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Tonsillectomy and Adenoidectomy in Singers
Journal of Voice Vol. 15, No. 4, pp. 561–564 © 2001 The Voice Foundation
Tonsillectomy and Adenoidectomy in Singers *John K. Jarboe, *Steven M. Zeitels, and †Barbara Elias *Department of Otology and Laryngology, Harvard Medical School, Division of Laryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; †Department of Otorhinolaryngology, University Hospital Groningen, The Netherlands
engines. Those performers who could be contacted were submitted to a phone survey. The survey included questions concerning the patient’s general well-being, the presence and frequency of persistent sore throats, and difficult swallowing. Specific questions regarding performing included (1) whether the patient was still singing, (2) when the patient resumed singing postoperatively, and (3) if the patient and/or observers noticed a change in the voice immediately (up to 4 months) after surgery, and at the time of the survey. The patients were asked to refrain from performance vocalization for 1 month subsequent to surgery. Their vocalization after this voice rest and before 4 months constitutes the immediate voice data. The average time between the date of surgery and the survey was 48.6 months, with a range between 9 and 98 months. The long-term follow-up period is this time between the surgery and survey date. Finally, the performers were asked if they noticed a change in resonance, reliability, or stamina in their voices, and if their quality of life was changed from the surgery, both in general and vocally. All of the patients underwent a suction cautery-assisted procedure by the senior author (SMZ) with careful preservation of the pharyngeal musculature. Minimally traumatic technique helped limit scarring of the surrounding palatal and pharyngeal tissues.4 This is enhanced by a submucosal infiltration5 of 0.75% marcaine with 1⁄100,000 epinephrine in the plane of the tonsillar capsule to hydrodissect the tonsil from the underlying superior constrictor layer. No soft palate was removed with the tonsil, and firm medial retraction is applied to the tonsil during the excision, again to protect the underlying soft tissue.
INTRODUCTION Tonsillectomy and adenoidectomy are two of the most common procedures performed by otolaryngologists. Indications for these procedures include recurrent or chronic adenotonsillitis, obstructive sleep apnea, and snoring. The pharyngeal resonating chamber is altered so that it is conceivable to modify the phonatory signature.1–3 These prior studies have not reported on patients involved in the vocal performing arts. This subgroup of patients has extremely precise control of the vocal tract and alteration of this anatomy can potentially change vocal quality. There is little reported data regarding this issue, so this retrospective study was designed to examine vocal performing artists’ self-perceived effects from tonsillectomy and/or adenoidectomy. METHODS A retrospective chart review was done to identify vocalists who had undergone tonsillectomy, adenoidectomy, or uvulopalatopharyngoplasty from January 1992 to December 1999. The cases were then analyzed for postsurgical clinical course and length of follow-up. A large number of the patients no longer resided in the area and an extensive effort was mounted to locate them through their parents, prior residences, matriculation offices, and general search
Accepted for publication February 12, 2001. Send correspondence and reprints requests to Steven M. Zeitels, MD, FACS, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114. e-mail: [email protected]
561
562
JOHN K. JARBOE ET AL RESULTS
Thirty-one singers were identified as having undergone a tonsillectomy, adenoidectomy, or both. Of these, 23 could be located and all of these participated in the phone survey. The patients’ professional demographics can be found in Table 1, with the majority of individuals being vocal students. The average time between date of surgery and the survey was 48.6 months, with a range between 9 and 98 months. This constitutes the long-term follow-up time reported in Tables 2 and 3. The average time of postoperative follow-up was 10.2 months, with a range from 1 week to 4 years. Despite instructions to restrict singing for 1 month, patients reported taking a performance rest period that lasted from 2 weeks to 3 months, with the majority waiting 1 to 2 months.
