The rash of singers who have canceled concerts this fall to undergo throat surgery — Adele, Keith Urban, John Mayer — might suggest that touring takes a terrible toll on the vocal cords. Yet doctors who specialize on vocal issues point to something else to explain the cancellations: new diagnostic tools and surgical techniques.
Dr. Steven M. Zeitels, the Boston surgeon who operated on Adele to fix bleeding in her larynx, said that over the last 15 years the use of fiber-optic cameras that can scan the vocal cords for minuscule injuries and abnormalities has become common. It is now possible to spot problems like bleeding, nodules and cysts earlier and to take swift action to fix them, he said.
"Is there some epidemic? No," he said. "The only thing different happening is the singers know better how to take care of themselves, the doctors know better how to take care of them, and what has been happening always is just getting noticed."
Dr. Natasha Mirza, the director of the Penn Center for Voice and Swallowing at the University of Pennsylvania, added that improvements in laser surgery and imaging technology, which enables doctors to see smaller growths and hemorrhages than before, have also reduced the danger of scarring that can destroy a voice. "Done properly, they are actually pretty safe, these procedures," she said.
Physicians say that there is no doubt that professional rock and pop singers on extended tours run a substantial risk of damaging their voices. The strain of singing full-voiced for an hour and a half is intense — as hard on the larynx as a professional football game is on a lineman's body — and the vocal cords need time to recover after each performance. Dr. Zeitels, one of the leaders in his field, recommends that a rock singer not perform two nights in a row, though he concedes "that's just not feasible."
Singers on tour often do back-to-back concerts, sometimes performing four times a week. A lack of sleep and poor diet on the road can affect the voice, as can drinking and smoking, Dr. Mirza said. Some pop singers are also more susceptible to damaging their vocal cords because they have not had classical training, and their emotive, raw-sounding vocal techniques can place extra stress on tissues, she said.
Gary Bongiovanni, the editor of Pollstar, a concert industry trade publication, said that touring today was no harder on vocalists than it was 30 years ago.
What has changed, he noted, is that pop singers today make less money on album sales and consequently depend heavily on live concerts and the sales of merchandise for their income. Canceled dates hit them hard in the pocketbook.
"There is a lot of pressure to tour now, because that's how most artists make their money," he said. "It's not like you can release a record and just stay home and collect royalties."
Because vocalists today have a greater awareness of the dangers inherent in continuing to perform with damaged vocal cords, Mr. Bongiovanni said, "medical concerns are going to win the argument at the end of the day."
"There is a whole industry built around maintaining vocal health," he added.
John Mayer, the bluesy singer and songwriter, is a case in point. He underwent surgery in late October to remove a granuloma — a lesion caused when the body responds to repeated irritation — and was forced to delay the release of a new album, still unfinished, until next year, because he had to rest his voice for at least a month after the procedure.
Mr. Mayer's manager, Michael McDonald, said that his doctors had been monitoring the growth for six months, and that it was only after extensive periods of rest failed to remedy the problem that he opted for surgery.
Mr. Mayer never let the need to tour weigh on his decision to have surgery, he said. "John needs his voice to continue to work in the profession he's in," Mr. McDonald said in an e-mail. "We were willing to sit out 2012 if that's what it took."
Many high-profile pop singers made the same call this year. Adele, the 23-year-old British soul singer, was in the middle of a breakout, with her album "21" dominating the pop charts, when shecanceled nine shows on her North American tour during the summer, then canceled several high-profile performances in September. She told fans that doctors had warned she would risk losing her voice if she continued. This month she canceled the rest of the year's performances and underwent laser surgery.
Keith Urban, the country star, also chose to undergo surgery this month to remove a polyp from his vocal cords and then to rest his voice for an indefinite period, canceling concerts for the next three months.
These are hard decisions to make, Dr. Zeitels said. The singers he has worked with — among them Julie Andrews, Steven Tyler of Aerosmith and Roger Daltry of the Who — say they and other pop vocalists often feel compelled, out of loyalty to fans, to perform even when they have upper respiratory infections, which is similar to a sprinter's trying to run with an injured hamstring.
The most common problems for singers are benign polyps, cysts, granulomas and nodules, which are growths akin to calluses that develop on the vocal cords. All these can bleed under the demands of performance. The bleeding can lead to fibrosis, or scarring. The scars leave vocal cords less pliable and soft; the voice becomes hoarse and cracks.
Dr. Zeitels said the first tip-off for a singer was usually that his or her voice did not recover as quickly after a performance. A doctor used to look at the vocal cords using a handheld mirror, but in recent years small cameras attached to fiber-optic cables have been developed, which snake through the nose into the throat.
Surgical techniques have advanced too. When Dr. Zeitel operated on Adele this month, he used a recently developed laser that can stop bleeding without scarring the tissue. In the past a surgeon would cauterize the wound, sometimes with a carbon dioxide laser. But in recent years doctors at Harvard and Massachusetts General Hospital have started using a green laser that pulses light and heats the blood in the capillaries without damaging the surrounding tissue.
"You don't actually burn the vocal cord at all," Dr. Zeitels said.