Alexa: What are the most common vocal issues that singers are actually facing these days? And how can we prevent them without falling into a trap of overthinking every tiny little symptom? 

Well, coming right up is an engaging and refreshingly honest chat with ENT voice specialist Nick Gibbins, who is here to break down the patterns that he sees in clinic, alongside giving us some practical insights on building stamina and working towards injury prevention. 

We're talking about what can actually be detected via laryngostroboscopy, reflux, hypermobility, rehabilitation, and Nick also tackles some questions from you, the listeners. 

So expect some expert knowledge, myth busting, couple of giggles along the way too, as well as plenty of down to earth, relatable discussions that every singer and teacher will benefit from hearing, thanks to the lovely Nick Gibbins. 

 And here he is. 

Nick Gibbins, welcome to [00:01:00] the podcast. How are you?  

Nick: I'm very well, thank you very much. I, I have been really looking forward to this and thank you. I'm, I feel very honored to, to be invited on and give you my tuppence worth of knowledge, so I'm really looking forward to it.  

Alexa: Well, I'm really looking forward to it too, because you've been so kind as to offer to kick us off with a song today. 

So in your own time, Nick, when you're ready.  

Nick: Well, I haven't got any clean ones, so that's a disaster.  

Alexa: Oh, no. Out of interest, what would you pick if you were to perform a song?  

Nick: Well, I, I really like, uh, You'll Be Back by King George III from Hamilton. Uh, that's my go-to karaoke piece. 

Also, yeah, some rude ones from The Horne, uh, ensemble, which, um, I dunno if you know them, they're a comedy music group that are on like 8 Out of 10 Cats Does Countdown and things like that. 

Those kind of lighthearted things. 

Alexa: Great. 

Thinking back to your earlier years and [00:02:00] little Nick Gibbins, what was he like and, and what did he aspire to be?  

Nick: Uh, my story about what he was like as a boy was, yeah, always running around climbing trees, hitting things with a stick, that kind of thing. 

Friends of my wife came around with two small boys and I've got two girls. And these two boys were feral. They described their children as boisterous. I mean, they were young boys. Right. And I remember when they left, I turned to my wife and I said I'm absolutely fine with girls and I now need to go and give my mother a ring and apologise for my entire childhood. 

'Cause apparently I was a boisterous child. Um, yes, energy levels were quite high, I I think in retrospect, of course, you know, you are in it, you, you think it's normal. But I think everyone around me was just, well, if we can just vaguely pen him in and we can keep an eye on him, then, then you'll probably be safe. 

But I had lots of trips to A&E with broken this, that and the other. Yeah, I was very [00:03:00] into sport, still am. Really like my, like my sports. And yeah, that, that's one side of it, which was, I think my, my parents were quite pleased at some point as a teenager, I, I got heavily into sports, so I then wasn't, I was spending all my energy on the pitch rather than being a tearaway somewhere, which is great. 

I'm one of those very rare lucky people that I thought I wanted to be a doctor when I was about eight. So, picking subjects for ALevels was easy. Picking a university was easy. Picking a course was easy. There weren't, you know, discussion was about five minute discussion each time. So that was that really. 

Um, I didn't know what quite, what I wanted to be. I just knew I wanted to be a doctor of some description. And then very quickly, I definitely wanted to be a surgeon. 

And then as I worked my way up, I actually fell into ENT purely by chance. Uh, I was actually think I wanted to do plastic surgery and was applying for jobs, and I happened to be doing an ENT [00:04:00] post at the time, realised it was an awful lot of fun, uh, really good anatomy, really good surgery. And, um, the rest, as they say is history, just one step to another. 

The voice, again, a little bit of luck. As I was training, my first job as a registrar- which you do registrar training for about six years before you become a consultant, or more if you do fellowships and things- but my first job the consultant who was doing the voice clinic was off for a bit and they just said, can you do the voice clinic? I said, yeah, sure. And I did it. Really enjoyed it, really liked the collaboration because there were, uh, speech therapists and, and, uh, vocal coaching clinic with us. I still work with a vocal coach now, and that was 15- 20 years ago. 

So it was, it was lovely to have that. And I, and I have a little bit of background. I'm not a singer myself. I can hold a tune, but I'm not a singer. What I really [00:05:00] enjoy is going to see singing. I always loved opera as a, um, as a grownup. As a child, I was more dragged to opera on a regular basis, but it would, you, you can't help but learn and immerse and, and learn by osmosis. 

So I was involved in that world from a, from a very young age. So the two just sort of slowly came together and, and here we are.  

Alexa: Can you tell us about who you are working with mostly in your clinic, and why you think that those people in particular or those cohorts of people end up booking an appointment with you? 

Nick: Well, I, uh, I have basically four main cohorts of singers. 

I've got the kids. Choiristers, musical theatre - they're on the stage with School of Rock, Matilda, things like that. Okay. So they are professional child singers. 

We don't really see many teenagers. You see them occasionally, but usually, or young teenagers.[00:06:00]  

The next cohort of patients is sort of 18 to 22, that kind of age, almost universally having sung at school or at college and then gone to a musical theatre college or a musical college of some description and the volume of work is suddenly ramped up. Whereas they were singing four or five hours a week, they're now singing two or three hours a day, and they get about a year, a year and a half in, and then some this slowly just sort of can't do it anymore. And not to the level that they want to do, and then they seek out an opinion. 

The third cohort is a bit older, usually 30, early thirties, and they've gone through the training and they've built up a lovely career on stage, in a band, wherever, and they're doing really well and their careers are just sort of [00:07:00] taking off and they're really on the up slope and they're getting more recognised and they're getting lots more offers of jobs, and something happens on stage or they're on tour and, and there's an event and something happens and then they come and see me. And it's usually because, you know, they've been doing it nonstop and gradually increasing for 10- 15 years. And then, they're right on the edge, like professional athletes, you're right on the edge of injury quite a lot of the time. Something happens and then they come and see me and we get them sorted out -fine. 

