When Frank Sinatra got a cold, Las Vegas got nervous.

Aware that the cancellation of a Sinatra performance because of voice problems would take millions of dollars off the gambling tables, it hardly was surprising there would be some hand-wringing along Glitter Gulch until Old Blue Eyes got better.

The same thing happens every day across the country to less famous people but, in total, the financial impact can run into the billions. And it’s not entertainers who are responsible for the bulk of the losses, but other professionals who use their voices at work, such as teachers, telemarketers, ministers and lawyers.

“Teachers account for $2.5 billion in lost workdays every year,” said Michael Towey, director of Waldo County General Hospital’s Voice and Swallowing Center of Maine, located in Belfast. “Eleven percent of all teachers report chronic voice disorders, and 58 percent suffer from some type of voice problems over the course of their careers.”

For the past three years, Towey and his staff have treated hundreds of Maine working people for voice problems. They do it with the help of digital laryngeal stroboscopy. The highly specialized, state-of-the-art procedure allows Towey to observe the movement of the vocal folds with a fiber-optic device. Vocal folds are commonly, but incorrectly, referred to as vocal cords. Digital stroboscopy is the only tool available for observing the functions and movements of the vocal folds.

Towey explained that people whose work depends on the use of their voices frequently develop bad habits. He compared the improper use of the voice to the muscular and carpal tunnel problems that occur when people use typing keyboards improperly.

“If you’re using the muscles of the voice wrong, it’s the same as sitting at a keyboard and using that wrong,” said Towey. “It creates a strain. It’s not a disease. It can be triggered by laryngitis or a sore throat.”

Towey said that an average teacher uses his or her voice more than two hours a day. A call center worker may use his or her voice up to eight hours a day. Lawyers, performers, coaches, politicians and salespeople all use their voices for hours at a time.

“That’s considered heavy vocal loading,” said Towey.

A voice that is fine in the morning and becomes a hoarse croak by the end of the day is a prime example of vocal dysfunction. When it occurs, people experience vocal fatigue and start taking time off from work or reducing their workload.

“It’s higher in telemarketers than other people and they respond by beginning to limit their productivity and limit the calls they answer. We have seen people from all over the state with work-related voice problems,” said Towey.

Towey said that patients are referred to the Voice and Swallowing Center by their physicians. He said the doctors use the results of the digital stroboscopy to make an informed diagnosis. In most cases, the problems can be corrected through a series of exercises and breathing techniques. In cases where polyps or nodules are found, medical intervention usually is prescribed.

“Some people, their jobs are on the line and they’re worried about their capability to do that job,” said Towey. “There is a very high recovery rate. In some of these people, we’ve been able to take care of a voice problem they’ve had for five or six years in one visit. The voice is very strong. When used right, you can use your voice all day.”

Under the procedure, a small tube with a miniature camera in its end is placed in the mouth and pictures of the vibrating vocal folds are transmitted onto a computer and video screen. There is also a narrower, more flexible fiber-optic scope that can be passed through the nose to observe the vocal folds.

The patient can observe the vocal folds on a monitor while the technician analyzes their movement patterns. Additional medical information, not able to be diagnosed using any other technique, also may be identified by the patient’s physician. The pictures are transferred to video disc and sent to the treating physician.

“You look down a person’s throat, and if a physician doesn’t see a disease there, they might think you are a malingerer, or it’s something in your head,” said Towey. “This technology corrects that.”

Towey said people with acid reflux are prime candidates for vocal dysfunction. The constant irritation of the vocal folds in combination with the acid will trigger the brain to signal the voice to work harder. That results in the voice being strained even more until at some point it crashes and they need to take time from work.

“People struggle with it, the muscle tension increases and their voice just gets worse and worse,” said Towey.

Towey said some companies and other employers are starting to take notice of the problem and have instituted training programs on the proper way to speak. He said teachers in England and Australia now are required to undergo such training. What once was viewed as strictly a medical problem now is beginning to be looked at as a work-related injury in many cases.

“When you get an employee that’s out a couple of days, that’s a cost. If they have to go to the doctor, that’s a health insurance cost. And if they’re not able to return to work, it’s an even greater cost,” said Towey. “Evaluation and therapy are a lot less expensive and it fixes the problem early.”

According to a 2002 study done by K. Jones and J. Sigmon for the archives of “Otolaryngology – Head and Neck Surgery,” 31 percent of telemarketers reported voice problem symptoms. Though most problems can be cured with rest, some need to be corrected with therapy or addressed medically.

“There are thousands of telemarketers in Maine and only a small percentage will have a problem,” said Towey. “But any company that pays attention to the bottom line can see that it could be a real problem.”

And problems stem from all kinds of occupations. Take Cheryl Chandler of Bangor, a nurse who found the answer to her prayers at the Voice and Swallowing Center.

“Mike Towey is my hero,” Chandler said. “He really did such a good job. He said ‘we can fix this’ and he did.”

Chandler spends her entire day talking. She injured her voice more than a year ago while singing for residents of a nursing home. The pain was so intense that Chandler was missing work and unable to do the things she enjoys the most – singing, laughing and telling stories.

Chandler said she tried a number of remedies, including doctors and speech therapists. She also endured “voice-rest” weekends when the only way she was allowed to communicate was by writing her thoughts on a pad of paper.

“Then someone told me about this guy in Belfast, the only one north of Boston doing this stuff,” she said. “It was a life-saving thing. I could not work a full shift without my throat hurting. I could not go through a day without pain. I am so grateful to Mike Towey. He was the exact person I should have been seeing all along.”

Through digital stroboscopy, Towey determined that Chandler suffered from muscle tension dysphonia, a condition where muscles around the vocal folds become strained. Towey proscribed a series of exercises and, after six months of treatment, Chandler’s voice is nearly back to normal.

“I’m a nurse and I had no idea you could do permanent damage to your voice,” she said. “I’m about 75 percent better. The only things that hurt my voice now are singing, laughing and telling stories. Now I can speak all day without pain.”

Employers are cautioned to refer workers who exhibit hoarseness at the end of the day, repeated throat clearing, missed work time due to “laryngitis,” frequent complaints of a tired voice, voice quality that varies throughout the day and throat or neck pain while talking.

Methods used to prevent vocal problems include drinking lots of water, as continuous voice use requires one pint of water per hour. The use of tobacco, caffeine, alcohol and dairy products can dry out the vocal folds. Menthol and glycerin throat lozenges also can dry the throat. People should avoid heavy, rich meals when working because they can cause abdominal pressure and reflux symptoms.

The problem is real and it continues to grow as new job types require workers to use their voices more and more frequently, said Towey. There always are exceptions, of course, and for some people, a scratchy voice can be a meal ticket.

“Take [the singer] Rod Stewart,” said Towey. “He has a horrible voice. There’s no clarity and it’s hoarse, but it’s uniquely his and you’re not going to try and fix that.”