Vocal Cord Surgery for Singers

Dr. Wohlt, in our last two interviews, we talked extensively about voice surgery on and vocal rehabilitation for professional singers. Today, I would like to discuss with you the key questions an artist facing vocal cord surgery should ask.

First of all, one has to understand that the decision to undergo vocal cord surgery is one of the most difficult decisions in a singer’s lifetime. The rest of his career and his future life's planning depend it. This decision is not made, however, until the artist has gone through an awareness-building process during which he incrementally comes to the realization that he can no longer accept the current state of his voice quality. This happens after a long line of cancelled performances and concerts before an audience. The causes for his impaired voice quality are usually due to organic changes to the vocal folds; these can include vocal cord nodules or vocal cord edema. Everything starts with the singer personally wanting to change things by undergoing vocal cord surgery; that is the first and most important decision on the way to improving his voice.

How can the singer be certain that the findings regarding his vocal cords truly indicate that surgery is needed?

This is when the singer is already asking the second key question, namely that about the indication for surgery. Whether the impaired voice quality is actually based on changes to the vocal folds that require surgery must be confirmed by laryngological examinations. At best, a videostroboscopy should be done by a voice doctor experienced in the treatment of professional singers. Indeed, only detailed knowledge of the findings can dictate the necessary steps leading to surgery.

That leads us to the question of who is the right surgeon. How can a singer be sure that he has found a highly qualified voice doctor or voice surgeon? What recommendations can you give us?

The question about the right doctor is with certainty one of the most crucial questions of all. As early as possible, the singer should do extensive research and, if possible, listen to the recommendations of other singers who have already undergone surgery. Fundamentally, however, I must emphasis that a voice surgeon who operates on professional singers not only needs to be a skilled surgeon. Above and beyond this, the voice surgeon must follow a holistic approach to the therapeutic management of professional singers. What is of even greater importance, however, is a profound understanding of professional singers’ voices and extensive practical experience with the profile of requirements for a singing professional. Furthermore, such surgeons should have extensive singing experience of their own. Without this singing experience, how else can the surgeon be in a position to adequately judge and differentially diagnose the professional singer's voice and its disorders?

In this regard, do you recommend voice departments in a hospital?

For surgery on professional singers, unequivocally: No! At university voice clinics, the principle of divided areas of competence reigns. That means that both experienced as well as less experienced doctors, speech therapists and singing voice therapists work on and with the patients who are professional singers. Due to the subdivision of the various areas of competency, the holistic nature and thereby the therapeutic thread in patient management is frequently lost. Additionally, it's a question of responsibility. Who is responsible for what? This might be compared to the construction business. If you have contracted a variety of companies to work on building your house, you will have difficulty determining whose responsibility it is to do what job. In my opinion, the attending voice doctor should be a competent doctor and a skilled surgeon, but also possess artistic competency. Therefore, I always advise singers to look for a doctor specialized in voice medicine or voice surgery who has enjoyed a sound musical education and singing training in addition to his or her top-notch operative expertise. It is rare to find doctors with these competencies at university departments. In fact, there are only very few doctors in Europe who are specialized in voice surgery for professional singers. The affected artist is well advised to go out and make an effort to find the right specialist.

Dr. Wohlt, could you please now explain to us: What is the type of doctor a singer should place less trust in. I know, it's a sensitive question.

Singers should be particularly wary of doctors who promise them a better voice quality than they ever had before their voice disorder started or who believe they can impress potential patients with the large numbers of operations they performed. The likes of such trumpeted pronouncements are not consistent with the factors and attitudes that an operation on the singer's voice – an intimate, creative task – demands: Meticulous circumspection, tranquility and inner bearing. Caution is also advised when such doctors are on the lookout for new areas of business and discover that vocal arts medicine for singers might be a field for them, although they do not possess the necessary medical or artistic experience. By asking the right questions in advance, singers can find out about the character and motives of the doctor into whose hands they are placing their fate and fortunes.

And once a singer has found the right doctor, what question should he then ask?

The next question should concern the optimal surgical procedure. This primarily involves asking about the operative technique, but also about the selection of suitable instruments and the best possible anesthesia. It is the voice surgeon's responsibility to propose a method that is the most gentle and risk-free for the singer.

Could you perhaps describe your method to us and also outline the potential risks to be aware of?

Over the last 15 years now, I have developed a special surgical technique for performing voice surgery and modified it to the singing voice. It is a type of plastic reconstruction work to reinstate the fine vibrations of the vocal cords. This later becomes the decisive criterion for achieving a soft, nuanced voice. I would say that this technique is my signature method: I have meanwhile performed it on hundreds of singers. Judging by the years of follow-up examinations on my patients, I know that this surgical technique produces excellent long-term vocal outcomes. I fundamentally operate on my patients under general anesthesia because that is the only way that allows the use of both hands during microdissection on the vocal folds. I would like to warn singers about what is called the “indirect method” performed with the conscious patient under local anesthesia sitting in the examination chair facing the surgeon. With this method, the surgeon employs a curved grasping forceps that is advanced through the oral cavity down to the patient’s vocal folds where the diseased tissue is plucked or torn off the vocal cord surface. The risk of injuring healthy vocal fold mucosa and thereby causing irreversible damage to the voice is not insignificant, especially given the potential for inadvertent movements by the patient. Furthermore, singers are urgently advised against the use of lasers during the operation. The thermal energy produced by the laser, which is essentially used like a “hot knife”, can leave behind severe burn injuries on the delicate mucosal layers of the vocal folds. The consequence can be irreversible, scar-like lesions on the vocal fold tissue. Since scar tissue is not capable of vibratory motion, this laser treatment sometimes ends in serious voice disorders.

So, after the vocal cord surgery has – hopefully – been successful, which questions should the singer now ask?

The next important issue now is the question about the postoperative treatment. In this context, I always recommend my singers to maintain at least a 10- to 14-day period of vocal rest. During that time, they should also take their indicated drug therapy. After the wound has healed – and this gets back to the question before last – the artist is advised to complete a program of vocal rehabilitation for professional singers. The aim here is to correct the functional pressure patterns of his or her voice.

As you will recall, we devoted our last interview to vocal rehabilitation for professional singers – another therapeutic concept you developed. Let's therefore move on to the next question.

These singers must ultimately ask themselves what are the personal consequences they would like to draw from their vocal cord surgery in order to avoid a similar medical scenario in the future. At such a juncture, it is often recommendable to adapt their repertoire and refrain from certain overly dramatic or uncomfortable opera roles. I have frequently done repertoire analyses on affected singers – in coordination with agents and vocal pedagogues.

Dr. Wohlt, you once said, surgery on a singer is like an artistic project. May I ask you to give us a summation on that today?

For myself personally, surgery on a singer is always an artistic act during which the voice surgeon is creatively shaping and forming the singer's instrument. This kind of undertaking essentially can only truly be performed by an artist himself. It entails great responsibility and is borne by the profound desire to create a work of brilliance for the singer. I wish for every performing artist that the Law of Resonance lead them to an “artist” in the practice of voice medicine.