Special

Repor t

A Vocalists Medicine Cabinet

by Dr. Anthony Jahn, MD

Special Report: Singers Ask Dr. Jahn.

This Special Report features Anthony Jahn M.D., noted author and professor of clinical otolaryngology at Columbia University College of Physicians and Surgeons. He currently has offices in New Y ork and New Jersey and writes a monthly column in Classical Singer. Dr. Jahn has been working with singers for years and is also the author of the best selling commodity in the Classical Singers Bookshelf, Care of the Professional V oice. Dr. Jahn regularly responds to questions in his monthly columns from classical singers all over the world. This report features some of those questions and answers. You can email him your questions at jahn@classicalsinger.com or write him at Dr. Jahn, Classical Singer magazine, P.O. Box 1710, Draper UT 84020.
DISCLAIMER: The suggestions given by Dr Jahn in these columns are for general informa. tion only, and not to be construed as specific medical advice or advocating specific treatment, which should be obtained only following a visit and consultation with your own physician.

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Table of Contents
Please note: other sections may also contain additional information regarding the topics listed below. See the index for other listings.

Hernia, Hoarseness and Overweight . . . . .4

Lozenges . . . . . . . . . . . . . . . . . . . . . . . . . .18

Hyperthyroidism . . . . . . . . . . . . . . . . . . . . .5

Whisper . . . . . . . . . . . . . . . . . . . . . . . . . .19

Anxiety and Mucus . . . . . . . . . . . . . . . . . . .6

Mucus and Phlegm . . . . . . . . . . . . . . . . . . 20

Ephedra . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Hoarseness . . . . . . . . . . . . . . . . . . . . . . . .21

Advair, GERD, and Acid Reflux . . . . . . . . . .8

Laryngitis . . . . . . . . . . . . . . . . . . . . . . . . . .22

Running and Thyroid . . . . . . . . . . . . . . . . . .9

Habits . . . . . . . . . . . . . . . . . . . . . . . . . . . .25

Diet and Alcohol . . . . . . . . . . . . . . . . . . . .11

Tonsils . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Belting . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Neti pots . . . . . . . . . . . . . . . . . . . . . . . . . .28

Allergies . . . . . . . . . . . . . . . . . . . . . . . . . .13

Broken Blood Vessel . . . . . . . . . . . . . . . . .30

Anti-depressant(s) . . . . . . . . . . . . . . . . . . .14

Asthma . . . . . . . . . . . . . . . . . . . . . . . . . .4, 8

Cyst(s) and Nodule(s) . . . . . . . . . . . . . . . .15

Womens Health . . . . . . . . . . . . . . . . . . . .31 PMS Menopause Thyroid Birth Control Menstruation Hormones Pregnancy

Fatigue and Hoarseness . . . . . . . . . . . . . .16

Smoking . . . . . . . . . . . . . . . . . . . . . . . . . .17 A Vo c a l i s t s M e d i c i n e C a b i n e t
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Question: I have enjoyed your articles in Classical Singer immensely. I am a 39-year old mother of six who has been singing since the age of 11. During my last pregnancy, I developed a hernia in my belly button and can really feel the separation of the abdominal muscles, which is worse than ever. Also, in the last four years or so, the asthma I had as an infant has returned. I am on Flovent, Ventolin, and Claritin, and take weekly allergy shots. I am wondering if the strength I had in my 20s will ever return, or am I simply too unwell physically to try to regain ground? I do notice near-pain when giving my diaphragm a workout, and I do not have the breath capacity that I used to have. (I have also lost E above high C and D also.) Also, I do notice in the area of middle C to about F or so a kind of dry hoarseness that develops if I sing for more than an hour or so. Is any of this related to my physical deterioration? Thanks for your time. Dr. Jahn: First of all, congratulations!! I am sure your children give you enough pleasure to make up for your vocal difficulties. Nonetheless, I would look into several areas. 1. Have a doctor (probably a general surgeon) check to see whether you have an abdominal (or umbilical) hernia. If you havent had any C-sections, this is less likely, and it may just be that the connective tissues have stretched a bit. If you do not need specific treatment (like repair of a hernia), consider wearing some kind of abdominal support when singing (like an elastic girdle), if this is not too restrictive. 2. You didnt comment on whether you were overweight or not. If yes, try losing weight, and strengthening your abdominal muscles, using machines, crunches, etc. You should visit a health club or spend a few sessions with a personal trainer to give you an idea of which exercises would be most helpful. 3. The use of steroids long-term (Flovent has steroids) can weaken the muscles, although if you didnt take them by mouth (like prednisone), this is unlikely. Do have a pulmonary function test done, however, since you may have a problem, which is not in the abdominal wall but the lungs themselves.

