Vocal Fold Cysts Research Articles

Vocal Fold Cyst: Causes and Cures.

Vocal Fold Cyst: Causes and Cures.

Dysphonia in children

Abstract Dysphonia is a frequent symptom in paediatric patients and it has a prevalence between 6 - 24%. In young patients, dysphonia has a direct importance because it impairs their communicative behaviour, their psychological status and also their social life. The most diagnosed voice pathologies in children are vocal nodules followed by vocal cord cysts, infectious and inflammatory causes, sulcus vocalis, laryngeal membranes, iatrogenic vocal cord paralysis, neurological causes, psychogenic factors, traumatic or irritative factors or, less commonly, laryngeal neoplasms. A correct diagnosis of dysphonia in paediatric patients is important for learning, voice training and their psychological development. Children with dysphonia have to be assessed with adequate equipment. It is recommended to use tools that are appropriate to the tolerance and cooperation of the patients and allow to have a good visualization of the vocal folds. Suitable preventive methods, early diagnosis, appropriate treatment of voice disorders should be taken into consideration in these cases. In this article, some of the most frequent causes of dysphonia in paediatric patients and their treatment options in order to achieve a proper voice are reviewed.

Analysis of therapeutic effect of fibrocystic degeneration of vocal folds

Objective:To explore the differences in clinical presentation and therapeutic outcomes between vocal fold fibrocystic degeneration and other common benign lesions, such as vocal fold polyp and cyst. Methods:Vocal function was assessed before and after surgery in 10 cases of vocal fold fibrocystoids, 30 cases of vocal fold polyps and 10 cases of vocal fold cysts at Department of Voice Medicine, Xiamen University Zhongshan Hospital. The voice Assessments included GRBAS（G-scale）, VHI-10 scale, Reflux Symptom Index（RSI） scale, stroboscope, acoustic objective analysis, and aerodynamics measurements. The acoustice analysis parameters included fundamental frequency（F0）, fundamental frequency perturbation（Jitter）, amplitude perturbation（Shimmer） and voice disturbance severity index（DSI）, while the maximum phonation time（MPT） was assessed for aerodynamics. Stroboscopic parameters included vocal fold straightness, vocal fold color, glottic closure and mucosal wave. All three groups underwent phonomicrosurgery and a follow-up review was conducted one month later. Pre-and post-operative function assessment parameters were compared across the three groups. Results:Significant differences were founded in the G grade, Jitter, Shimmer, DSI, glottic closure and mucosal wave between the vocal fold fibrocystic degeneration group and the vocal fold polyp and vocal fold cyst group（P<0.05）. Most voice function parameters in all three groups showed significant improvement after surgery（P<0.05）. The improvement of VHI（10）, RSI and mucosal wave scores in the vocal fold fibrocystic lesion group was significantly different from that of the vocal fold polyp group（P<0.05）. Conclusion:Vocal fold fibrocystic degeneration is a more severe than that of vocal fold polyps and cysts, which are two common benign vocal fold lesions. Phonomicrosurgery is an effective treatment for vocal fold fibrocystic degeneration, but its curative effect are less favorable compared to those for vocal fold polyps and vocal fold cysts. Therefore, a detailed preoperative evaluation is essential for predicting surgical outcomes.

Accuracy of Diagnosis of Benign Vocal Fold Lesions among Ear, Nose, and Throat Residents.

Introduction Benign vocal fold lesions (BVFLs) disrupt the superficial lamina propria, impacting vocal fold pliability. Investigating the diagnostic competency of ear, nose, and throat (ENT) residents in identifying BVFLs, we hypothesize that factors such as residency year, subspecialty focus, and training center influence diagnostic accuracy. Objectives To assess the accuracy of diagnosis of BVFLs among ENT residents and to correlate diagnostic accuracy with the year of residency. Methods An observational cross-sectional study included all ENT residents in Saudi Arabia. It was performed in August and September 2021 using a self-administered online questionnaire that assessed demographic variables and included three images with open-ended questions on diagnosing vocal fold lesions. Results A total of 61 ENT residents (62.3% male) were included in this study. The images of vocal fold cyst, vocal fold polyp, and vocal fold nodule were correctly diagnosed by 60.7%, 88.5%, and 91.8% of residents, respectively. There was a correlation between the year of residency and the accuracy of diagnosing a vocal fold cyst ( p = 0.029). Residents interested in laryngology correctly diagnosed all three lesions more frequently than other residents. Conclusion The ability of residents to diagnose vocal fold cysts was moderate. In particular, the senior residents were able to diagnose polyps and nodules with excellent accuracy.

