Prevalence of Abnormal Laryngeal Findings in Healthy

Singing Teachers
*Robert T. Sataloff, *Mary J. Hawkshaw, *Jennifer L. Johnson, †Brienne Ruel, ‡Allen Wilhelm,
and §Deborah Lurie, *xPhiladelphia, Pennsylvania, yNashville, Tennessee, and zLincoln Park, New Jersey

Summary: Objective. To determine the prevalence of abnormal laryngeal findings during strobovideolaryngoscopy
and objective voice measurement in healthy singers without significant voice complaints.
Study Design. Prospective evaluation of professional singing teachers.
Setting. A quiet room in a hotel during a convention of the National Association of Teachers of Singing.
Subjects. Seventy-two volunteers (60 females and 12 males), all of whom were trained singers without significant
voice complaints.
Main Outcome Measure. Abnormalities observed on strobovideolaryngoscopy.
Secondary Outcome Measure. Abnormalities identified during acoustic analysis.
Results. Abnormalities were found during strobovideolaryngoscopy in 86.1% (62 of 72 of subjects, many of whom
had more than one abnormality. For the purpose of this study, the authors defined ‘‘normal’’ as having no structural
pathology (masses, cysts, ectasias, and so on) and a reflux finding score (RFS) of less than 7. Subjects’ evaluations
were considered ‘‘abnormal’’ if they had at least one documented laryngeal pathology and/or an RFS  7. The most
common findings were signs associated with laryngopharyngeal reflux (LPR). Subjects were also identified with prom-
inent varicosities or ectasias, incomplete glottic closure, and structural abnormalities. LPR was observed in 72% of
patients using the physical findings (arytenoid erythema and/or edema) relied on typically to establish the clinical di-
agnosis as well as using the RFS (16.7% in women and 25% in men). Posterior laryngeal mucosal hypertrophy was also
demonstrated in 64% of the participants. Acoustic analysis of female subjects showed that shimmer, relative average
perturbation, and maximum fundamental frequency differed significantly from widely used norms.
Conclusion. Laryngeal abnormalities occur commonly in asymptomatic patients. Physicians must exercise caution in
establishing a causal relationship between an observed abnormality and a patient’s voice complaint. Baseline examina-
tions of voice patients when they are healthy and asymptomatic should be encouraged to establish each individual’s
‘‘normal’’ condition.
Key Words: Singer’s health–Strobovideolaryngoscopy–Occult laryngeal abnormalities–Objective voice measures–
Acoustic voice measures–Reflux finding score–Reflux laryngitis–Laryngopharyngeal reflux–Asymptomatic voice
abnormality.

INTRODUCTION are responsible for the patient’s problem. This study was carried
Strobovideolaryngoscopy and objective voice measures are out to determine the prevalence of abnormal findings in a select
critical in the diagnosis and management of any patient with group of vocally healthy singing teachers with no significant
voice complaints. Strobovideolaryngoscopy provides valuable voice complaints.
information regarding the anatomy and function of the vocal Similarly, objective acoustic voice measures are used com-
folds, as well as supraglottic and subglottic structures. This monly in clinical practice. However, the normative values refer-
slow-motion evaluation of the mucosal layer of the leading enced routinely were not established on trained singers. This
edge of the vocal folds helps detecting asymmetries of vibra- study evaluated acoustic measures in healthy singing teachers
tion, structural abnormalities (including vascular abnormali- to determine whether their results were consistent with the nor-
ties), small masses, submucosal scars, and many other mative values used in most clinical voice laboratories.
aberrations that cannot be seen under ordinary light. However, In the present study, the authors examined strobovideolar-
expert interpretation of findings is required. Some individuals yngoscopic findings and objective voice measurement findings
without voice complaints have vocal fold abnormalities that in 72 healthy singing teachers in an effort to help determine the
cause no symptoms. If these are discovered during examination prevalence and variability of occult vocal fold pathology.
of a voice complaint, it is easy to conclude erroneously that they
METHODS
Accepted for publication January 17, 2012.
From the *Department of Otolaryngology—Head and Neck Surgery, Drexel University
At the 2008 Convention of the National Association of Teachers
College of Medicine, Philadelphia, Pennsylvania; yDepartment of Otolaryngology, of Singing in Nashville, TN, volunteers were recruited for par-
Vanderbilt Voice Center, Nashville, Tennessee; zKayPentax, Lincoln Park, New Jersey;
and the xDepartment of Mathematics, St. Joseph’s University, Philadelphia, Pennsylvania.
ticipation in this study after institutional review board approval
Address correspondence and reprint requests to Robert T. Sataloff, Department of had been obtained. Seventy-six healthy singing teacher partic-
Otolaryngology—Head and Neck Surgery, Drexel University College of Medicine, 1721
Pine Street, Philadelphia, PA 19103. E-mail: rtsataloff@Phillyent.com
ipants (13 males and 63 females) completed a brief question-
Journal of Voice, Vol. 26, No. 5, pp. 577-583 naire, underwent strobovideolaryngoscopy, and provided
0892-1997/$36.00
Ó 2012 The Voice Foundation
a digital recording of speech and nonspeech utterances. All par-
doi:10.1016/j.jvoice.2012.01.002 ticipants had no voice complaints and reported no major
578 Journal of Voice, Vol. 26, No. 5, 2012