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Question: My question is about the risks involved in having RAI treatment for a hyperactive nodule causing hyperthyroidism. My internist has recommended this and the RAI uptake and scan test. But I read that this could cause dry mouth and/or vocal cord damage. What is your opinion about this? I dont feel comfortable with this approach at all and would be very grateful to get your input before I proceed further. Dr. Jahn: Radioactive iodine treatment of benign thyroid nodules is a very effective method of obliterating functioning thyroid tissue (thyroid tissue that is normal or overactive). First, it is occasionally used for certain low-grade malignancies, but in most cases the disease treated is benign. So, thats the first good news. Second, the advantage of the isotope is that it goes specifically to thyroid tissue. It is therefore not like other forms of radiation, where an entire part of the body (such as the neck) is irradiated, including all of the tissues present. It is highly specific. This is also good news, since it does avoid damage to the mucous and salivary glands, the major cause of dryness in other forms of radiotherapy. Third, another advantage of this treatment is that it automatically shuts down the entire thyroid, which theoretically could include other smaller areas of abnormal activity which were perhaps not palpated on examination, or biopsied when your diagnosis was made. And finally, RAI treatment avoids a surgical procedure, which may on occasion present complications to the larynx. The main disadvantage of RAI is that it makes you dependent on oral thyroid medication for the rest of your life. This medication, usually Synthroid, replaces the thyroid hormone that your body manufactures and needs to be taken daily. It also needs to be monitored periodically by your internist or endocrinologist. To specifically answer your questions, I am not aware that this treatment causes a significant dryness or damage to the voice. Beside surgery and RAI, you may have one other treatment option available. Some hyperactive thyroid tissue can be suppressed with Synthroid alone, without ablating the thyroid using RAI. You may wish to explore this with your endocrinologist.

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Question: I am a cardiologist at the Minneapolis Heart Institute caring for an opera singer for whom I have prescribed Propanolol in doses of 5-20 mg before performances. She read your article in Classical Singer and noted that anti-anxiety drugs might affect voice quality. She is very concerned that the Propanolol falls under that category because it affects the central nervous system. Can I reassure her? Thank you for your response. Dr. Jahn: If she has had no problems so far, you can certainly reassure her. The main issue in our experience is that it takes some of the excitement out of performance, which in a patient with stage fright is exactly what you may want to do. Some singers feel that it flattens the performance, since they lose the adrenaline rush, which may be important to the drama of the performance. It should have no significant effect otherwise (in terms of pitch or range). She should try it before a less important performance or audition and see how it affects her before using it for an important engagement.

Question: I have a problem where I am always clearing my throat. I always have mucus on my vocal cords. I dont have any allergies that I know of. Any suggestions? Dr. Jahn: I have several thoughts. Do you drink enough water? You need 8-10 glasses a day (two with each meal, two between each meal), in addition to any coffee, tea or other drinks. Try to avoid milk products for a few weeks. Irrigate your nose twice daily with salt water to reduce any postnasal drip. Try to avoid drying medications, such as antihistamines, antidepressants or decongestants. And finally, if you have any heartburn or gastroesophageal reflux, have it treated.

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Question: I remember you talking about ephedra, but unfortunately I cannot find the article. I am an opera singer and I wanted to know what kind of effect this herb could have on your voice. Dr. Jahn: Ephedra is a vasoconstrictor and has an effect somewhat similar to ephedrine, sudephedrine, and adrenaline. It can be drying and can make your heart rate pick up. In general, the effect is similar (although different in degree) to taking a Sudafed tablet. While the drying effect is important for all ages, the effects on the heart may be significant in older singers, particularly ones with hypertension or cardiac disease. Older men may also experience difficulty with urination, particularly if they have an enlarged prostate.

Question: Ive had a bad cold, then laryngitis, but I still have it after five weeks! I sound terrible. Ive been doing the normal vocal rest, plenty of fluids, etc. I think Im getting a little better. Im on Biaxin. Have you ever heard of laryngitis going on this long? Dr. Jahn: Persistent hoarseness after a cold could be due to several factors. If all of the cold symptoms have resolved except for the hoarseness, the most likely cause is abnormal posturing of the larynx. During the cold, if the singer continues to try to sing, he or she may need to muscle the voice more to try to get an acceptable sound. This excess muscle tension usually involves squeezing or grabbing at the laryngeal level. After several days, this adaptation becomes the norm, and the singer unconsciously uses excessive laryngeal pressure. As the cold resolves, adaptation becomes maladaptation. It must therefore be consciously un-learned, concentrating on releasing tension in the neck, lowering the larynx and opening the back of the throat. A good voice therapist can be helpful with this. We also see this situation after colds which involve a lot of coughing. Less common causes of persistent hoarseness are hemorrhage of the vocal fold from coughing and gastroesophageal reflux (GERD), particularly when the illness involved gastrointestinal symptoms such as regurgitation and vomiting.

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Question: Have you ever heard of any voice changing effects from using the drug Advair? What about Advair combined with Prednisone? My doctor put me on both (Prednisone was temporary) and my middle voice has gone completely out of whack. Ive stopped the Advair and am almost done with my Prednisone. Can you suggest any better alternatives for preventing asthma other than Advair, something that will not affect the voice? Dr .Jahn: I spoke with my local representative from Glaxo, the drug company that makes Advair. The answer, according to the company, is that a number of patients do get husky or hoarse with Advair. This is due to the steroid component of the drug, which is the same as found in Flovent. According to Glaxo, the hoarseness is temporary and ends after a couple of weeks. However, Glaxos response deals with the general populace, not singers specifically. My guess is that the hoarseness may persist, in a subtle but still vocally-impacting form, as long as you stay on the medication. You may wish to consider a non-steroidal (i.e., not cortisone) alternative, either as an inhaler or as a pill.

Question: Im writing a paper on acid reflux because I have been diagnosed with GERD. What I dont understand, though, is how the acid gets from the esophagus to the vocal folds to cause hoarseness and eventually even more vocal problems. Does the acid actually come all the way up the esophagus to the back of the throat and then actually drain down and reach the vocal folds? Dr. Jahn: It is exactly as you say: the acid refluxes up the esophagus, past the upper sphincter of the esophagus, which is right behind the larynx. It is then believed to spill over into the posterior part of the larynx. This is why most reflux-related changes are posterior, over the arytenoids or between them. Acid can also pool in the pharynx, causing a sore throat, and even earache.

