Research Article|Articles in Press

Extreme Vocals—A Retrospective Longitudinal study of Vocal Health in 20 Professional Singers Performing and Teaching Rough Vocal Effects



      Rough vocal effects, extreme, or extended vocal techniques to sound intentionally hoarse or rough are an integral part of many genres and styles, and research has recently demonstrated the involvement of supraglottic narrowing and vibrations to produce such sounds. The vocal health of singing with rough vocal effects is poorly documented, especially in a longitudinal manner, while much vocal pedagogy continuously treats the sounds as harming to or dangerous for the vocal mechanism.


      To longitudinally investigate the vocal health of professional singers who perform the five rough-sounding vocal effects Distortion, Growl, Grunt, Rattle, and Creaking as part of their singing and teaching.


      Twenty singers underwent nasoendoscopic examination, filled in SVHI questionnaires, and were assessed by GRBAS with a 14-year interval in a retrospective longitudinal study (from 2007 to 2021). Endoscopic materials were assessed by Reflux Finding Score and a hybrid version of the Stroboscopy Rating Scale.


      Singers presented at initiation of study with an average SVHI of 9.2 (±9), which decreased at time of follow up 14 years later to an average of 5.12 (±6). Laryngeal assessments (RFS and SRS) revealed low averages at initiation of study as well as at conclusion of the study with only small fluctuations in averages, with findings mainly relating to arytenoid asymmetry.


      The participating singers perform and teach rough vocal effects continually and present with healthy laryngeal mechanisms and within-normal SVHI and GRBAS scores. The findings suggest that controlled supraglottic narrowing and techniques to allow for supraglottic structures to engage in vibration as an additional noise source can be performed sustainable and in a healthy manner if performed with correct vocal technique.

