Discover Hope

Our voice is by far one of our most cherished instruments that we use in order to communicate with those around us. We use our voice to share ideas, emotions or our beliefs. It a tool to communicate a personal brand — a personality. And for many, their voice is their tool to make a living.

Performance and professional voice users comprise of musicians, actors and news anchors, to occupations including teachers, coaches, salespeople and receptionists. Each of these occupations put an incredible amount of stress on a person’s voice and vocal cords, making vocal health a top, but many times forgotten, priority.

Meet Danielle Cozart Steele (she/her/they/them). Originally from a small, rural town in Indiana, she has a presence, personality and classically-training singing voice that has captured the attention of the Greater Cincinnati region and beyond.

Danielle is a graduate of Butler University and the University of Cincinnati College Conservatory of Music and has a career as a performing soprano, expert opera coach and choral conductor for the Young Professionals Choral Collective, based right here in Cincinnati, Ohio.

Danielle is the epitome of a professional voice user.

Pre-Nodules and Vocal Fatigue

Danielle’s exposure to music and performance began at an early age and really took off in high school through various Broadway and show choir ensembles.

In her first year of college at Butler, she began sporadically losing her voice. After a vocal assessment, clinicians discovered that Danielle was showing signs of pre-nodules.

Vocal nodules can impact anyone, not just elite voice performers. They are noncancerous growths on the vocal cords caused by vocal misuse and by overusing the vocal cords, growths or nodules, that continuously hit together, causing friction that ultimately ends up developing calluses or damage to the vocal cords. The result typically ends with a raspy, hoarse, unpredictable voice quality.

But after several vocal therapy sessions, a combination of breathing exercises and vocal modification techniques, Danielle’s voice was back and performance-ready.

Danielle went on to complete four years at Butler without any vocal issues, but it was during her training and education at the UC College Conservatory of Music when she, again, began experiencing vocal fatigue.

Simply put, vocal fatigue can feel like it is hard to use your voice. It takes more effort to speak, or in Danielle’s case, sing.

While she was at UC, Danielle was using her voice more than she ever had before. She began noticing her upper-middle range would suddenly give out, preventing her from reaching notes that she had once perfected.

Thankfully, vocal therapy seemed to remedy the issue yet again, and she continued on to develop her career as a professional performer, voice teacher and conductor.

Vocal Hemorrhage and Surgery

Throughout her career, however, she continued experiencing intermittent voice loss.

“It wasn’t anything I could attribute to something like allergies because it would go away within a week,” Danielle said. “I figured I had just been overusing my instrument [my voice].”

It wasn’t until Danielle took one of her own students in for a standard vocal checkup that she discovered the cause of the challenges she had been dealing with since high school.

After Danielle’s student was evaluated, the clinician did a routine check on Danielle’s throat, as well. That’s when they found that Danielle’s vocal cords were actively hemorrhaging.

“The physician said that they had never seen an active bleed [or vocal cord hemorrhage] in clinic,” Danielle explained. “The physician said that she couldn’t believe I wasn’t having trouble speaking.”

A vocal hemorrhage is bruising of the vocal cords due to friction at high impact or frequency. The usually, pearly-white structure becomes bright red due to bruising and bleeding.

Imagine going to a concert and screaming your favorite song lyrics or cheering on your favorite team during one of the biggest games of the year. Your voice will likely become hoarse or raspy due to overusing your vocal cords.

For Danielle, her “golden range,” or the upper-middle range, became very fuzzy.

“My usually very clear instrument felt tired and lost its balance,” said Danielle. “Picture an Olympic athlete doing the balance beam, seeing them lose their balance but not fall on the beam. I assumed my loss of vocal balance was due to a technique issue I needed to work on.”

The clinicians suspected that all of Danielle’s troubles up to this point has been due to the active hemorrhaging blood vessel on her vocal cord.

“I realized that all of the technical training I had received as a performer is what actually allowed me to function, as well as I had been with a cord that was hemorrhaging. It was essentially counterbalancing my symptoms,” Danielle said.

It was at that point in her career that Danielle had a choice to make: discontinue being a professional vocalist or have vocal surgery, an unfortunate stigma within the musical industry that can also be career-ending.

KTP Laser: A Vocal Fold Surgery Technique Only Available at UC Health

Being a conductor, vocal teacher and performer, herself, leaving that all behind wasn’t an option for Danielle. Teaching and performing was her passion and her life’s work.

Danielle decided to investigate what the surgical route would entail. In the spring of 2019, she was referred to Rebecca Howell, MD, director of the Voice and Swallowing Center at UC Health and associate professor in the Department of Otolaryngology-Ear, Nose and Throat at the UC College of Medicine.

Dr. Howell has extensive education, training and experience in the diagnosis and treatment of voice and swallowing disorders. She completed her residency at George Washington University in Washington, D.C., and her fellowship training — the highest level of medical education to become a subspecialist — at Augusta University in Augusta, Georgia.

“By the time Danielle was referred to me, she had already been having difficulty with her range for several years,” said Dr. Howell. “With vocal fold hemorrhages, we know that there is a 40% chance of recurrence, and that’s exactly what she was experiencing.”