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Question: Ive recently become a serious runner. Ive been running for years, but have begun to increase my mileage up to 25 miles per week. Im not training for a marathon or anything; I just enjoy running. And, as my family has grown and my time has been squeezed, I find it a very efficient way to stay in shape. Is there any known effect on the voice of which I should be aware? I generally run outdoors unless its extremely cold (well below freezing) or icy, then I stay indoors on a treadmill. Any information would be greatly appreciated. Dr. Jahn: As a relatively recent convert to running, I congratulate you. By all means, keep it up. I think if you were to have any problems, they would have already developed, since you are doing 25 miles a week. The most important issues are catching cold and exposure to pollution and allergies. First of all, dress appropriately. If you run outdoors, try to get to a warm environment soon after the run, rather than cool down completely outdoors. Breathe through your nose as much as possible: it decreases exposure to pollutants and allergens, warms the air, and helps expand the lungs, due to the so-called naso-pulmonary reflex. If you do have allergies, dont run outdoors during allergy seasons or at times when the pollen count is high. Drink lots of water, since you lose more, both in sweat and exhaled vapor, when running. And keep it up! Question: I read with interest your article in Classical Singers March 2002 issue on thyroid problems in women and singers. However, you leave out the next step: what will thyroid medication do for or against the voice? Is this a noticeable problem? The local nurses say it should make no difference and it may be theyre right. On the other hand, theyre awfully good at reassuring people. Dr. Jahn: The answer to your question is actually simple. If you are hypothyroid, which means under active, you should be on enough thyroid replacement medication to bring your levels up to normal thyroid, or euthyroid, levels. If you overdose, the result is the same as having an overactive thyroid. The most noticeable effect on the voice would be a tremor. You would also have a number of non-vocal symptoms.

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Classical Singer Reprint: March 2002 Your Thyroid Gland: A Singers Primer by Dr. Anthony Jahn
f there were a competition for the gland with the most significant impact on the singing voice (although I frankly cannot imagine who in his right mind would sponsor such a silly contest), the thyroid would most likely win hands down. Since the thyroid gland is so important to singers, a too-short (and vocally-slanted) discussion of thyroid disorders is the subject of this column. The thyroid is one of the endocrine glands of the body, glands that secrete their hormones directly into the blood stream. Exocrine glands secrete their products, such as tears, skin oils and mucus, outward, onto the inner and outer surfaces of the body. The thyroid consists of two ovoid lobes that are connected by a short bridging center portion called the isthmus. The gland is curved around the front part of the upper trachea like a shield. (In Greek, thyreos means shield-like.) A list of all of the effects brought about by thyroid hormones would be very longthe thyroid affects almost every part and tissue of the body. Most importantly, the thyroid sets the metabolic thermostat of the body. If the thyroid is over-active, your body is in overdrive: your heart beats rapidly, and you are constantly hungry but cannot gain weight, sweating and always feeling too warm, and prone to emotional excess. Conversely, the under-active thyroid leads to chronic fatigue, sluggishness, constipation, and a constant sense of feeling too cold. (Sounds like half the people you know?) These are the stereotypical clinical presentations of hyperthyroidism and hypo-thyroidism. But the real story is much more subtle. The real story is one that singers must know, since they are, as a group, particularly prone to thyroid disease and affected by its more subtle manifestations. Why are female singers at risk? Because thyroid disease, be it over-activity, under-activity or tumors, is almost exclusively a condition of women. And as women grow older, the incidence of thyroid disease (usually under-activity) increases. There are forms of thyroid disease that affect 10

both sexes equally, such as goiter, which may result from inadequate iodine intake but with the wide availability of seafood and iodized salt, it is rare. Still, thyroid disease in men is relatively uncommon. Occasionally, a mass grows within the thyroid. These nodules (or tumors) are most oftenalthough not alwaysbenign. Their true nature can usually be diagnosed by a painless fine-needle biopsy performed in the doctors office. It is for masses like these that the doctor feels for when he examines your neck. At other times, the entire thyroid, or a part of it, may be diffusely enlarged. This condition is usually associated with hypothyroidism, rather than a tumor. Acute inflammation of the thyroid, more common in women, presents with pain, discomfort on swallowing, and tenderness over the mid-portion of the neck. Although the treatment is usually simple, acute thyroiditis can damage the gland and leave it under-active. By far the commonest thyroid problem we see in singers, however, is a painless, inconspicuous low-grade hypo-thyroidism. The onset of the condition is insidious, its effects subtle. Usually there is nothing to feel in the neck and the diagnosis is made on clinical suspicion. Even a mildly under-active thyroid can affect the voice. A singer may complain that the voice feels heavy, unresponsive, and has lost its color. There

