July 15, 2019

Tonsillectomy in Singers (Voice Changes After Tonsillectomy)

Even singers may suffer from recurrent tonsillitis and strep that may warrant tonsillectomy with or without adenoidectomy. But unlike non-singers, there is a significant concern that this common operation may adversely affect the singing voice whether in terms of sound, resonance, reliability, and/or stamina.

Over the years, there have been a few studies to investigate what changes to the voice may or may not occur in the singing population, in particular, whether any adverse changes may occur to the singing voice.

In 2001, researchers reported that 4% of singers felt an immediate adverse change in resonance that resolved with time. Additionally, 13% felt an adverse change in voice reliability and 17.4% reported an adverse change in stamina. With respect to reliability, this did resolve with time. However, 4.3% stated continued adverse change in stamina that did not resolve with time.

Beyond that, 25-52% of singers reported no change (whether for better or worse) in any of these criterias.

About 80% reported overall improvement in quality of life (presumably due to less frequent tonsillitis).

One year later in 2002, researchers attempted to more objectively evaluate what vocal changes may occur after tonsillectomy. Before and 1 month after surgery, 10 patients' (not necessarily singers) voice were analyzed using Multi-Dimensional Voice Program with focus specifically on F0, formant freq and bandwidth, jitter, shimmer, and NHR. Overall, they found only minimal changes and therefore, only little effect on the acoustic parameters measured.

In 2008, researchers attempted to evaluate additional objective parameters. Before and 1 month after surgery, 40 male adults' (not necessarily singers) voice were tested using the Multi-Dimensional Voice Program (fundamental frequency, Jitter percent, Shimmer, noise-to-harmonics ratio, voice turbulence index, soft phonation index, degree of voiceless, degree of voice breaks, and peak amplitude variation) as well as nasal resonance, speech articulation, and voice handicap index.

The data showed that 1 month after tonsillectomy, there were improvements in all acoustic parameters:

• subjective decrease of hyper-nasality
• improvement of speech articulation and VHI were achieved
• reduction of the nasal resonance
• Mean F0 decreased from 195 to 168Hz.
• Jitter, Shimmer, NHR, VTI, SPI, DUV, DVB, vAm all significantly decreased 1 month after tonsillectomy (these are all measures of how raspy the voice is)

Why would tonsillectomy (a supralaryngeal structure) influence voice which originates at the laryngeal level? After all, tonsil removal doesn't physically change the voicebox and its contents.

It is speculated that large tonsillar tissue has a damping effect causing a reduction in quality and precision of the vocal sound output. Such damping effects influence the "noise" that the voicebox produces. Also, tonsillar tissue may cause important turbulent air flow through the vocal cords leading to resistance that can interfere with regular voice production. Furthermore, a decrease in airflow resistance after tonsillectomy may also result in less laryngeal adductor force necessary for phonation.

More simplistically stated, consider an organ pipe. The large diameter organ pipes have a different fundamental pitch compared with a small diameter organ pipe. Furthermore, consider the amount of air pressure required when blowing through a small diameter pipe vs a large diameter pipe.

Removing the tonsils essentially changes the diameter of the "pipe" above the vocal cords (from a small diameter to a large diameter) resulting in subtle but measurable changes in acoustic parameters.

Just from my own personal observations having performed tonsillectomy in singers, there is an unfortunately prolonged period of adjustment for singers to "relearn" how to sing with their "new" throat after tonsillectomy that may last months and sometimes even up to one year. Back-to-basics singing lessons and practice may be required before a singer will feel totally comfortable and re-achieve exquisitely precise control over every aspect of their voice.

Keep in mind that this singing adjustment period is totally different and separate from the immediate post-surgical recovery from pain and healing which typically lasts about 3-4 weeks.

References:
Tonsillectomy and Its Effect on the Singing Voice. Arch Otolaryngol. 1942;35(6):915-917. doi:10.1001/archotol.1942.00670010923008

Tonsillectomy and adenoidectomy in singers. J Voice. 2001 Dec;15(4):561-4.

Effects of tonsillectomy on speech spectrum. J Voice. 2002 Dec;16(4):580-6.

Effects of tonsillectomy on speech and voice. J Voice. 2009 Sep;23(5):614-8. doi: 10.1016/j.jvoice.2008.01.008. Epub 2008 May 12.




Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids. He is also the chief medical officer of O2Labz, a medical and scientific 3D animation company.

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