Analysis of 1782 Pediatric Hoarseness Cases: A Clinical Retrospect Study

ObjectiveThis study aims to clarify the clinical characteristics of pediatric voice disorders. MethodsThe clinical data of 1,782 pediatric patients presenting with voice disorders were retrospectively analyzed. These cases were categorized into four age-based cohorts: 0–3 years, 4–7 years, 8–11 years, and 12–15 years. Variables such as gender disparities, laryngoscopic manifestation, disease types, and acoustic parameters were thoroughly examined. ResultsA total of 1,782 children with acoustic hoarseness were included in this study, comprising 1,325 males and 457 females. When the sex ratio among the children in each group was compared, males were found to outnumber females. A notable male predominance was observed across all age groups.Laryngoscopic results revealed that the most prevalent condition was vocal cord nodules (1,363 cases, 76.48%), followed by vocal cord polyps (271 cases, 15.20%). Other diseases included laryngeal papillomas, vocal fold movement impairment, vocal cord cysts, functional dysphonia, leukoplakia of the vocal cords, and benign laryngeal tumors such as laryngeal amyloidosis and subglottic granular cell tumors. Among these, adenoid hypertrophy was presented in 382 children (21.44%). Additionally, the Reflux Finding Score (RFS) was conducted, and 799 cases (44.83%) were found to have a score above 7.The distribution of various diseases across different age groups indicated that children with vocal cord nodules (637 cases, 46.74%), vocal cord polyps (109 cases, 40.22%), and laryngeal papillomas (35, 36.84%) were predominantly found in the 4–7 years age group. Pediatric acute laryngitis (3 cases, 75%) and vocal fold movement impairment (8 cases, 36.36%) were more common in the 0–3 years age group. Functional dysphonia (4 cases, 66.67%) and vocal cord leukoplakia (4 cases, 80%) were mainly observed in the 12–15 years age group, while vocal cord cysts were predominantly seen in the 8–11 years age group (4 cases, 57.14%).A comparative analysis of acoustic parameters among 153 children showed statistically significant differences in jitter, fundamental frequency (F0), voice handicap index (VHI), reflux symptom index (RSI), and reflux finding score (RFS) across different pathologies. ConclusionThis study highlighted that vocal cord nodules, vocal cord polyps, and laryngeal papillomas were the primary causes of pediatric hoarseness, although the possibility of tumors and rare diseases cannot be disregarded. There was a noticeable gender bias towards males, and functional dysphonia was significantly more prevalent in older children.

Hemorrhagic Pseudocyst (Polyst) and True Hemorrhagic Cyst of the Vocal Fold

ObjectiveThough haemorrhagic vocal fold polyps are a common entity, haemorrhagic vocal fold cysts have not been previously described. In our study we have evaluated patients who were diagnosed on stroboscopy as “haemorrhagic” cysts. MethodsThis 18-month retrospective study has received institutional ethics clearance. Using the database of our voice clinic, 14 patients diagnosed as haemorrhagic cyst by stroboscopy were reviewed. Age, sex, chief complaints, symptom duration, videostroboscopy findings, surgical details and the histopathology was noted. ResultsOut of a total 14 patients, 12 were males with a mean age of presentation as 41 years. Duration of hoarseness ranged from 2 - 24 months. Videostroboscopy revealed a markedly decreased amplitude of the mucosal waves over a well-delineated ovoid or spheroid haemorrhagic lesion, which seemed tethered down by overlying vocal fold epithelium. All patients had operative findings of a well encapsulated haemorrhagic lesion in the superficial lamina propria with anterior and posterior fibrotic bands. Histopathology of 13 patients was similar and revealed a haemorrhagic polypoidal lesion. A pseudo-capsule could be identified occasionally. These lesions seemed to be haemorrhagic pseudocysts, named “polyst” by us. In one male patient the histopathology revealed a true vocal fold cyst (type C Koren) with haemorrhage. ConclusionA haemorrhagic pseudocyst (polyst) of the vocal fold has stroboscopic and surgical findings resembling a true vocal fold cyst with haemorrhage, however histologically it resembles a haemorrhagic polyp. A true haemorrhagic cyst however is typically a type C Koren cyst with haemorrhage. Both these entities have not been previously described.