The types of procedures that were done are detailed in Table 4. Of the two patients who underwent a tonsillectomy and phonomicrosurgical resection of vocal fold lesions, one patient had the phonosurgery at the time of tonsillectomy, and one had this surgery subsequent to the tonsillectomy. All the respondents were still using their voices in performing, in some capacity. With regards to sore throats, 56.5% of the patients had resolution of their sore throats postoperatively. Of the 10 patients with persistent sore throats, 7 had only one or two per year, with the remaining 3 reporting three or more. Tables 2 and 3 show the vocalist’s responses to the telephone survey regarding self-perceptions of their voice. Table 2 indicates the responses of how the procedure changed the sound, resonance, reliability, and
TABLE 1. Patients’ Professional Demographics Vocal students
Professional singers
Total
15
1
16
3
4
7
Female Male
TABLE 2. Telephone Survey Responses
TABLE 3. Telephone Survey Responses
Better
Worse
Same
Changes in sound, immediate
52.2 %
0%
39.1 %
Changes in sound, long-term
73.9 %
0%
26.1 %
Changes in resonance, immediate
43.5 %
4.3 %
39.1 %
Changes in resonance, long-term
65.2 %
0%
30.4 %
Changes in reliability, immediate
30.4 %
13.0 %
52.2 %
Changes in reliability, long-term
52.2 %
0%
47.8 %
Changes in stamina, immediate
30.4 %
17.4 %
43.5 %
Changes in stamina, long-term
60.9 %
4.3 %
30.4 %
Better
Worse
Same
General quality of life
82.6 %
0%
17.4 %
Vocal quality of life
78.3 %
0%
21.7 %
TABLE 4. Procedures Performed Type of surgery Tonsillectomy
Number of patients 14
Adenoidectomy
1
Tonsillectomy and adenoidectomy
5
Tonsillectomy with uvulopalatopharyngoplasty
1
Tonsillectomy with phonomicrosurgical resection of vocal fold nodules
2
Journal of Voice, Vol. 15, No. 4, 2001
TONSILLECTOMY AND ADENOIDECTOMY IN SINGERS stamina of the patients’ performing voice. The surveys revealed that no patient felt worse (either immediately or on long-term) and a majority felt better. (When the total percentages do not add up to 100%, this indicates that the respondents were not accounted for, answered that they were not sure, or did not remember.) Short-term vocal impairment was described by 5 patients: vocal resonance (1) and reliability (4). In the final assessment, only one patient felt worse in any of the four categories on long-term follow-up, specifically stamina, and this patient couldn’t definitively relate this to her tonsillectomy and adenoidectomy. The rest of the patients either felt better or the same in long-term follow-up. Table 3 presents two quality of life issues, both general and vocal quality changes. As the survey indicates, a large majority felt that their procedure improved both their general and vocal quality of life. No patients felt that these qualities had worsened. DISCUSSION Otolaryngologists are familiar with the potential vocal resonance changes associated with nasopharyngeal and/or oropharyngeal pathology. Surgery on this region of the vocal tract understandably carries a risk in altering the anatomy such that voice could change. The presence of enlarged tonsils can lead to a muffled vocal quality and can also produce hyponasal speech by closing off the nasopharyngeal airstream. It has also been reported that enlarged tonsils can produce hypernasal speech by preventing nasopharyngeal closure by the soft palate.1 Hyperplastic adenoid tissue can also cause hyponasal speech. Tonsillectomy can potentially affect the speaking voice by enlarging the resonating chamber and altering the formant frequencies,2, 3 or by altering the conformation of the tonsillar fossae. Potentially, part of the soft palate musculature can be removed or disturbed. This could theoretically lead to scarring and subsequent limitation of fine motor control or even velopharyngeal closure. Velopharyngeal incompetence can also occur subsequent to tonsillectomy and/or adenoidectomy if a submucous cleft is not identified preoperatively No studies could be identified that focused on tonsillectomy and/or adenoidectomy in the performing
563
