Folia Phoniatr 1990;42:24-30

© 1990 S. Karger A G , Basel 0 0 15-5705/90/0421-0024S2.75/0

Voice Disorders Among Players of Wind Instruments? Claus Ocker3. Wolfgang Pascherb, Marianne Röhrsb, Walburg Katnyb>1* aHochschule für Musik und darstellende Kunst, Hamburg, BRD; bPhoniatrische Abteilung, Hals-Nasen-Ohren-Klinik, Universitätskrankenhaus Hamburg-Eppendorf, BRD

1 We should like to thank our translators Mark Bruce and Andrew Elliott.

basis of the following hypotheses: ( 1) playing a wind instrument is injurious to the voice; (2) vocal impairment is specifically related to particular instruments; (3) laryngeal vi­ brato, employed especially by flautists, is in­ jurious to the voice, and (4) the degree of vocal impairment is directly related to the level of skill of the instrumentalist.

Method of Investigation With regard to their phoniatric case histories, we asked each subject about voice and speech problems independent of vocal strain, and whether such prob­ lems arose after playing their instrument. We also inquired as to special musical techniques, particularly the vibrato. On the basis of our above-mentioned team discus­ sions, we developed a standard procedure for the vocal examination, based on the daily routine phon­ iatric investigation of patients, which was performed before and after playing. The subjects were asked about subjective signs of vocal strain experienced while playing. The speaking voice was evaluated by the 2 experienced phoniatricians. independently lis­ tening to and observing the following criteria: normal or disturbed sound of voice, quality of glottal attack, articulation, breathing and posture, muscular tension, vocal abuses such as frequent clearing of the throat or

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In the course of our phoniatric investiga­ tions of patients with functional voice disor­ ders, we often suspected that playing a wind instrument might have a negative influence on the vocal tract. This hypothesis was sup­ ported by observations made by the singing teacher on our team of 2 phoniatricians, an ENT specialist, and the above-mentioned singing teacher. One student of his had diffi­ culties with his speaking voice following his trumpet lessons. Furthermore, our singing teacher had observed a tendency among tlute players toward 'blowing' the tone instead of singing. Some of his students learning pro­ fessional singing, who also played a wind instrument, had difficulties in quick and light articulation during singing that may have been connected to pressing the instru­ ment against the lips with undue force, or overtensing the mouth while playing. These observations and suspected correlations be­ tween playing a wind instrument and learn­ ing singing led us to undertake the investiga­ tion reported below. We proceeded on the

Voice Disorders Among Players of Wind Instruments?

Evaluation o f the Data We adopted an evaluation procedure based on a quantitative division into three groups: (I) clearly positive criteria. (2) inconclusive criteria, and (3) clearly negative criteria. (1) Positive criteria were assumed when at least two criteria in each of the three categories already mentioned - voice quality, microlaryngoscopy, mi­ crostroboscopy - showed deterioration. (2) Inconclusive criteria were assumed when only one criterion in each of the three categories changed. (3) Negative criteria were assumed when all three categories showed unchanged findings or even ame­ lioration. This rating was undertaken by 2 phoniatricians independently by (a) reviewing the data taken down on the prepared forms for the phoniatric investiga­ tions in the course of these investigations; (b) listen­ ing to the voice recordings, and (c) reviewing the vid­ eotapes. especially focussing on visible aberrations of posture, breathing, laryngeal movements and muscu­ lar tension during playing. In case of disagreement in rating we classified the data as inconclusive. We

divided the wind instruments into three groups: flutes and recorders, reed instruments, and brass instru­ ments. We also distinguished between three different qualification groups: professional players, music stu­ dents, and amateur players.

Results

The data of the 63 subjects taking part in our investigation are shown in tables 1-3. Comparing all our data, three combinations showed statistically significant results, using the test for small samples according to Fisher. As shown in table 4, out of all 63 players of wind instruments, 27 already had a ques­ tionable (n = 18) or manifest (n = 9) func­ tional voice disorder before I hour’s playing without having had a vocal strain or inten­ sive playing before examination that day. Out of these 27 subjects, in 5 cases the voice got worse after 1 hour's playing in contrast to 22 subjects with unchanged or improved voice. Four out of the 5 were reed instru­ ment players. As shown in table 5, 6 out of the 9 profes­ sionals taking part were in the group of 36 players without voice disorder before 1 hour’s playing. None of the 6 showed voice