The last cohort is much smaller and usually in their forties, fifties, or sixties. And it's people who are, they know what they're doing with their voice. They've been doing this for decades and often it's, I have a few people who just check in, I'm going to Japan for a month and I'm singing, let me have a a, a scope. Let me take the recording to Japan in case something happens. And that's just a really professional outlook. I don't [00:08:00] often see older, more mature singers with massive problems. It's usually the younger lot who have the issues that we need to sort out that involve surgery or therapy or, or what have you. 

So those are the four main groups really.  

Alexa: Amongst those cohorts when you are performing the scope, are you noticing that there is a pattern amongst them? Or is there a pathology or a partic injury that seems to be more common amongst one of them and not the other? Have you got any insights on that? 

Nick: Yes. I will preface everything I'm about to say by saying, if you're listening to this and you think you fit into this category, don't assume that you are in this category. You know, because a lot of things can give you very similar voice, very similar symptoms. 

Having said that, we had a look at our data over the last 15 [00:09:00] years. It was very interesting. 

In the child group, in the pediatric group- we're talking six to 10 year olds- we saw the occasional vocal fold cyst. You know, that happens. But we saw lots and lots of reflux, like rampant reflux that the children had no symptoms from at all, but their, their throats look like there's lots of stuff going on. And I don't know whether that's because- I still don't know whether that's because -there is lots of reflux going on, or because the children just accept the reality with which they're given. That's what their throat has always felt like, and that's normal to them, which is entirely possible. 

 In the teenagers- teenagers are really interesting. In the younger teenagers where I said we don't see that many patients, but they're primarily boys. And it's primarily epithelial cysts. And what I mean is those epithelial lesions just lumps on the edge of [00:10:00] the vocal fold. Nodules, pseudocysts, something, a bruise. 

Getting into the later teenagers where you start getting into the musical theatre, it switches many more females to males. And we're seeing lots of muscle tension and we're seeing some more intracordal stuff. So stuff that probably has been there from birth that, it's just, that's the way their voice sounds. But with the ramping up of the amount they're singing, it starts causing a problem. And it might be it causes a problem because that cyst pops and causes some scarring and some stiffness. It might be because to get around that cyst they're having to employ lots and lots of muscle tension and they end up like this and they just get stuck and the range goes gradually narrower and narrower, and then it gets stuck. So they come to us. But it is really interesting that, you know, young teenagers- boys, older teenagers- girls. I mean it was [00:11:00] 80 20 either way and just within a few years. So that was quite interesting. 

The older- let's call 'em the thirties, in the singers- a large number of muscle tension issues. If we subdivide them, there are the group that are going, I've just been struggling, gradually struggling for a while, a year, 18 months, and now I'm just can't quite hit those... I've lost a two or three semitones off the top. I can hit those top notes for 10 minutes and then they all fade away. I've gotta catch through my passaggio, something like that. And the vast majority of them are gonna be some sort of muscle tension issue that's gradually built up. And I call it just gradual vocal overload and they never quite reset and it's just gradually gets tighter and tighter. 

The other subset is, I've been on tour, everything was fine. Then something happens. You can have a, a bleed, uh, literally a pulled muscle. You palpate the front of the neck and there's tenderness there and they [00:12:00] just have to rest it. So there, there's, there's an event, and there's something I can sort out, and then recovery and then back to normal. Or a lot of muscle tension, which is often, and if anyone's been in my clinic and heard me say this, they would've heard me say this a hundred times, which is often you are too well trained. You're trained enough to get around the issue. You have the vocal gymnastics to work around it and turn it into a stylistic way of, uh, a sound, you know, just change the colour of the voice slightly to get around the thing, that thing, that they know is there, to the point where they can't get round it anymore, and then they end up in my clinic. So then we need to sort them out. 

And then the old ones really, uh, we can ignore them, put 'em in brackets at the top. 'cause really the, they're fine. If you've got 20 or 30 years down the line you're gonna be okay. So it's those, those are really the cohorts. 

So stuff in the, in the children's, the, the late teenagers with the cyst and the overload again. And [00:13:00] then an event on tour or muscle tension, gradual vocal overload over a period of time.  

Alexa: And why do you think in particular that there is maybe an influx of reflux? I quite like that rhyme, for the younger singers? 

Nick: Yeah, so, so I think the reflux, and this is purely my hypothesis with no evidence behind it whatsoever. 

We've all seen newly hatched babies and they just, there doesn't seem to be any kind of stopping stuff go down, come back up, go down, you know, it is just, there's no valve or anything. As we grow those muscles develop, the bottom of the esophagus does a 90 degree turn to go into the stomach through the diaphragm. And I think the muscles around the diaphragm gradually get firmer and tighter as you grow. And I think that grad, doesn't pinch it off, but it gradually just tightens it up a little bit and that stops you having the reflux. But I think probably, maybe it's 50 50, it's physiological reflux. [00:14:00] That's just the, the amount of reflux we all had when we were eight years old. Maybe. 

I don't know is the honest answer. And maybe that's the reason why the, the children at that age don't notice anything. I mean, some do, some say, yes, I've got a painful throat. Yes, I actually, I can feel it in my tummy and I get gas, you know, and, and that's fine. That's clear. But the others, maybe it's just physiological. 

I'm wary of tarring everyone with the reflux brush because it, is the thing that everyone thinks about- in ENT as well as singing, right. 

So you've got clear gastric or esophageal symptoms. I've got bloating, I've got churning in the stomach, I've got heartburn. You know, that's obvious. Buckets of acid coming up into your esophagus, in your chest. Fine. You need some pills and we need to try and sort that out, and there's a pathway. 

Then there's the stuff that happens in the throat without stuff going on in the esophagus or the stomach, and that's much more [00:15:00] contentious. There was a very clear trial, that came out of Newcastle a couple years ago, maybe a bit longer, about the use of PPIs, Omeprazole, lansoprazole, that family of drugs with LPR laryngopharyngeal reflux without esophageal gastric symptoms, it makes not a blind bit of difference and yet still people are going on them and still people are getting given them. 