vocalist. Based on the patient responses herein, this investigation revealed that tonsillectomy and adenoidectomy are unlikely to produce undesirable vocal changes in singers. Any significant limitation in singing or performing was noted during the initial healing process, and a lingering abnormal sensation persisted in only one patient. Despite the fact that this individual reported reduced vocal stamina, she felt significantly improved in most other parameters, including general and vocal quality of life. Furthermore, this patient did not specifically identify her procedure as the direct cause for her slight loss of stamina. Finally, since she has not been seen in 3.5 years, there could be a number of other reasons for the perception of reduced stamina. The impact of recurrent tonsillitis on a performer’s career is not insignificant. Other than the obvious effects that hyperplastic tonsils and adenoids can have on vocal quality, the morbidity of the symptoms themselves can have a deleterious impact. Recurrent episodes of tonsillitis and adenoiditis may inhibit effective practice or performance leading to restriction in training and career advancement. For this reason, we have noted that performers seem to be less tolerant of low-grade discomfort associated with subacute pharyngitis. Therefore, the symptoms associated with adenotonsillitis and its influence on the singer’s career is frequently the pivotal parameter by which the performer decides to proceed with a tonsillectomy and/or adenoidectomy. The survey responses generally reflected great satisfaction with the surgical procedure. It was surprising that a majority of individuals expressed improvement in their voice in a number of ways. This is probably due to the reduction in discomfort allowing for progress in training and possibly because of an enlarged resonating chamber. Due to a number of interdependent factors, it is difficult to attribute this solely to the surgery since a majority of the patients were conservatory students, who were heavily motivated toward skill acquisition. Normal maturation of vocal technique undoubtedly occurred as a result of training and/or voice therapy in the intervening years since the tonsillectomy. Also, two patients underwent phonomicrosurgical resection of nodules concurrently with, or subsequent to, their tonsillectomy, which obviously affects their vocal quality. These factors were not controlled for in the survey other than relyJournal of Voice, Vol. 15, No. 4, 2001
564
JOHN K. JARBOE ET AL
ing on patient memory to relate changes in voice to the primary procedure. CONCLUSIONS Performing vocalists are not impervious to routine problems for which tonsillectomy and adenoidectomy are appropriate treatments. There is scant literature regarding the efficacy of this surgery in this population and its perceived effect by the singer. Understandably, pharyngeal surgery in vocalists is approached with trepidation by singers, their coaches and teachers, and surgeons. In the individuals that could be located, patients’ perceptions were that tonsillectomy and/or adenoidectomy did not lead to vocal impairment. Although this investigation was comprised of a retrospective survey and not a prospective investigation, it suggests that patients should not be dissuaded from these procedures when indicated. Regardless, this surgery should be done with careful consideration since there are the routine risks as well as the vocal incapacitation during the recovery period. Although a majority of the patients perceived an improvement in their singing, this
Journal of Voice, Vol. 15, No. 4, 2001
should not be discussed as an indication for surgery, simply a possible coincidental outcome. The information herein suggests that tonsillectomy and adenoidectomy can be performed safely in vocal performing artists despite their specialized requirements for pharyngeal function. REFERENCES 1. Kummer AW, Billmire, DA, Myer CM. Hypertrophic tonsils: the effect on resonance and velopharyngeal closure. Plast Reconstr Surg. 1993; 91(4):608–611. 2. Hori Y, Koike Y, Ohyama, G, Otsu S, Abe K. Effects of tonsillectomy on articulation. Acta Oto-Laryngologia (Stockholm). 1996; 523(suppl):248–251. 3. Chuma A, Cacace A, Rosen R, Feustel P, Koltaii P. Effects of tonsillectomyand/or adenoidectomy on vocal function: laryngeal, supralaryngeal and perceptual characteristics. Int J Pediatr Otorhinolaryngol. 1999; 47:1–9. 4. Sataloff RT. Common Infections and Inflammations and Other Conditions, in Professional Voice: The Science and the Art of Clinical Care. San Diego, Calif.: Singular Publishing Group; 1997:429. 5. Zeitels SM, Vaughan CW. A submucosal vocal fold infusion needle. Otolaryngol: Head Neck Surg. 1991; 105:478–479.