After the first vocal hemorrhage, a patient is typically put on vocal rest for one week. They then come in for a checkup to examine if the vocal cords have healed or if the hemorrhaging has returned. For performers, if the hemorrhaging recurs, surgery is then discussed.

Dr. Howell and Danielle discussed her options: traditional vocal fold surgery or utilizing what’s called a KTP laser for treatment.

“A KTP laser is a green light laser that can be used to ablate the hemorrhaging (blood) vessels without disrupting the tissue around it,” explained Dr. Howell. “This is a particularly great technique for singers because we’re not having to cut anything or make an incision.”

The KTP laser technique is not widely used among general otolaryngologists (ear, nose and throat physicians) because of the extensive training it takes to become proficient in its technology. The technology is unique to UC Health, otolaryngologists and the region. A patient would need to travel at least two hours outside of Cincinnati to receive this treatment.

Danielle had no hesitation about moving forward with the KTP laser approach.

The Difference at UC Health Voice and Swallowing

“The team at UC Health was so attentive to my physical, emotional and career needs and concerns,” said Danielle. “I knew I was in the best, most competent hands, but it was Dr. Howell who put me at ease.”

The KTP laser is not the only unique aspect to Danielle’s care, Dr. Howell went on to explain.

“Patients who are treated with the KTP laser are cared for the exact same way as those who receive traditional vocal fold surgery. They each have post-surgery appointments with us, voice therapy, and so forth,” she said. “It’s our people and multidisciplinary care teams that is unique to UC Health.”

The UC Health Voice and Swallowing team is comprised of subspecialized physicians and surgeons, but also tremendous speech pathologists; three of whom are also have vocal performance backgrounds.

Together, physicians, surgeons, speech pathologists and the patient decide what the next steps should look like, from the moment the patient walks into UC Health through their recovery.

“I have the best team,” said Dr. Howell. “Our schedulers, medical assistant, speech pathologists — everything runs magically because they all care about our patients.”

A Setback and Newfound Peace

Surgery itself lasted less than one hour and on the same day, Danielle was discharged from UC Medical Center to begin recovery at home.

Long term, Danielle’s recovery and outcome were exactly what Dr. Howell expected, but it wasn’t without a few speedbumps along the way.

“At the time of my surgery, my son was 1 and a half years old, so I was worried about sickness that can come with having young kids,” said Danielle. “The day after surgery, I got bronchitis and was sick for 100 days. I know because I counted.”

The constant coughing from the bronchitis caused Danielle’s vocal folds to hemorrhage again, so she was put on vocal rest — no speaking or singing — for one month.

During her period of vocal rest, Danielle took the time to self-reflect. Rather than letting her unexpected setback cause fear or frustration, she experienced a profound sense of peace.

“Fear is never a good motivator for making a decision,” said Danielle. “Dr. Howell gave me reassurance. I know my instrument, but they are the experts. Going from a place of fear to trust is very powerful.”

The community around Danielle, including her care team, friends, family, coworkers and students, was incredibly nurturing. “I never felt disconnected,” she said.

“I felt so cared for by everyone that I was content with not having a functional instrument for the time being.”

Vocal Injuries Should Not Be Seen as Career-Ending

Two years post-surgery, bronchitis and vocal rest, Danielle’s outcome has been beyond her “wildest dreams.”

“I quickly became aware I had a completely healed vocal cord,” Danielle recalled. “It’s like I traded in a sedan for a sports car. There is color in my voice again.”

Everything Danielle heard about vocal surgery within the performance community proved untrue.

“Our society looks at sports athletes and says, ‘Wow, that was a hard hit,’ and hopes for a full recovery,” explained Dr. Howell. “But there’s an unfortunate culture of blame when injuries happen to vocal athletes. Danielle was doing all the right things. She just uses her voice at a much higher level than non-professional or other performance voice users.”

At the end of the day, it simply comes down to the anatomy. The blood vessel on Danielle’s cord is the result of genetic bad luck. It was vulnerable sheerly because of its location on the striking surface of the cord. Had it been located in a slightly different place, she might never have experienced a bleed at all.

But vocal injuries are not and should not be seen as career-ending.

In August 2020, almost exactly one year to the day from her surgery, Danielle sang an outdoor performance for the Cincinnati Opera as part of their COVID-19 pandemic outreach response.

About a year later, Danielle was preparing for her first audition since COVID-19 put a pause on all performances beginning in the summer of 2020.

“I pulled out my aria book and sang through them,” said Danielle. “I was amazed again at the agility of my voice, having not thoroughly warmed up in over a year.”

“Before surgery, I had a specific warmup regime and cool down, and still do, but I couldn’t have just rolled out of bed and sung through these extremely difficult arias like I’m able to do now.”

Danielle no longer lives in fear of her profession or voice being taken from her due to injury thanks to the expertise and compassionate care provided at the UC Health Voice & Swallowing Center and the leading-edge technology and research that is only available at an academic medical center.

“People say they can hear the difference in my voice,” said Danielle. “I am flabbergasted in how fantastic my results are.”