By Gianna Wichelow, Senior Manager, Editorial and Publications

Unlike an orchestral player, a singer’s instrument is their body, and when a singer at the Canadian Opera Company develops a problem with their instrument, they seek the expert and compassionate help of Dr. Jennifer Anderson, head of the Voice Disorders Clinic at St. Michael’s Hospital here in Toronto.

Like many others who have gone into medicine, Dr. Anderson has a strong background in music. At the age of 16 she was trying to choose between becoming a violinist or a doctor. She chose the latter and when Dr. Anderson completed her ENT training at the University of Toronto (UofT), she was asked to do specialty training which required a master’s degree in speech pathology. Since assuming the medical director role at the Voice Disorders Clinic in 1996, the clinic has acquired a reputation for excellent care and has become the largest voice centre in the country. The team at the Voice Clinic includes two speech pathologists, Marta DeLuca and Gwen Merrick, who have expertise in vocal performance as well a vocal pedagogist, Mary Enid Haines.

Anderson explains, “The most common problems we see in the voice clinic are due to voice abuse and misuse: for example, a typical patient is the chatty person who is a cheerleader, sings in the choir and talks on her cell phone – a lot. The trend of texting and e-mailing on smart phones is actually giving some voices a much-needed rest. I also see voice professionals – people who are performers, teachers, or anybody who uses their voice to make a living – develop a voice problem when several things happen at the same time which causes voice strain. For example, a teacher is moved to an open-concept classroom and has a severe bronchitis that fall. We also diagnose related voice problems like vocal nodules, polyps and both cancerous and noncancerous tumours in the larynx (vocal folds). Less common are problems such as breathing issues from scar tissue or irritative reactions in the throat.”

According to Dr. Anderson, singers and performers are more likely to appear in her clinic because they are more aware of their voices and often identify that there is something wrong. Sometimes they’re getting by with their performances but they know their voice is not quite right.

“Singers value their health, and there’s only the rare opera singer who smokes. One of the things I find very difficult for opera singers is that if they do not perform, despite what could be many weeks of preparation, they may not be paid so there is a huge pressure to sing even if the performer is sick. Occasionally, a virus has gone through a whole opera cast. The best prevention, when working with a group when someone gets a virus, is a lot of hand washing. Singers do get very worried about getting ill at the wrong moment.” As with anyone feeling not quite themselves, psychology can sometimes play a part. “I’m not a trained psychologist but when you meet someone who has a concern about their voice, there’s sometimes a lot of anxiety around what it means for their career. The education about the physiology of producing voice has changed for singers; they understand so much more, which is helpful. But sometimes when they come in, it turns out they have an important performance or audition coming up and the stress is building. They’re wondering if what’s going on is structural or something wrong with their vocal cords, or is it something they are doing wrong. Young singers can find that terrifying. Singers have spent years investing in a skill set and when things are not going well, can start to wonder if it is their technique at fault. That may or may not be the case but the concern can affect confidence and vocal performance. I find that becomes a real issue in some individuals.”

Curious about the small and rather mysterious vocal cords, I made an assumption that they were also quite fragile, which, it turns out, is not necessarily true. Dr. Anderson explains, “It’s amazing what the vocal folds can put up with, if you think about what singers can do. Vocal folds can vibrate up to 1,000 times a second, with a huge range of intensity. The same way a ballet dancer’s feet are not necessarily that attractive, sometimes vocal folds look like they have been on a long journey. They change, and there can be certain identifying marks. Lots of singers know what their cords look like and they can identify a particular structural image that has been there for years. The voice system works best when the vocal folds are smooth, straight and symmetrical, but most importantly, really supple. The folds have to act more as a fluid rather than a solid. They have to be able to ripple and vibrate. It is an air-driven system, so if the vocal folds are too stiff or too heavy, if there’s something on them, then you can set the air in motion but it won’t easily vibrate. Or the voice sounds very rough, because the vibrations are very irregular.

“The system has got what is called plasticity. There is a capability to evolve, a lot of capacity to change. You learn one way of doing something, but that doesn’t mean that is the only way. So there are singers who have had injuries, like a hemorrhage, and they may have to learn another skill set to move on.”

Such is the demand on the busy clinic at St. Michael’s that efforts are being made to expand the team. There’s also a campaign to raise funds to hire a PhD scientist to research voice disorders. This would be a joint research program between medicine and music at UofT. “One subject they would work on, for example, is the relationship between vibrato and vocal tremor, which sound like the same thing but may not be that easy to understand. One is a natural tremor that you find in vibrato and you use it because, in singing, it is a desirable quality, but it already had to be wired in neurologically. The other is pathological and a patient has it all the time, and you can’t turn it off. What’s the connection? Other questions we would like to know more about would be, why is someone able to learn certain skills so easily and someone else struggles to do the same thing? What is the effect of large tonsils on a singing voice? I have performed tonsillectomies on singers because the tonsils were so large, it seemed to be affecting their resonance, but it has not been formally researched. The goal of the voice research chair is to combine experts from three areas: music, medicine and communication science, to work collaboratively in voice research. We would also like to promote better voice care education and I have already directed several voice courses that have brought together speech pathologists and physicians who have an interest in voice issues.”

Also along the lines of looking to the future, Dr. Anderson invites young singers each year from UofT’s Opera Division for an annual field trip to the Voice Disorders Clinic. “They get a sense of what we do, what we look at, what their vocal cords look like and how they vibrate. The students seems to enjoy the experience and it enhances their knowledge.” What other advice does she have for young singers? “I think globally looking after yourself with a good diet, enough sleep and exercise is just common sense but it makes a difference in performers. I don’t think most young singers relax enough and that tension ends up being an issue for lots of singers. Most of them know to be careful about things they read on the internet relating to a healthy voice. Here’s an example: for a while I saw quite a few singers who were all drinking licorice root tea before their performance. It was a trendy thing to do. It has a sort of sweet flavor but it’s a diuretic which means it can dry out the vocal folds which is not a good idea before singing.”

A sick singer can feel as despondent as a weight lifter with a bad back. But with the understanding of the plasticity of the human body, and with the support and expertise of specialists like Dr. Anderson, they know that they’ll have access to the best care available. And thanks to those remarkable little vocal cords, as part of the entire voice-producing system, we in the audience can be transported once more by the beauty and expression of the human voice.

“Dr. Anderson knows just what is at stake for an opera singer”

In every major city with a world class opera house, there is at least one ENT [ear, nose and throat] specializing in the treatment of voices, sung and spoken. Over the years I have relied on such experts in Vienna, Berlin, Munich, New York and London to help me in times of illness or vocal concern. In Toronto we are lucky to have Dr. Jennifer Anderson at St. Michael's Hospital, who tends to the needs of many of Toronto's top opera, musical and theatre performers. One tends to forget that singers are like athletes. Our tiny vocal cords undergo a real workout during an operatic performance and, like an athlete, a singer has to keep in good shape through constant practice and exercise. Dr. Anderson knows just what is at stake for an opera singer. There is often a huge psychological component at play and she is very sensitive and understanding to just how much pressure a singer is under. If a singer is ill, it can be dangerous for him or her to carry on performing. However, many singers feel the financial pressure to carry on performing despite illness or fatigue. This can lead to many vocal problems in the long run. Dr. Anderson understands the pressure and conflict that many singers experience and she counsels them with kindness and wisdom. She has often fitted me immediately into her extremely busy schedule of surgery and hospital clinics when I have been ill or have had other vocal concerns. Her work as Director of the St. Michael's Voice Disorders Clinic is praiseworthy.
Adrienne Pieczonka