition to the benefits detailed above, it is traditionally recognized as a good warm-up for the instrument and relaxes oral and facial muscles.

The Witch’s Voice

To accustom the subject to the feeling of connected singing throughout the various registers, we actually used the assist of suprahyoid muscles, in this case to lengthen the folds as a pitch rose out of the chest voice and to help promote more complete closure.  The sound of the voice is rather spread and excessively bright and does resemble that of a witch.  Riggs reveals that this exercise dates back to the days of castrati and was used to train the voice on how to bridge out of chest voice through the first passaggio (or bridge, as SLS calls it), into the lower portions of the head voice.  This exercise can not be carried too high, because the involvement of the high larynx muscles puts too much pressure on the larynx as the pitch rises.  As soon as the goal of introducing the subject to a connected sound is accomplished, the exercise should be dropped.

Low Larynx Exercises

According to Bastian, a correlation exists between a lower laryngeal position and more efficient adduction.  We used a bit of a cry or whimper (a “Yogi Bear dumb sound” perhaps is more appropriate) in the voice to promote a lower laryngeal position in this exercise.  This imposition of the “dumb sound” causes the suprahyoid muscles to disengage and the infrahyoid muscles to lower the larynx.

While this is a rather clinical article, I hope you will return to see the positive results from this study.