And and this is on the background of everyone refluxes 5% of the time and we're designed to take a bit of reflux. That's 'cause we have lots of redundancy in the human body. It's an imperfect thing. We're gonna get a bit of reflux. Fine, who cares? As long as it's not causing any problems. If you've got persistent throat symptoms and I look down and go, well, it does look a bit irritated and the timing of your symptoms fits, then I'm gonna give you some lifestyle measures to follow and, and I'm sure that every singer listening to the podcast will know them. 

It's: eat early at night; make sure you go to [00:16:00] bed with an empty stomach; plenty of water; steaming- everyone steams. Lovely. Nothing in the water, just water by the way. And then Gaviscon and Gaviscon inerts -sits on top of -the, everything in the stomach like a barrier stops, things splashing back up. And usually if you are getting a bit of reflux once every two or three days, gives you ongoing symptoms, do that, those measures for 2, 3, 4 weeks. And usually you'll find it just slowly fades away and just vanishes back to your bog standard 5% of the time. I'm sorry I've tangented, tangented off a little bit, but the influx of reflux very, very often singers will come in and go, I've tried all the reflux stuff because it's an easy thing to do and actually it's not a bad thing to do. 

It is good vocal hygiene. I would just say make sure you're staying away from the tablets unless, one- you've seen a doctor about it or, two -you are getting gastric or esophageal that burning and bloating and all that kind of stuff low [00:17:00] down. And I say that 'cause now stuff is available over the counter, so it is possible that you can get people just taking it because it's an easy thing to take rather than because it's actually gonna make a difference.  

Alexa: So for those singers who are in that later cohort where they may be going on to a training programme and things are ramped up a little bit... it might be that those singers haven't done as much singing before, they come from a dance background mainly, and they started singing just very recently, or vice versa. 

How can teachers like us and the institutions themselves help prepare for this increase of vocal load and this required stamina, do you think?  

Nick: Yeah, it's a, it's a really good question. 

I am not a singing teacher. But what I do have a bit of background in is a bit of sports science and, and ENT. My strong view, just, you know, and there are books [00:18:00] out there that I believe strongly that the singer is the vocal athlete. Of course there is enormous artistry. We're talking about the colour and the emotion and and so on and so forth, and that's great, but put that to one side and what have you actually got? You've got muscles and ligaments and tendons. You've got breath support. You've got a physiological system that needs to work fine tuned and needs to work really well to do that. It's exactly the same as an athlete, which is you don't just run, if you are a runner, you do weights, you do stretching, you're doing lots of other stuff. 

And it's the same... I really believe that that should be the same as singing. You should have almost the, the vocal equivalent of cross training, whatever that is, I dunno what that is. But having the base of the pyramid as a really strong base. So you have all those ligaments and muscles are strong in every direction, so you can then [00:19:00] adapt to whatever it is you are going to be asked to do. 

And I think that's vital in the... especially in the musical theatre. 'cause you're asked to do enormous amounts of singing and you're gonna be dancing and probably acting and projecting a spoken word as well. And on top of that, you need to have the stamina and durability with all those little muscles too, be able to know what you're doing to reset, to go back to and start it all again tomorrow and do eight shows a week. Now lots of people are able to do that, and that's great, but I see lots of musical theatre people in my clinic, and that's not unexpected. Not because it's musical theatre, but because it's a physical activity. 

There is a clear statistic that runners, it's something like 85% of runners will get an injury at some point. Okay. Now, I'm not saying singers were as, as up in that level, but there was always the, the myth of, you know, you have a vocal injury and it's a disaster and, [00:20:00] and the world is ending. Whereas actually, I think, uh, the generations coming through are realising that it's a physical activity and if I get injured I'm gonna get it sorted out and then I'll come back and it'll be great. So, it's not to be expected, but if it happens, it's, it shouldn't be this is incredibly rare. It's not. Lots and lots of people get some sort of vocal injury and there's, you know, a wide range as, as we briefly mentioned before. 

So yeah, I think preparing, in the same way that you don't train for a marathon by doing a few 5K runs and then going to run a marathon, you need to build it up. So there needs to be a buildup that bottom rung of the, of the, the pyramid to, of all over vocal stamina before you launch into it. 

So I'd be a strong advocate, and schools do this for sports and I think schools and musical theatre colleges should do this for singing as well, which is [00:21:00] before the rugby season starts in September everyone who's going to be trying out for the rugby team, get sent a training scheme for the three months beforehand and they slowly build up for three months. 

And so they are not match fit, but they are fit and they're strong. They've done all the right exercises so that they can start and not get injured. And I think that's a pretty good analogy where I think perhaps, getting the 18 year olds or, you know, whenever you entered that, that particular college, often 18, sending stuff out, if you've been accepted earlier in the year, sending out a training scheme and saying, this is what we'd suggest you do so that you are ready to go, in September or October. 

That would be my, my suggestion. But I'm not a singing teacher. I, I, you know, you can throw it all out the window if you want.  

Alexa: I guess then there's a question of who monitors the way they're doing it, you know. What if they're [00:22:00] training it in, in a way that's inefficient, you know, should they be taking it to a singing teacher and then who's actually available to finance that? 

So yeah, there's the broader picture I guess is... just has those little nuances in that we'd have to sort of figure out.  

Nick: Yeah, yeah. Absolutely. Um, and that's why, you know, I, you know, preface by just saying not, I'm not singing teacher, it's just the, the pure functionality of those muscles launching into a lot of singing can be problematic.  

Alexa: Maybe there's something alongside of, of some videos or something that would accompany the PDF or whatever of the description. I mean, how many people go onto YouTube and do a couple of exercises there? I mean, some videos are really great and others may not be as useful, but if there was somebody within that expertise who could do those accompanying videos, then that might be...  