Tonsillectomy and Adenoidectomy in Singers *John K. Jarboe, *Steven M. Zeitels, and †Barbara Elias *Department of Otology and Laryngology, Harvard Medical School, Division of Laryngology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; †Department of Otorhinolaryngology, University Hospital Groningen, The Netherlands
engines. Those performers who could be contacted were submitted to a phone survey. The survey included questions concerning the patient’s general well-being, the presence and frequency of persistent sore throats, and difficult swallowing. Specific questions regarding performing included (1) whether the patient was still singing, (2) when the patient resumed singing postoperatively, and (3) if the patient and/or observers noticed a change in the voice immediately (up to 4 months) after surgery, and at the time of the survey. The patients were asked to refrain from performance vocalization for 1 month subsequent to surgery. Their vocalization after this voice rest and before 4 months constitutes the immediate voice data. The average time between the date of surgery and the survey was 48.6 months, with a range between 9 and 98 months. The long-term follow-up period is this time between the surgery and survey date. Finally, the performers were asked if they noticed a change in resonance, reliability, or stamina in their voices, and if their quality of life was changed from the surgery, both in general and vocally. All of the patients underwent a suction cautery-assisted procedure by the senior author (SMZ) with careful preservation of the pharyngeal musculature. Minimally traumatic technique helped limit scarring of the surrounding palatal and pharyngeal tissues.4 This is enhanced by a submucosal infiltration5 of 0.75% marcaine with 1⁄100,000 epinephrine in the plane of the tonsillar capsule to hydrodissect the tonsil from the underlying superior constrictor layer. No soft palate was removed with the tonsil, and firm medial retraction is applied to the tonsil during the excision, again to protect the underlying soft tissue.
INTRODUCTION Tonsillectomy and adenoidectomy are two of the most common procedures performed by otolaryngologists. Indications for these procedures include recurrent or chronic adenotonsillitis, obstructive sleep apnea, and snoring. The pharyngeal resonating chamber is altered so that it is conceivable to modify the phonatory signature.1–3 These prior studies have not reported on patients involved in the vocal performing arts. This subgroup of patients has extremely precise control of the vocal tract and alteration of this anatomy can potentially change vocal quality. There is little reported data regarding this issue, so this retrospective study was designed to examine vocal performing artists’ self-perceived effects from tonsillectomy and/or adenoidectomy. METHODS A retrospective chart review was done to identify vocalists who had undergone tonsillectomy, adenoidectomy, or uvulopalatopharyngoplasty from January 1992 to December 1999. The cases were then analyzed for postsurgical clinical course and length of follow-up. A large number of the patients no longer resided in the area and an extensive effort was mounted to locate them through their parents, prior residences, matriculation offices, and general search
Accepted for publication February 12, 2001. Send correspondence and reprints requests to Steven M. Zeitels, MD, FACS, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114. e-mail: [email protected]
561
562
JOHN K. JARBOE ET AL RESULTS
Thirty-one singers were identified as having undergone a tonsillectomy, adenoidectomy, or both. Of these, 23 could be located and all of these participated in the phone survey. The patients’ professional demographics can be found in Table 1, with the majority of individuals being vocal students. The average time between date of surgery and the survey was 48.6 months, with a range between 9 and 98 months. This constitutes the long-term follow-up time reported in Tables 2 and 3. The average time of postoperative follow-up was 10.2 months, with a range from 1 week to 4 years. Despite instructions to restrict singing for 1 month, patients reported taking a performance rest period that lasted from 2 weeks to 3 months, with the majority waiting 1 to 2 months.