systemic illnesses. Exclusion criteria included a voice (singing

TABLE 1.
or speaking) complaint for which the subject would typically Conditions Related to Minor Voice Complaints
consult a laryngologist for evaluation. After exclusions, 72 sub-
jects (60 females and 12 males) were included in the study. Complaint Frequency
Data collection occurred in a quiet room at the conference ho- Allergies/asthma 11
tel. All stroboscopic examinations were performed with the sub- Reflux 8
jects seated, and no topical anesthetic was used. Stroboscopic Postnasal drip/sinusitis, bronchitis 7
examinations were recorded using the KayPentax (Montvale, Minor technical issues—suboptimal clarity, 6
NJ) Model #RLS 9100-B laryngeal stroboscope. Laryngeal suboptimal range, fatigue, wobble
examinations were performed using the rigid KayPentax 70 History of vocal fold hemorrhage 1
History of vocal fold polypectomy 1
laryngeal telescope. The authors’ standard protocol for strobovi-
deolaryngoscopic examination was used and has been published
previously.1,2 Speech and nonspeech tasks were used during the ranged in age from 27 to 82 years, with a mean (±standard
strobovideolaryngoscopic examination. Subjects were asked to deviation [SD]) of 48.7 ± 12.0 years.
state their full name, to read the Rainbow Passage, sing ‘‘Happy The participants completed the questionnaires that were re-
Birthday,’’ and to sustain an jɑj at a comfortable pitch. With the viewed before their strobovideolaryngoscopy examination
telescope in place, they were asked to sustain the vowel jij at and voice recordings and used later for statistical analysis.
different pitches and to perform glissando singing maneuvers Thirty-eight participants (53%) reported no voice problems.
and other tasks to assess vocal fold movement and flexibility, Thirty-four participants (47%) reported minor voice issues
pitch range, laryngeal nerve function, vocal fold vibration, mu- and/or ongoing medical conditions that might affect their voice
cosal wave, and glottic competence. Repetition of short syllabic (Table 1), but none thought they needed laryngologic care cur-
voicings (jij-jhij-jij-jhij) were used, as well. The observable rently. Fifty-nine participants (82%) reported no medical prob-
characteristics that were analyzed included supraglottic function lems. Thirteen (18%) reported systemic illnesses, which are
(or hyperfunction), bilateral vocal fold motion, symmetry of vo- summarized in Table 2. All participants were asked whether
cal process height, arytenoid joint motion, presence of arytenoid they had sought medical evaluation within the previous year
edema or erythema, consistency of secretions, presence of supra- for voice issues, and all responded no. Of the participants
glottic masses, posterior laryngeal hypertrophy, vocal fold sym- who reported chronic medical conditions, none felt that their
metry in amplitude and phase, vocal fold periodicity, vocal fold condition(s) had any impact on their vocal quality or endurance.
wave forms, glottic closure, vibratory function of each vocal All subjects were trained singers, with most having studied
fold, presence of masses or scars, and presence of prominent vas- for 15 years or more. Many were still active as soloists. Most
culature. Reflux finding scores (RFS) were also calculated.3 All of them performed in public four times a year or less
stroboscopic examinations were stored on disk for reevaluation (55.6%), but 34.7% performed once a month or more.
at a later time by a senior author (R.T.S.). Clinical impressions For the purpose of this study, the authors defined ‘‘normal’’
and findings of two examiners (M.J.H. and R.T.S.) were com- as having no structural pathology (masses, cysts, ectasias, and
pared for interrater reliability. Review and interpretation of all so on) and a RFS of less than seven. Subjects’ evaluations
strobovideolaryngoscopic examinations focused on the pres- were considered ‘‘abnormal’’ if they had at least one docu-
ence or absence of true vocal fold pathology, disorders of mobil- mented laryngeal pathology and/or an RFS  7. Laryngeal ab-
ity, and the presence and severity of laryngopharyngeal reflux normalities in this healthy population of singing teachers
(LPR). Acoustic analysis of the digital voice recording was per- were found during strobovideolaryngoscopy in 86.1% of the
formed using the KayPentax computerized speech lab (CSL). 72 subjects evaluated, many of whom had more than one ab-
The Rainbow passage and sustained jɑj utterances were used. normal finding. The presence of laryngeal pathology by gen-
Selected variables were assessed, including fundamental fre- der was 86.7% for females and 88.3% for males. Data are
quency, perturbation measures, and other measures of phona-
tory range. TABLE 2.
Systemic Illnesses

