What a goitre can do to a voice - A Case Study

Abstract

This paper is a case study which narrates in detail the first-hand experience of a professional singer who observed the growth of a multi-nodular goiter over nearly 20 years, until surgery, in the form of a total thyroidectomy, became the only option to regain previous stable and consistent vocalising. Initially, the singer had sufficient knowledge of the phonatory process but only intuition about a prognosis. The conservative medical decision to watch and wait was recommended over radical surgery: the singer lacked the confidence to challenge that recommendation. The patient observed increasingly persistent symptoms over the two years before surgery: these were inadequate balance of vocal registration particularly across the lower passaggio, unreliable and breathy tone, and difficulty in sustaining tone in a legato line. However the closure of the airway with arms elevated above the head became a more frightening symptom. Finally the significant vocal, neck and breathing symptoms presented as a clear reason for requiring action. Thyroid surgeons know that retrosternal extension of the thyroid goitre is a clear indication for thyroid surgery in an otherwise well patient, even in the absence of symptoms. The surgery was carried out in 2006. The singer's large asymmetric goitre was identified as having extended from the hyoid bone at its highest point to deeply retrosternal at the level of the aortic arch especially on the right side, with significant tracheal narrowing and deviation to the left. For any singer there is the extra stressful issue of vocal function following surgery: stories of laryngeal nerve injury are commonly cited as the reason not to operate. However, there is little documented research on how an enlarged goitre affects the voice. The paper documents the accumulative symptoms, the consultative process, the planning and outcome of the surgery, and the targeted physiotherapy rehabilitation program. This case study represents one singer's experience, with descriptions and observations from the Endocrine and E.N.T. Surgeons and the treating physiotherapist. Firstly it is offered to practitioners as an insight into the sensitivities of the real-life issues facing a singer with an obstructive goitre. It is also intended to give guidance and support to any other singer who may face a similar challenge.