Nick: You could, you can imagine that, you know, a musical theater college [00:23:00] getting their, their teachers to do a string of videos and putting on their, their YouTube channel and then saying, look, here, here are the links to the, the videos. This is what we suggest. We'll see you in September. 

But you know, you, you are, you're absolutely right. You don't want them to turn up having done three months of work, that's rubbish, and then having to unpick it all from day one. So what do you do? 

But that's, but the, but the, the point of all that was, I think the, the primary issue I see is that big step up in volume. So if the pre-training is not it, it's gonna cause too many problems, which you're absolutely right, you can see it might cause problems. Then phasing them in, in terms of the sheer amount they're doing on a day-to-day basis over a period of weeks would be sensible. But then, you know, you then cutting into how much term time, you know, and so, yeah, I'm not [00:24:00] sure the, the exact answer is, but, um, some sort of graduated increase in the amount of physical activity they're doing, I think would be really, really sensible. 

Alexa: In your opinion, is any voice capable of doing eight shows a week or going on tour and doing these big shows? Or is there anything sort of anatomically or structurally that you've seen that may suggest a singer's physiological max in terms of weekly voice use or general voice use that it can actually cope with? 

Nick: Oh, good question. Um, in answer to your first question, can people do it? Yes. They've been doing it for years and they will continue to do so. Yes. Can people run into trouble also? Yes. 

Can I tell by looking at someone's larynx, uh, someone from the front or looking endoscopically and looking at someone's larynx? No. [00:25:00] No chance at all. I can't tell you when I look at larynx, whether that's a soprano, a mezzo, a tenor. You cannot tell. It's impossible. You can't tell by looking at larynx if they can sing or if they're gonna be a good singer. And therefore, extrapolating from that, you, you definitely can't tell whether, if they are a singer, whether they can do eight shows a week by looking at the anatomy. 

So, in fact, one of my colleagues, Declan Costello, who I'm sure a lot of your, your listeners, will, will know who's a very good singer himself, and a laryngologist, he was asked by the BBC, uh, you may remember a programme about can we turn a, essentially a, a muggle into a professional something. Professional MC, a professional artist, a professional chef, and enter a competition and see if they can win a competition in about eight weeks. 

And he was asked, can we do that? Can you look at people's larynxes? And, and then tell us who, who's gonna be a good singer? And he said, [00:26:00] no, you can't. And they never ran with that programme for that reason. 'cause there was no way of looking at any of the anatomy and saying, you can do this. I wish there was, 'cause then, you know, you really could pick people out of a lineup, couldn't you? 

But there isn't.  

Alexa: Yeah. Auditions will be different.  

Nick: Yeah.  

Alexa: Get, get your larynx out.  

Nick: Scope first, then, audition. Well, it's interesting, in Germany, anyone entering musical theatre, they all have to have a scope before they start, don't they?  

Alexa: That would be a, a really ideal world. Yeah.  

Nick: But different country, different rules. 

Alexa: Wanna do it for free? 

Nick: I'd take all the time, wouldn't it?  

Alexa: Yes. It would. No more skiing for you.  

Nick: Oh, no, no. Definitely not.  

Alexa: Can you tell then by looking at a larynx, if there are other things going on? Like can you see something like hypermobility during a scope?  

Nick: [00:27:00] Um, I hesitate because yes and no. You can definitely see lots of things in the larynx. Infections. You have a whole catalogue of excellent photos of horrible looking larynxes with diseases of this and the other. And it's interesting that I've seen quite a few very good musical theatre singers, you know, up on stage in the West End. Great. You know leading singers and it is quite difficult to describe, but the overall tone of everything in the larynx just looks good. It is not specific. I can't say, oh, it's because this is slightly wider. And, and and this isn't a position like that? No, it is just... you see someone walking down the street and you just go, they're an athlete. You know they are. They've got the shape, the legs look a certain way. They just look good. They look [00:28:00] like they've done a lot of athletics or whatever. And I can say that about the larynx 'cause I do see larynxes and go, that just looks spot on. Everything looks smooth. The control is fantastic. But I cannot put my finger, no one can, you cannot put my finger on why it looks good. It just does. 

I mean that's not very helpful, and I can't tell whose larynx is gonna look like that, but when they do come in, you just go, oh, that's, that's, that's a good looking larynx. 

But then, you know, there, there are lots of things in the vocal folds. So I can see systemic conditions that can affect the, the vocal folds. So you see bits and pieces, we'll leave that to one side 'cause that's more sort of very medical things. 

Hypermobility big thing. And I think increasingly recognised. Hypermobility, big spectrum, huge umbrella of, you know, you've got extreme end of Ehlers Danlos syndrome where they're, they're in real trouble and they've [00:29:00] got lots of connected tissue problems with eyes and blood vessels and all sorts of stuff. 

Then you've got, um, sorry, I was thinking more of Marfans, but Ehlers Danlos has, has similar kind of overlap. Then you've got the other end where you are a bit flexible. We do think, we don't have the exact data 'cause what you need is a massive epidemiological study, which we just don't haven't, which we haven't done and we don't have the ability to do, is is there a higher rate of hypermobility in musical theatre than in the normal population? 

And my gut is to say yes. And the reason I hypothesise that it is yes is for two reasons. One, if you are quite supple and a little bit hypermobile at that end, right, you're gonna be much more flexible and probably a lot of dancers have a touch of something, right? Also the [00:30:00] maneuverability and the mobility of the joint around the larynx the same. 

So you have a much more mobile, a much more, ability, a greater ability to physically move the larynx and move the vocal folds. And I think that that leads to people who are naturally good at singing and naturally good at dancing and flexible, probably. There's probably certainly a cohort of those people who have just always been really good singers who have a touch of the hypermobility. 

