While stress velopharyngeal incompetence (SVPI) may have inconspicuous manifestations in most individuals, it is a career-threatening condition affecting musicians who are brass and woodwind instrumentalists [6]. SVPI is a condition that results from the abnormal movement of the velum (soft palate), which separates the oropharynx from the nasopharynx. It can arise from congenital anomalies including anatomical and structural defects such as cleft palate, post-adenoidectomy state, and neuromuscular disorders [7]. It is a structural or functional pathology due to an inability to properly seal the soft palate against the pharyngeal wall, resulting in nasal air leakage [7, 8]. Because these professional musicians depend on sustaining high intraoral pressures while performing their instrument, this loss of pressure through nasal emission greatly impacts and impairs their performance and their careers [6–9]. It is quite uncommon with only 45% of plastic surgeons and otolaryngologists reported being familiar with SVPI and 27% reported ever seeing a patient with this condition [9]. Despite this, studies have reported up to 34–39% prevalence of SVPI in musicians [7, 9]. The intraoral pressure in normal speech rarely exceeds 5–6 mm Hg and at this low pressure, the manifestation of SVPI is not apparent; however, brass and woodwind instrumentalists can reach as high as 130 mm Hg during performance.

Currently, there is no clear consensus in the management for SVPI [7]. Many previous case reports and articles have described treatment approaches of SVPI for musicians ranging from conservative modalities to operative interventions [7, 10–18]. Conservative approaches include rest, speech therapy, and physical therapy [7, 10]. One non-surgical strategy employed by physical therapy is a palatal sucking exercise, which entails sucking through a straw to hold a small piece of paper to the bottom of the straw by suction, yielding full functional recovery in a bassoonist patient after a 2 year follow-up [11, 12]. One case reported a simple solution of using a nose peg device to prevent nasal air escape during performance [13]. Other case reports have discussed minimally invasive and effective injection augmentation procedures. In one case report, 5.0 mL and 2.4 mL of autologous fat was transferred to the soft palate in SVPI patients (French horn and oboe players), resulting in a complete resolution of symptoms and return to activity 2 weeks after intervention and no recurrence after 1 year follow-ups [14]. Similarly, autologous fat was injected into the posterior pharyngeal wall of a trombone and saxophone player with SVPI; both musicians had complete resolution of symptoms after 2 weeks when follow-up assessment demonstrated the posterior pharyngeal wall was significantly augmented [15]. However, these benefits only lasted for 3 weeks for one patient while the other patient remained symptom free during a 3-year follow-up. Other cases showcased the effectiveness of pharyngeal augmentation via submucosal injection with 3 mL of Teflon (bassoonist) and 1.8 mL hyaluronic acid (clarinetist) as bulking agents with endoscopic confirmation showing no further leakage and both musicians were symptom-free and able to resume their musical careers after 1 year and 6-month follow-up, respectively [16, 17].

Different viable surgical approaches can be considered and performed by plastic surgeons to treat SVPI. Dibbell et al. discussed their experience of successfully executing a V-Y pushback palatoplasty with superiorly based pharyngeal flap in a trumpeter and an oboist [6]. This V-Y pushback was successful because it provided a functional solution; the V-Y flap aids and supports the palate above, thus preventing herniation into the nasopharynx [6]. Both patients experienced complete resolution of symptoms and returned to playing after 6 weeks. They remained SVPI free 1.5 and 2 years postoperatively and were able to pursue their musical careers [6]. Visser et al. described achieving symptom freedom from SVPI in clarinetists after performing an inferior-based pharyngeal flap, frequently used in cleft palate surgery [8]. The clarinetists resumed playing after 4 weeks and remained asymptomatic 2 and 4 years postoperatively. Furthermore, McVicar et al. documented a case where a sphincter pharyngoplasty with superiorly based palatopharyngeal muscle flaps was performed on a clarinetist; the patient resumed clarinet playing after 4 weeks and remained asymptomatic 2 years post operation [18].

Woodwind and brass musicians may experience other HEENT complications that can potentially be career-ending, including injury to the embouchure – the interface between the player’s lips and an instrument’s mouthpiece – from chronic pressure associated with playing wood wind and brass instruments, as well as defects of the lip secondary to Mohs Micrographic Surgery. The embouchure is imperative for the proper production of sound, tonal manipulation, and overall musical expressiveness [19].

Disruption of the embouchure, such as injury to the orbicularis oris muscle (Satchmo’s syndrome), greatly affects the performance of woodwind and brass musicians [19]. Not only does injury to the orbicularis oris stifle the quality of performance but it is also associated with pain and fatigue. Papsin et al. described nine brass players who underwent surgical repair of the orbicularis oris muscle [19]. The operative technique was described as wide-awake surgery with the patient participating during the procedure. After isolating the muscular defect, a skin flap was raised overlying it, and the patient is asked to increase intraoral pressure to pinpoint the defect visually. Interrupted 4-0 Vicryl sutures were used to reapproximate the healthy muscle edges [19]. All nine musicians who underwent the procedure returned to their playing after 6 to 12 weeks and reported premorbid level of performances with no major complications or recurrences.