Does Vocal Fold Pathology Play a Role in Determining the Timeline of Presentation to an Ear, Nose, and Throat Surgeon?

Abstract Background: The primary objective is to study the average time duration between the onset of vocal symptoms and presentation to an ear, nose, and throat (ENT) surgeon, in different vocal pathologies. Our second objective is to study gender distribution among various pathologies. Methods: Our voice clinic records were retrospectively reviewed for 1 year, from August 2022, for details regarding gender, and the average time taken for presentation (ATTFP) in months, to an ENT surgeon. Disorders were grouped into vocal fold nodules, polyps, cysts, paralysis/paresis, sulcus, spasmodic dysphonia (SD), and premalignant and malignant conditions. Results: A total of 17 patients of vocal fold nodules (15 females), 47 vocal fold polyp patients (45 males), 40 vocal fold cyst patients (24 females), 64 paralysis/paresis patients (44 males), 41 sulcus patients (31 males), 35 SD patients (22 females), and 65 premalignant and malignant condition patients (51 males) presented to us. The ATTFP for nodules was 8.1 months, 6.8 months for polyps, 10.2 months for cysts, 22.8 months for idiopathic and 6 months for other causes of paralysis/paresis, 32.4 months for sulcus, 26.1 months for SD, and 10.2 months for premalignant and malignant conditions. Conclusion: Sulcus patients took the longest time to present to an ENT surgeon, followed by SD patients, both groups averaging over 2 years. Vocal fold paralysis/paresis patients with a nonidiopathic diagnosis were the earliest to present. A high male preponderance in vocal fold polyps (96%) as opposed to a high female preponderance in vocal fold nodules (88%), both considered phonotraumatic lesions, warrants further research into possible varying etiopathogenesis.

A Retrospective Study of Glottic Cyst Histopathology and Its Clinical Presentation.

To understand the frequency and clinical presentation of the four types of vocal-fold cyst described by the Koren classification. Glottic cysts operated in a 1-year period were grouped retrospectively into Koren A, B, C and D (KA, KB, KC, KD). The age and sex of the patient, cyst location, laterality, associated lesions, profession, daily water consumption, duration of symptoms prior to surgery and postoperative healing time were noted. Of 30 cysts, 14 KA, 10 KB, 4 KC and 2 KD were identified. Average age of symptoms in KA to KD was 45, 52, 40 and 37 years. KC and KD were found only in females unlike the male predominance of KA and KB. Striking zone was the location of 28/30 cysts with a focal pit in 1 KC and mucosal bridge in 1 KD. There was no significance to laterality or profession. Average daily water consumption was 1.8, 1.75, 2 and 2L in KA to KD. Average duration of symptoms up-till surgery for KA to KD was 2.6 years, 1.4 years, 2.9 years and 1 month. Post-operative healing time for KA to KD was 6.6, 7.4, 11.7 and 10 weeks. KA was the commonest cyst excised followed by KB, KC and KD. The KD patients were earliest and youngest to present. All KC and KD cysts were found in females unlike the male predominance of KA and KB. As majority of the cysts were found on the striking zone, phonotrauma may be one of the etiologies for all four cysts.