As a group, singers are particularly prone to thyroid disease and affected by its manifestations.
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may be some loss of range (particularly the top) and loss of resonance. This is due to the fact that in hypo-thyroidism there is retention of fluid in the soft tissues (called, in its more obvious stages, myxedema). The vocal folds become swollen and sluggish. The voice that is generated by the larynx will then encounter pharyngeal walls, palate and tongue, which are also edematous, heavy, and acoustically altered. Hypo-thyroidism can also affect muscular function, and thus impair the fine motor control a singer needs. The causes for hypo-thyroidism (indeed, for all thyroid disease) may be multiple and are not always known. There is definitely a familial tendency for some forms of thyroid disease: if your mother had thyroid problems, you need to be on the lookout. There is one form of hypo-thyroidism which is associated with autoimmune diseases, or those that develop when the body mistakenly damages its own components. This condition is called Hashimotos thyroiditis (also known, depending on your cultural ancestry, as Graves disease or Basedows disease). It is particularly prevalent in middle aged women. It may be associated with decreased saliva and mucus (another bane of the singers life), dry eyes, and occasionally arthritis. Other, nonvocal manifestations of hypo-thyroidism may also occur, including dry skin, thick dry hair, loss of hair or menstrual problems. When the diagnosis of hypo-thyroidism is obvious, it iswell, obvious. But early hypothyroidism is anything but obvious. It can be heralded over months by a gradual deterioration in vocal quality, fatigue and other nondescript symptoms. As a (female) singer, you need to be aware of this condition, since your physician, trained to look for the more classic manifestations of thyroid disease, and you may not hear these subtle changes. Once the suspicion arises, a simple set of blood tests may uncover the problem and put you on the therapeutic road to thyroid (and vocal) health.

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Question: I am a 29-year-old singer in my third year of voice studies. I will be taking part in a physiciansupervised diet at a hospital. I currently weigh 260 pounds and will be fasting with liquids for 3 weeks and then moving on to an all protein diet/fast. The fast will also include a regular exercise routine of walking, cycling and some swimming. Will this rapid weight loss adversely affect my singing? Dr. Jahn: I congratulate you on this difficult undertaking. From the point of view of your general health, longevity, and even vocal longevity, you are doing the right thing. I hope you succeed in taking it off and keeping it off. In terms of the voice, a rapid loss of weight will likely have some effect. You may be low on energy, and find that your support has changed. Also, the color of the voice may be somewhat different, since the shape of the resonators and the tissue turgor have changed. I can not predict exactly what these changes would be in your individual case, but it may be that you will have some adjustments to make, since you are used to working with your old instrument. Nonetheless, you should do this, and with some effort at listening and adjusting, you should be able to sing fine. You know that a number of top singers, including Pavarotti, have lost a lot of weight and are doing fine.

Question : I had two shots of alcohol when I went out with some friends and I have to sing Thursday. The alcohol isnt out of my system yet and my voice sounds terrible. How can I get the alcohol out of my system by Thursday? Is it possible? Dr. Jahn: Today being Wednesday, I would assume that the alcohol will be gone by Thursday, if it was only one or two shots. Drink lots of water to rehydrate, and try to get some moderate exercise today (not exhaustive- like vigorous walking for about an hour).

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Question: Thanks very much for your very informative two-part article on nodules. I was particularly interested on your comments on belting. I often use chest voice in my lower register, and didnt know if that qualifies as belting. In general, I change to legit voice as soon as it begins to feel uncomfortable. I would appreciate your opinion on this. Dr. Jahn: Chest voice in the lower register is appropriate, and in fact that range is the proper domain for chest voice. Belting refers to carrying up the chest voice (meaning the muscle mechanics used to produce chest voice) into the head voice range. This means that you have, often with a great deal of effort, shifted your passaggio upward. Many belters, particularly untrained singers, do not use head voice at all, and put great strain on their laryngeal muscles and vocal folds. I would suggest that you make sure first that you have mastery of your full range, chest and head, with a clean and seamless passaggio. Know where this lies for you comfortably. Then you have the option of pushing chest up a bit when the music calls for it. In most cases this should not cause damage. You can also blend the voice, using some of the head voice muscles along with chest voice muscles, to further reduce strain on the vocal folds. Of course, I cannot comment in your individual case, since every instrument is different. You should check with your teacher, and, if you feel strain or hoarseness, with a laryngologist.

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Question: Im studying classical voice and I read your article on medications and how they affect your voice. I have severe allergies and I have to take Claritin-D and Nasonex. I would appreciate if you could tell me how these medicines will affect my voice and what I could do to help my voice from being dehydrated. I would also like to know if immunotherapy (allergy shots) would be better for my voice. Dr. Jahn: If you have allergies, the best treatment is to identify what they are and avoid, or minimize, exposure. This includes measures such as not jogging outside on high pollen-count days, or covering your feather comforter or pillows if necessary. An allergist can test you and tell you what you may be allergic to. Immunotherapy, which involves weekly injections, is time-consuming and costly, but may be your best option if your allergies are present all year round (perennial). If they occur only for a few weeks in the spring or fall (seasonal), then what youre doing is fine. Some people find antihistamines drying, although Claritin is not normally bad in this way. The main complaint I hear about Claritin is that it is too mild for some allergies. The cortisone-containing nasal sprays are again useful, although some of them dry the lining of the nose and can even cause nosebleeds. Nasonex is not normally one of the culprits. To minimize drying, drink lots of water, and you may even consider taking a medication such as guaifenesin, to increase your watery mucus. If you use saline spray in your nose before the cortisone spray (then blow it out before the medication spray), it will decrease nasal dryness. Apart from the drying effect, Im not aware that either of these medications would harm your voice.

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Question: Although I have never suffered from allergies before, since relocating I am fairly certain that I have allergies to the indigenous trees around here. I find that the walls of my throat and vocal folds are covered in a thin, clear, and quite pesky mucus. My teacher has suggested Claritin to help with the congestion that has also been a problem of late. I have heard that these newer antiallergy medications are not as dehydrating and wondered what you thought about them. Dr. Jahn: My suggestion is first to be tested for allergies and find out whether you can avoid any of these allergens. Then, if you plan to stay in your current location, think about desensitization. The newer antiallergy meds include Claritin, Allegra, and Zyrtec, and each person reacts differently to these. You need to try them. Stay well hydrated, including using saline spray to wash the pollen out of your nose. Finally, I recently heard from one of my patients that holistic MDs are using stinging nettle capsules to reduce allergies. This may be worth a try, since this would certainly be nondrying.