Table 1. Number of subjects taking part in the study by qualification and instrument groups Player’s qualification

Instrument groups

Total

flutes

reed

brass

Amateur Student Professional

12 7 2

7 12 1

8 8 6

27 27 9

Total

21

20

22

63

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compulsive swallowing, rhinolalia and sigmatism. It should be noted that we included the evaluation of lip and jaw' movements in the voice examination in accordance with usual practice. We also determined the medium speaking range. In addition to the ENT examination of the nose, throat and larynx, we performed an indirect microlaryngoscopic examination with at least X 6-10 optic magnification and taking a photograph when possi­ ble. Particular attention was paid to asymmetrical adduction and the condition of the vocal cords, in­ cluding redness and well visible blood vessels and mucus stranding. We also performed a microslroboscopic examination with the same optically magnified indirect mirroring. Frequency, amplitude of oscilla­ tion, and again, mucus stranding were evaluated. All these data were taken dowm on a prepared form. The subjects then had to play their instruments for 1 h. This situation was videotaped repeatedly dur­ ing the course of playing. The tapes, together with our personal observations, provided us wdth information concerning the laryngeal movements, breathing, pos­ ture, and muscular tension while playing. After I hour's playing, all the above-mentioned data were retaken in the same way by the same observers.

25

26

Ocker/Pascher/Rôhrs/Katny

Table 2. Condition of the voice before I hour’s playing by instrument group Condition of the voice before 1 hour’s playing

Instrument groups

Total

flutes

reed

brass

Manifest voice disorder Questionable voice disorder No voice disorder

4 6 11

3 6 11

2 6 14

9 18 36

Total

21

20

22

63

‘Manifest voice disorder' refers to clearly positive criteria as rated by 2 phoniatricians independently. 'Questionable voice disorder' was chosen when the phoniatricians did not agree in their findings or when the criteria for rating were inconclusive. 'No voice disorder’ refers to clearly negative criteria.

Table 3. Condition of the voice after I hour's play­ ing by instrument group

Table 4. Players with questionable or manifest functional disorders before 1 hour’s playing

Condition of the voice after 1 hour’s playing

flutes

Condition of the voice after 1 hour's playing

Deteriorated voice Improved voice Unchanged voice

5 4 12

8 5 7

6 2 14

19 11 33

Voice improved or unchanged Voice deteriorated

Total

21

20

22

63

Total

reed

Total

brass

deterioration in contrast to I 5 of the 30 ama­ teur and student players. Regarding articulation (table 6), again the reed instrumentalists showed alteration in contrast to the others.

Discussion In playing a wind instrument, a close con­ nection is formed between the instrument and the body of the player through the oral cavity. In this process, the respiratory tract plays an important role. The preconditions and possible pathological effects of wind in­

Instrument groups

Total

reed

others

5

17

22

4

1

5

9

18

27

strument playing have been examined com­ prehensively, not only from physiological [1-13], stomatological and dental [14-16] viewpoints, but also from pulmonary [3. 8, 10, 17-20] and cardiovascular [21. 22] as­ pects. Some laryngological aspects (e.g. the appearance of functional Iaryngoceles) have also been discussed [23]. However, there is no paper dealing with the phoniatric aspects of voice deterioration due to playing wind instruments. With regard to anatomical and physiolog­ ical viewpoints, the glottis divides the respi­ ratory tract into its upper and lower parts. The lower respiratory tract provides the air

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Instrument groups

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Voice Disorders Among Players of Wind Instruments?

Table 5. Players without voice disorders before I hour's playing

Table 6. Players without articulation problems before 1 hour's playing

Condition of the voice after 1 hour’s playing

Articulation after 1 hour's playing

Total

profess. others Voice improved or unchanged Voice deteriorated

6

15

21

0

15

15

Total

6

30

36

necessary for playing the wind instrument, and the upper tract, including the oral cavi­ ty, directs the air stream. Thus, the glottis contributes at least passively to the regula­ tion of the air stream (13, 24], In addition, the glottis can play an active role - in the vibrato of the flute [25] or in producing espe­ cially high air pressures. The pressures found in the oral cavity when a particular instru­ ment is being played are also shared by the inner larynx. Furthermore, the larynx is con­ nected to the pharynx, lower mouth, and neck and thus takes part in the air motions. These aspects, as well as the observation of singing teachers and phoniatricians. sug­ gested the need to investigate the effects of playing wind instruments from a phoniatrical viewpoint, whereby the condition of the speaking voice as well as the results of microlaryngoscopic and microstroboscopic exami­ nations were given consideration. The study of the particularly close con­ nection between the lips of the player and his wind instrument leads us to the problem of the so-called ‘embouchure* (German: Ansatz). This concept describes a comprehen­ sive but not quite clearly defined functional connection between the mouth of the player and the instrument. One can say that this