Vocal fold cyst: A narrative review

Abstract Vocal fold cysts are benign lesions of the larynx and affect both children and adults. The vocal fold cysts can be classified into two types such as mucous retention cysts and epidermoid cysts. Vocal overuse is often associated with the formation of the cyst on the vocal fold. The aetiological factor behind this lesion may be due to occupation. It frequently affects the people who use their voices professionally. The most common symptom of the vocal fold cyst is dysphonia or hoarseness of the voice, increased vocal effort, fatigue, strain and if the lesions are large enough, feeling of dyspnoea with phonation. If the size of the vocal cyst is very large, it may manifest life-threatening stridor. This lesion can create mental and emotional tension in daily life and affect the daily life of the patient. The vocal fold cyst is easily recognised and managed. Videostroboscopy is one of the most important techniques for the diagnosis of the vocal fold cyst. The vocal fold cyst rarely resolves entirely. The treatment options include speech therapy and transoral microlaryngeal surgery. Early diagnosis of the vocal fold cyst can lead to effective treatment and good vocal recovery. This article discusses the epidemiology, aetiopathogenesis, clinical features, diagnosis and present the treatment of vocal fold cysts.

"Pre and Post Treatment Comparison of S/Z Ratio in Benign Laryngeal Lesions".

Benign laryngeal lesions like vocal nodules, vocal polyp, vocal fold cysts are mostly found in patients complaining of change in voice. S/Z ratio has become the most frequently used clinical tool to assess phonatory mechanics. This study shows the pre-treatment and post-treatment comparison of S/Z ratios in patients with benign laryngeal lesions. To evaluate the outcome of microlaryngeal surgery in patients with benign laryngeal lesions using S/Z ratio as an outcome parameter. During this study, 65 patients with complaints of change in voice, with clinical evidence of benign laryngeal lesions underwent microlaryngeal surgery. Improvement in symptoms were measured preoperatively and postoperatively using S/Z ratio. This ratio was calculated by asking the patient to to maximally sustain 'S' and 'Z', repeated thrice. S/Z ratio was calculated by dividing the maximum duration for which /S/ was sustained by the maximum duration for which /Z/ was sustained. A ratio of more than 1.4 suggested a vocal cord disorder. There was statistically significant difference observed in S/Z ratio values, from pre-treatment to 6months post-treatment, with P value 0.001. Pre and post treatment assessment of patients with benign vocal fold lesions showed significant improvement in S/Z ratio postoperatively. It is the simplest and a reliable objective method of voice assessment and can also be used in assessing the outcome of the treatment.

Prevalence of Benign Vocal Fold Lesions: Long-Term Results From a Single European Institution

Hoarseness and limited voice capacity are often associated with benign vocal fold (VF) lesions. Despite their high clinical prevalence, epidemiological investigations focusing on these structural alterations are rare. The aim of the study was to present current European data on five typical lesion types (VF nodules, polyp, cyst, contact granuloma, Reinke´s edema). Retrospective investigation. Video recordings of laryngoscopies from all patients with one of the above-mentioned VF pathologies were subjected to a review process. Data collected arose from a single institution over a period of 13years. They were evaluated statistically with respect to lesion type, sex, age at first diagnosis, and affected side. In a total of 535 patients, VF polyps occurred most frequently, followed by Reinke's edema and nodules. Each of the lesion types studied was significantly associated with sex and, except VF cysts, all diagnoses were also significantly related to age. Female sex was a risk factor for VF nodules, cysts, and Reinke's edema, whereas male sex was associated with polyps and contact granulomas. VF nodules occurred predominantly in young patients, VF polyps in middle-aged, Reinke's edema, and contact granulomas in later adulthood. The predominantly affected side (bilateral, right, or left VF) depended on sex. Different prevalences from previous studies resulted from inconsistencies in terms of classification framework, terminology, and definition. In addition to endoscopic findings, socio-cultural backgrounds must also be considered when studying benign VF lesions. Prophylactic voice care education for all populations and concomitant efficacy studies are required. Further research is needed to verify possible correlations between sex and the affected side. A non-binary view could broaden the spectrum of phoniatric research issues.

