BLA CONNECTIONS | Series 5,   Episode 2 

Mr Declan Costello on Singing and Laryngology

Have you ever considered the connection between singing and laryngology?

In this episode, Declan Costello, a celebrated consultant ear, nose, and throat surgeon, ENT and Audiology News editor and current President of the British Laryngological Association, explores this topic with host Natalie Watson.

With a background as a Choral Scholar at St John’s College, Cambridge, Declan’s passion for singing led him to become a specialist in voice disorders.

We also delve into the intricate world of voice disorders, particularly as they relate to singers—voice disorders in singers versus non-singers, and the evolving views on reflux and persistent throat symptoms.

We hope you enjoy listening to this episode.

Transcript

Mr Declan Costello
It’s worth remembering, and the BLA do talk about this a lot, but it’s worth remembering that laryngology is about more than voice, laryngology is voice, airway and swallow. All those three things are really critical in their own right. I would just say for singers, don’t be fearful of coming to see a laryngologist. It’s always nice when a patient is pleasantly surprised at how straightforward it is to have a laryngoscopy; it’s not remotely as traumatic as you might have thought.

Natalie Watson
Welcome to BLA Connections – A Clear Voice, to the second episode of series five. I’m your host Natalie Watson, and I’m delighted to bring you discussions and insights from experts from across the globe on all things laryngology.

In today’s episode we explore what it’s like to be a singer and a laryngologist, talking to our BLA president, Mr. Declan Costello. Declan Costello is a consultant ear, nose and throat surgeon specialising in voice disorders. He studied music at St. John’s College, Cambridge, where he was a choral scholar and went on to study medicine at Imperial College. As a singer himself, he has a particular interest in treating voice disorders in performance. He has published a number of books and has written many chapters, including the chapter on larynx for the 42nd edition of Grey’s Anatomy. As well as being our current president of the British Laryngology Association, he is on the Presidential Council of the European Laryngological Society, and you may have read his excellent editorials as editor of ENT and Audiology News. And he is an examiner for the EBE ORL-HNS. He runs frequent courses on vocal anatomy and health for singers and other performers, and gives lectures around the world on voice related topics. He continues to sing regularly, and with several groups, including the Holst singers. Thank you so much for joining us today, Declan.

Mr Declan Costello
It’s lovely to be here. Thank you for the invitation.

Natalie Watson
It’s a pleasure to have you on. So what is your singing background? We’ve alluded to that a little bit, but expand on that.

Mr Declan Costello
Well, at school I sang in school choirs. I wasn’t, I mean, I was a good singer. I wasn’t a particularly serious singer. And I certainly wasn’t a chorister in one of the cathedrals or anything. But I did quite a lot of singing at school. And as I went through my schooling, it looked like I was going to become a medic, both my parents were medics, and it looked like I was going to go into that. But then as I went through sixth form, my voice started improving. And it looked like I might want to do a choral scholarship. And at that time, you couldn’t do a choral scholarship where I wanted to go, which was St. John’s Cambridge. You couldn’t do that and study medicine at the same time, because they’re both too time consuming. And I thought I would study music, and enjoyed that very much. The music course at Cambridge was quite academic, but the singing I did as a choral scholar, you know, we were singing seven times a week, so there was loads of music going on. And then halfway through the music degree, I realised that actually, I did want to study medicine, after all. So I finished the three years of music, applied to medical school, and then did a further five years of study, and carried on doing some singing while I was at Imperial. I did some deputising, some depping in the cathedrals around London, and sang with various other groups and have carried on singing since then.

Natalie Watson
I mean, it’s brilliant that you kept your interest all throughout medicine as well. And that’s obviously what we advise people to do now, because you need that outlet, don’t you?

Mr Declan Costello
Yeah absolutely. And I think the singing I did tailed off quite a lot after I started as a junior doctor, just because we had young kids and there isn’t time and this and that. But actually, as I got a bit more senior, there was more time to do singing. And you’re right, I think it’s really important that people keep up their interest. When prospective medical students come in for work experience placements, in my clinic, quite often, they’re very young, and they don’t really know what they want to do. But they just feel that they’re sort of on this treadmill without ever really having thought about it properly. And I always say to them, Look, if you’re, if you enjoy Spanish, or you enjoy history of art, or you enjoy music, go off and do that for a few years. There’s no great harm in that, it’s not a race to the finish. And if you want to study medicine afterwards, like I did, then that’s perfectly possible. So do what you enjoy doing. But you’re right. It’s easy to become quite one dimensional in medicine I think if all you ever do is to work.