Question: I have recently been prescribed Prozac, 20 mg daily. Are there any possible effects on the larynx/singing voice that I should look out for, and, if so, what can I do to minimize them? Dr. Jahn: Prozac, an important and effective antidepressant, is widely used. I have many patients who take this medication, and none has reported a side effect specific to the voice. I do know that some antidepressants are drying, and you may need to increase your fluid intake. The PDR reports a small incidence of pulmonary problems, and certainly if you develop difficulty breathing, you should speak to your doctor and discontinue the medication. The mood-alteration of antidepressants and anti-anxiety medications are not specific in their effect on the voice, but certainly your vocal performance may be affected. To the best of my knowledge, none of these effects are permanent.

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Question: I have sung professionally for the past nine years (I am now 37). Three years ago I had vocal cord surgery to remove a cyst on my right cord. Due to a resulting stiffness on the cord, my voice hasnt been the same since (inconsistent, occasional crackling in certain areasI can eventually work through the trouble areas once I get really warmed up and get the stiffness to loosen up). I do battle acid reflux, for which Ive been on high doses of medication for two years now, and persistent postnasal drip that I cannot seem to get stopped. I recently started studying with a wonderful teacher, who has me singing very well technically, but in the last three months, I havent been able to get my voice to clear itself of the crackling again, no matter how long I sing. So back I went last month, and lo and behold, my doctor now says I have a plugged mucus duct, which has manifested itself into a large raised area exactly over the last surgical site. He told me earlier that microscopic mucus ducts can be severed during surgery and may not drain well after thatthus creating my current problem. He says he typically has to do surgery to remedy this type of situation. I am terrified at the thought of another surgery, since I didnt do so well with the last one. Have you dealt with plugged mucus ducts before, and if so, were you able to remedy the situation without surgery? I am very open to suggestions (exercises, medications, rest, no rest), as Im looking at the end of my professional singing career otherwise. Dr. Jahn: You present a difficult problem. Vocal fold cysts are difficult to remove, since they are in the substance of the fold rather than on the surface (like polyps or nodules). Their removal, no matter how expertly done, always leads to more scarring than surface lesions. It is not always possible to remove the cyst intact, and if even a tiny bit of the cyst lining remains, it can cause regrowth. The plugged mucus duct your doctor referred to is most likely some re-growth, with reaccumulation of mucus material. There is unfortunately no medical therapy to make this go away. The best treatment is removal, since mere drainage may allow it to re-accumulate. You could ask your doctor whether some cortisone could be used postoperatively to reduce scarring, but I would leave this to his discretion. Lasers would not be used for this kind of surgery. As far as postnasal drip, my treatment is hydration (8-10 glasses of water a day), a mucusthinning medication such as Humibid or SSKI drops, and nasal irrigation. Find a yoga shop and buy yourself a Neti pot, which is a device for washing your nose out. Do this twice a day. Good luck!

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Question : I am a professional singer and voice teacher who has just moved to Arizona after living all my life (32 years) in the Southeast. Since coming to Arizona I have had problems with vocal fatigue and a bit of hoarseness that I have never experienced before. Flagstaff is at an elevation of 7000 feet and I am wondering if my problems have to do exclusively with the altitude, and how to combat them. Last year I was diagnosed with Reflux, but was later told by a trusted ENT that the cords were dry but not refluxed. For this reason, he put me on Humibid and Vancenase. An ENT here in Flagstaff took me off those medications and back on Prilosec, and Ive not sung very well since. Unless Im missing something here with the altitude factor, Ive almost decided to go back to the Vancenase/Humibid cocktail. Do you have any suggestions? Im told that the folds are white and healthy. That is why I doubt the reflux idea. Any thoughts would be greatly appreciated. Dr. Jahn: There are several vocal problems related to high altitude that you need to think about. First, there is generalized fatigue, related to the fact that there is less oxygen. Your heart has to pump harder to push the oxygen-carrying red blood cells around your body. Patients typically complain of fatigue and palpitations. After a few months, your body makes more red cells (increased hemoglobin), so this condition will get better. Secondly, it is difficult to sustain the voice, a problem which may be tied in with inadequate oxygen. Third, the air is often dryer than at sea level, and mucous membranes dry out. Based on what you have told me, I dont think reflux is your main problem. Check your blood count, and start taking vitamins with iron if the count is low. Drink lots of water and try to stay humidified in your home. Good luck!

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Question : I am a classical singer (tenor) but I am also a smoker (10 cigarettes per day for 8 years.) My current age is 30. Would you please give me a scientific briefing on how smoking can affect my voice, and most of all what are the benefits I will draw if I quit? I really need your opinion. Are there other singers who smoke? And can you give any examples? Dr. Jahn: It is true that many singers in the past have been smokers. It is also true that there have been many winners in the Special Olympics, but would you not rather be a winner in the REAL Olympics? In other words, you should be singing at your best, rather than succeeding in spite of a (self-imposed) handicap. In brief, smoking involves inhaling tar and other toxic matter into your lungs. Over the long term, lung tissue is damaged, and this impairs your breath control, even your breathing (chronic obstructive lung disease). The bronchi and trachea can clear some of this, by means of tiny cilia that sweep things up and out of the lungs. But nicotine paralyses these cilia, so the tar stays around. You can only get rid of the stuff by coughing it up, another potentially damaging maneuver. Additionally, smoke is drying and carcinogenic. Again, many singers smoke, but you will do better in the long run if you quit. You will have a longer career, with a better voice in your later years. I would also say that if you smoke only 10 cigarettes a day, it shouldnt be hard to quit. Good luck!

