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Clinical Voice Analysis of Carnatic Singers

Article  in  Journal of Voice · November 2013

DOI: 10.1016/j.jvoice.2013.08.003 · Source: PubMed

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Clinical Voice Analysis of Carnatic Singers
*Ravikumar Arunachalam, †Prakash Boominathan, and †Shenbagavalli Mahalingam, *yChennai, Tamil Nadu, India

Summary: Background and Objective. Carnatic singing is a classical South Indian style of music that involves
rigorous training to produce an ‘‘open throated’’ loud, predominantly low-pitched singing, embedded with vocal nu-
ances in higher pitches. Voice problems in singers are not uncommon. The objective was to report the nature of voice
problems and apply a routine protocol to assess the voice.
Methods. Forty-five trained performing singers (females: 36 and males: 9) who reported to a tertiary care hospital
with voice problems underwent voice assessment. The study analyzed their problems and the clinical findings.
Results. Voice change, difficulty in singing higher pitches, and voice fatigue were major complaints. Most of the
singers suffered laryngopharyngeal reflux that coexisted with muscle tension dysphonia and chronic laryngitis. Speak-
ing voices were rated predominantly as ‘‘moderate deviation’’ on GRBAS (Grade, Rough, Breathy, Asthenia, and
Strain). Maximum phonation time ranged from 4 to 29 seconds (females: 10.2, standard deviation [SD]: 5.28 and males:
15.7, SD: 5.79). Singing frequency range was reduced (females: 21.3 Semitones and males: 23.99 Semitones). Dyspho-
nia severity index (DSI) scores ranged from 3.5 to 4.91 (females: 0.075 and males: 0.64). Singing frequency range and
DSI did not show significant difference between sex and across clinical diagnosis. Self-perception using voice disorder
outcome profile revealed overall severity score of 5.1 (SD: 2.7). Findings are discussed from a clinical intervention
perspective.
Conclusions. Study highlighted the nature of voice problems (hyperfunctional) and required modifications in assess-
ment protocol for Carnatic singers. Need for regular assessments and vocal hygiene education to maintain good vocal
health are emphasized as outcomes.
Key Words: Carnatic singing–Indian singing–Singing frequency range–Vocal hyperfunction–Voice analysis.

INTRODUCTION strenuous schedules, the nature of singing, poor vocal hygiene,

Singers are frequently compared with athletes due to the de- and health practices.7 A study7 on vocal and nonvocal habits in
mands and sophistication involved in using the phonatory appa- Carnatic singers revealed that singers engage in long-duration
ratus. Singers use their voices in special ways to suit particular singing, irregular eating habits, and frequent throat-clearing.
styles of music.1 Carnatic singing, the classical music of South It is well known that professional voice users are at greater
India, is a highly evolved art form, learned from masters (usu- risk to develop voice problems than the general population.8
ally called gurus) through rigorous practice. It requires a power- A survey on voice problems in professional voice users in India9
ful voice with emphasis on low-pitched and loud singing. revealed a high point prevalence rate of 48% among singers.
Execution of long musical phrases/notes across varying oc- Singing voice is unique and assessment of singing voice
taves, tempos, and with distinct clear articulation of vowels requires a multidimensional approach that involves all aspects
and consonants are essential for Carnatic singing. of voice such as structural and behavioral changes, functional
Carnatic singing emphasizes singing on a right shruthi or impact of voice disorder, and so forth. Therefore, a comprehen-
tonic pitch with correct breathing.2 Along with tonal quality, sive protocol is needed to assess various vocal functions
open-throated singing with forward placement of voice ideal- in singers. This comprehensive protocol will also facilitate
izes a good voice in Carnatic singers.3 Scientific literature de- communication of results among professionals (ear, nose, and
scribes various aspects of vocal production and ornaments in throat [ENT] surgeons, speech language pathologist [SLP],
North Indian4 and South Indian classical singers.5,6 The vocal voice specialist, and so forth). Involving the singers while mak-
lessons in Carnatic singing are graded with skills on pitch ing decisions on management will lead to better client care.10,11
matching, flexibility of voice across range, and open-throated Analysis of the findings from comprehensive voice assessment
projected voice with good tone placement. protocol will help planning management strategies. A
These rigorous training methods and practices pose enor- retrospective analysis was carried out based on documents
mous stress on the vocal apparatus of singers. In addition, from a tertiary care hospital to report inferences on findings
singers are more prone to develop voice problems due to their from assessment of voice in Carnatic singers.