RESULTS Systemic Illness Frequency

Participants included in this study reported no voice problems Autoimmune: rheumatoid arthritis, 4
that they considered significant or that the investigators could scleroderma, Raynaud’s phenomenon,
hear during speech or singing. Three participants were excluded optic multiple sclerosis, and CREST
owing to their inability to complete strobovideolaryngoscopy. syndrome
Two of these were disqualified because of hyperactive gag re- Hypertension and elevated cholesterol 2
Thyroid disease (without voice symptoms) 2
flex, one because the vocal folds could not be viewed clearly
Celiac/gallbladder disease 2
as a result of a prominent u-shaped epiglottis. One participant’s Depression 2
data were missing from the recorded sample and not included. Insomnia 1
Thus, all analysis was based on the data for the remaining 72
CREST, limited cutaneous scleroderma.
subjects. There were 60 females and 12 males. The subjects
Robert T. Sataloff, et al Abnormal Laryngeal Findings During Strobovideolaryngoscopy 579

TABLE 3.
Percent of Patients With Abnormal Strobovideolaryngoscopy Findings Ranked From Highest to Lowest Prevalence
Variables Female (n ¼ 60) Male (n ¼ 12) All (n ¼ 72)
Arytenoid erythema/edema 43 (71.7) 9 (75.0) 52 (72.2)
Posterior hypertrophy 37 (61.7) 9 (75.0) 46 (63.9)
Incomplete glottic closure 24 (40.0) 1 (8.3) 25 (34.7)
Reflux finding score (7) 10 (16.7) 3 (25.0) 13 (18.1)
Varicosities and/or ectasias 9 (15.0) 4 (33.3) 13 (18.1)
Structural abnormalities 11 (18.3) 1 (8.3) 12 (16.7)
Paresis 10 (16.7) 1 (8.3) 11 (15.3)
Phase symmetry 7 (11.7) 0 (0) 7 (9.7)
Left vibratory function 3 (5.0) 0 (0) 3 (4.2)
Right vibratory function 1 (1.7) 0 (0) 1 (1.4)
Notes: Data are presented as n (%).

