My school project on Bill Kaulitz

[melluransa]

Hi guys! I’ve been really excited over the past few weeks about this project I had to do for a class. The class is about the larynx and voice disorders people can get. You know, like how singers are always losing their voice and canceling shows and stuff. Well, we had to chose a celebrity to do this project on. We had to give background information, make a mock evaluation, and a mock treatment plan. This was to be presented to the class and also had to be in a mock evaluation report.

My first choice for a celeb was Bill Kaulitz, and he’s who I ended up doing the project on!



So, my first choice was Bill. But I wasn’t sure if he was normal enough. Other people were reporting on American celebs like Sophia Bush, Rachel Ray, Steven Tyler, Fran Drescher, Whitney Houston, Julie Andrews, Adele, sports team coaches, Michael J. Fox, etc etc. Bill is so different (and so much more awesome) than them. I hesitated to sign up with him as my project, and I went the safe route and selected Jordin Sparks.

There was no information on Jordin Sparks. I’d have to make everything up about her case and making up cases is hard (Yes, I've made up cases for assignments). Forget that! Plus, she's nowhere NEAR as awesome as Bill.

I wondered if I should step a little out of my comfort zone and do the project on lovely Bill. This was kind of a big deal to consider. There are 33 people in the class, and I’ve been in the academic program with them for 4 years. I know them and they know me, and we’re going to be professional colleagues one day. I wasn’t sure if I wanted to share someone as wonderfully different as Bill with them. Additionally, sharing him with them was really personal, since Bill is a huge part of my personal/lesure/recreational life. Aside from wearing the occasional TH or Bill shirt and TH wristband, my classmates have no idea about my fascination with Bill.

Additionally, this was a project consisting of a professionally-written (mock) report as if I really had evaluated Bill, and also a presentation that would be graded in line with the higher standards of graduate school. Kinda didn’t want to blow it.

But I got over myself with a little discussion and input from some of you guys and I went for it! I told the teacher I was changing my celeb to Bill. She was taken by surprise and I was gleeful. Later in the written feedback, the teacher wrote, “I like how you came up with someone different :-)” And yes, there was seriously a smiley face.

So, that was the buildup to eventually selecting Bill. After that, it was easy to research the topic, write the report, and make the presentation. I even knew what video clip to use in the presentation. That all came very easily. It was all done in love~ It wasn't even work, you know?

Then, it was presentation day! I was maybe 5th or 6th to present. We were all presenting that day (it was dreary and boring). I knew it would be dreary so I tried to have a little fun with my presentation, since we like watching people have fun more than watching people who are clearly bored and uninterested in their own topic. I guess my passion for Bill shone through a little bit? I kept referring to him as “my guy.” XD “I evaluated my guy….” “So, the symptoms my guy presented with were…” *huge grin* I wish I really could call him "my guy."

I even made a little video, which no one else did. They showed video clips that they found on youtube, but I *made* my own video. I did it for multiple reasons (save time waiting to reach a desired point in the vid, commentary within the vid instead of trying to talk over it, control over what the vid contained). The teacher later gave written feedback and said: “Nice work with your clip! Very unique – you went the extra mile.”

The presentation took around 8 minutes to present, which went a little over the limit of 5-7 minutes. I made the class laugh maybe four times, which was four times more than how much other presentations made people laugh. If I remember right, it was about the hairspray, the shrugging/clavicular breathing, interpreting the endoscopy, and the video saying “ow.” People seemed to enjoy it!

I heard a few murmurs after presenting the video clip where we saw pretty pretty Bill. Wonder what they said. The murmurs didn’t last long, and they didn't bother me in the least. When it was over, people seemed to clap enthusiastically. But maybe I was just high on the happiness that Bill usually brings me.

In the written feedback, the teacher said my content was very nice and detailed, the background information on Bill and his voice problem was good, and that overall, she “really enjoyed” my presentation! :D :D :D :D I got 50 out of 50 points. :D It went super well!