Natalie Watson
Yeah. It’s good for the well being of everyone, isn’t it? It’s a marathon, not a sprint, as you said. So. Now this is quite a loaded question, this next question. Was singing the biggest influence in making the decision to be a laryngologist in particular?

Mr Declan Costello
Yes, I think it was. I mean, when I left medical school, I didn’t know that I was going to go into ENT. As an SHO, I did some Orthopaedics. I did some plastics, I did some A&E and I really enjoyed all of those. But actually when I did my ENT SHO jobs, I enjoyed those and decided I wanted to apply for a specialist training post in ENT and then having got into ENT it was fairly clear from early on that laryngology was going to be what I wanted to do. And laryngology, you know when this was 15 years ago, but laryngology was a very, very, very small niche. So I was painting myself into a little bit of a corner, as I got more and more senior in my training, it looked a little bit unlikely that I was going to find a post to slot into, but I was very lucky to get a job at the Queen Elizabeth in Birmingham soon after I finished my training, so it worked out well.

Natalie Watson
That’s exactly how I felt. I was thinking, am I really boxing myself in too much of a little niche?

Mr Declan Costello
But we’re lucky because laryngology is an expanding specialty and actually over the last few years with you, and with a number of other appointments around the UK, laryngology, I think is increasingly being recognised as an important subspecialty. And that’s something we definitely need to push for with our medical training authorities, for sure.

Natalie Watson
Absolutely. And that’s why we’re doing so much work with the SAC and trying to work on the curriculum to really highlight how varied and diverse airway, swallow, and voice is in laryngology and how essential it is for everyone. So do you think it helps being a singer and a laryngologist? And do you think it’s essential?

Mr Declan Costello
So to answer the second part of that question first? No, I don’t think it’s essential. It’s worth remembering, and the BLA do talk about this a lot ,but it’s worth remembering that laryngology is about more than voice; laryngology is voice, airway and swallow. All those three things are really critical in their own right. But with regards to voice, I mean, no, I don’t think it’s essential to be a singer to be a laryngologist, you’re a singer yourself and you know, that it’s nice to be able to talk to singers in a language they will understand, and actually to have some sort of empathetic relationship, where if somebody is talking about a particular piece of music, or a particular phrase, or a particular scenario, when you’re performing, actually to have lived that and to have experienced it yourself and to know what it feels like to be in that moment, I think is really helpful. And the singers really appreciate being able to have those sorts of conversations. But is it essential? No.

I mean, the majority of patients I see in the run of my practice, obviously are not singers. I do see a lot of singers in my practice. But most people are not singers. And I think if you’re going to be a laryngologist, who is seeing a lot of singers, if you’re not a singer yourself, you do have to make an effort to understand different repertoires, different genres of music, what different eras of classical music sound like, and how the different voice types fit in with those, and the different demands on particular voices, if you’re singing Handel, versus if you’re singing Vagner or Verde, you know, they’re very, very different beasts.

Natalie Watson
And I guess we can make a similarity with orthopaedics. If you are a knee surgeon and you want to know, what are the stresses? What are the impacts? What’s the exercise regime that this person is doing? You know, are they a skier? Are they a footballer? And in that way, you have to kind of understand what you’re doing, and what consequences that we’ll have for that individual person. And again, it’s just having an insight. It doesn’t mean that you have to be the best footballer in the world, but so long as you’re the best orthopaedic surgeon it’s okay!

Mr Declan Costello
No, that’s right. And I think it’s no surprise that the orthopaedic surgeons who specialise in foot and ankle, I mean, I don’t know who James Anderson’s foot and ankle surgeon is, for example, but I suspect that the person who does James Anderson’s foot and ankle is, him or herself, a sports person, and understands precisely the forces and the difficulties that they’re going through. And again, in the same way, as with laryngology, as you say, you can have those conversations about how they’re striking the ground. And in the same way that we work very closely with speech and language therapists and with voice coaches, an orthopaedic surgeon will be working with very specialist physiotherapists, and with sports coaches, as well on footstrike, and that sort of thing.