Articulation unchanged Articulation changed Total

Instrument groups

Total

reed

others

9 7

34 4

43 11

16

38

54

signifies ‘the positional relation between the mouthpiece and the oral cavity and the sum of all those processes in the areas which influence tone production’ [ 15, transl. M.B.]. Schlenger [26. transl. M.B.] says of all wind instruments, ‘thus, the embouchure is a functional concept, that is the employment of anatomical and physiological factors of the human body to produce a tone on the wind instrument*. In order to initiate the vibrato in instru­ ments. an air stream with greater pressure than that of the atmosphere is required. To allow the expiration to (low with the re­ quired pressure, and to achieve the optimal utility for the musical phrase, the air stream must be formed and held back in the oral cavity. The rapid, deep inspiration is fol­ lowed by a delayed expiration. Basically, the breathing technique required corresponds to the ‘breath support* of a singer, but the player of a wind instrument displays a much higher degree of muscular tension in the lips and face [26]. The starting position and tension of the muscles which form the embouchure are fundamentally dependent on the pressure and air volume required for a particular tone on each instrument. On the other hand, the

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Player’s qualification

tone produced is dependent on the air pres­ sure within the oral cavity and the volume and velocity of the air stream [3-7, 10-12]. These parameters vary, both in the absolute values and in their cross-relations, between the individual groups of instruments. How­ ever. we can say that for all types of instru­ ments, the pressure in the oral cavity rises with increasing pitch and loudness, with the exception of pitch in the clarinet [3-7, 10, 11], Along with the pitch, the velocity of the air stream also increases, and in this, for its part, is also dependent on the air pressure in the oral cavity [5, 10. 11, 12]. The expiration period for brass instru­ ments is shorter than for other wind instru­ ments. This corresponds to the generally higher air How values [10-12, 14], The lowpitched brass instruments expend the great­ est amounts of air. while the oboe displays the lowest rate of How, demanding an espe­ cially refined breathing technique [3. 4. 12, 13]. According to Seidner [3], the air pres­ sure in the oral cavity is lowest for flutes, followed by the reed instruments. The high­ est air pressure values are found for brass instruments. The most effective coordina­ tion of these physical parameters places con­ siderable demands on the instrumentalist, and represents an important part of his skill. The considerations outlined above led us to the four hypotheses stated at the beginning of this report. (1) Despite many individual observa­ tions. the thesis that playing a wind instru­ ment is injurious to vocal function cannot be statistically maintained. In all voice parame­ ters examined and in all groups of instru­ ments. we found some players with un­ changed vocal functions, some with worse functions, and in some cases improved vocal functions were observed.

Ocker/Pascher/Rohrs/Katny

(2) When we found a deterioration in the voice, we could establish a connection to our second hypothesis under certain conditions. When the first examination revealed an ex­ isting voice disorder, we found a statistically significant rise (test according to Fisher, p = 0.03) in the occurrence of worse functions after 1 hour of intensive practising on reed instruments. This was not the case with other groups of instruments. Contrary to flute and brass instruments, in reed instru­ ments, and especially double reed instru­ ments such as the oboe, the resistance which must be overcome at the start of the tone is very great [12, 13, 16]. This apparently ex­ erts an influence on the vocal tract. The oboe, with its very tight opening of the em­ bouchure. allowing only very small air flow volumes, demands greater control of air stream and air pressure through the oral cav­ ity and the expiratory muscles than is re­ quired for other instruments [12, 13]. We must emphasize, however, that this negative influence only becomes apparent when a functional voice disorder already exists, usually consisting of excess tension in the form of a vocal hyperfunction, as evaluated by our above-mentioned methods of investi­ gation. In addition, playing of a reed instru­ ment exerts an influence on articulation such as transitory sigmatism and visible tension of the lips. In the group of all those players who displayed no problems in their articula­ tion, we registered a statistically significant (test according to Fisher, p = 0.01) trend among the reed players toward an impair­ ment of the articulation after playing. (3) The laryngeal vibrato (especially as employed by flautists), expected to have di­ rect influence on the vocal cords, proved to have no observable effects. It seems to repre­ sent a thoroughly physiological use of the