Okay. Not enough for it to be detrimental, but to maybe, you know, people are just naturally inclined to that because they are, find it naturally easy. When it gets a bit worse, you can get into some issues, partly because the of the hypermobility and the hypermobility affecting the connective tissue in around joints and of the vocal folds and everywhere else, but [00:31:00] also of the control that people use to try and control the flex, the hyper flexibility. So we see a lot of tension issues when you've got a lot of flexibility in a joint, wherever it is, larynx, anywhere else, and everything gets really tight around it. 'cause it's just trying to hold it in place. And the brain is goal orientated. It just wants to get the note out. It just wants to move your arm in that, you know, run down the road or move your arm or throw the thing. And if it, if you are going to throw the thing and your arm's gonna come out of its joint, it's gonna tighten everything up to hold it in place. It's a really simplistic view, but it's that's, that's what we've got. We've got actual problems with the hypermobility causing a lack of control. 'cause things are not being able to, on the normal level of neurological control you need is not enough to keep everything in line. 

And then you've got [00:32:00] going out the other side, enormous amounts of tightness and tension around that joint, trying to hold everything in place and control it. And, you know, singers and dancers, they're like, you know, you've gotta have the control to come in on that pitch, to do that glissando, to, to do that movement. 

Probably do all the, all those three things at the same time. So can I see that in the larynx? Yes. I can't see it 'cause it's not, there's a lump, therefore it's hypermobile, it's a pattern of what I'm seeing when the singer does certain things and we run them through their paces in clinic and you see how things are moving and you go... 

and often the question later in the, in the consultation comes, Any issues with your joints? Any issues with your tummy? A bit hypermobile. Oh yeah. A bit hyper mobile. Hmm. Yeah. Thought so because of what we've seen in the larynx, but not specifically because there is a thing where I've gone, you've got [00:33:00] that therefore your hypermobile. 

Do you see what I mean?  

Alexa: And I guess it's good also to remind ourselves that there might be singers who consider themselves to not to be particularly flexible, but actually can still have hypermobility.  

Nick: That is absolutely true. Yeah. Um, they may, uh, there's the, I'm not as flexible as that person, therefore I can't be hypermobile. 'Cause hypermobile are like, really, you know, contortionists. No, no. Just because you're not as flexible as Jeff doesn't mean that you don't have any hypermobility. 

I'm, I'm a bit wary about the hypermobile thing as well. I'm just gonna put in a little asterisk next, everything I've just said, which is in the same way that suddenly everyone hooked onto reflux. I don't want everyone to hook onto hypermobility. You're saying that is something that we see, we very rarely see a singer or a dancer come through the door and we go you need to go and get a rheumatological opinion, and you've got Ehlers Danlos and you know, this is not for you. It's often, [00:34:00] ah, that may just play a little part in the overall picture. It's not the thing, if you see what I mean.  

Alexa: As someone who performs surgeries, it surprised me that you haven't played operation. 

 I'd like to know how steady that hand is to get the wishbone.  

Nick: Yeah, no, you don't.  

Alexa: No. Maybe no. Maybe actually yes. That's not a good idea to know.  

Nick: But, but actually it's a really good point. Uh, we joke, but if I'm operating on the larynx, so tomorrow afternoon I've got four operations on the voice box, right, on the vocal folds. 

I know that the night before I, and the morning of the operation, I have to do exactly the same thing. So I have to have the same amount of coffee. I have the same things to eat. Um, so I know that I'm going to be steady. 'Cause I'm looking down at the microscope, I'm often using a laser. I'm using, you know, fine instruments, which are yay long, , and any little shake here is [00:35:00] gonna magnify down the vocal folds. So at the end of the scope, at the level of vocal folds. So I am always really careful about, how much coffee I have. Not too much, not too little, what I eat, you know, no alcohol the night before, that kind of thing. 

Whereas that may not be the same when I'm playing operation. I'm there for a drink.  

Alexa: Yeah, you've had a few bevies and you're buzzing all over the place. Like who gave this guy a pair of scissors or whatever you use  

Nick: Everyone just looking horrified at me.  

Alexa: Yeah.  

Nick: Don't judge me.  

Alexa: Have you got something that you would be squeamish about, and maybe not with voice, hopefully, but is there something in terms of the body that you'd be like, I could not touch that? 

Nick: The one thing I really couldn't do is, is put a suture in an eye. I just,  

Alexa: yeah.  

Nick: Ugh. But, but I've done, without being too graphic, I've assisted in big head and neck cancer [00:36:00] operations where you've taken the eye out, had to just take, you know, big bits out and taking the eye out and I'm perfectly fine with that. 

But just the idea of like sticking a needle. Uh, yeah. Yeah. Not the eyeball. Mm. Maybe it's because I'm shortsighted. I've had laser surgery myself. That was fine. But the idea of me doing that to someone else, just, yeah. Yeah. That gives me the heebie-jeebies. 

Alexa: When it comes to surgeries, what is the best advice for the recovery stage? Are we talking complete rest? What's your opinion on that? How do we get to the next stage after a surgical intervention?  

Nick: Yeah, really good question. And again, there's lots of debate out there. It used to be any surgery is like two weeks of absolute voice rest, some people a month, you know, it's crazy. There is very little evidence at all about what's good and what's not good. 

What I'm [00:37:00] going to tell you is purely my opinion and therefore obviously is completely right.  

Alexa: Oh, obviously, yeah.  

Nick: But I'll explain why I do this and then hopefully it'll make sense and it seems to make sense and it seems to work. And maybe the the right answer is, is different, but I don't think it probably is too far different from what I do. 

So if we just break it down into one of three things, and I'm not talking about external operations, we'll ignore all those for the time being. So if I'm looking down and I'm doing something to someone's vocal folds, if I'm injecting something, I just say, um, voice rest, that day they can start speaking the next day. 

Realistically, it's actually voice rest for about three or four hours. And the premise behind that is there is a hole where the needle's gone in and that hole needs to heal over and it takes about three or four hours. Platelets come in. It's not very big. It's like a blood test. It, there you go. 