I made two videos about it, where I present it to share with you guys. It’s in two parts.

Also, the evaluation report is below! It's three pages on a microsoft word document. I wrote it as if I actually did have Bill as my patient. That report is a lot like what an actual, professional report would be! See? That’s how I write and that’s what I’m going to be writing as part of my job one day.

So without further ado, here is my presentation! The second video has that picture of the vocal folds but I promise that's the grossest pic for anyone who is squeamish. I am, believe you me. In an earlier class, the teacher showed us some youtube videos of surgery procedures for the voice and I couldn't watch those. This is just a still image of some inflamed and cysty vocal cords.

Here is the video clip of Bill that I made and showed in class as part of the presentation.

So, did you learn anything about cysts?

And here is the report I wrote up! It's a little more detailed than a real-life report would be because this was for an assignment. I had to be very thorough.

In the report, I even mentioned Tom and how Tom reported that Bill had no difficulty swallowing. Teeheeheee! *wicked grin* I wrote this report about a situation where I'd be getting Bill as a patient right after his 2 weeks of vocal rest, because realistically, that's when I'd ever be involved. I would never have been involved in the initial evaluation, the diagnosis, the surgery, or any of that. Just afterwards.

Voice Evaluation Report

Name: Bill Kaulitz
Type of Case: Vocal fold cyst
Age: 22 years
DOB: 9/1/1989
Address: Not a resident of the United States
Phone: +49-89-636-48018 (International Number)
Date of voice evaluation: 7/19/2012

REFERRAL: The patient was referred by Dr. Katie Smith, M.D., otolaryngologist, City, State.

HISTORY OF THE PROBLEM: The patient is a professional singer who was touring with his musical group when he was referred. The patient had performed 43 shows before his voice pathology significantly interfered with his performances. He also participated in numerous interviews and appearances during the tour, which required him to talk excessively. The patient lost his voice onstage and the tour was cancelled, which resulted in him seeking immediate medical attention.

At that time (7/5/2012) the patient reported, hoarseness, reduced pitch range, soreness, intermittent aphonia after prolonged use, increased effort and tension, fatigue, and difficulty singing. He said his voice was “out of voluntary control” and “difficult to find.”

Dr. Katie Smith, M.D. and otolaryngolist, performed rigid laryngoscopy and videostroboscope. The evaluation revealed an epidermoid cyst on the right vocal fold embedded in the lamina propria, bilateral vocal fold thickening, and swelling and irritation on the side opposite the lesion. The musocal wave was observed in the left vocal fold, and not observed on the right side, which contained the cyst. The complete absence of a mucosal wave across the surface of the cyst aided with the differential diagnosis of the cyst from a nodule or polyp. Additionally, the lesion was shiny, translucent, and had a dilated and pronounced blood vessel over its surface.

The cyst was severe and would have resulted in permanent vocal fold scarring if not removed, so surgery was the immediate option. The cyst was excised in a surgical procedure on 7/5/2012 and performed by Dr. Smith. The patient was ordered to undergo 2 weeks of vocal rest, and was prescribed corticosteroids to reduce swelling.

After two weeks of vocal rest, the patient was evaluated by Dr. Smith again, and a videostrobic examination was administered to assess healing and readiness for voice therapy. Dr. Smith declared the patient ready to phonate again as of 7/18/2012. The patient is motivated to begin voice therapy and regain his voice. He desires to return to singing as soon as possible.

MEDICAL HISTORY: In 2006, the patient took anabolic steroids for 6 months to stimulate appetite and bone growth. Side effects resulted in fluid imbalance and water retention, which was resolved in 2007. Currently, he reports to smoking since his adolescence and consumes alcohol occasionally.

SOCIAL HISTORY: The patient reports talking excessively and speaking loudly. He is a social young man. He has been singing since age 12, and has been in the music business with his twin brother and other band members since he was 15 years old. His musical and business career is very important to him. His brother attends every medical appointment and voice therapy session with him.