AIM OF THE STUDY

Accepted for publication August 5, 2013. The aim of the present study was to report the nature of voice
From the *Department of Ear Nose Throat/Head and Neck Surgery, Sri Ramachandra
Medical College and Research Institute, Porur, Chennai, Tamil Nadu, India; and the problems and demonstrate the application of a routine voice
yDepartment of Speech, Language and Hearing Sciences, Sri Ramachandra University, protocol on 45 trained and performing Carnatic singers who re-
Porur, Chennai, Tamil Nadu, India
Address correspondence and reprint requests to Prakash Boominathan, Department of ported to a tertiary care hospital with various voice concerns.
Speech, Language and Hearing Sciences, Sri Ramachandra University, Porur, Chennai
600116, Tamil Nadu, India. E-mail: praxb77@yahoo.com
Journal of Voice, Vol. 28, No. 1, pp. 128.e1-128.e9 MATERIALS AND METHODS
0892-1997/$36.00
Ó 2014 The Voice Foundation
Forty-five Carnatic singers (36 females and 9 males) in the age
http://dx.doi.org/10.1016/j.jvoice.2013.08.003 range of 18–74 years (mean: 39.7 years and standard deviation
Ravikumar Arunachalam, et al Clinical Voice Analysis of Carnatic Singers 128.e2

FIGURE 1. Number of years of experience of singers (N ¼ 45).

[SD]: 13.42) with voice concerns, who reported to a tertiary mouth. The singers were instructed to sit in an upright, re-
care center were included in the study. Number of years of ex- laxed posture. Mouth to microphone distance was main-
perience of the singers (Figure 1) varied from 8 to 61 years of tained at approximately 30 cm. Following steps were
formal training and performance in Carnatic singing. Mean used to obtain a phonetogram:
years of experience in singing (both training and performance) a. Phonation/singing profile: The singers were asked to
for females and males were 23.80 (SD: 12.87) and 20.90 (SD: sing a basic (complete) scale (sampo:rana ra:gam)
10.55), respectively. In this group of singers, the number of called the ‘‘Ma:ya:ma:lavagoulai raagam.’’ This scale
years of singing experience between females and males did has seven notes (seven consonant-vowel syllables) in
not differ significantly (P ¼ 0.47). However, because the effect its ascending phase (aarohanam) and the same seven
of years of training and practice was high, no attempts were notes in the descending phase (avarohanam). The
made to correlate the years of experience with nature of singers were instructed to sing the notes using their com-
problem. fortable singing frequency range covering three octaves
All singers were assessed using a comprehensive voice as- (stha:yi:) (Lower octave: mandra stha:yi:, mid octave:
sessment protocol12 developed and followed in the hospital. madhya sthayi:, and upper octave: ta:rasthayi) and at
The protocol consisted of: three speeds (slow tempo: vilambitka:lam, medium
tempo: madhyamaka:lam, and fast tempo: durithaka:-
1. Structured interviews to elicit symptoms reported by the lam). The same was repeated in three different volume
singers and obtain relevant information on onset and pro- conditions, namely regular, soft, and loud.
gression of the voice problem, vocal and nonvocal habits, b. Speaking profile: Reading a passage (Rainbow pas-
and so forth. sage) or conversational speech sample in three differ-
2. Videostroboscopy: ATMOS media stroboscope was used ent intensities (soft, moderate, and high) levels each
for stroboscopic analysis and involved assessments of for minimum of 30 seconds was recorded. DSI was cal-
parameters such as glottal closure pattern,13 regularity, culated by the software by using the following
symmetry of the vocal fold vibration, mucosal wave, am- formula:
plitude of vocal fold vibration, nonvibratory portion, and
hyperadduction of ventricular folds. The ENT surgeon
evaluated for gross laryngeal pathologies. The SLP eval- DSI ¼ ½0:133MPT þ ½0:00533F0  high
uated vocal functions and behaviors.
 ½0:263I  low  ½1:183jitter þ 12:4:
3. Perceptual assessment of speaking voice: GRBAS scale14
was used.
4. Aerodynamic measures: Maximum phonation time
(MPT) and s/z ratio were noted. 6. Self-evaluation of subject: Voice disorder outcome pro-
5. Acoustic analysis: Singing frequency range and dys- file (V-DOP)16 was administered for assessing individ-
phonia severity index (DSI),15 a single weighted multi- ual’s perception of voice problems in domains such as
parametric measure was calculated using ATMOS physical, emotional, and functional aspects.
lingWAVES Phonetogram Pro and Signal Analysis Mod-
ule (version 2.4). Recording was done using a condenser A data recording sheet was constructed with all components
microphone attached to a sound pressure level meter of voice assessment and details of all singers were documented
(Center 322) mounted on a tripod. It enabled adjustment by the investigators. Mann-Whitney U test was used to compare
of height and alignment of the microphone to the singers’ the singing frequency range and DSI scores between females
128.e3 Journal of Voice, Vol. 28, No. 1, 2014