summarized in Table 3. The most common pathologies for the females, there was a significant difference detected in the mean
entire group were arytenoid erythema and/or edema (72.2%), noise-to-harmonic ratio scores by normality. Mean scores for fe-
posterior hypertrophy (63.9%), incomplete glottic closure males were compared by the most common pathologies found, in-
(34.7%), RFS  7 (18.1%), and varicosities and/or ectasias cluding arytenoid erythema, posterior hypertrophy, arytenoid
(18.1%). For females, the most common pathologies were ar- edema, incomplete glottic closure, RFS  7, and paresis. No dif-
ytenoid erythema and/or edema (71.7%), posterior hypertro- ferences were found by pathology. There were too few males to
phy (61.7%), incomplete glottic closure (40%), structural perform this analysis. Acoustic analysis of the rainbow passage
abnormalities (18.3%), RFS  7 (16.7%), and possible vocal also was evaluated. Mean scores for females and for males
fold paresis (16.7%). For males, the most common patholo- were compared with regard to the presence of pathology, and
gies were posterior hypertrophy (75%), arytenoid erythema no differences were found. These results are not presented.
and/or edema (75.0%), varicosities and ectasias (33.4%), For three acoustic variables, the means in the study pop-
and RFS  7 (25.0%). ulation differed from the norms provided by KayPentax and
Of the 13 subjects who had a RFS  7, all had arytenoid er- used widely by clinicians using CSL. These were shimmer,
ythema and/or edema. Of the 59 subjects with a RFS < 7, 39 relative average perturbation (RAP), and maximum funda-
(66.1%) had arytenoid erythema and/or edema. mental frequency (max F0). Parallel histograms to illustrate
Using the presence of arytenoid erythema or edema or poste- the distribution of each measure by gender are displayed in
rior hypertrophy as a clinical indication of LPR, there were 12 Figures 1–3. Comparison of descriptive statistics, including
patients with no clinical findings and a 0 RFS score. There were mean and median, was performed to determine whether
eight patients with hypertrophy only, 14 with erythema or the differences were because of the effects of an outlier
edema and no hypertrophy, and 38 with erythema/edema and (or outliers) or indicated true differences for singers
hypertrophy. (Tables 6–8).
Acoustic analysis of the subjects’ phonation of jɑj was per- For the males, the mean and SD of jɑj shimmer are similar
formed. Mean scores for females (Table 4) and males to the Kay norms. For the females, the mean and SD are both
(Table 5) were correlated with the presence of pathology. For larger than the Kay norms. The median shimmer is 3.5%.

TABLE 4.
Analysis of jɑj by Overall Diagnosis for Female Subjects
TABLE 5.
Subjects With at Least One Analysis of jɑj by Overall Diagnosis for Male Subjects*
Subjects Abnormality Detected by
Subjects With at Least One
Acoustic Diagnosed as Strobovideolaryngoscopy
Abnormality Detected by
Measure Normal (n ¼ 8) (n ¼ 52)
Normal Strobovideolaryngoscopy
F0 205.87 ± 40.48 209.19 ± 30.93 Measure Subjects (n ¼ 2) (n ¼ 10)
RAP 0.86 ± 0.86 0.54 ± 0.37
F0 134.27 ± 26.15 123.25 ± 15.15
Shimmer 4.47 ± 2.20 3.63 ± 1.64
RAP 0.24 ± 0.14 0.23 ± 0.09
NHR* 0.16 ± 0.05 0.13 ± 0.02
Shimmer 2.31 ± 0.41 2.65 ± 0.77
VTI 0.05 ± 0.01 0.04 ± 0.01
NHR 0.13 ± 0.01 0.14 ± 0.01
Notes: Data are reported as mean ± standard deviation. VTI 0.05 ± 0.02 0.04 ± 0.01
Abbreviations: F0, fundamental frequency; RAP, relative average pertur-
bation; NHR, noise-to-harmonic ratio; VTI, voice turbulence index. Notes: Data are reported as mean ± standard deviation.
* P < 0.05. * P ¼ NS.
580 Journal of Voice, Vol. 26, No. 5, 2012

FIGURE 1. Distribution of shimmer measurements by gender.

With regards to jɑj RAP, for the males, the mean and SD are of F0-max are greater than Kay norms for both male and female
lower than Kay norms. However, the sample size is too small participants.
to draw any inferences. For the females, the mean and SD are A summary of normative values for the 60 healthy female
both larger than the Kay norms. The median RAP is 40%. How- singing teachers is presented in Table 9. The normative values
ever, there is much more variation in RAP within the group of for the 12 healthy male singing teachers in this study are pre-
female singers. For Rainbow Passage F0-max, the mean and SD sented in Table 10.

FIGURE 2. Relative average perturbation distribution by gender.

Robert T. Sataloff, et al Abnormal Laryngeal Findings During Strobovideolaryngoscopy 581

FIGURE 3. Distribution of maximum fundamental frequency by gender.