The types of procedures that were done are detailed in Table 4. Of the two patients who underwent a tonsillectomy and phonomicrosurgical resection of vocal fold lesions, one patient had the phonosurgery at the time of tonsillectomy, and one had this surgery subsequent to the tonsillectomy. All the respondents were still using their voices in performing, in some capacity. With regards to sore throats, 56.5% of the patients had resolution of their sore throats postoperatively. Of the 10 patients with persistent sore throats, 7 had only one or two per year, with the remaining 3 reporting three or more. Tables 2 and 3 show the vocalist’s responses to the telephone survey regarding self-perceptions of their voice. Table 2 indicates the responses of how the procedure changed the sound, resonance, reliability, and
TABLE 1. Patients’ Professional Demographics Vocal students
Professional singers
Total
15
1
16
3
4
7
Female Male
TABLE 2. Telephone Survey Responses
TABLE 3. Telephone Survey Responses
Better
Worse
Same
Changes in sound, immediate
52.2 %
0%
39.1 %
Changes in sound, long-term
73.9 %
0%
26.1 %
Changes in resonance, immediate
43.5 %
4.3 %
39.1 %
Changes in resonance, long-term
65.2 %
0%
30.4 %
Changes in reliability, immediate
30.4 %
13.0 %
52.2 %
Changes in reliability, long-term
52.2 %
0%
47.8 %
Changes in stamina, immediate
30.4 %
17.4 %
43.5 %
Changes in stamina, long-term
60.9 %
4.3 %
30.4 %
Better
Worse
Same
General quality of life
82.6 %
0%
17.4 %
Vocal quality of life
78.3 %
0%
21.7 %
TABLE 4. Procedures Performed Type of surgery Tonsillectomy
Number of patients 14
Adenoidectomy
1
Tonsillectomy and adenoidectomy
5
Tonsillectomy with uvulopalatopharyngoplasty
1
Tonsillectomy with phonomicrosurgical resection of vocal fold nodules
2
Journal of Voice, Vol. 15, No. 4, 2001
TONSILLECTOMY AND ADENOIDECTOMY IN SINGERS stamina of the patients’ performing voice. The surveys revealed that no patient felt worse (either immediately or on long-term) and a majority felt better. (When the total percentages do not add up to 100%, this indicates that the respondents were not accounted for, answered that they were not sure, or did not remember.) Short-term vocal impairment was described by 5 patients: vocal resonance (1) and reliability (4). In the final assessment, only one patient felt worse in any of the four categories on long-term follow-up, specifically stamina, and this patient couldn’t definitively relate this to her tonsillectomy and adenoidectomy. The rest of the patients either felt better or the same in long-term follow-up. Table 3 presents two quality of life issues, both general and vocal quality changes. As the survey indicates, a large majority felt that their procedure improved both their general and vocal quality of life. No patients felt that these qualities had worsened. DISCUSSION Otolaryngologists are familiar with the potential vocal resonance changes associated with nasopharyngeal and/or oropharyngeal pathology. Surgery on this region of the vocal tract understandably carries a risk in altering the anatomy such that voice could change. The presence of enlarged tonsils can lead to a muffled vocal quality and can also produce hyponasal speech by closing off the nasopharyngeal airstream. It has also been reported that enlarged tonsils can produce hypernasal speech by preventing nasopharyngeal closure by the soft palate.1 Hyperplastic adenoid tissue can also cause hyponasal speech. Tonsillectomy can potentially affect the speaking voice by enlarging the resonating chamber and altering the formant frequencies,2, 3 or by altering the conformation of the tonsillar fossae. Potentially, part of the soft palate musculature can be removed or disturbed. This could theoretically lead to scarring and subsequent limitation of fine motor control or even velopharyngeal closure. Velopharyngeal incompetence can also occur subsequent to tonsillectomy and/or adenoidectomy if a submucous cleft is not identified preoperatively No studies could be identified that focused on tonsillectomy and/or adenoidectomy in the performing
563