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28

29

larynx when performed without excess ten­ with regard to wind instrument players who are also singers. sion of the vocal tract. (4) The relation between the degree of Finally, we would like to point out that training of the player and the risk of vocal the playing of a wind instrument can have a deterioration through practising proved to positive effect on the vocal functions, al­ be clearly statistically significant (test ac­ though this trend was not statistically signif­ cording to Fisher, p = 0.03). None of the 6 icant in our small sampling. Perhaps this is professionals in the group of 36 players with due to the relaxing and satisfying effects of originally normal vocal functions displayed making music. a deterioration after practising, but half of the 30 students and amateur musicians did. Stimmstörungen bei The instrumental teacher is confronted ßlasinstrumentalisten? daily with the problem of excess tension through incorrect posture and faulty or im­ Aufgrund unserer Untersuchungen können wir mature technique among his students, evi­ feststellen, dass die Belastung des Vokaltrakts wäh­ dently one of the roots of excess tension in rend des Spielens von Blasinstrumenten nicht immer phonation. For instance, Frucht [5] reports ein Risiko für die Stimmfunktion darstellt. Trotzdem that in a comparison between a student in kann unter gewissen Bedingungen und bei gewissen Spielern, als Folge von zusätzlichen Belastungen, ein his 3rd year of training and the student's negativer Effekt auftreten. Speziell Blasinstrumentaliteacher, the student consistently used higher sten mit vorbestehenden Stimmproblemen, wie wir pressures in producing the same tone at the auf statistischer Grundlage beweisen konnten, sind besonders gefährdet. Entgegen unserem ursprüngli­ same volume. chen Verdacht, den wir durch die Beobachtung der On the basis of our investigations we can Sing- und Sprechstimme hegten, bestätigte sich dieser conclude that strain on the vocal tract while in unserer Untersuchung nur gegenüber der Sprech­ playing a wind instrument does not generally stimme. für die wir einfacher zu definierende Krite­ represent a risk for the functioning of the rien erarbeiten konnten. Dies betrifft nicht die Sing­ voice. However, under certain conditions it stimme. trotz der höheren Anforderungen an die zar­ can have a negative effect in certain individ­ ten Stimmfunktionen. Trotzdem können wir die Skepsis der Gesangslehrer gegenüber den Sängern, die uals. due to additional tension. Players of Blasinstrumente spielen, nicht vollständig zerstreuen. wind instruments with existing disorders in Wir möchten betonen, dass das Blasinstrumentspiel vocal functions are especially at risk, as we einen positiven Einfluss auf die Stimmfunktionen were able to demonstrate on a statistical ba­ ausüben kann, obwohl dieser Trend nicht signifikant sis for reed instrument players. Although our in unserer kleinen Statistik nachgewiesen werden konnte. Vielleicht hat der entspannende und befriedi­ original suspicions were aroused by observa­ gende Effekt des Musikmachens einen entsprechen­ tions of problems with the speaking and den Einfluss. singing voice, our results apply only to the speaking voice, for which it was possible to Troubles de la voix chez les joueurs establish more easily defined criteria. This d'instruments ä vent? may not apply to the singing voice, however, which places much greater demands on the Sur la base de leurs examens les auteurs estiment finer vocal functions. Thus, we cannot to­ que les efforts subis par le tractus vocal en jouant d'un tally dispel our singing teacher’s skepticism instrument ä vent ne constituent pas habituellemenl

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Voice Disorders Among Players of Wind Instruments?