ORAL-PERIPHERAL EXAMINATION: The structure and function of the patient’s oral mechanism was within normal limits for the support of speech and voice production. The range of motion, strength, and accuracy of articulatory movements was evaluated to be adequate. The patient swallowed water without difficulty, and his brother reported that the patient has no difficulty with feeding and swallowing. The patient was observed to have good posture and typical healthy breathing.

VOICE EVALUATION:
The patient attempted phonation the first time during the session. Speech was attempted successfully, and the patient sang a short excerpt from a song. Perceptual qualities were noted, and near the end of the session, a VisiPitch was used to instrumentally measure the patient’s voice.

General Quality: The patient’s first attempt at voicing was a success. His voice was weak, hoarse, and breathy at the beginning of the session, but increased in strength and clarity as the session continued. By the end of the session, the patient’s voice had reduced hoarseness, breathiness, and weakness.

Respiration: The patient demonstrated posture to support phonation tasks. The patient demonstrates abdominal breathing for speech, and clavicular breathing for singing. The patient’s s/z ratio was 1, and within normal limits.

Phonation: During quiet speech, the patient’s voice contained glottal fry at the ends of sentences and during certain words. The timing of the patient’s glottal fry was appropriate for the prosodic inflection of his speech.
The patient’s singing style utilizes occasional glottal fry and late onsets in voiceless consonant-vowel sequences. He alternates between a soft, breathy singing voice, and a strong, forceful singing voice.
The patient’s maximum phonation time was 20 seconds, which was within normal limits.

Resonation: Perceptually observed to be within normal limits

Pitch: The patient’s reported pitch range is 4 octaves. However, at the time of evaluation he was only comfortable attempting a 2 octave range. During the evaluation, he experienced no pitch breaks. Instrumental assessment revealed the patient’s fundamental frequency to be 130 Hz, which is within normal limits for trained voice users. The patient’s frequency perturbation (jitter) was revealed to be 0.80, which is slightly outside normal limits.

Intensity: Perceptually, the patient’s vocal intensity was appropriate when speaking. During evaluation, his loudness levels were appropriate for the vocal task. However, the patient reported singing with considerably more force when performing. Instrumentally, the patient’s dB levels during a reading passage were 60 dB and within normal limits. The patient’s amplitude perturbation (shimmer) was revealed to be 0.40, which is within normal limits.

Rate of Speech: When speaking his native language, the patient’s speech rate is 220 words per minute, which is higher than the norm (160-170 wpm). When speaking his secondary language (English) his speech rate is 170 wpm.

Hearing: The patient reported having hearing loss, but the nature of which was not known. He reports being in loud environments very often. The patient passed a hearing screening at the frequencies 1000 Hz, 2000 Hz, and 4000 Hz at 25 dB. However, due to his concerns he was referred to John Bayer, CCC-AuD in City, State, for further evaluation.

Laryngeal Strength and Tone: Visible tension was observed in the supralaryngeal and sublaryngeal neck muscles during the singing task. The patient recruited neck and shoulder muscles to aid in inhaling large amounts of air, and shrugged with every inhalation. When asked to support singing using his abdominal muscles, the patient experienced difficulty.

Vocal Abuse and Misuse: At the time of the evaluation, the patient exhibited clavicular breathing and laryngeal tension. The patient reported a large number of abusive vocal behaviors before his surgery, such as smoking, alcohol consumption, excessive talking, increased volume when talking and singing, tension, emotional stress, glottal fry, excessive, prolonged loudness, continued use of the voice despite strain and fatigue.

IMPRESSIONS:
The patient’s voice has functionally recovered from surgical removal of the cyst, and he is able to phonate to achieve speech. During the evaluation, the patient revealed that his vocation and habits of vocal abuse and misuse put his voice at risk for further voice disorders.