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Question : I live in Oregon, famous for allergens molds and pollens of all kinds. I take a daily antihistamine/decongestant combination, Allegra-D, but I still have lots of gunk flowing down the back of my throat. I call it the gunk curtain. To break it up, I have developed the habit of sucking Halls Mentho-lyptus lozenges because they are very effective at clearing the passages. I am a lyric-coloratura soprano, and the gunk often closes off my top. Sucking the lozenges frees my top and I can sing the high passages without choking on the gunk. Recently another singer scolded me for using them. She said they contain anesthetics and could damage my voice. In truth, Ive used them intermittently for years without any apparent harm, and Ive never used an anesthetic throat spray or a specifically anesthetic lozenge. I used to suck on Mentho-lyptus when I was a professional opera chorister in Seattle and Edmonton. So, what is the real truth? Are they harmful? If so, could you recommend a lozenge that would break up the gunk equally well yet not be harmful? What do you recommend for chronic allergy problems such as mine? My regular doctor is excellent, but not a laryngologist, and he has no experience with singers problems, so he does not know the answer to this question. Dr. Jahn: The short answer to your question is that Mentho-lyptus is not an anaesthetic, although too much menthol can be an irritant, certainly if it is inhaled. You have had no problems with it so far, and I see no reason to stop using it. The more complete answer to your problem would be that you should have skin testing for allergies to find out what you may be allergic to, and if necessary begin desensitization treatments. If the allergies are to inhalants (pollen, spores), ask the allergist about how to minimize exposure (such as avoiding outdoor activities at certain times of day, using air purifiers, etc), and use lots of saline spray in your nose to wash away pollen. Higher voices, especially in the higher range, are more critically affected by allergies and anything else that increases swelling or mucus on the vocal folds. Drink 8-10 glasses of water a day to thin this out. Some patients have had good experience with slippery elm lozenges to thin the mucus. One voice teacher has used the dietary supplement L-cysteine with good effect. Although acetyl-cysteine is available in this country as a nebulizer to break up thick mucous plugs for serious pulmonary problems such as cystic fibrosis, I have no personal experience with this orally ingested L-cysteine.

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Question : Thank you for your valuable contribution to Classical Singer. The information is extremely relevant to my own performing but more importantly, to my teaching. I took a course on the subject of vocal fatigue through the speech pathology department at the University of Minnesota while completing my D.M.A. in vocal performance. The issue of the whisper was discussed and it was noted that this is one of the most fatiguing uses of the voice in that it engages (contracts) the largest number of internal laryngeal muscles. If you agree with this, here is my question: Is breathy singing more fatiguing than singing that is not breathy to the listeners ears? Is there less approximation of the glottis in breathy singing (as Ive been told is common in adolescent female singing) and is this breathy singing in anyway similar in function to the fatiguing affects of the whisper?

Dr. Jahn :As you know, the vocal folds do not only approximate with phonation or singing. They also come together with whistling, pushing and whispering, and generally move back and forth during normal respiration. There are two kinds of whisper, the voiced and unvoiced. The unvoiced whisper is barely audible and is not generally used. It involves almost unrestricted airflow through the larynx. The voiced whisper does involve some vibration of the vocal folds or other laryngeal structures, and can be soft, stronger (like a stage whisper), and even a whisper-like singing

voice, as you mentioned. In these cases the vocal folds are held firmly by the laryngeal muscles, although they do not completely approximate, at least not along their entire
length. In terms of muscle effort, this sort of whisper is definitely more tiring than well-supported singing or speaking. Breathy singing usually involves strong muscular effort pushing the vocal folds together, but leaving a gap, usually posteriorly. This is very effortful, involves high laryngeal tension, and may in the long run lead to nodules.

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Question : I have had problems with excess phlegm for several years now, and this has made it very difficult for me to count on my voice being there consistently. I have been to multiple doctors, and all have looked at my sinuses and throat with the scopes and screens and seen mucus lacing my vocal cords and collecting inside my sinus cavities. When this mucus gets on my cords, they simply do not phonate properly and, in the worst case, I can lose my voice. I have had two sinus surgeries in the past two years, for my maxillaries and my ethmoids. I have taken countless antibiotics and steroids, plus nasal sprays such as Flonase and Atrovent. I have tried reflux medication and been tested for allergies, the latter being the standard tests, all of which have come up negative. I have had this problem whether I have been in Europe or the States, in New York or Oregon or California. I have had it in all seasons of the year and all climates. I have had it when my weights been up or down, when Ive been exercising or not, when Ive watched my diet or not. Pedagogically, I have had it while studying with different teachers, when Ive been singing well technically or less so, when Ive been working a lot or not at all. The most recent lab test, of a glass slide taken about a month ago, showed that the mucus was not bacterial but in the allergic or non-allergic family. Since I have tested negative for allergies, my ENT has now suggested nonallergic rhinitis. I would appreciate any ideas that you might care to share. Perhaps I could then discuss them with my doctors out here on the West Coast. I look forward to hearing back from you. Please accept my best wishes and thanks. Dr. Jahn: Thank you for your question. In brief, my recommendations for your problem would be the following: Get tested for FOOD allergies. Go on a non-dairy diet. Get tested for thyroid function. Drink 8-10 glasses of water a day. Try mucus thinners. If you have colleagues who sing in Europe or Israel, have them bring back acetyl cysteine, which is available in those countries (not in the USA) as an effervescent tablet. This breaks up mucus quite effectively. Let me know how you make out.