100

80

Percentage
60
42.2%
40 35.5%
31.1%
26.7%
22.2 % 22.2% 20%
20

0
Change in voice Difficulty in Difficulty in Discomfort & Difficulty in Throat tightness Dryness of
"singing higher "singing lower pain while sustaing voice and strain while throat and vocal
octaves" octaves" singing for longer singing fatigue
duration

Symptoms
FIGURE 2. Symptoms reported.

and males. Significant difference in singing frequency range Perceptual assessment

and DSI scores across clinical diagnosis was analyzed using Perceptual voice analysis of speaking voice was assessed using
Kruskal-Wallis test. GRBAS scale. The perceptual voice quality ratings ranged be-
tween normal and severe deviation. The findings of the percep-
tual voice analysis are presented in Figure 4.
RESULTS
Symptoms reported Aerodynamic measures
The percentage analysis (Figure 2) was used to document Mean and SD of MPT (/a/, /i/, and /u/) and s/z ratio for females
symptoms reported by the Carnatic singers. Change in voice and males are presented in Table 2. MPT was found to be re-
was reported by 42.2% and 35.5% complained of difficulty in duced than the expected in this group of singers (females:
singing higher pitches. Difficulty in reaching lower pitches, 10.2 seconds [SD: 5.28] and males: 15.7 seconds [SD: 5.79]).
dryness of throat, and vocal fatigue were reported in 31.1% of In this study, the mean values of s/z ratio were within normal
singers. Discomfort and pain while singing were reported in limits (females: 1.02 [SD: 0.04] and males: 1.11 [SD: 0.16]).
26.7% of singers. Difficulty in sustaining voice for a long dura-
tion and ‘‘throat tightness and strain’’ while singing were re- Acoustic analysis
ported in 22.2% of singers. The average duration of
Singing frequency range. Singing frequency range for fe-
symptoms (Figure 3) reported by singers was 1.5–6 months.
males and males across clinical diagnosis is presented in
All singers reported abusive vocal habits such as prolonged
Figure 5. The median singing frequency range for males was
loud singing, practicing in extremes of pitch, and inadequate
23.99 Semitones and for females was 21.3 Semitones. In this
voice rest between concerts. Nonvocal unhealthy habits re-
study, singing frequency range (in Semitones) was found to
ported were improper meal timings, consumption of spicy/
be reduced in singers across clinical diagnosis. Singers with
oily food, and reduced intake of water in 60% of singers.
vocal fold polyp, edema, presbylarynges, and nodule had sing-
ing frequency range lesser than those with laryngopharyngeal
Videostroboscopy findings reflux (LPR), chronic laryngitis, and muscle tension dysphonia
ENT surgeon and SLP jointly assessed the structural and func- (MTD). However, there was no statistically significant differ-
tional aspects of larynx. ENT surgeon evaluated the medical ence between singing frequency range among clinical diagnosis
status and made clinical diagnosis. SLP evaluated vocal func- (P ¼ 0.62). No statistically significant difference was observed
tion and behavioral factors. Clinical diagnosis and diagnosis in singing frequency range between females and males
based on functions are tabulated in Table 1. (P ¼ 0.15).

12
Average duration of
symptoms (months)

10

8
6
6

4
2.5 3
2 1.5 2 2
2

0
Change in voice Difficulty in Difficulty in Discomfort & Difficulty in Throat tightness Dryness of throat
"singing higher "singing lower pain while singing sustaing voice for and strain while and vocal fatigue
octaves" octaves" longer duration singing
Symptoms
FIGURE 3. Average duration of symptoms (in months).
Ravikumar Arunachalam, et al Clinical Voice Analysis of Carnatic Singers 128.e4