Correlation Between Laryngoscopic Appearance and Histopathology in Vocal Fold Cysts

Cysts are benign vocal fold lesions typically divided into mucous retention or epidermoid subtypes. The conventional paradigm that the former are translucent and the latter opaque fails to encompass the heterogeneity of cyst appearance on laryngoscopy. This study aims to characterize the relationships between clinical cyst characteristics and histopathology. Retrospective cohort METHODS: Clinicodemographic data, videostroboscopy findings, and histopathology results were retrospectively reviewed for adults who underwent surgical excision of vocal fold cysts at our institution between 2006 and 2021. Diagnostic histopathologic material was available for 69 patients (age: 50.4±15.1years, 68.1% female). Clinically, most cysts were opaque (69.6%) and located at the vibratory margin (82.6%). 11.6% were infraglottic. Significant associations existed between cyst location and epithelial type, with infraglottic cysts and those at the superior surface more commonly exhibiting ductal (P=0.003) and squamous (P=0.002) epithelium, respectively. Cyst opacity did not correlate with histopathology (P=0.415). Epidermoid cysts were more likely to exhibit clinical inflammation (P=0.002).

Patient tolerance in office-based blue laser therapy for lesions of the vocal folds: Correlation with patients' characteristics, disease type and procedure-related factors.

To report patient tolerance in office-based blue laser therapy for vocal fold lesions. A retrospective review of the medical records of patients who underwent office-based blue laser therapy for lesions of the vocal folds between November 2021 and February 2023 was conducted. A total of 48 patients were included. Patient tolerance was assessed using the Iowa Satisfaction with Anesthesia Scale (IOWA). Patient tolerance was analyzed in relation to patients' demographic characteristics, disease type and severity, and procedure-related factors. The mean tolerance score of the study group was 1.51 ± 1.1. There was a significant difference in the mean tolerance score between smokers and non-smokers (p = .038). Patients with vocal fold cyst (n = 3) had the highest mean tolerance score followed by patients with vocal fold polyps (n = 15). There was a nonsignificant difference in the mean tolerance score between benign lesions of the vocal folds and leukoplakia. Patients with lesions extending to more than half the vocal fold had less tolerance than those with lesions limited to less than half the vocal fold (1.91 vs. 1.27, p value .041). There was a moderate and significant negative correlation between vocal fold movement VAS, swallowing VAS, and tolerance score. The mean total duration of the procedures was 10.38 ± 4.8 min. There was a mild negative correlation between the duration of the procedure and tolerance. Office-based blue laser therapy for vocal fold lesions is a well-tolerated procedure. Patient should be instructed how to breathe quietly and avoid swallows to improve tolerance to surgery. 4.

Which is a better management for vocal fold cyst: cold knife or laser resection?

BackgroundThe objective of the study is to compare the conventional microlaryngeal surgery and the CO2 laser in the treatment of cysts of vocal folds, regarding the postoperative quality of voice.This study was conducted on 53 cases with vocal fold cysts. The cases were randomly allocated into two groups: group 1 (27 cases) was operated by the conventional technique, and group 2 (26 cases) was operated with CO2 laser microlaryngeal operation. At 3-month postoperative, evaluation was done by stroboscopic evaluation of vocal folds, grade of hoarseness, roughness, breathiness, asthenia, and strain (GRBAS) scale and Arabic version of Voice Handicap Index (VHI).ResultsThe stroboscope assessment revealed that glottic closure was complete, symmetrical motion, the reappearance of the mucosal wave, normal amplitude, and periodicity in all patients. There is insignificantly different between either group as regards the postoperative scores on VHI and GRBAS scale.ConclusionThere is insignificantly different when comparing laser to conventional microlaryngeal surgery for excision of vocal fold cysts regarding the quality of voice.

Glottic Neurofibroma: An Unusual Case Report.