Ocker/Pascher/Röhrs/Katny

30

References 1 Stone WH: On wind-pressure in the human lungs during performance on wind instruments. Philo­ sophic Mag (Ser 4) 1874:48:113-114. 2 Barton EH. LawsSL: Air pressures used in playing brass instruments. Philosophic Mag (Scr 6) 1902: 3:385-393. 3 Seidner S: Zur Physiologie und Pathologie der Berufsbläser. Wien Med Wochenschr 1934:906909. 936-938. 993-995. 4 Schneider HG: Experimentelle Beiträge zur Phy­ siologie des Blasinstrumentenspiels. Wiss KarlMarx-Univ Leipzig 1955/56:375-380. 5 Frucht AH: Zur Physiologie des Blasinstrumcntcnspiels. Die Blechbläser. Arch Gesamte Physiol 1937:239:419-429. 6 Roos J: The physiology of playing the oboe. Arch Néerl Phonét Exp 1940:16:137-153. 7 Roos J: The physiology of playing the Ilute. Arch Néerl Phonét Exp 1936:12:1-26. 8 Berger KW: Respiratory and articulatory factors in wind instrument performance. J Appl Physiol 1965:20:1217-1221. 9 Berger KW. Hoshiko MS: Respiratory muscle ac­ tion of trumpet players. Instrumentalist 1964:19: 91-94. 10 Bouhuys A: Lung volumes and breathing patterns in wind-instrument players. .1 Appl Physiol 1964: 19:967-975. 11 Bouhuys A: Sound power production in wind instruments. J Acoust Soc Am 1965:37:453-456.

12 Bouhuys A: Pressure-flow events during wind in­ strument playing. Ann NY Acad Sei 1968:155: 264-274. 13 Bouhuys A: Physiology and musical instruments. Nature 1969:221:1199-1204. 14 Schmidt B: Die Berufskrankheiten bei Blasmusi­ kern im Bereich der Mundhöhle: med. Diss.. Hal­ le. 1950. 15 Ebersbach W: Klinisch-experimentelle Untersu­ chungen zur Pathologie des Blasinstrumenten­ spiels bei Berufsmusikern: Habschr. Leipzig, 1969. 16 Becken H: Die Korrelation von Mundorgan und Klarinette unter besonderer Berücksichtigung anatomischer Voraussetzungen und praeventivmedizinischer Aspekte: Diss.. Halle, 1975. 17 Borgia JF. et al: Some physiological observations on French horn musicians. J Occup Med 1975:17: 696-701. 18 Jagic N, Lipiner J: Lunge und Atmung bei Blä­ sern. Wien Klin Wochenschr 1919:32:683-687. 714-718. 19 Navratil M. Rejsek K: Lung function in wind instrument players and glassblowers. Ann NY Acad Sei 1968:155:276-283. 20 Rejsek K, Navratil M. Glücksmann J: Zur Frage des Lungenemphysems bei Blasinstrumentcnspielern. Arch Gewerbepathol Gewerbehyg 1961:18: 343-348. 21 Tucker A. Faulkner ME. Horvath SM: Electrocar­ diography and lung function in brass instrument players. Arch Environ Health 1971;23:327-334. 22 Faulkner M. Sharpey-Schäfer EP: Circulatory ef­ fects of trumpet playing. Br Med J I959:i:685686 23 Kiml J: Some disorders in players of wind instru­ ments. Cesk Otolaryngol 1973:22:175-179. 24 La Place M: La trompette et le cornet dans le jazz, et la tnusique populaire. La respiration. Brass Bull July 1984. 25 Gärtner J: Das Vibrato unter besonderer Berück­ sichtigung der Verhältnisse bei Flötisten. Regens­ burg. Bosse, 1974. 26 Schienger K: Beiträge zur Physiologie und Päda­ gogik des Blasinstrumentenspiels unter besonde­ rer Berücksichtigung der Flöte: phil. Diss.. Berlin 1935.

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Claus Ocker Hochschule für Musik und darstellende Kunst D-2000 Hamburg 20 (FRG)

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un risque pour la fonction vocale. Toutefois, dans cer­ taines conditions, ces efforts peuvent avoir chez cer­ tains individus un effet négatif du fait d'une tension excessive. Les personnes présentant au préalable des troubles de la fonction vocale y sont spécialement exposées. Ces constatations ne concernent que la voix parlée pour laquelle il est plus facile d’établir des cri­ tères bien définis que pour la voix chantée, bien que celle-ci exige des mécanismes vocaux plus subtiles. C'est pourquoi nous ne pouvons totalement écarter les craintes des maîtres de chant pour leurs élèves jouant d'un instrument à vent. Il se pourrait, par ail­ leurs, que le fait de jouer d’un instrument à vent puisse avoir un effet favorable sur la fonction vocale en raison de faction relaxante et de la satisfaction que procure le fait de jouer de la musique.

Voice disorders among players of wind instruments?

Folia Phoniatr 1990;42:24-30 © 1990 S. Karger A G , Basel 0 0 15-5705/90/0421-0024S2.75/0 Voice Disorders Among Players of Wind Instruments? Claus O...
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