So just because if I say voice rest [00:38:00] for three or four hours, people get it wrong. So I just say voice rest that day, start speaking tomorrow, nice and easy. And that's anything that fat or steroid or um, platelet rich plasma, you know, whatever. There's loads stuff. Doesn't really matter. One day. 

If there is something on a surface to the vocal fold, a nodule, a pseudocyst, a polyp, uh, hemorrhagic polyp or something, okay, um, it's not involving the body of the vocal fold. It is literally a rising from the surface. I take it off. And my aim as a surgeon is to literally just take the epithelium off and leave all the superficial lamina propria, the jelly-like substance that allows the vocal folds to vibrate and everything deeper to that, completely alone. 

So they've basically got a graze on the surface of the vocal fold. Now I say three days voice rest, complete voice rest. I normally operate on a Friday morning. I just say, have a quiet weekend. Start speaking on Monday. The reason I do that is there are some [00:39:00] canine studies where they've taken the epithelium off. Then they've looked at multiple days afterwards and it's about three days. It's completely re epithelialised. So I go, alright, great. Three days. It's pretty much epithelialised. 

And then there's the balance between leaving it well alone, no speaking at all. And then what happens is the healing carries on and you start forming scar, which then gets stiffer versus let's start mobilizing that so that as the scar inevitably forms, it, forms in the way that we want it to form with the speech therapy exercises and the exercises that person's going to do. So that's three days voice rest for an epithelial lesion. 

An intracordal lesion. So you've got an epidermoid cyst inside the vocal fold. Or a scar or a pit or a, you know, whatever, it doesn't really matter where I'm having to make an [00:40:00] incision on the top of the vocal fold, open up the trap door, take the thing out, and then replace the space that I've created with something, with some gel or something, and then put the flap back down again, I used to say three days for that as well, but I had a few patients who said they tried speaking and it just wasn't right and they left it for five days, which seemed more comfortable, and then they started the exercises. So now I say intracordal stuff, five days. And that fairly universally from the patients is, seems about right. 

Some people delay it for a week. I just say whatever happens, you can't go beyond a week without starting to use your voice, even if it sounds terrible. I always warn people, I say you, there's always a J shaped recovery where the first time you speak, it's gonna be all over the place. You're gonna panic, you're gonna say something horrible is wrong. 

It's not. Everyone's voice always gets a little bit worse, then it gets better. And usually after about two weeks for epithelial, [00:41:00] three weeks for intracordal lesions, you're about where you were before the operation and then we're off to recovery.  

Alexa: We had a couple of questions come in for you, and one is to do with this rehabilitative process and this came from our Facebook group. 

And the question was with interest in hearing your thoughts about 'the validity of singing teachers in voice recovery as there seems to be noise from certain corners devaluing the work that singing teachers do to help rehabilitation. So yeah, what are your thoughts on that?'  

Nick: First of all, singing teachers have a vital role in the rehabilitation of singers who have undergone some sort of therapeutic measure. 

If I describe the pathway that we use, which is a now very well-trodden pathway, let's say they do have a thing on their vocal folds, so they're gonna come to me, I'm gonna do the surgery. Great. We've done say the three days voice rest, [00:42:00] like we just discussed. They've done very well. They've gone to speech therapy and they've done speech therapy for a good few sessions, a few weeks, four to six sessions, something like that. 

So after about four weeks they've done about four sessions. We then start dovetailing the speech therapy with vocal rehabilitation coaching. And the reason we do that is, especially when the singers are, are well trained and they're good at taking instruction and advice, they often absolutely nail the the exercises. Perfect. And they're getting this lovely vibration, lovely airflow, good breath support and closure is good. And we're thinking, oh, this is great. This is going really well. Right? Go and sing. And then you just sing like they were singing before with all the muscle tension patterns they built up 'cause there was a thing on their vocal folds. 

That's not their fault. That's just the, the muscle pathways, the neuromuscular [00:43:00] pathways , are now set in that way and we need to reset them. So the vocal rehabilitation coach takes those exercises and literally just blurs them into singing in their modal register. Then singing in extended register glissandoing up through their passaggio up into their head voice. 

And then, you know, getting them into singing voice by using the setup that the speech therapist has gotten. Then the vocal rehabilitation coach said, this is great. She's not teaching,, or he, to be fair, mainly she, but, or he, um is not teaching that person to sing, is just getting them back into their singing voice. 

At which point she then, or he sends them off back to their singing teacher who will pick them up ideally and start working into the rep that they want to be working towards.[00:44:00]  

The issue is, I think is, and there's been lots of discussion over the last few years, so the vocal rehabilitation coaching, it's the gap in between, it's, it's it's surgeon, speech therapy, singing teacher, and the sort of gap in between is the vocal rehabilitation. 

And it's that blur between the medical side, recovery into the artistic side, getting back on stage. Right now there is no official pathway to, to learn how to be a vocal rehabilitation coach. There is no exam. So, and there is no regulation. So you can just set yourself up as a vocal rehabilitation coach. 

And therefore, just the fact that that is the way it is opens the door to getting a very wide spectrum of experience and a very wide spectrum of, skillset sets. So you can pick a vocal rehabilitation coach and you, [00:45:00] you might get lucky and they'll be awesome. You might get someone who might just not quite know what they're doing, quite frankly. 

We talked about this before. The no one goes into this saying, I'm just gonna fleece people for money and I'm gonna take their money in to hell with them. Everyone's going in with the best interests of the singer at heart. So they're really trying their best. And I think there is a role to, for that vocal rehabilitation coach to fill that gap, but not to go off into the singing teaching, um, and not to be straying into the speech therapy. 

So there need to be boundaries set and currently there are no boundaries set. And that's probably where some of the, um, discourse and, and some of the back and forth comes in is because a say I can, you know, you imagine a singing teacher saying, well, hang on a second, you are teaching them their rep. Why, why haven't you handed them back to [00:46:00] me? That's my job. You can see that happening. 