Natalie Watson
It’s really the understanding, isn’t it, of their world. So is there a downside to being a singer?

Mr Declan Costello
I can’t think of any particular downsides to being a singer in the laryngology world. No, I mean, occasionally patients will talk to me about very, very small niches of repertoire. And I have to sort of go well, can you explain that to me a bit? Because I don’t think I’ve heard of that person. So I feel like a bit of a numbskull at times like that. But no, I don’t think there’s a particular disadvantage.

I think it’s important to have a bigger picture view of voice disorders, particularly when you’re not seeing a singer necessarily. It always interests me that patients who are singers clearly are very locked into how their voices feel, and when you’re examining them and getting them to do particular vocal gestures with the endoscope in, they’re very, very good at mimicking. When I’m seeing a patient who’s not a singer, and you ask them to pitch a particular note, so that you can see their larynx moving, it always interests me when somebody chimes in on a completely different note , and you think okay, fine, so I’m not necessarily seeing a singer here. And I think a lot of music, a lot of singing in particular is about mimicry, actually, and your ability to hear a sound and then actually to reproduce that but that’s just about a musical ear, I think as much as anything.

Natalie Watson
Absolutely. Talking a little bit more clinically now, what are the common pathologies you see in singers?

Mr Declan Costello
Well, the majority of the time a singer who comes to see me has a particular problem in part of their range, often in their upper registers. And I guess the most common pathology would be small blemishes, I would call them, on the free media vibrating at the vocal folds. It’s always very interesting having conversations with singers about pathology. And part of the trick, I think, is to explain things in a way that is kind, accurate, and thoughtful. But that doesn’t induce absolute gut wrenching fear in them, that this is the end of their careers. Because when a singer walks through the clinic door, their morbid fear is that actually this is the end of their working life. And that particularly applies to vocal folds nodules. That there is an absolute, pathological fear in singers of having nodules for historical reasons, I guess. So explaining pathology in a kind way that allows people to understand and realise that this is not the end of the world, I think is a very important thing to do.

So I guess in answer to your question about what the commonest pathologies are, the majority of the time for singers who come through actually there is no definable mucosal pathology necessarily, but of the pathologies that come through, I guess, a unilateral pseudocysts, or a small polyp or something along those lines would be the most common nodules that are reasonably common.

I actually try not to use the word nodules, precisely because of the fear it induces in singers. I talk about anterior vocal folds swellings, or contact lesions, or thickening to the vocal folds and these sorts of things. And then every once in a while, a patient will come through the door who’s had an acute haemorrhage, and you know, that leads on to its own issues, and how you manage that. Reflux. I mean, reflux is just such a huge and contentious topic. I perhaps slightly controversially, take the view that you really can’t diagnose reflux based on what you see in the larynx, unless they’ve got gross redness, and you can see acid billowing up into the larynx. So I think the last 20 years have been interesting to say the least, about how we’ve managed reflux, and I think we’re coming to a slightly more nuanced view of it now.

Natalie Watson
All of these persistent throat symptoms, and it’s one of the most popular podcasts actually, in series four, with James O’Hara, talking about persistent throat symptoms, and how changing views of reflux, whether it’s a thing, or whether it’s part of a thing. And I think it’s obviously got some further exploration to go.

Mr Declan Costello
Yeah, refinement. And James O’Hara is extremely good on talking about this, very sensible, very pragmatic. And Janet Wilson before him, again, had a very sort of sensible view of things and didn’t oversell the reflux side of things. We, in the past 20 years, we’ve been very, very wedded to PPIs. And fortunately, now, I think we’re moving away from that, which is, which is a good thing.

Natalie Watson
So we’ve talked about what common pathologies you see in singers, do you approach the assessment and treatment of singers (as in medical treatment, and surgical treatment) of singers any differently than you do with non singers?

Mr Declan Costello
Yes, I think the approach is different from lots of different points of view. If you saw a subtle little swelling on one vocal fold in a non-singer, and if their voice was causing them very little in the way of problems, you would probably leave that alone, by and large, assuming you were confident it was benign. In a singer, that lesion may only be causing very subtle intermittent problems in their uppermost registers. And if you’re not a singer, that wouldn’t have caused the problem. But actually, for a singer who can’t sustain a top C, that is potentially a career ending thing. So I’m much more prone to addressing small lesions surgically in a singer than I would be in a non-singer, with the caveat that I’m not gung ho when it comes to surgery and singers. And I will obviously try all means possible through voice coaching and voice therapy and other measures to try to avoid that if possible. But if a singer has come to a fork in the road, where they either stop singing, or they have something fairly radical done, like an operation for a small lesion, then sometimes it does come to that.