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        • Sobol M
        • Sielska-Badurek EM
        • Osuch-Wojcikiewicz E.
        Normative values for singing voice handicap index - systematic review and meta-analysis.
        Braz J Otorhinolaryngol. 2020; 86: 497-501
        • Castelblanco L
        • Habib M
        • Stein DJ
        • et al.
        Singing voice handicap and videostrobolaryngoscopy in healthy professional singers.
        J Voice. 2014; 28: 608-613
        • Phyland DJ
        • Oates J
        • Greenwood KM
        Self-reported voice problems among three groups of professional singers.
        J Voice. 1999; 13: 602-611
        • Phyland DJ
        • Thibeault SL
        • Benninger MS
        • et al.
        Perspectives on the impact on vocal function of heavy vocal load among working professional music theater performers.
        J Voice. 2013; 27: 390 e31-9
        • Leppavuori M
        • Lammentausta E
        • Peuna A
        • et al.
        Characterizing vocal tract dimensions in the vocal modes using magnetic resonance imaging.
        J Voice. 2021; 35: 804.e27-804.e42
        • McGlashan J
        • Thuesen MA
        • Sadolin C
        Overdrive and edge as refiners of “Belting”?: an empirical study qualifying and categorizing “Belting” based on audio perception, laryngostroboscopic imaging, acoustics, LTAS, and EGG.
        J Voice. 2017; 31: 385.e11-385.e22
        • Sundberg J
        • Bitelli M
        • Holmberg A
        • et al.
        The “Overdrive” mode in the complete vocal technique: a preliminary study.
        J Voice. 2017; 7
        • Yanagisawa E
        • Estill J
        • Kmucha S
        • et al.
        The contribution of aryepiglottic constriction to “ringing” voice quality—a videolaryngoscopic study with acoustic analysis.
        J Voice. 1989; 3: 342-350
        • Sadolin C
        Rough, Ready, and Able.
        International Music Publications IMP, Warner/Chappell, Copenhagen, Denmark1991
        • Sadolin C
        Complete Vocal Technique.
        Shout Publishing, Copenhagen, Denmark2021
        • Aaen M
        • Christoph N
        • McGlashan J
        • et al.
        Extreme vocal effects distortion, growl, grunt, rattle, and creaking as measured by electroglottography and acoustics in 32 healthy professional singers.
        J voice. 2021; (In Press, Corrected Proof)
        • Aaen MH
        • McGlashan J
        • Sadolin C
        Laryngostroboscopic exploration of rough vocal effects in singing and their statistical recognisability—An anatomical and physiological descriptions and visual recognisability study of distortion, growl, rattle, and grunt using laryngostroboscopic imaging and panel assessment.
        J Voice. 2017; (In Press)
        • McGlashan J
        • Sayles M
        • Sadolin C
        • et al.
        Vocal effects in singing: a study of intentional distortion using laryngostroboscopy and electrolaryngography.
        AES. 2013;
        • Thuesen MA
        • McGlashan J
        • Sadolin C
        Curbing-the metallic mode in-between: An empirical study qualifying and categorizing restrained sounds known as Curbing based on audio perception, laryngostroboscopic imaging, acoustics, LTAS, and EGG.
        J Voice. 2017; 31: 644.e1-644.e10
        • Achey MA
        • He MZ
        • Akst LM
        Vocal hygiene habits and vocal handicap among conservatory students of classical singing.
        J Voice. 2016; 30: 192-197
        • Donahue EN
        • Leborgne WD
        • Brehm SB
        • et al.
        Reported vocal habits of first-year undergraduate musical theater majors in a preprofessional training program: a 10-year retrospective study.
        J Voice. 2014; 28: 316-323
        • Santa Maria C
        • Sung CK
        • Baird BJ
        • et al.
        Vocal hygiene in collegiate singers-does formal training relate to practices?.
        J Voice. 2021; 35: 859-868
        • Sielska-Badurek EM
        • Sobol M
        • Olszowska K
        • et al.
        Contemporary commercial music singing students-voice quality and vocal function at the beginning of singing training.
        J Voice. 2018; 32: 668-672
        • Behlau M
        • Oliveira G
        Vocal hygiene for the voice professional.
        Curr Opin Otolaryngol Head Neck Surg. 2009; 17: 149-154
        • Ahmad K
        • Yan Y
        • Bless D
        Vocal fold vibratory characteristics of healthy geriatric females–analysis of high-speed digital images.
        J Voice. 2012; 26: 751-759
        • Sielska-Badurek E
        • Osuch-Wojcikiewicz E
        • Sobol M
        • et al.
        Combined functional voice therapy in singers with muscle tension dysphonia in singing.
        J Voice. 2017; 31: 509.e23-509.e31
        • Neto L
        • Meyer D
        A joyful noise: the vocal health of worship leaders and contemporary christian singers.
        J Voice. 2017; 31: 250.e17-250.e21
        • Hapner E
        • Gilman M
        The vocal load of Reform Jewish cantors in the USA.
        J Voice. 2012; 26: 201-204
        • Cohen SM
        • Jacobson BH
        • Garrett CG
        • et al.
        Creation and validation of the singing voice handicap index.
        Ann Otol Rhinol Laryngol. 2007; 116: 402-406
        • Nacci A
        • Bastiani L
        • Barillari MR
        • et al.
        Reflux symptom index (RSI) and singing voice handicap index (SVHI) in singing students: a pilot study.
        J Voice. 2020;
        • Barsties B
        • Maryn Y