So I think in answer to your question, I've gone sort of full circle in answer to your question. Do singing teachers have a role to play in rehabilitation? Absolutely, they're essential because otherwise you get to the end of vocal rehabilitation coaching and then you just cast off into the wind and good luck to you. 

No, it's, you need that stability. And we often say to people before we sign 'em off, saying it's so important to touch base with your singing teacher on a regular basis, even if it's once every two or three months, just to just keep ticking over and ticking over and ticking over so you know that your technique is on point. 

When you are left to your own devices, you think you're on point, but you're not. You're slowly drifting off or you can be. But I think that pathway from speech therapy to vocal rehab coach to singing teacher is a really important one. And, and that flow is both ways. [00:47:00] So I get referred patients all the time from singing teachers going something's not quite right. I've tried a load of things. All very sensible things. It's still not quite right. Let's just make sure your vocal folds are all right. Send 'em to me and I'll scope and then we can go from there. So I can either carry on with the confidence I know the vocal folds are fine and I can keep doing my singing teaching or Oh no, there is something. 

That's fine. We'll deal and then we'll go through that pathway. We'll get you back to your singing teacher at the end of the pathway. So I hope that answers your question. There is not controversy, but there is, I think because of the lack of regulation, there is a blurring of edges of what people do and then people can easily overstep accidentally, I think.  

Alexa: We had another question that came in which says, I'm a singer and a singing teacher and I have a problem that [00:48:00] I can only explain as an ache in the throat with a graze feeling at the vocal fold level. So in, in part of that, it's the question of can we actually feel our vocal cords to start with? 

Nick: I'm pausing because it's actually a very difficult question. You can't feel your vocal folds. However, and the reason I say you can't feel 'em very specifically is because no one can say something's gone down there and it's on my right vocal fold. And the reason for that is there is, there is basically one nerve that supplies a whole area, including the vocal folds on both sides, including the top part of the trachea and an area above the vocal folds. 

So it's a whole area. You must remember the reason we've got vocal folds is not to sing and speak. That's a distant forth in the reasons that we've got vocal folds. [00:49:00] One is to breathe, and two is to, and really, really importantly, is to protect our lungs. 

And we all know this, something goes down the wrong way. You're coughing and spluttering and tears are streaming and snot streaming out in your nose, and there's nothing you can do about it. It's a very well, well worked reflex. 450 million years worth of reflex, right? You can't fight it. And it's great 'cause it protects your lungs, but when it goes down, you can vaguely say, oh, it's gone down the right side of my throat or the left side of my throat. But it is not more specific than that. So you cannot feel the vocal fold. 

What you can feel, and I, everyone listening to this will know is that I can feel when my vocal folds aren't quite coming together. You have an innate sensation of, of where your vocal folds are in space, even when you don't think about it. So when you're singing and going, this isn't quite right, you can pinpoint and say, it's not [00:50:00] quite right because.dot dot the edges aren't quite coming together and it's a bit breathy. 

I'm, I'm squeezing.  

Alexa: Like when you feel a bit puffy.  

Nick: Exactly. And you go, yeah, I, well, you know, I've got a cold. I tried singing and it was just, you know, very thick and no, no resonance and so on and so forth. Those descriptions are of what happens when your vocal folds are moving and the whole process of air vibration outflow tract, what they're not is a feeling of what is going on on your vocal fold. 

So it's, it's highly, highly sensitive area. But a really poorly specific area. So incredibly sensitive. You know, something's there, but you cannot pinpoint where it's, there are very specific cases where you can, but I will ignore those. But in general, can I feel my vocal folds? No. But you can get a lot of propreoceptive , feedback [00:51:00] from, from what it feels like when air is going through them and so on and so forth. 

Alexa: So the second part of the, the question for this person was that it seems that this feeling of an ache in the throat with a graze feeling seems to come on particularly flaring in the luteal phase of the cycle. This person's had lots of singing teachers and studied singing to a high level. They've had a stroboscopy and there's nothing wrong, nothing's been found, and they're wondering if you might have any idea what this might be and to direct in, in the best way possible.  

Nick: Yeah, that's a, that's a really difficult question. It's... there are very well recognised features of premenstrual voice. 

 What's really interesting about premenstrual voice is that objectively there is no difference to the voice. Subjectively, that woman [00:52:00] absolutely knows her voice is not the right, its not the same, but it's, it is interesting that they, it cannot be picked up by objective measures or by other people listening. 

So it's, it is a, it is a fascinating area. So that, that's an interesting thing about the luteal phase, which may explain why she's feeling something, but perhaps everyone else is going, well, it sounds fine, you know? So maybe, maybe, maybe, maybe. Bottom line is I can't really say without looking at the vocal folds. 

And I know you said this stroboscopy before and says it was normal. But with the best will in the world, there are stroboscopies and stroboscopies. Um, there are people who do this all day every day, and there are people who do them occasionally. And those people who do them all day every day who have a real specialist interest in the voice, are gonna pick up much subtler and smaller things. 

What I will say is that if it's been going on for that long one, it's not gonna be anything horrible. There's no [00:53:00] sinister features here. It's not gonna be a hidden cancer or a hidden disease. It's been going on for years and years and years. It fluctuates in intensity. Again, nothing horrible. 

It sounds like most of the time, uh, it's normal. I may have got that wrong, but it, if, if you know a good percentage of the time the voice is actually normal, that's great. That means there is normality there. Okay. So whatever it is that's knocking her off normality, we should be able to get back to it if you can find the source of what's knocking her off centre. 

But that's about the limit of what I'm gonna be able, I'm gonna be able to say without seeing her in person, taking full history, doing the full exam at the usual thing. So good luck to your contributor and your listener. I hope she finds the right place.  

Alexa: Yeah, yeah, absolutely. 

And I, I can imagine that you get that a little bit, uh, with, uh, people maybe saying to you, well, I've got this feeling. What is it? [00:54:00] I, I know that if I had a, doctor, ENT in the family, I'd be like, Ooh, what's this thing I'm feeling?  