Solitary neurofibromas of the larynx occur sporadically and usually tend to involve the aryepiglottic folds. Non-plexiform variants of neurofibromas involving the glottis are extremely rare and may have defined margins versus plexiform subtype which are often unencapsulated and associated with Von Recklinghausen's disease. We report an unusual case of isolated glottic neurofibroma in an elderly male with gradually progressive hoarseness of voice with stroboscopy findings of a right unilateral, bulky subepithelial lesion mimicking a vocal fold cyst. He underwent laser-assisted trans-oral microlaryngeal surgery and excision of lesion in-toto by micro-flap technique following which histopathological examination reported a neurofibromatous lesion. On performing immunohistochemistry the S-100 protein was positive which confirmed the diagnosis. The patient has been recommended regular follow-up to watch for recurrence.

An Unusual Cause of Vocal Fold Cyst in a 15-Year-Old Boy

Vocal fold cysts are benign lesions of the larynx. Vocal fold cysts can be unilateral or bilateral and often confused with vocal nodules, particularly when symmetrical. The most common clinical presentation of this lesion is hoarseness of voice. The vocal fold cyst is usually secondary to vocal abuse. Endoscopic examination or videostroboscopy is an important tool for clinical confirmation of the vocal fold cyst. Transoral microlaryngeal surgery followed by speech therapy is an ideal treatment option for vocal fold cysts. Playing with a flute for a prolonged period is rarely reported with vocal fold cyst. Here, we report a case of true vocal fold cyst I in a 15-year-old boy who regularly practices flute.

The Effect of Platelet-Rich Plasma Injection on Short Term Vocal Outcomes Following Phonosurgery-A Pilot Study.

Background and Objectives: The efficiency and optimal voice rest period following phonosurgery remains debatable. Platelet-rich plasma (PRP) is a safe and cheap alternative to many bioactive agents being studied on animal models, and is already in use in many medical areas. We investigate the short-term effects of PRP and voice rest on voice outcomes following phonosurgery as an alternative to voice rest alone. Materials and Methods: A prospective single-blinded pilot study was conducted. Sixteen patients with a diagnosis of vocal fold cyst and polyps were included, forming equal groups (PRP and voice rest vs. voice rest alone). Voice analysis was carried out on the preoperative day, day three, and week three following surgery. The measured parameters were fundamental frequency (F0), noise–signal ratio (NSR), harmonic poverty (HP), attack alteration (AL), pitch instability (PI), and amplitude instability (AI).VHI(Voice Handicap Index)-30 questionnaires were carried out before surgery and three weeks following surgery to assess the impact of subjective voice change on quality of life. PRP was obtained using commercial kits with separator gel. Results: An average 3.68-fold increase in platelets was obtained with PRP. No side effects were noted after injection. All voice parameters improved on day three and week three following surgery. Statistical significance was noted only in the fundamental frequency of male patients (p = 0.048) in favor of the PRP-voice rest group. In addition, the VHI- 30 questionnaire results between preoperative and postoperative assessments showed statistically significant differences in total VHI score (p = 0.02) as well as the physical (p = 0.05) and emotional (p = 0.02) scale in favor of the PRP-voice rest group. Conclusions: PRP presents short term safety in patients who undergo phonosurgery, although long-term outcomes are unknown. PRP and voice rest are superior to voice rest alone when considering subjective assessment of the voice. When analyzing acoustic parameters, PRP and voice rest are not superior to voice rest alone.

Concomitant bilateral vocal cord cysts in a 12-year-old patient treated by one-stage mini-microflap CO2 laser microsurgery: case report and review of the literature

Concomitant bilateral vocal cord cysts in a 12-year-old patient treated by one-stage mini-microflap CO2 laser microsurgery: case report and review of the literature

Benign Laryngeal Lesions

Benign laryngeal lesions represent a diverse set of pathologies whose clinical presentation may range from no symptoms to dyspnea and/or dysphonia. Flexible fiberoptic laryngoscopy and videolaryngostroboscopy are important in distinguishingdifferent types of lesions, and management and treatment are dependent on the identification of these lesions, as they have different etiologies. Some lesions such as vocal fold nodules and polyps are primarily phonotraumatic and may benefit fromspeech therapy and vocal hygiene as initial approaches. Vocal fold cysts and benign tumors may benefit from microlaryngeal approaches, while capillary ectasias, polypoid corditis, laryngoceles, saccular cysts, and papilloma may benefit from laser therapy. Vocal fold granulomas may arise from various etiologies such as intubation, traumatic behaviors, or reflux. Polypoid corditis arises from smoking. This review is intended to provide an overview of the variety of lesions that encompass non-malignant laryngeal lesions that is both suitable for junior and senior residents. This review contains 12 figures, 5 tables, and 64 references Keywords: Benign laryngeal lesions, Laryngocele, Polyp, Cyst, Polypoid Corditis, Papilloma