I think, also the psychology and the timing of approaching an operation for a singer is really important. If that’s the route you’re gonna go down. Singers very often will just want to get it done as soon as possible, just get it done, get it done, but actually, the recovery period after an operation, depending on the nature of the lesion, but the recovery period is a number of weeks, and they need to just factor that in, and just build in some headspace. And if that means working around the lesion for the next couple of months before you plan to do an operation, and that then gives them two or three months afterwards to recuperate, then so be it rather than rushing into it now and trying to get through it as rapidly as possible.

Natalie Watson
Yes, I mean I’m always very cognisant of that as well, you know, because most of them are self employed, and therefore actually taking two to three months out of work, which is basically what we’re forcing them to do after surgery, it’s really quite a challenge financially.

Mr Declan Costello
Yes, it’s huge. It really is. And actually, there are the organisations in the UK that have been enormously helpful over the last few years. So the British Association of Performing Arts Medicine (BAPAM), and Help Musicians UK, who provide practical advice, and signposting to the relevant professionals. But also in HM UK’s case, they provide funding for singers and performers as well who need medical intervention. So no, they’re absolutely fantastic. But you’re right, having surgical procedures as a singer, if that’s the route you’re going to have to go down, it is not a cheap way to go, it really is not.

Natalie Watson
But sometimes it is necessary, if that’s what they want to do, to try and get through their troubles. And it’s our duty to kind of help them through that, and counsel them along the way. Any final words from you, anything you want to leave the listeners with?

Mr Declan Costello
I guess, if there are singers listening, you know, we’ve talked a lot about pathology and things that can go wrong, and recovery periods and all the rest of it. I would just say for singers. And I say this, when I do talks for singers around the place, don’t be fearful of coming to see a laryngologist. I think there was a time perhaps a couple of generations ago when going to see a laryngologist was a slightly traumatic experience. And the techniques for examining people were a lot more unpleasant than they are now. It’s always nice when a patient is pleasantly surprised at how straightforward it is to have a laryngoscopy; it’s not remotely as traumatic as you might have thought. And you know, the other thing is that for singers, they quite often will have problems for a number of weeks, or months, and have been worried about going to see laryngologist for fear of what might be found and they leave it to leave it or leave it and then suddenly three or four months down the line, they’re psychologically, they’re in an absolute pickle, and then come in in a bit of a watery mess. And actually, if they had been able to draw a line under it sooner, and come after just a few weeks and moved on, I think that would have been very beneficial for them. So you know, get to see a laryngologist sooner rather than later. Keep a video of your larynx as well. I think it’s very useful for singers to have a video of their larynx.

And for the laryngologists and SLTs who are listening, be kind and sympathetic to the singers who see. If you’re not sure of what you are looking at, or if you think there’s something that you’re missing, by all means chat to colleagues, I speak to colleagues all the time about subtle this, and subtle that, and asking for second opinions. So have networks of people you can engage with.

Natalie Watson
Absolutely, collaboration is the key. So thank you so much for joining us today, sharing your experience of being a singer and a laryngologist, and highlighting the nuances of looking after the singing population.

Mr Declan Costello
Pleasure. Thank you very much, Natalie, lovely talking to you.

Natalie Watson
We hope you have enjoyed listening to BLA Connections, A Clear Voice. I have been your host, Natalie Watson. Please do tune in this series, for more laryngology topics. We would also love to hear from you. Please feel free to email with any topics you would like us to explore, any questions you have, along with any suggested experts you would like to hear from. Also, if you’d like to contribute to these podcasts, please email enquiries@britishlaryngological.org
Our full series can be found in the podcast provider of your choice, or you will find all stored on our BLA Connect app for easy access. Thank you to all our listeners. And we hope you have found our podcast informative. Please remember to subscribe and do leave a review with your podcast provider. We do appreciate your likes, subscribes and reviews.

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