PROGNOSIS:
If suggested recommendations are followed, the patient’s prognosis is fair. Positive prognostic factors are his is based on his high motivation to return to his job and the patient’s determination to not allow vocal problems to happen again. Negative prognostic factors are the nature of the patient’s job as a singer, and the environments he is in that encourage vocal misuse and abuse behaviors.

RECOMMENDATIONS:
It is recommended that the patient receive voice therapy twice a week for 4 weeks.

Recommended therapy targets:
• Establishing healthy and efficient voice use
o Reducing tension and strain
o Using abdominal breath support
o Reducing loudness
o Implementing vocal rests
• Counseling and education and the vocal mechanism and healthy/unhealthy use of the voice
• Elimination of vocal abuse and misuse behaviors

Recommended therapy techniques:
• Abdominal breathing training
• Change loudness levels
• Chant talk
• Counseling
• Easy onset
• Education about the voice
• Eliminate abuse and misuse
• Reduction of emotional stress
• Hierarchy analysis
• Hydration
• Laryngeal massage
• Negative practice
• Professional singing training
• Periods of vocal rest
• Yawn-sigh


Evaluation Completed by:

_______________________
Melluransa Marshmallowpants
Graduate Clinician


Resources

American Academy of Otolaryngology. (n.d.) Fact sheet: nodules, polyps, and cysts. American Academy of
Otolaryngology, and Head and Neck Surgery. Accessed 7/21/2012 from http://www.entnet.org/HealthInformation/nodPolypCysts.cfm

Colton, R.H., Casper, J.K., Leonard, R. (2011). Understanding voice problems: A physiological perspective
for diagnosis and treatment: Fourth edition. Philadelphia, Pennsylvania: Wolters Kluwer.

Chang, C. (2011). The voice with normal speech, but loss of upper range quality. Falquier Professional
Voice Care of Northern Virginia. Accessed 7/22/2012 from
http://www.fauquierent.net/voiceupper.htm#cyst

DDP/The Local. (2008). Tokio Hotel singer to have surgery. The Local: Germany’s News in English.
Accessed 7/22/2012 from http://www.thelocal.de/society/20080325-10879.html

Schweinfurth, J., Ossoff, R.H., Rosen, C.A., Talavera, R.M., Slack, C.L., & Meyers, A.D. (2010). Vocal
fold cysts: Treatment and management. WebMD. Accessed 7/21/2012 from
http://emedicine.medscape.com/article/866019-overview

RTL. (2009). Special: 100% Tokio Hotel Documentary. RTL Plus Television, Air date: 6/10/2009.
Accessed 7/22/2012 from http://www.youtube.com/watch?v=RJAD-JGsUjM

Comments

[steinsgrrl.livejournal.com]

Wow, this is awesome, and I just read your report! I can't get youtube at work, but I can't wait to see your videos. This is really interesting to read, as a fan who sat and worried through this whole period. Of course, I don't understand much of the medical language, but to see a report on this as it might have been written by the doctor that saw him (and as the doctor you're going to be) is fascinating. I'm really in awe of you, tbh.

[melluransa.livejournal.com]

Thank you! The presentation is way more interesting than the report. I'm not that awesome! Just maybe a little bit. :)

Huh, I wasn't around then so I didn't have that experience influencing me in any way. I can imagine how this is insightful to you! What I laid out in the report is what they probably did with Bill, except maybe with more meds. His cheeks were so swollen from the steroids, which I learned are given because they make swelling go down which allows for better visualization of the cyst without the swelling looking all red and getting in the way. Funny -- it's like the swelling went down on his vocal cords but increased in his chubby cheeksies.

[ginger-veela.livejournal.com]

This is the coolest thing ever. :D Congratulations!

[melluransa.livejournal.com]

You might be right. XD Thank you!