Managing Perimenopausal and Menopausal Voice Changes

Managing Perimenopausal and Menopausal Voice Changes Nancy Bos (bio), Joanne Bozeman (bio), and Cate Frazier-Neely (bio) SINGING A CAPPELLA TO ZYDECO Readers of this column are likely familiar with the concept of cross-training for singers (see Robert Edwin's article, "Cross Training for Singers," Journal of Singing 65, no. 1 [September/October 2008]). Originally used in athletics, cross training is participation in a variety of sports and training methods to maintain balanced muscular development and flexibility, and to minimize injury from overdoing one type of physical activity. Tennis players may swim, golfers may jog, skiers may rock climb. Athletes may also balance workouts in other ways from doing yoga to having specific strategies in the weight room and gym. Broadly speaking, cross training as applied to singing would include: • Singing regularly throughout the entire range, including frequent vocalizing on pitches outside of the typical range of the singer's repertoire. • Exercising the voice in targeted ways to increase or maintain strength and flexibility, appropriate to the vocal conditioning and to the demands of various styles. • Practicing repertoire from more than one vocal style or genre. (This may or may not include performing in these styles.) As teachers and researchers interested in the special context of female singers during midlife, we have recently authored a book on the topic: Singing Through Change: Women's Voices in Midlife, Menopause, and Beyond (StudioBos Media), which affirms that cross training can help women to continue singing healthily over time. A singer's voice is affected by hormonal changes throughout life, though individual responses vary. Reproductive hormones, more broadly considered sex steroid hormones, have receptors that are found throughout the body: the neuromuscular, respiratory, and skeletal systems, connective tissues, the gut, and the larynx. In addition, the entire central nervous system, which supports the systems of phonation, emotion, and communication, is sensitive to hormone levels. Therefore, it should not be surprising that even subtle shifts in hormone levels can impact singing. Along with the hormonal changes of menopausal transition, the gradual aging process and the rich, though complex psycho-social challenges of midlife may cause women to experience minor to profound voice changes. Cross training is a pedagogic framework that teachers should consider when working with female singers in this age span. Several women's stories follow that illustrate how a flexible and creative use of cross training concepts helped these singers negotiate [End Page 375] the evolution of their voices in midlife (considered ages 40–60), and beyond. ________ Lexi, age 57, has been studying singing since she was a child, in styles such as pop, big band, and contemporary Christian music. A semiprofessional for many years, she occasionally ran into vocal trouble as a self-proclaimed vocal overdoer. At age 27, because of ongoing hoarseness, she saw a renowned laryngologist and worked with a speech therapist to optimize her speaking voice. She then started singing lessons with a pop and commercial jingle singer and found professional success while studying with him. She also became a singing teacher herself. In her early 40s, Lexi was having a lot of trouble with her voice while recording an album. Her laryngologist diagnosed a vocal fold cyst, and before she could have surgery to remove it, it burst and left a sulcus, a groove or divot on the surface of the vocal folds. She was also having perimenopausal symptoms in her late 30s and early 40s, but was not aware that fluctuations in hormones could have an impact on the voice. Lexi again worked with a speech therapist and a new singing teacher that the therapist recommended. They helped her regain her singing voice as well as her confidence. At age 47, Lexi was back again at her laryngologist's office, this time struggling with hoarseness, lack of stamina, what she called errant pitches, and "glitching." Glitching for Lexi is when a single note or short series of notes in the middle of a phrase simply don't phonate—complete silence for a brief moment in the middle of singing. The doctor found nothing alarming in the exam, but recognized the impact of menopause on her voice, especially since Lexi had gone off hormone...