        The improvement of internal consistency of the acoustic voice quality index.
        Am J Otolaryngol. 2015; 36: 647-656
        • Barsties VLB
        • Maryn Y
        • Gerrits E
        • et al.
        The acoustic breathiness index (ABI): a multivariate acoustic model for breathiness.
        J Voice. 2017; 31: 511.e11-511.e27
        • BB VL
        • Maryn Y
        • Gerrits E
        • et al.
        A meta-analysis: acoustic measurement of roughness and breathiness.
        J Speech Lang Hear Res. 2018; 61: 298-323
        • Villafuerte-Gonzalez R
        • Valadez-Jimenez VM
        • Sierra-Ramirez JA
        • et al.
        Acoustic analysis and electroglottography in elite vocal performers.
        J Voice. 2017; 31: 391.e1-391.e6
        • Sataloff RT
        • Hawkshaw MJ
        • Johnson JL
        • et al.
        Prevalence of abnormal laryngeal findings in healthy singing teachers.
        J Voice. 2012; 26: 577-583
        • Poburka BJ
        • Patel RR
        • Bless DM
        Voice-vibratory assessment with laryngeal imaging (VALI) form: reliability of rating stroboscopy and high-speed videoendoscopy.
        J Voice. 2017; 31: 513.e1-513.e14
        • Miller NA
        • Gregory JS
        • Aspden RM
        • et al.
        Using active shape modeling based on MRI to study morphologic and pitch-related functional changes affecting vocal structures and the airway.
        J Voice. 2014; 28: 554-564
        • Guzman M
        • Acevedo K
        • Leiva F
        • et al.
        Aerodynamic characteristics of growl voice and reinforced falsetto in metal singing.
        J Voice. 2019; 33: 803.e7-803.e13
        • Guzman M
        • Barros M
        • Espinoza F
        • et al.
        Laryngoscopic, acoustic, perceptual, and functional assessment of voice in rock singers.
        Folia Phoniatr Logop. 2013; 65: 248-256
        • D Zangger Borch
        • Sundberg J
        • P-Å Lindestad
        • et al.
        Vocal fold vibration and voice source aperiodicity in “dist” tones: a study of timbral ornament in rock singing.
        Logopedics Phoniatrics Vocology. 2004; 29: 147-153
        • Zangger Borch D
        • Sundberg J
        Some phonatory and resonatory characteristics of the rock, pop, soul, and swedish dance band styles of singing.
        Journal of Voice. 2010; 25: 532-537
        • Lindestad PA
        • Sodersten M
        • Merker B
        • et al.
        Voice source characteristics in Mongolian “throat singing” studied with high-speed imaging technique, acoustic spectra, and inverse filtering.
        J Voice. 2001; 15: 78-85
        • Aaen M
        • McGlashan J
        • Thu KT
        • et al.
        Assessing and quantifying air added to the voice by means of laryngostroboscopic imaging, EGG, and acoustics in vocally trained subjects.
        J Voice. 2021; 35: 326.e1-326.e11
        • Aaen M
        • McGlashan J
        • Sadolin C
        Investigating laryngeal “Tilt” on same-pitch phonation-preliminary findings of vocal mode metal and density parameters as alternatives to cricothyroid-thyroarytenoid “Mix”.
        J Voice. 2019; 33: 806.e9-806.e21
        • Saldias M
        • Laukkanen AM
        • Guzman M
        • et al.
        The Vocal Tract in Loud Twang-Like Singing While Producing High and Low Pitches.
        J Voice. 2021; 35: 807.e1-807.e23
        • Murry T
        • Zschommler A
        • Prokop J
        Voice handicap in singers.
        J Voice. 2009; 23: 376-379
        • Abou-Elsaad T
        • Baz H
        • Afsah O
        • et al.
        Validation and adaptation of the singing voice handicap index for egyptian singing voice.
        J Voice. 2017; 31: 130.e1-130.e6
        • Baracca G
        • Cantarella G
        • Forti S
        • et al.
        Validation of the Italian version of the singing voice handicap index.
        Eur Arch Otorhinolaryngol. 2014; 271: 817-823
        • Esen Aydinli F
        • Akbulut S
        • Ozcebe E
        • et al.
        Validity and reliability of the Turkish singingvoice handicap index-10.
        J Voice. 2020; 34: 304.e9-304.e15
        • Garcia-Lopez I
        • Nunez-Batalla F
        • Gavilan Bouzas J
        • et al.
        Validation of the Spanish version of the voice handicap index for vocal singing (SVHI)].
        Acta Otorrinolaringol Esp. 2010; 61: 247-254
        • Ghaemi H
        • Dehqan A
        • Mahmoodi-Bakhtiari B
        • et al.
        The singing voice handicap index (SVHI): validation and adaptation into Persian.
        J Voice. 2020; 34: 158.e17-158.e23
        • Gunjawate DR
        • Aithal UV
        • Bellur R
        Adaptation and validation of the Kannada singing voice handicap index-10.
        J Voice. 2019; 33: 582.e1-582.e4
        • Gunjawate DR
        • Aithal VU
        • Guddattu V
        • et al.
        Adaptation and validation of the Kannada version of the singing voice handicap index.
        J Voice. 2017; 31: 507.e7-507.e11
        • Lorenz A
        • Kleber B
        • Buttner M
        • et al.
        Validation of the German version of the singing voice handicap index.
        HNO. 2013; 61: 699-706
        • Rangarajan A
        • Santhanam DP
        • Selvaraj JL
        Translation and validation of Tamil version of singing voice handicap index-10 (TSVHI-10).
        J Voice. 2020; 34: 158.e9-158.e16
      1. Sielska-Badurek EA-O, Sobol M, Cioch A et al. Adaptation and validation of the singing voice handicap index into Polish. (1749-4486 (Electronic))