TABLE 1.
Stroboscopic Findings, Clinical Diagnosis, and Diagnosis Based on Function
No. of Subjects Stroboscopic Findings Clinical Diagnosis Diagnosis Based on Function
13 (11 F and 2 M) Vocal fold edema, interarytenoid LPR Hyperfunctional voice disorder
band/discoloration, and
arytenoid congestion.
10 (7 F and 3 M) Excessive muscular tension in MTD (grades I, II, and III) Hyperfunctional voice disorder
larynx (glottic and supraglottic),
normal structures, ventricular
band hyperadduction, and
strain.
9 (7 F and 2 M) Soft pliable nodules with mucosal Vocal fold nodule Hyperfunctional voice disorder
waves.
8 (6 F and 2 M) Inflammation and hypertrophied Chronic laryngitis Hyperfunctional voice disorder
larynx, increased stiffness of
fold; mucosal wave reduced or
absent.
3 (3 F) Aperiodic and asymmetrical Vocal fold edema Hyperfunctional voice disorder
movements.
1 (1F) Soft pliable polyp; aperiodic and Vocal fold polyp Hyperfunctional voice disorder
asymmetric movements.
1 (1 F) Atrophy and bowing of vocal fold, Presbylarynges Hyperfunctional voice disorder
compensatory hyperfunction. (compensated)
Abbreviations: F, female; M, male.

Dysphonia severity index. DSI is a single weighted score 5.1 of 10 which indicated that the singers who participated in
to calculate the severity of the voice problem.15 In the present the study experienced voice problems.
study, DSI scores of 45 Carnatic singers ranged from 3.5 to
4.91 indicating severe deviation to normal voice quality. The DISCUSSION
median of DSI scores for females and males were 0.075 and
Symptoms reported
0.64, respectively. Figure 6 presents the DSI scores for females
Literature from West17–19 reveal acute changes in voice,
and males across different clinical diagnosis. No statistically
problems in voice projection, and dynamic aspects of voice
significant difference was observed in DSI between females
(pitch range) as the major complaints among singers. In the
and males (P ¼ 0.07). Furthermore, it was observed that there
present study, changes in voice quality, difficulty singing
was no statistically significant difference between DSI among
in extreme pitches (high and low), fatigue, discomfort, and
clinical diagnosis (P ¼ 0.28).
pain while singing were common symptoms reported by
Self-evaluation of subject. The mean and SDs of the each singers. Voice symptoms exhibited by singers can be
domain (physical, emotional, and functional domain) and total associated with infections and inflammations of phonatory
V-DOP scores of singers is presented in Table 3. The results of apparatus. Furthermore, persistence of vocal symptoms may
self-perceptual evaluation revealed that the overall severity was be associated with inappropriate and excessive use of voice

Strain 6.9 20.7 65.5 6.9

normal
Asthenia 10.3 27.6 48.3 13.8
slight
deviation
Breathiness 3.5 44.9 31 20.7 moderate
deviation
severe
Roughness 17.2 48.3 27.6 6.9 deviation

Grade 3.5 13.8 62.1 20.7

0 10 20 30 40 50 60 70 80 90 100
Percentage of singers
FIGURE 4. Perceptual findings.
128.e5 Journal of Voice, Vol. 28, No. 1, 2014