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Question : My doctor says my larynx is normal, but Im still slightly hoarse. What is going on? Dr. Jahn: This is a frustrating, and not infrequent, occurrence. The voice is not right; you go to the doctor, who looks down at the larynx, and pronounces that everything looks fine. But why are you still hoarse? What is the correlation between the appearance and the function of the larynx? While in some cases what we see explains what you feel (and hear), in other cases the correlation is not so clear. To begin, most larynges do not look perfect. Even if the voice is at its finest, depending on the instrument used for examination, it may be possible to identify tiny imperfections and asymmetries. While the magnifying videostroboscope is the best way to identify structural problems, it is important not to obsess over these minute structural details, provided the voice is fine. Laryngology for singers is a functional, not an aesthetic discipline. I have seen a number of singers who are overwhelmed by the amount of visual information presented in these examinations. It is up to the doctor to sort out what is functionally significant, and what is merely incidental. For example, a small blood vessel on the upper surface of a vocal fold is usually not significant. It only becomes important if the patient presents with a history of recurrent hemorrhage or hoarseness that can be clearly tied to this anatomic variant. Taken to the next level, even vocal folds with potentially important abnormalities, such as nodules, may be acceptable if there is no impairment to the voice. Particularly among pop singers, but even with some operatic voices, the singer can function acceptably, and for a long time, with small swellings. These are not cancerous, and there is no reason to treat them until they significantly impede performance.

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The flip side of this situation is the normal appearing larynx which produces a hoarse voice. How can this happen? Quite easily, if we consider two points:

1. Limitations of the physical examination. Examination of the larynx can be performed with a mirror, a flexible nasal scope, and a rigid oral scope, with or without video magnification and strobe. Each of these techniques has limitations. The mirror does not analyze minor degrees of stiffness or asymmetry of movement. The flexible nasal scope gives a fuzzier image, which can miss tiny lesions. Videostroboscopy can give a distortion of color, since the image is electronically processed by the video monitor, rather than seen by the observers eye. And each of these methods looks only at the upper surface and free margin of the vocal folds. There is no way to examine the undersurface of the folds in the office, and in some cases this is where an enlarged blood vessel or polyp may lurk. 2. Inferring function from structure. It is very easy for a healthy larynx to produce an unhealthy voice. Abnormal posturing of the vocal folds can produce a voice that is hoarse, breathy, choked, or pressed. If the laryngeal position is very high and forward in the neck, if the vocal folds are overly compressed, if the false vocal folds are squeezed together, the voice may become so hoarse as to actually disappear. It surprises many people that the larynx in acute laryngitis often looks nearly normal. The voice disappears due to edema and spasm in the pharynx, causing the pharyngeal muscles to pull the larynx up into a high, nonfunctional position. How can you maximize the value of your laryngeal examination? During examination, be sure that you demonstrate to the doctor what brings on your hoarseness. The vocal folds at rest may look fine, but singing at the top of your range may show abnormalities of structure or posture. If your hoarseness comes on typically after fifteen minutes of warming up, there is no point looking at the larynx before you have vocalized. If hoarseness is intermittent, the examination should try to catch the moment when dysfunction occurs. Until we develop a 24-hour laryngeal monitor, identifying transient vocal dysfunction will continue to be an elusive goal for both patient and laryngologist.

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Question: I have noticed that many of my singer friends do not trust conventional medicine; myself included! We need good health to perform and we are willing to do about anything to get it! You are an open-minded medical doctor; what do you think of all this?... Dr. Jahn: In this new millenium, we find ourselves in the midst of an alternative medicine renaissance. There are many reasons for this, both positive and negative, including an everincreasing access to information about other cultures and the wisdom of the past, as well as advancing research in neuropsychology, cellular biology and the mind-body connection. The computer has greatly empowered healthcare consumers to take an active role in their wellbeing. These factors, along with smoldering dissatisfaction with the cost and quality of conventional care provided by HMO-suffocated physicians has, for better or worse, led to bold and unconventional new directions in self-treatment. Driven by a welter of feel-good literature, we are today uncritically and indiscriminately ingesting a huge pharmacopoeia of plant and animal extracts in hopes of a healthier life. There are many pitfalls as we enter these uncharted waters. One is the semantic confusion between medications, drugs, and dietary supplements. Since these self-administered formulations are not prescribed for an illness, somehow they are seen as natural, herbal or organic, without the negative connotation of prescribed drugs. Just because a substance is plant-derived does not mean that it is invariably beneficial. In reality, many of these substances are potent, and potentially harmful. It is important to remember that many of the most powerful prescription drugs (such as digitalis and some chemotherapy agents) are derived directly from plants, and are anything but gentle. Another general problem with over-the-counter (OTC) formulations is that they are not standardized industry-wide for activity, bioavailability and consistency. Higher price does not guarantee greater potency. For example, a Consumer Reports article on calcium supplements a few years ago found that one of the most effective supplements was the cheapest. Although the legitimate drug market is partly driven by the pharmaceutical industry, there are some scientific controls, such as the need to provide proof of efficacy through rigorous double-blind studies. The dietary supplement industry is driven for the most part by consumer whim. Although many supplements have an impressive pedigree, including references in old Asian medical writings, you must remember that current methods of diagnosis are much more specific. Therefore, therapy originally recommended for symptoms such as phlegm or fatigue may not be effective for specific diseases such as acid reflux or anemia.