[th-tinie.livejournal.com]

This is amazingly done and so interestin. I will explore it more in full when I get some time to sit down and watch and read more properly (I have been forced away for work for a week, but hopefully I will be able to watch all the films). I can't wait to read and see more. Not the least I long to hear your beautiful voice in the film!!

[melluransa.livejournal.com]

Thanks! I can just imagine you sitting down, with a mind like a sponge ready to absorb this information in full. :)

[th-tinie.livejournal.com]

My mind is TOTALLY a sponge for information that I enjoy. Luckily, it's the opposite for boring stuff... so there'll always be enough room. :D

[kseenaa.livejournal.com]

Now THAT... is just very cool. :-)

(Just, why is the sounds so low on your vids?)

[melluransa.livejournal.com]

Thanks! And I have no idea. -_- Isn't the volume always so low? I think it's because I edit videos in iMovie, which makes the volumes low. I've tried ways to get it higher but they don't work. :-(

[kseenaa.livejournal.com]

Uhu... Not always. Just on your vids. I have to crank up the volume on my speakers nearly to max to even get a chance to hear what you are saying. :-/

[melluransa.livejournal.com]

D: I'm sorry!

[kseenaa.livejournal.com]

It's weird, to be sure. :-P But at least I go into looking at your vids knowing it, so I crank up the volume in advance. Maybe ask other vid-makers how and why and such?

[zeph317toho.livejournal.com]

Dear Ms. Marshmallowpants,

You are amazing! <3 Incredible, even! It's awesome that you decided to go with Bill and obviously had so much fun doing your report! It's no wonder you got full marks. Congratulations, you totally deserved it! :D This is really fascinating stuff! And how exciting that your whole class got into it, too. Maybe you can convert a few more to the glory of Bill! xD

P.S. You're the best!

[melluransa.livejournal.com]

Dear Ms. Zephy Kaulitz,

Thank you! <3<3<3 Doing my report on your husband was so fun! Bill has had a remarkable (remarkable doesn't always mean "good" in the medical world) vocal career and he's very near and dear to my heart. :D I bet my classmates saw my passion in the topic.

I wonder if any of them googled his name afterwards. The glory of Bill.... as much as I want Bill to spread his glory, I also kind of want to keep him to myself and ourselves... you know? He's our special guy, our little (not so little) princess (with a beard).

Love love love,
Ms. Marshmallowpants-Kaulitz

P.S. Au contraire -- 'tis you who are most wonderful, the pinnacle of favor in my eyes! You make me smile, make my eyes sparkle, and flood my heart with love. <3

[elizabeth21r.livejournal.com]

This is crazy interesting!! No wonder your professor gave you the best possible grade and your classmates enjoyed it! I admit I couldn't understand lots of stuff but I am totally unfamiliar with the vocab you guys use in your work. But I really enjoyed the videos - and the mute vid of Bill singing... I confess to not actually noticing his throat, OOPS! I'm very happy it all went well eventually, I was sure it would because you're always awesome =)

[melluransa.livejournal.com]

Daawww, thank you! ^_^ It's hard to watch Bill's throat and shoulders specifically for that contraction and shrugging on inhalation. He's such an unhealthy singer, no wonder he has problems... but at least he does that exhale/grunt during live shows now, like I talked about in the video. That alone helps a ton.

I'm glad it went well too! Thanks for talking through it with me! <3

[psychicherz.livejournal.com]

That is really interesting. I had never noticed the clavicular breathing before...you have a good eye!

Since you know a lot about vocal disorders, I just thought I'd throw this out there in case maybe you could help. When I was younger I had a very strong alto voice, but in college I started losing my voice easily. I can't, for example, hand out flyers talking continuously to people for more than 2 hours (max 3) without having pain and hoarseness. Sometimes my singing voice is missing part of the upper range (but I can sing notes higher and lower than the missing part). If I try to push it and form those notes in the missing range anyway, there's a weird, strangled, sort of trilling sound.