Another recent case described a trumpeter who was unable to play his instrument after Moh’s resection for squamous cell carcinoma of his lower lip [20]. This was due to soft-tissue depression at the site of the reconstruction, which prevented him from being able to properly seal his lips around the mouthpiece [20]. After hyaluronic acid filler treatments proved unsuccessful, the patient underwent lip reconstruction with mucosal V-Y advancement flap augmented by an acellular dermal allograft to fill the soft-tissue defect for an overall stronger seal [20]. The patient was able to resume playing in 8 weeks and remained satisfied with his ability to perform postoperatively, though his notes were limited to those lower on the scale. Table 1 provides a summary of all the interventional approaches to HEENT disorders discussed here.

Nerve entrapment syndromes are common among all musicians, including compression of the median nerve at the wrist (carpal tunnel syndrome) and the ulnar nerve at the elbow (cubital tunnel syndrome) [21]. Carpal tunnel syndrome is the most common entrapment neuropathy in both musicians and in the general population [22], and definitely one of the most common syndromes that plastic surgeons treat. In one particular study, Lederman et al. reported 143 of 640 musicians (22%) had entrapment neuropathy [23]. Overall, the assessment and treatment of compressive neuropathies for musicians is identical to non-musicians [5]. Early diagnosis via physical exam and electrodiagnostic studies is of the utmost importance [24].

Conservative treatment modalities are similar across all types of entrapment neuropathies and should be first considered with postural changes, physical therapy, bracing splinting, nonsteroidal anti-inflammatory drugs (NSAIDs), steroid injections, and rest [5, 25]. These non-surgical, conservative modalities are important in musicians who might be especially sensitive to even mild symptoms and deficits of these conditions and relief thereof. Thus, the risks versus benefits of surgery must be weighted carefully. Surgical release and decompression may be indicated if the musician’s career is at stake and if conservative management is ineffective.

In cases refractory to conservative therapy, and when surgery is indicated, it is imperative to perform the surgery at its early stages for rapid return to music performance and prevent muscle wasting [5, 21, 25, 26]. Surgical management of carpal tunnel syndrome involves median nerve release by dividing the transverse carpal ligament [27]. Open carpal tunnel release is the most common technique involving the dissection of the transverse carpal ligament [27, 28]. However, the open release carries a significant recovery time before musicians can play pain free and is associated with risks to palmar cutaneous nerve damage, which is not ideal for musicians [28]. Minimally invasive intervention, such as endoscopic or mini-open procedures, are also viable options for carpal tunnel syndrome [27, 29]. Both techniques minimize surgical trauma and require less recovery time; however, such procedures are associated with increased risks of incomplete release of the transverse carpal ligament, leading to recurrence of carpal tunnel syndrome [29]. We recommend weighing the risks and benefits of either approach with each patient on an individual basis.

With ulnar neuropathy, simple decompression or transposition may be indicated [25]. While outcomes have been very successful in musicians with these types of treatments, the results must be guarded since outcome measures were not clearly described [30]. One specific example showcased a left elbow ulnar nerve entrapment in a French horn player who presented with a vague left arm and hand pain for 2 months that greatly affected instrument playing [24]. After conservative management failed to alleviate symptoms for several months, decompression surgery of the ulnar nerve at the left elbow drastically improved symptoms and the patient had complete resolution of symptoms and was able to return to playing 3 months postoperatively.

Arthritis (osteoarthritis, rheumatoid arthritis [RA] or other degenerative joint diseases) and the concomitant symptoms of pain, swelling, and mobility issues, can have a profound impact on a musician’s performance in both its early stages (swelling and low-level pain) or late stages (tendon rupture and considerable joint deformity) [31]. Because of the wide range of different complications and the location of arthritis patients, the surgeon should carefully evaluate the patient and how they play their instrument because individualized surgical decisions need to be made with understanding of how a specific instrument is played. While there are multiple ways to repair a ruptured tendon – tendon transposition, tendon transplantation, arthrodesis, or arthroplasty – it is necessary to obtain a full history and examination of the patient, as well as get to know the needs of the instrumentalist. A pianist uses their fingers differently compared with a violinist, which also is very different from the finger technique of trumpeters. For instance, one case report described a case where an arthroplasty was performed on the affected first joint of the right thumb from RA in a guitarist, in order for that finger to be movable for techniques such as finger picking. An arthrodesis was performed for the left thumb of the same patient for the purpose of stabilization of the neck of the guitar, and provide counterweight to the finger pressures on the strings [31]. Ell [31] discussed several operative strategies in the management of different musicians with arthritis. Other published cases of tailored surgical intervention of musicians with arthritis are detailed in Table 2 [3, 32–35].