DISCUSSION 69% of the singing teachers without voice complaints. They

Abnormal findings on strobovideolaryngoscopy may be caus- found abnormalities of vocal fold mobility in 71% of teachers
ally related to a patient’s voice complaint. However, abnormal with vocal complaints and 23% of teachers without voice com-
occult laryngeal findings occur in healthy (nontreatment seek- plaints. All volunteers (100%) had abnormal laryngeal findings
ing) individuals without voice complaints. Lundy et al4 re- consistent with LPR.
ported the incidence of laryngeal abnormalities that they In 2001, researchers from the Center for Voice Disorders at
found in 65 singing students at a local school of music. They Wake Forest University reported their findings of occult laryn-
reported a high incidence (73.4%) of findings suggestive of geal pathology in a population of adults older than 40 years with
LPR in this group and 8.3% (5 students) were found to have be- no history of voice problems.7 They evaluated 100 volunteers
nign vocal fold masses (2 had nodules and 3 had cysts). Elias with flexible laryngoscopy and found laryngeal abnormalities
et al5 evaluated the strobovideolaryngoscopic examinations of suggestive of LPR in 64% of this cohort and vocal fold bowing
65 professional singers without voice complaints. They re- in 72%. Only 12% had normal laryngeal examinations. Studies
ported a overall 58% incidence of abnormal findings and such as these highlight the variability of vocal fold findings in
a 9% incidence of benign lesions (nodule, cyst, and varicosity). patients without and with vocal fold complaints and emphasize
Forty-two percent had findings consistent with LPR. the need for caution in determining causal relationships
In another study, Heman-Ackah et al6 examined a volunteer between vocal fold abnormalities in individuals’ voice
group of 20 singing teachers, seven of whom had voice com- complaints.
plaints and 13 of whom had no voice complaints. They identi- There were several variables not controlled in this study,
fied benign vocal fold lesions (cyst and polyp) in a surprising which may have had impact on the authors’ findings. There

TABLE 6. TABLE 7.
Comparative Statistics Comparative Statistics jɑj RAP
Category Females Males Category Females Males
Kay norms 2.00 ± 0.79 2.52 ± 1.00 Kay norms 0.38 ± 0.21 0.34 ± 0.33
All study participants 3.74 ± 1.73 2.60 ± 0.73 All study participants 0.58 ± 0.47 0.23 ± 0.09
Study participants 3.56 ± 1.46 2.60 ± 0.73 Study participants 0.54 ± 0.37
(without extreme Median: 3.5 Median: 2.52 (without extreme Median: 0.39 Median: 0.19
outliers) IQR: 2.11 IQR: 0.94 outliers) IQR: 0.40 IQR: 0.30
Abbreviation: IQR, interquartile range. Abbreviations: RAP, relative average perturbation; IQR, interquartile range.
582 Journal of Voice, Vol. 26, No. 5, 2012

In the authors’ prior publications, they have generally made the

TABLE 8.
Comparative Statistics Rainbow Max F0
diagnosis based on erythema and/or edema of the mucosa over-
lying the arytenoid cartilages and posterior aspect of the larynx.
Category Females Males Using these criteria, they suspect that approximately 72% of the
Kay norms 252.7 ± 26.6 150.1 ± 24.4 subjects in the study have LPR. This impression is strengthened
All study participants 329.2 ± 53.1 226.5 ± 43.3 in the approximately 64% who also demonstrated posterior la-
Study participants 322.5 ± 47.1 ryngeal mucosal hypertrophy. These numbers are consistent
(without extreme Median: 339.2 Median: 227 with their previous observations and with those of many other
outliers) IQR: 78.5 IQR: 0.58.8 investigators. However, the authors’ also calculated RFS. Using
Abbreviations: F0, fundamental frequency; IQR, interquartile range. this criterion, only 18% in females and 25% in males were diag-
nosed with reflux. They have presented both numbers in this ar-
ticle in order that readers may compare the results with other
was no measurement of general physical fatigue, inadequate literature that uses clinical signs, as well as with literature that
sleep, or degree of personal stress. Most participants had trav- relies on the RFS. Although the RFS was introduced as a vali-
eled by air from various parts of North America to attend this dated measure, controversy regarding validity remains. Addi-
meeting. Many voiced complaints of ‘‘jet lag’’ and ‘‘dryness’’ tional research should be encouraged to help determine
secondary to air travel and hotel and meeting rooms. All partic- whether the diagnosis of reflux is underestimated by the RFS,
ipants reported increased talking with colleagues and friends overestimated based on laryngeal signs, or whether the accurate
throughout the day and socializing at night. Examinations number of subjects with LPR lies between these determinations.
were performed at various times throughout the meeting days.
Many participants were examined in the morning (when reflux
may be more apparent in some people), and others were exam- CONCLUSION
ined after the lunch hour (when signs of reflux may be less ap- Strobovideolaryngoscopy is invaluable in the diagnosis and
parent in some, but more apparent in others). All subjects were treatment of voice disorders. However, abnormal findings are
offered the opportunity to reschedule their examinations if they common in asymptomatic subjects. Great care must be exer-
did not feel that they could perform well because of time or cised in determining whether an abnormality identified during
physical constraints. In addition, caution must be exercised in examination is related causally to the patient’s voice complaint.
inferring any information for the male population because the Abnormal acoustic measures also are common in asymptomatic
sample size is small. subjects. Baseline testing of healthy, asymptomatic patients can
The methods of reporting LPR in this study warrant special be invaluable in establishing a ‘‘normal’’ condition of each
comment. Clinical diagnosis of reflux (in the absence of confir- individual, and such examination should be encouraged
mation by 24-hour pH/impedance study) remains controversial. especially for voice professionals so that long-standing,