vocalist. Based on the patient responses herein, this investigation revealed that tonsillectomy and adenoidectomy are unlikely to produce undesirable vocal changes in singers. Any significant limitation in singing or performing was noted during the initial healing process, and a lingering abnormal sensation persisted in only one patient. Despite the fact that this individual reported reduced vocal stamina, she felt significantly improved in most other parameters, including general and vocal quality of life. Furthermore, this patient did not specifically identify her procedure as the direct cause for her slight loss of stamina. Finally, since she has not been seen in 3.5 years, there could be a number of other reasons for the perception of reduced stamina. The impact of recurrent tonsillitis on a performer’s career is not insignificant. Other than the obvious effects that hyperplastic tonsils and adenoids can have on vocal quality, the morbidity of the symptoms themselves can have a deleterious impact. Recurrent episodes of tonsillitis and adenoiditis may inhibit effective practice or performance leading to restriction in training and career advancement. For this reason, we have noted that performers seem to be less tolerant of low-grade discomfort associated with subacute pharyngitis. Therefore, the symptoms associated with adenotonsillitis and its influence on the singer’s career is frequently the pivotal parameter by which the performer decides to proceed with a tonsillectomy and/or adenoidectomy. The survey responses generally reflected great satisfaction with the surgical procedure. It was surprising that a majority of individuals expressed improvement in their voice in a number of ways. This is probably due to the reduction in discomfort allowing for progress in training and possibly because of an enlarged resonating chamber. Due to a number of interdependent factors, it is difficult to attribute this solely to the surgery since a majority of the patients were conservatory students, who were heavily motivated toward skill acquisition. Normal maturation of vocal technique undoubtedly occurred as a result of training and/or voice therapy in the intervening years since the tonsillectomy. Also, two patients underwent phonomicrosurgical resection of nodules concurrently with, or subsequent to, their tonsillectomy, which obviously affects their vocal quality. These factors were not controlled for in the survey other than relyJournal of Voice, Vol. 15, No. 4, 2001
564
JOHN K. JARBOE ET AL
ing on patient memory to relate changes in voice to the primary procedure. CONCLUSIONS Performing vocalists are not impervious to routine problems for which tonsillectomy and adenoidectomy are appropriate treatments. There is scant literature regarding the efficacy of this surgery in this population and its perceived effect by the singer. Understandably, pharyngeal surgery in vocalists is approached with trepidation by singers, their coaches and teachers, and surgeons. In the individuals that could be located, patients’ perceptions were that tonsillectomy and/or adenoidectomy did not lead to vocal impairment. Although this investigation was comprised of a retrospective survey and not a prospective investigation, it suggests that patients should not be dissuaded from these procedures when indicated. Regardless, this surgery should be done with careful consideration since there are the routine risks as well as the vocal incapacitation during the recovery period. Although a majority of the patients perceived an improvement in their singing, this
Journal of Voice, Vol. 15, No. 4, 2001
should not be discussed as an indication for surgery, simply a possible coincidental outcome. The information herein suggests that tonsillectomy and adenoidectomy can be performed safely in vocal performing artists despite their specialized requirements for pharyngeal function. REFERENCES 1. Kummer AW, Billmire, DA, Myer CM. Hypertrophic tonsils: the effect on resonance and velopharyngeal closure. Plast Reconstr Surg. 1993; 91(4):608–611. 2. Hori Y, Koike Y, Ohyama, G, Otsu S, Abe K. Effects of tonsillectomy on articulation. Acta Oto-Laryngologia (Stockholm). 1996; 523(suppl):248–251. 3. Chuma A, Cacace A, Rosen R, Feustel P, Koltaii P. Effects of tonsillectomyand/or adenoidectomy on vocal function: laryngeal, supralaryngeal and perceptual characteristics. Int J Pediatr Otorhinolaryngol. 1999; 47:1–9. 4. Sataloff RT. Common Infections and Inflammations and Other Conditions, in Professional Voice: The Science and the Art of Clinical Care. San Diego, Calif.: Singular Publishing Group; 1997:429. 5. Zeitels SM, Vaughan CW. A submucosal vocal fold infusion needle. Otolaryngol: Head Neck Surg. 1991; 105:478–479.