pressure, stress, and inappropriate vocal technique lead to

TABLE 2.
Mean and SD of MPT (/a/, /i/, and /u/) and s/z Ratio
increased musculoskeletal tension.22
In the present study, 17.7% of singers and 20% of singers had
Parameters findings of laryngitis and vocal fold nodule, respectively. La-
(Unit) Females, Mean (SD) Males, Mean (SD) ryngeal inflammations, vocal nodules, and polyps are reported
/a/ (s) 10.2 (5.28) 15.7 (5.79) to be common in singers.23
/i/(s) 10 (3.8) 20 (3.9) The study had four singers above the age of 60 years; how-
/u/(s) 9.8 (3.5) 20 (4.5) ever, only one female singer aged 74 years showed age-
s/z Ratio 1.11 (0.16) 1.02 (0.04) related structural changes in larynx such as atrophy, bowing/
phonatory gap, and hyperfunction of ventricular folds (compen-
sated) with asymmetrical movements of vocal folds and re-
such as improper singing technique or singing at loud volume duced mucosal wave. Voice problems due to aging process
during rehearsals or performance.17 Increase in laryngeal mus- are common24 resulting in structural alterations and functional
cle tension is another common problem in singers leading to limitations25 in voice production.
voice disorders.20 Throat tightness and strain while singing re- All subjects had hyperfunctional voice disorder in this study,
ported in this study may be associated with increased musculo- irrespective of their age, sex, and singing career length. Al-
skeletal tension in the larynx and perilaryngeal area. though one would assume more a singing technique–related
In this study, the average duration of symptoms reported reason for MTD among singers, the findings in this study alerts
varied from 1.5 to 6 months. A survey on Carnatic singers7 to other possible reasons for functional voice disorders. Culture
in India revealed that long-lasting voice problems (lasting relevant variations in work style (and possibly pressure), diet
more than a week) were more common among singers. This and food habits, and life style cannot be neglected to cause
was assumed to be related to apprehension and reluctance in structural and functional changes in the larynx.
singers to seek professional/medical treatment for problems
at an early stage. Singers prefer trying ancient home reme-
dies/practices for voice-related concerns before consulting Perceptual assessment
professionals for help in India. On contrary, study done by Perceptual voice evaluation is regarded as the gold standard
Rosen and Murry18 in Western singers stated that singers for documenting voice disorder severity.26 In this study, voice
were more sensitive to subtle voice changes and presented quality of the speaking voice was rated using GRBAS scale.
early to clinics. The overall grade rating (G) revealed moderate deviation in
most of the singers in speaking voice. The perceptual voice
Videostroboscopy findings change in speaking could be attributed to the hyperfunctional
Reflux laryngitis was the most common findings in Carnatic voice usage and structural changes noticed in vocal folds.
singers. A study on vocal and nonvocal habits in Carnatic Increased musculoskeletal tension of the phonatory apparatus
singers by Boominathan et al7 had revealed that singers re- may lead to increased effort while speaking resulting in phys-
ported irregular dietary patterns, prolonged loud singing prac- ical perceptible strain. This study was limited to analyzing
tice, enormous work stress, and insufficient rest between speaking voice only as it was routinely followed as part
concerts. Earlier survey reports7 and current findings relate as- of the protocol. However, perceptual voice quality ratings dif-
sociation of dietary habits, life style changes, and work fer with speaking and singing voices.27 Auditory perceptual
pressure. rating of singing voice requires standard tool that accommo-
Around 33% of singers were diagnosed to have primary dates different aspect of singing voice. In addition, incor-
MTD (grades I, II, and III). It is reported in literature that laryn- porating a rating scale for singing voice may be ideal in
geal musculoskeletal problems are very common in profes- comprehensive assessment of professional voice users such
sional voice users, especially in singers.20,21 Effects of work as singers.

30 Females Males
Median Singing frequecny range

26.5
23.2 23.75
25 22.7 22.95 23.04
21.6 21.35
18.7 18.9
20
(Semitones)

13.9
15

10

0
LPR Vocal fold Chronic Vocal fold Vocal fold Presbylarynges Muscle Tension
nodule laryngitis edema polyp Dysphonia
Clinical diagnosis
FIGURE 5. Singing frequency range for females and males across clinical diagnosis.
Ravikumar Arunachalam, et al Clinical Voice Analysis of Carnatic Singers 128.e6

2
1.59 1.68
1.5 Females Males

Median DSI scores

1 0.87
0.64
0.5
0.5 0.38
0.17 0.09 0.09
0

-0.5

-1
-0.96
-1.5

-2
-2.09
-2.5
LPR Vocal fold Chronic Vocal fold Vocal fold polyp Presbylarynges Muscle Tension
nodule laryngitis edema Dysphonia
Clinical diagnosis
FIGURE 6. DSI scores for females and males across clinical diagnosis.