TABLE 9.
Normative Ranges for Females (n ¼ 60)
68% Range 95% Range

Measure Mean SD Lower Upper Lower Upper

ah-F0 208.74 31.98 176.76 240.72 144.78 272.7
ah-RAP 0.58 0.47 0.11 1.05 0.36 1.52
ah-Shimmer 3.74 1.73 2.01 5.47 0.28 7.2
ah-NHR 0.135 0.025 0.11 0.16 0.085 0.185
an-VTI 0.042 0.012 0.03 0.054 0.018 0.066
Rainbow
Mean F0 203.85 21.31 182.54 225.16 161.23 246.47
Minimum F0 117.05 27.68 89.37 144.73 61.69 172.41
Maximum F0 329.21 53.09 276.12 382.3 223.03 435.39
Semitone range 18.53 4.98 13.55 23.51 8.57 28.49
SD semitone 3.14 0.65 2.49 3.79 1.84 4.44
Mean dB 62.53 2.32 60.21 64.85 57.89 67.17
Minimum dB 44.61 1.71 42.9 46.32 41.19 48.03
Maximum dB 70 3.46 66.54 73.46 63.08 76.92
Range dB 25.39 3.42 21.97 28.81 18.55 32.23
SD dB 3.61 0.56 3.05 4.17 2.49 4.73
Abbreviations: F0, fundamental frequency; RAP, relative average perturbation; NHR, noise-to-harmonic ratio; VTI, voice turbulence index; SD, standard
deviation.
Robert T. Sataloff, et al Abnormal Laryngeal Findings During Strobovideolaryngoscopy 583

TABLE 10.
Normative Ranges for Males (n ¼ 12)
68% Range 95% Range

Measure Mean SD Lower Upper Lower Upper

ah-F0 125.09 16.38 108.71 141.47 92.33 157.85
ah-RAP 0.23 0.09 0.13 0.32 0.04 0.42
ah-Shimmer 2.60 0.73 1.87 3.32 1.14 4.05
ah-NHR 0.14 0.01 0.13 0.15 0.12 0.16
an-VTI 0.04 0.01 0.03 0.06 0.02 0.07
Rainbow
Mean F0 126.64 20.16 106.48 146.79 86.32 166.95
Minimum F0 77.51 7.53 69.98 85.04 62.45 92.56
Maximum F0 226.57 43.32 183.25 269.88 139.94 313.20
Semitone range 18.25 3.79 14.46 22.04 10.66 25.84
SD semitone 3.36 0.76 2.60 4.12 1.84 4.88
Mean dB 63.60 1.97 61.63 65.57 59.66 67.54
Minimum dB 45.88 2.48 43.41 48.36 40.93 50.83
Maximum Db 71.68 2.81 68.87 74.48 66.06 77.29
Range dB 25.80 4.08 21.71 29.88 17.63 33.96
SD dB 3.85 0.60 3.25 4.44 2.65 5.04
Abbreviations: F0, fundamental frequency; RAP, relative average perturbation; NHR, noise-to-harmonic ratio; VTI, voice turbulence index; SD, standard
deviation.

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