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How to tell a singer they need to see an ENT

    You suspect a student has a severe vocal problem and needs to see an ENT. How do you break the news? Alexa Terry explores ways to approach difficult conversations with empathy and professionalism.

    As vocal coaches, there is a first time for everything. The first time teaching a student, the first time chasing payment and the first time informing clients of a price increase. While a whole bag of emotions accompanies all these firsts, there is no rehearsal to prepare us for these scenarios and no witchery for us to practice to foretell the outcome. So, we often frantically seek advice and emergency back-up from fellow teachers and business owners.

    In this new series, we look at ways to face these challenges, to make them easier to navigate with logic, and quieten that cacophony of “what-ifs”.

    Advising a visit to an ENT

    For some, advising a singer to arrange an ENT appointment is daunting (*shoots hand in the air*), perhaps due to the overwhelming apprehension which can cloud the logic behind our reasoning. This is something which Professor Steve Peters addresses in The Chimp Paradox. Peters says: “The Chimp is the emotional machine that we all possess. It thinks independently from us and can make decisions. It offers emotional thoughts and feelings that can be very constructive or very destructive… you are not responsible for the nature of your chimp, but you are responsible for managing it.” (The Chimp Paradox by Professor Steve Peters).

    It’s this chimp (mine’s called Chuckie) that can rustle up an overwhelming portion of “what-ifs” in such scenarios:

    • What if my recommendation provokes upset and anxiety?
    • What if they ask what I think the diagnosis might be? Should I give my opinion?
    • What if an injury is diagnosed and they blame me?
    • What if the singer can’t afford it? Are there any other options?
    • What if an injury is diagnosed and the singer wants to continue lessons? How can I do that safely?
    • What if the singer decides not to arrange an ENT visit?
    • What if nothing is found and they blame me for wasting their money?

    How can we manage our emotional “pea-souper” or “Chimp” so that we can approach this situation with clarity and logic, and in a way which keeps the interests of the student at heart?

    Calming the “what-if” tsunami

    Be a pillar of support

    A potential vocal injury diagnosis can make a singer feel anxious and vulnerable and give rise to a tidal wave of “what-ifs” of their own. They may well ask: “what if I’m not a good singer after all?”, “what if this makes me less employable?” or “what if others find out and I get a bad reputation?”. While their worry is, arguably, inevitable, it can be eased with our support. We can offer to accompany them to their appointment and check-in with them between sessions; we can also give our encouragement by reiterating our belief that they are a very able singer with potential, which may help to maintain morale. In my experience, singers (and parents/guardians of younger singers) are simply grateful for our care and attention.

    Share experiences and choose helpful language

    When I discuss vocal health with students, I often share stills and video recording from my own laryngoscopy. This helps show my understanding and empathy to the singer, but also alleviates some of the stigma surrounding vocal injury and requiring a laryngoscopy in the first place. The singer also gets to see how quick and painless the procedure usually is.

    With the entire dictionary at our mercy, we can choose to advise and explain the procedure in a way that is light yet informative, and that implies a sense of team spirit. I find that unleashing the inner geek (*snorts*) by expressing how fascinating it can be to witness the inside of the body at work can soften the blow. Moreover, we can turn the tables on a singer’s outlook by explaining that a laryngoscopy is not just for moments of concern. It can also be used as a preventative measure, or to provide us with what Dr Reena Gupta calls a “baseline scope”.

    Step away from the stethoscope

    While we may be able to recognise the signs and symptoms of vocal injury, we are not doctors or laryngologists. Therefore, it is best if we hang up our white coat and refrain from vocalising our prognosis.

    The “blame game”, responsibility and the role of CPD

    When it comes to vocal damage, there is rarely one single cause. In her book The OHNI Voice Book (check out our review HERE), Dr Reena Gupta divides vocal injury into two categories: the acute (momentary incidents which caused the injury, like a forceful sneeze) and the chronic (an injury caused by continuous overuse or misuse), and how injury occurs when there is too much overlap between these two types.

    Additionally, the contact time a vocal coach has with a singer is limited – some sessions last just 20-minutes. After a singer leaves our studio, we have no direct control over what they do. With this in mind, it is highly unlikely that a well-informed teacher could be accused of inducing vocal damage. Nor could they be identified as the sole cause of the injury.

    Sometimes, the weight of responsibility we feel for our clients can surpass what is reasonable for us to bear. The way a student chooses to use their voice outside of the studio is not in our direct control. But we can be educated in our suggestions and hone our craft as pedagogues. Being responsible for continuing our personal development through learning, research and workshops, means we are giving our clients informed and accurate information, thus supporting our decisions in their training.

    Regardless, it is vital that we have our public liability and public indemnity insurances to cover ourselves for any potential claims against our business.

    Have a support network

    As sole traders, we usually work alone with no “other” to share the load. Therefore, having a support network is just as important for the self-employed voice teacher as it is for the singer. Confiding in a community of people who can advise and assist (like us BASTians) is invaluable. Additionally, organisations such as the Incorporated Society of Musicians (ISM) and the Musicians Union (MU) provide their members with legal advice, insurance and tax completion services.


    The cost of a private laryngoscopy in the UK varies from £240 to £600. This is simply unaffordable for a lot of people. It is possible to visit an ENT through the NHS, and an NHS voice clinic directory is available on the British Voice Association website (BVA). However, for NHS appointments, a GP referral is required but the doctor may not send the singer to a laryngologist. We can advise the singer to explain to their GP that they are a vocalist and would like to be referred to an ENT who specialises in voice.

    If the singer needs to be seen quicker than the NHS can accommodate, but they’re having financial difficulty, encourage them to check whether they or their family have health insurance that will cover an appointment with our recommended private specialist. Otherwise, it is an expensive investment, but one very much worth their while.

    Wasted dollar

    When a singer is referred to a laryngologist, it is because we suspect there is a problem. And that’s all it is from us, an inkling, a fancy, a concern. The only way to confirm or deny our notion and to determine the true state of the vocal folds is via laryngoscopy. For me, there is no real negative to having a scope. If an injury is diagnosed, we can ensure that the singer undergoes the appropriate rehabilitation. Equally, if the results prove the vocal folds to be clear, then we have been provided with “baseline scope”. In both cases, there has been no monetary waste.

    Rehabilitation involvement

    The nature of the injury will determine the rehabilitation method. For example, a vocal haemorrhage will require voice rest. A soft nodules diagnosis may call for a series of speech therapy sessions. As a vocal coach, we are a vital member of the singer’s support network. Therefore, we can ask the singer for permission to discuss their case with their ENT and SLT. That way, we can ensure that we can fulfil our role as part of the recovery team.

    If we don’t feel comfortable working with a rehabilitating voice at this time, we can refer the singer on to another teacher for a while, while still keeping in contact with them to support their recovery and progress.

    No action is taken

    If, despite our efforts, the client does not wish to see an ENT and injurious symptoms persist, don’t be afraid to cancel further sessions. With a concoction of assertiveness and kindness, we can ensure that we aren’t working blindly. It might also help the singer understand how important it is to see an ENT and push them to arrange it.

    With these ideas in mind, perhaps advising our clients to see an ENT won’t seem quite as scary. It means that we’re doing our job – and doing it well.

    There are many ways to manage difficult conversations like advising a student to arrange an ENT appointment. If you would like to share your strategies, visit the BAST trainers in the BAST Facebook group. CLICK HERE