        • Cohen SM
        • Witsell DL
        • Scearce L
        • et al.
        Treatment responsiveness of the singing voice handicap index.
        Laryngoscope. 2008; 118: 1705-1708
        • Hirano M
        Clinical Examination of Voice.
        Springer-Verlag, Wien, New York1981
        • Iwarsson J
        • Bingen-Jakobsen A
        • Johansen DS
        • et al.
        Auditory-perceptual evaluation of dysphonia: a comparison between narrow and broad terminology systems.
        J Voice. 2018; 32: 428-436
        • Nacci A
        • Baracca G
        • Romeo SO
        • et al.
        Endoscopic and phoniatric evaluation in singing students.
        J Voice. 2019; 33: 135-142
        • Caffier PP
        • Ibrahim Nasr A
        • Ropero Rendon MDM
        • et al.
        Common vocal effects and partial glottal vibration in professional nonclassical Singers.
        J Voice. 2018; 32: 340-346
        • Belafsky PC
        • Postma GN
        • Koufman JA
        The validity and reliability of the reflux finding score (RFS).
        Laryngoscope. 2001; 111: 1313-1317
        • Aaen M
        • Christoph N
        • McGlashan J
        • et al.
        Deconstructing timbre into 5 physiological parameters: vocal mode, amount of metal, degree of density, size of larynx, and sound coloring.
        J Voice. 2021; (In Press, Corrected proof)
        • Garaycochea O
        • Navarrete JMA
        • Del Rio B
        • et al.
        Muscle tension dysphonia: which laryngoscopic features can we rely on for diagnosis?.
        J Voice. Sep 2019; 33: 812.e15-812.e18
        • Saldias M
        • Guzman M
        • Miranda G
        • et al.
        A computerized tomography study of vocal tract setting in hyperfunctional dysphonia and in belting.
        J Voice. 2019; 33: 412-419
        • Hanayama EM
        • Camargo ZA
        • Tsuji DH
        • et al.
        Metallic voice: physiological and acoustic features.
        J Voice. 2009; 23: 62-70
        • Austin S
        Read the footnotes! Garcia on the timbres.
        J Singing. 2016; 72: 363-370
        • Garcia M
        A Complete Treatise on the Art of Singing: Part Two. 1975. Da Capo Press, University of Michigan, Michigan1984
        • Vurma A
        • Ross J
        Where is a singer's voice if it is placed “Forward”?.
        J Voice. 2002; 16: 383-391
        • Lombard LE
        • Steinhauer KM
        A novel treatment for hypophonic voice: Twang therapy.
        J Voice. 2007; 21: 294-299
        • Guzman M
        • Barros M
        • Espinoza F
        • et al.
        Resonance strategies revealed in rock singers during production of high notes.
        J Singing. 2014; 71: 183-192
        • Bestebreurtje ME
        • Schutte HK
        Resonance strategies for the belting style: results of a single female subject study.
        J Voice. 2000; 14: 194-204
      2. Lovetri J The confusion about belting: a personal observation. J NY Singing Teacher's Assoc. 2012;10(Sept-Oct):4-7.

        • McCoy S
        A classical pedagogue explores belting.
        J Singing. 2007; 63: 545-549
        • Miles B
        • Hollien H
        Whither belting?.
        J Voice. 1990; 4: 64-70
      3. Complete Vocal Institute. CVT In Numbers. Accessed 27th May 2022.

        • Claros P
        • Claros-Pujol A
        • Claros A
        Arytenoid asymmetry in opera singers.
        Eur Ann Otorhinolaryngol Head Neck Dis. 2018; 135: 389-392
        • Sadolin C
        Complete Vocal Technique.
        Shout Publishing, Copenhagen, Denmark2017
        • Maccallum JK
        • Cai L
        • Zhou L
        • et al.
        Acoustic analysis of aperiodic voice: perturbation and nonlinear dynamic properties in esophageal phonation.
        J Voice. 2009; 23: 283-290
        • von Germeten Guro
        Exploring Original Cast Recordings as “Vocal Scripts”: Navigating “Vocal Omnivorousness” and Learning “The Sungs” of Musical Theatre.
        Voice and Speech Review. 2021; (In press): 1-17