Timing Crucial for Successful Voice Surgery in Female Singers

Newswise — Tissue in the vocal cords and the female reproductive system react similarly to the hormonal changes present during a woman's menstrual cycle. In some women, the change in vocal cord tissue is pronounced, resulting in what researchers call "premenstrual voice syndrome" (PMVS).

Premenstrual voice syndrome is characterized by vocal fatigue, decreased range, a loss of power, slight hoarseness, and loss of certain singing abilities (such as ability to hit the highest notes). The syndrome usually starts four to five days prior to menstruation and affects about one third of women, particularly those women whose voice is important to their career. The idea that hormonal changes during the menstrual cycle can affect the singing voice is not new. In the past, many European opera houses excused female singers from performing during the premenstrual and early menstrual days (known as grace days).

What is new is that vocal surgery (phonosurgery) is now available to maintain performance level of the singing voice. Since is it well known that the physiology and anatomy of the vocal cords are altered by female menstruation, researchers, Jean Abitbol, MD, and Beatrice Abitbol MD, both at 1 Rue Largillière and Patrick Abitbol, MD, Chef de clinique "Assistant des Hôpitaux de Paris, all in Paris, France, assessed whether the timing of voice surgery in female singers with premenstrual voice syndrome was important. The results of their findings will be presented in "Timing for Phonosurgery in Premenstrual Voice Syndrome," at the American Laryngological Association annual meeting, April 30 — May 1, 2004, JW Marriott Desert Ridge Resort & Spa, Phoenix, AZ.

Methodology: Of 550 women, 187 voice professionals aged 21 to 42 (including 27 women who previously underwent phonosurgery with poor functional results) who were determined to have PMVS were included in this study. To define PMVS, the study was done over the course of three menstrual cycles. No subject was taking oral contraceptives; estrogen and progesterone levels were measured and determined to be normal in all subjects; vocal cord smears were done on the same day as cervical smears with a perfect correlation in all subjects at ovulation and on days 25-27 of the cycle.

Vocal examination was done at the time of ovulation and in the premenstrual phase. Digital or video recordings were made of the vocal fold anatomy and of the laryngeal chronokinetic study. Videostroboscopy was used to analyze the vocal folds, the epithelium, the aspect of the vascularity, the amplitude of the vibration, the mobility of the crico-arytenoïd joint, the edema of the fold and the appearance of ephemeral nodules.

A spectrographic study was also done: the patient was asked to emit an /i/ in the mid-range for as long as possible (maximum phonation time), a pianissimo /i/, and /i/s at the extreme low and high points of her vocal range. She was then asked to sing "Frère Jacques" to test vocal agility. The laryngeal chrono-kinetic study also included notation of the quality of glottic closure and the muscular contraction of the vocal folds in high and low notes. The mobility and the suppleness of the left and right cricoarytenoid joints were examined by asking the patient to emit a series of staccato notes (fast /i/-/i/-/i/-/i/).The vibration of the vocal mucosa was studied by stroboscopy, observing in slow-motion its amplitude during phonation and precise electro-laryngogram completed the visual evaluation of the vocal folds mucosa quality during emission of vowels.

Results: In the premenstrual phase, all the patients showed edema (swelling) of the vocal cords with thickened mucus and loss of suppleness, resulting in disturbed muscular and vibratory function. During the ovulatory phase, hypersecretion of mucus was noted on the folds of eight subjects (4.2 percent), causing frequent throat clearing for three to four days. Nothing similar was noted with the 179 other patients. Voice fatigue was noted in all patients.

Maximum phonation time was decreased in 98 cases (52.5 percent). The mobility of the crico-arytenoïd joint was decreased in 107 cases (57.2 percent). Of the 187 women, 37 women (19.7 percent), have only vocal signs of the vocal premenstrual syndrome, without any generalized systemic manifestations. Other results:

"¢ Vascular signs: 153 subjects (81 percent) experienced vascular dilatation, tortuous ectatic vessels, micro-varices, hemangiomas, and rarely submucous hemorrhages."¢ Mucosal signs: 187 subjects (100 percent) experienced edema of the vocal mucosa, thickened and diminished glandular secretion, impairment of amplitude, and asymmetric vocal fold vibrations."¢ Muscular and mucosal signs: 88 subjects (47 percent) experienced decreased muscular tone and diminished power of contraction of the vocal muscle, narrow range, and posterior chink."¢ Vocal cord nodules: 36 subjects (19.25 percent) had bilateral and symmetrical nodules located on the middle third of the vocal folds, which lower the register of voice by about two to three tones."¢ Inflammatory signs: eight subjects (4.2 percent) had inflamed nasopharyngeal mucosa; seven subjects (3.75 percent) with an allergic-type tracheitis."¢ Submucosal vocal cord hematoma: 24 subjects (12.8 percent) lost their singing voice but retained speaking voice.

Conclusion: The results of this study indicate that the timing of phonosurgery in female singers is crucial; every effort must be made by the surgeon to avoid phonosurgery during the premenstrual phase. Surgery performed between the fifth and 20th day of the menstrual cycle will ensure the accuracy and effectiveness of the surgical procedure itself as well as recuperation, which otherwise could be marked by increased vocal swelling, bleeding, and a prolonged healing time.