In the event of traumatic injuries to the hand or upper extremity, plastic surgeons play a major role in the reconstruction of the defect in order to restore function and structure to enable musicians to continue their career. There have been at least four case reports of hand trauma or injury where plastic surgeons were able to successfully restore the musicians’ ability to perform their respective instruments.

Cobley et al. presented a young pianist who sustained traumatic digital amputations from a lawn mower accident at the mid shaft of the middle phalanx of the middle and ring fingers, and middle phalanx of the little finger [36]. In order to allow the patient to reach an octave on the piano, reconstruction consisted of lengthening the residuum of a traumatically amputated little finger by osseodistraction on a young pianist using a mini external distraction device to elongate the finger by 2 cm in 6 weeks [36]. The device was removed after 8 weeks, revealing great cosmetic results and bone consolidation was achieved in 6 months. The elongated digit is stable and has good sensation and the patient is free from complications after a 1-year follow-up. In another amputation case, Tuncer et al. describes a musician who had a table saw crush injury that resulted in amputation of their left thumb distal at the MCP level [37]. At this level of injury (mid-level and metacarpal segment injuries), a toe-to-thumb reconstruction was indicated because reimplantation was not feasible [37]. The operation consisted of a second toe transfer due to a better fit to the hand. The patient experienced no postoperative complications and showed good strength in opposition, adduction, and IP flexion at 3-month follow-up and was able to resume playing his instrument [37].

Another case detailed a young musician who sustained a power sander injury on the DIP joint of the right index finger losing skin, subcutaneous tissue, and tendon enthesis from the whole area of the defect, with the bone exposed dorsally [38]. In normal circumstances, arthrodesis is a quick and effective surgical option, but the musician prefers restoration of joint function. Thus, a homodigital island flap functional reconstruction with vascularized extensor tendon was indicated and performed. The patient was able to return to work 8 weeks after surgery and able to play his guitar with no restriction of movement 3 months postoperatively.

In the event of a wrist fracture, resection of the distal ulna (Darrach procedure) has proved to be the ideal operation for musicians where wrist pronation and supination are critical [39]. Winspur et al. details the procedure that was performed successfully on five musicians who were all able to return to their full professional careers [39]. The procedure itself is quick and simple and the recovery is rapid, allowing early rehabilitation on the instrument [39].

One particularly debilitating condition that musicians face is focal dystonia, which consists of abnormal involuntary sustained muscle contractions or spasms, leading to abnormal posturing of isolated muscle groups that ultimately interferes with performance [5, 21, 25, 26]. This may manifest as finger flexions, extensions, or tremors while playing the instrument. The etiology is poorly understood and its incidence is estimated to be only 1 in 200 musicians [40]. However, it is deemed one of the most serious medical conditions in musicians and only about 38% of musicians are able to continue playing despite treatment [41].

Treatments for focal dystonia in musicians are presently not effective and include rest, NSAIDs, steroids, tricyclics, bromocriptine, botulinum toxin, biofeedback, psychotherapy, and surgery [21]. The patient may also benefit from occupational therapy and evaluation by a psychiatrist for behavioral interventions that may improve symptoms. This is of particular importance as the patient’s focal dystonia may be rooted in psychiatric causes such as anxiety and may manifest through other means such as neurosis as well [41]. Recently, deep brain stimulation has gained attention as a safer and more efficacious neurosurgical option for focal dystonia; however, more studies regarding its long-term outcomes must be assessed [42]. Even with these interventions, focal dystonia may remain refractory and progress in debilitating symptoms for the patient. It is important to tailor treatment modalities across the multidisciplinary team, as individualized treatment plans may often prove more effective.

Linburg–Comstock syndrome is a condition characterized by tenosynovial interconnection between the flexor pollicis longus and flexor digitorum profundus tendon of the index finger, which provokes simultaneous flexion of the distal joint of the thumb with the flexion of the distal joint of the index finger [43, 44]. The etiology of whether this anomaly is congenital, acquired, or both is under debate [45]. However, it is undeniable that this condition of coupled flexion is often associated with pain [46] and can greatly impact musicians. Surprisingly, Linburg–Comstock syndrome is incredibly common with a prevalence of 31% but can be up to 60–70% in violinists [43, 44, 46]. While this anatomical variation rarely requires treatment in most individuals, some musicians may pursue the operational avenue. A previous case report of a violinist with Linburg–Comstock demonstrated that the surgery to excise the tendinous connection was quick, safe, and simple; the violinists returned to playing after 3 weeks and 6-month follow-up revealed full pain-free function with no complications [47].