Nick: Yeah. I mean, to be honest, I don't mind that so much. It's when they say I've got this thing on my toe. I, I don't, I, what's this rash? I dunno.  

Alexa: I dunno. Oh, Nick has been so lovely chatting with you. 

Thank you so much for your time. I just have one last question to ask you, because some of these,  

Nick: of course,  

Alexa: things that we've kind of picked up on today has been about not getting fixated on certain things like reflux, whenever we've talked about maybe some symptoms, it's not getting too het up about certain things. 

Where do you think this potential preoccupation and real worry and fixation on vocal health has come from, and what can we do to make sure it doesn't escalate further while still keeping good vocal hygiene in place?  

Nick: [00:55:00] Another tricky question. You've, you've wheeled out all the good questions tonight, haven't you? 

That's great. Um,  

Alexa: great. Or are you secretly cursing me inside?  

Nick: Uh, no. I,  

Alexa: yeah, you couldn't possibly say,  

Nick: I possibly say no. Um... It's easy to say don't get fixated on this. It's much harder to do it. 

The people, especially younger people, get fixated on the vocal health because that's what they really, really want to do. 

And they will do anything to make sure that they are, go to the next step, they go to the next level. They finish the end of year, they get their or their showcases right. They, whatever it is. And part of that, you know, a lot of it's technique and practice and, you know, it's all the boring stuff, which is practice, practice, practice, practice, practice.[00:56:00]  

But they look for any angle. If I've got a bit of reflux and I sort that out, maybe I'll be better. The reality is is that humans are incredibly imperfect creatures and stuff is there most of the time to a greater or lesser extent. And it's, working through the stuff that you have to do without... 

you know, and things will rise up. Okay. There seems, there, there would always this myth about the voice. The voice has to be perfect. Everything's perfect. Any slight niggle is a disaster, right? That's not real life. Real life is stuff happens and you're gonna be just a bit off one day and you're gonna be a bit sore. And, but then the next day you're gonna be fine. 

It's an acceptance that, that [00:57:00] we are human, we're fallible, and as is the mechanism. You do approach things professionally without being obsessive. An acceptance that the, the voice is like every other bit of the body -not perfect, and it's going to vary and obsessing about, whatever it is, reflux or anything else that comes along, one is not healthy for you, full stop. And two, probably isn't the reason why you've had some vocal issues. Okay? It might be a contributory factor, but the voice is not in isolation. It's multiple, multiple things. Your emotion, your physical state, the tension of the muscles in the throat, potential tension of the muscles in the larynx, how you slept last night, what bit of your cycle you're on, and all the other things that, that all pile into making a voice. Okay? 

Again, I know it's easy for me to say [00:58:00] don't obsess about one of the one or one of these things. But I think it, it also reiterates my feel about having that base of the pyramids again, the looking after your voice. 

Just the, the trouble is it's all really boring stuff that no one, everyone wants a magic pill. What you want is you want to eat healthy, you wanna get good sleep, keep yourself well hydrated, you are gonna practice, practice, practice and do the all the warmups properly and do all the cool downs properly so that you have this incredibly robust mechanism and, and instrument so that you can then go and turn it to, in whichever direction that you want to go. 

The obsession about vocal health I don't think it's new. I think it's always been there. I think it's just to a greater or lesser extent I think right now it's just accentuated a little bit. It'll be something else it, after I've retired it, that just [00:59:00] happens to be it at the, at the, at the current time. 

And I don't think there's anything particularly wrong with it. I think vocal health is, is really important. It is one of those strange things that we bang on about how important it's about vocal health and then when people get obsessed by it, it said, no, no, no back off, back off. No, not that much. It's just important just to tick over on a daily basis and being a professional and looking after yourself is, like I was talking about earlier about my operating, it's like. I know how much coffee to have. I know not to have a glass of wine the night before. I know, you know, just there are certain things that I know work for me. 

And so if a singer is doing a particular pattern of of work, of practice, of performing, then they should work out what works for them.  

Alexa: And that's why we are here as well, isn't it? To help guide them into what that could be. 

Nick: Absolutely. There is no right way of doing it. 

It's the right way that [01:00:00] for you and how you prepare yourself, how you sing, that's, that's you. You can learn the basics and then you have to figure out what it is for you.  

Alexa: Oh, Nick, I could ask you so many more questions, but I will leave it there and maybe hopefully invite you back one time if, uh, if you'd be up for coming back on. 

Nick: I would love to come back on. It's been such fun.  

Alexa: Oh, amazing. Where can we follow you in the meantime, know where you, you may be presenting at some conferences or following the work that you're doing?  

Nick: Yeah. I'm currently president of the British Laryngiological Association. So go onto the BLA website and we have various bits and pieces there. 

Personally, I'm speaking at the, it's, an international European conference, C-E-O-R-L-H-N-S. Nice and short, snappy title in Gothenburg next week. And then we've got, uh, some conferences later in the year as well. I'm going to Mumbai as well speaking about muscular skeletal issues with the voice, which is gonna be really cool. 

And then we have our BLA cutting edge conference, three days in [01:01:00] the Royal Society of Medicine in September, which is an amazing, I mean, I'm, of course I'm gonna say that, but mainly my colleague Chadwan Al Yaghchi who is the president-elect of BLA, he was gonna be taking it from me in 2027. And, uh, he, it's his, it's his baby. And it is a really wonderful, wonderful three day conference. 

We also have a voice clinic course that we run. It was only once a year -we're gonna probably increase that a little in introduction to the voice clinic, which is lots of cases and then practicing scoping and things like that, primarily for speech therapy. But we do see quite a lot of singing teachers in the course as well. 

So, get onto the website if you're interested. I'll see you at the next one.  

Alexa: Oh, that's brilliant. Well get your practice on of operation because I'll invite you for a, for a game and a, and a bottle of wine. We'll see how you go. Thank you so much - Nick Gibbins. 

Nick: Excellent. I look forward to it. Pleasure - bye..