Aerodynamic measures stricted for singers with mass lesions such as nodules, polyps,
Singing requires a highly coordinated breathing and phonation. and edema. Presence of extra mass in vocal fold may lead to dif-
In this study, MPT was reduced than expected in both females ficulty in reaching higher pitches.29 However, no statistically
and males. Carnatic singing emphasizes the importance of significant difference in mean singing frequency range was ob-
breathing for singing and improving breath support and control. tained across different pathologies. Flexibility in reaching dif-
However, no formal training or exercises are taught to achieve ferent pitches is an essential component for ‘‘good’’ singing.
the required breath support and control for singing.7 Reduced Also reduced flexibility and restricted range could be attributed
MPT can be due to the poor coordination between breathing to excessive and inappropriate use of vocal mechanism result-
and phonation. These could be attributed to underlying vocal ing in or from structural abnormalities.
pathology or improper technique used for singing. Dysphonia severity index. DSI is a sensitive and objective
measure to analyze voice quality.15 In the present study, DSI
scores of the singers revealed normal to severe deviation. Devi-
Acoustic analysis
ant values noticed in DSI are due to abnormal values in I-low,
Singing frequency range. Study done on frequency range jitter, and MPT. Despite perceptible problems reported by
in trained Carnatic singing5 revealed that singers traversed 2– singers, a few of them showed normal DSI values. This directs
2.5 octaves comfortably when compared with historic expecta- the need for clinicians to correlate laboratory-based measures
tions of three octave singing. The average frequency range for and clinical findings with patient feelings to arrive at appropri-
males was 23.99 Semitones and in females, it was 21.3 Semi- ate management strategies. Normal DSI values also may indi-
tones.5 In Carnatic singing, overall range is lesser (26 ST)5 cate that singers can modify the functional capacity of their
compared with Western classical singing (38.4 ST).28 In the phonatory apparatus to provide a ‘‘serviceable voice’’ linked
present study, the singers showed a reduced singing frequency to psychophysical effort (difficult to quantify) despite structural
range than expected. Most of the singers in this study reported limitations.
difficulty in reaching higher and lower octaves as their major
Self-evaluation of subject. In overall severity of the voice
concern. Mean singing frequency range was observed to be re-
problem, the average score was 5.1 of 10. This revealed self-
perceived severity in overall voice quality. Furthermore,
TABLE 3. V-DOP scores revealed concerns in all domains predominantly
Mean and SD of Each Domain and Total V-DOP Score of related to physical and emotional aspects of voice production.
Subjects Functional domain scores were lesser than physical and emo-
tional domain. This could be because the questions in V-DOP
Domains Mean SD
focused on speaking voice and it did not address any specific
Severity 5.1 2.7 issues to singing voice. In the study by Rosen and Murry,18
Physical 40.4 21.5 while determining the degree of handicap reported by singers,
Emotional 39 23.1 voice handicap index (VHI) scores were lower than the general
Functional 31 24.2
voice patient’s. They concluded that a low score did not neces-
Total 110.24 73.20
sarily indicate a weak handicap and rather pointed out that
 128.e7
TABLE 4.
Clinical Diagnosis and Management Decisions
Management

No. of Subjects Clinical Diagnosis Diagnosis Based on Function Medical Therapy

13 (11 F and 2 M) LPR Hyperfunctional voice disorder Antireflux medications: proton Vocal hygiene instructions,
pump inhibitors with/without conservative voice use, and
prokinetics for 6 wk postural correction
9 (7 F and 2 M) Vocal fold nodule Hyperfunctional voice disorder — Vocal hygiene instructions,
conservative voice use, and
postural correction
Voice therapy—breathing and
vocal function exercises31
8 (6 F and 2 M) Chronic laryngitis Hyperfunctional voice disorder Anti-inflammatory medications Vocal hygiene instructions,
with/without steroids conservative voice use, and
postural correction
Voice therapy to unlearn
hyperfunctional behaviors
3 (3 F) Vocal fold edema Hyperfunctional voice disorder Anti-inflammatory medications Vocal hygiene instructions,
conservative voice use, and
postural correction.
Voice therapy—breathing and
vocal function exercises31
1 (1 F) Vocal fold polyp Hyperfunctional voice disorder Microlaryngeal surgery Vocal hygiene instructions,
conservative voice use, and
postural correction.
Voice therapy—breathing and
vocal function exercises31
after surgery
1 (1 F) Presbylarynges Hyperfunctional voice disorder — Vocal hygiene instructions,
(compensated) conservative voice use, and

Journal of Voice, Vol. 28, No. 1, 2014

postural correction.
Voice therapy—breathing and
vocal function exercises31
10 (7 F and 3 M) Muscle tension dysphonia Hyperfunctional voice disorder — Vocal hygiene instructions,
(grades I, II, and III) conservative voice use, and
postural correction.
Voice therapy—laryngeal
massage, breathing and
vocal function exercises31
Abbreviations: F, female; M, male.
Notes: Discussing specifics of every subject is beyond the scope of this article, and so most observable signs are documented in the above table.
Ravikumar Arunachalam, et al Clinical Voice Analysis of Carnatic Singers 128.e8

questions should address the specific needs of this group. As the volved in this field, including speech pathologists, laryngolo-
primary focus of VHI was on speaking voice, the questionnaire gists, and singers/performers, and singing teachers regarding
was less sensitive in identifying voice problems in singers.18,30 prevention, early identification, and treatment of individuals
This indicates the need to develop a PROM (patient-reported with voice concerns.
outcome measures) tool to assess this group of singers.

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