I've been to ENT doctors at different hospitals four times now (over the years) to see if I had nodes or polyps (sp?) with that gross nose-camera, at the recommendation of various vocal coaches, and every time they said my vocal cords appeared normal. Can you think of some other possible cause/habit/reason for this? I'm wondering if there's something else that they should be looking for or that I need to know to ask them about.

[melluransa.livejournal.com]

That's weird that they have no clue and you've seen multiple people. My first guess would be nodes and polyps too. Since there's no apparent cause, I'd start by looking outside the throat -- what are the situations? Are you ever stressed or emotional when pushing to use your voice? How much water do you drink? Do you have to use your voice for long periods of time? Do you talk from sunrise to sunset? What is the air quality of the environments are you in (dry, dusty, smoky, loud)? Do you have any other health things going on? When did this start/is it associated with any particular event? Was it sudden or gradual?

So many questions! It's so much more than what's in your throat, I believe. It sounds to me like they're just focusing on your vocal cords and not considering you as a whole person, but I might be mistaken. It could just be functional (without cause) dysphonia (atypical voice quality). Despite that there's no firm diagnosis as of yet, you could still get voice treatment for it. An speech-language pathologist/voice therapist can help you because the principles are still the same, even without a diagnosis.

One of the first things I'd suggest is vocal rest/relaxation and hydration. If this has been a developing problem for a few years, it might take a while for those to take effect. If you find yourself using your voice harshly like in the video (AH-pul for apple), try to use it more gently (hhhaaapple for apple).

I also recommend keeping a voice journal where you write about the way you used your voice that day, rate your voice that day, write how you feel (stress/anxiety), and any factors that could affect the voice (smoky environments, loud events where you scream more, etc). Keeping a voice journal can help you see the way you're using your voice over time, like how a food journal helps you see what food you're eating. It can help you notice thing, increase your awareness of your voice, figure out what the cause might be, and it would be a really valuable tool for a voice therapist if you decide to seek more treatment.

I hope this helps! I hope I didn't overwhelm you, or recommend that you do stuff you've already been doing. ^_^;; Please feel free to ask more questions!

[psychicherz.livejournal.com]

Thank you so much! I've never seen a speech-language pathologist, so that is a good idea.

Years ago I used to have bad acid reflux, but I changed my diet completely as a result and drink about 3L of water a day, almost no dairy/citrus/chocolate/spicy food, don't smoke, rarely drink alcohol. I purposely don't work in environments where I'd have to talk a lot now, but for about 5 years (around when I started noticing problems) I spent a lot of time at loud rock gigs singing along, shouting over djs in clubs, etc.

I had also thought maybe talking at the wrong pitch is causing this, but idk. As a child, adults would often comment on how I had a "manly" speaking voice (my family still laugh about it...) but I talk now in a normal female range. Perhaps this is artificial--my singing voice is deep, like Fiona Apple deep--but I've been talking this way for so long, I have no idea how to tell if it's "natural". It's reflexive at this point.

I will start keeping a voice journal! I hadn't thought of doing that, and it seems like it could be helpful. I would love if I could find some sort of pattern or cause. And like you say, it would be useful for a voice therapist.

Thank you so much for your suggestions. I really appreciate it. As someone who loves to sing, it can be so frustrating sometimes.

[melluransa.livejournal.com]

Yep! An SLP can help for sure, even when no one can figure out what exactly the diagnosis is.

The acid reflux will do it for ya. Over the years it probably damaged your throat tissues, even though it's stopped now. :( The acid reflux is probably a significant factor, along with the history of vocal abuse. >.< And you also spoke in a vocal register that wasn't natural for a while? I think that's a contributing factor to how Julie Andrews developed nodules...

Finding a pattern would be awesome! Even if you don't find a pattern, it's very useful to raising your awareness about your voice! It's so important, the voice -- especially to you who loves to sing! I wish you the best of luck! <3