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A final warning concerns how the body handles these supplements. I have studied several texts on Chinese medicine, and have found nothing on the topic of drug toxicity or overdose. Some supplements are stored in the body, and may accumulate to toxic levels. The commonest examples are Vitamin E or Vitamin A. Since most of us take these without a prescription, and proceed on the premise that if a little is good, a lot is better, we may be harming ourselves. How should alternative medicine be used? I see three general benefits, which may not be as readily available through conventional medical measures. First, use any method to improve your immune defenses. This may include dietary manipulation (dark leafy vegetables, decrease simple carbohydrates), dietary supplements (judicious use of vitamins), and methods for stress dissipation (meditation, yoga). As antibiotics become more and more ineffective, improving our general immunity may become more important. Second, look at methods to improve your circulation. The blood carries nutrients, eliminates wastes, and conveys immune cells to every part of your body. Methods include exercise (conventional and traditional, such as chi-gung), dietary supplements that thin the blood (Chinese herbs such as tree-ear mushroom, as well as plain old aspirin), and massage. Third, make use of the mind-body connection. The placebo effect so maligned in conventional medicine is nothing less than the mind-body connection. It is the extremely important work the body does to heal itself. For some, this healing involves certain rituals such as religious rites or crystals, for others the ingestion of certain harmless supplements. Do not minimize the power of the mind over the body. The connection, through the brain, neurotransmitters and hormones, is well-known and important. As a last note, keep in mind that if you are chronically, seriously ill, you should see a physician. He or she can help you make a diagnosis and make sure you are not harming yourself with selftreatment.

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Question : I have a terrible habit of biting my lip. I know it sounds very minor, but Ive been doing it for about 20 years now Im 25 and my jaw is constantly tight and sore from the pressure of biting down on my lip. What can I do to stop this? Im afraid it will effect my singing in the long run if Im always clenching my jaw. Any suggestions? Dr. Jahn: Habits like this are very difficult to break. Some people habitually bite the inside of their cheek, and actually develop little fibromas along the bite line. I have a couple of suggestions. If you do clench your teeth, especially at night, you may have your dentist make a bite block. This is a clear acrylic cover that goes over your lower teeth, and reduces clenching. It may also remind you not to bite your lip. Physical therapy to the jaw muscles and TM joint can also loosen things up. Lastly, there is now an experimental study on the use of botulinum toxin (Botox) injections to the jaw muscle, to reduce the pressure on the TM joint by slightly weakening the jaw muscles. This is not yet widely available as treatment, but it may be useful, not for stopping the lip biting but for reducing resultant jaw tension. Im forwarding your question to my colleague Dr. Andrew Blither in New York, who is the chief investigator in this study, and if he thinks you may benefit from this, he will contact you.

Question : I have a problem where I am always clearing my throat. I always have mucus on my vocal chords. I dont have any allergies that I know of. Any suggestions? Dr. Jahn : I have several thoughts. Do you drink enough water? You need 8-10 glasses a day (two with each meal, two between each meal), in addition to any coffee, tea or other drinks. Try to avoid milk products for a few weeks. Irrigate your nose twice daily with salt water to reduce any post-drip. Try to avoid any drying medications, such as antihistamines, antidepressants or decongestants. Finally, if you have any heartburn or gastroesophageal reflux, have it treated.

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Question : What effect do the tonsilsor the removal of the tonsilshave, if any, on the singing voice? I can feel my uvula when I sing, now that they are removed. Dr. Jahn: The tonsils play an important and active role in young childrenthey help to acquire immunity for the body. In adults, however, they are inactive, usually rudimentary, and have no function. When these small and scarred tonsils are removed (hopefully for a good reason), there is usually no effect on the voice. When the tonsils are huge, however, often singers tell me they feel they have more room in the back of the throat. Large tonsils, which are chronically infected, can encumber palate movement to a minor degree. When enormous, they can create a hyponasal,hot potato voice. Proper removal, in turn, can allow greater freedom and flexibility in the back of the throat. This removal must, however, preserve as much mucous membrane as possible, with minimal scarring of the base of the soft palate on either side. A surgeon who is familiar with the mechanics of singing should do it

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Classical Singer Reprint: August 2002

Antihistamines, Decongestants or Neither?
Allergies have been worse than ever and singers need help sorting out drug companies claims from fact. Dr. Jahn to the rescue! by Dr. Anthony Jahn
fter our mild winter and globalwarming type spring, allergies have been worse than ever. Even patients who seldom have allergies, or who suffer only for a few weeks, are complaining. The pharmaceutical industry, ever ready for challenge and opportunity, is bombarding the airwaves, and our offices, with newer medications, each of which is easier to take, more effective, and less sedating. What to make of the wealth of information? Antihistamines, as their name implies, counteract the effects of histamines released by the body. Histamine is one of many inflammatory substances that cells release to react to physical insult. The insult may be trauma, such as a scratch to the skin, or contact with foreign substances, such as allergens. Histamine is contained in small packets, or granules, within some of our cells. When the cells release the granules, inflammation resultsredness, swelling, and itching. One of the effects of histamine is to make blood vessels leaky. This allows blood cells and other blood products to move out of the vessels and to the area of inflammation to address the injury and deal with the invaders, whether pollen, poison ivy resin, or insect bite. This is all good. What is NOT good is the bodys inappropriate overreaction to benign bits of dust, pollen and your cat. This is allergythe bane of millions of otherwise perfectly healthy people. Antihistamines counteract inflammation by blocking the effect of histamines. This can be done at many different levels, beginning with the point of histamine release, to sedating the brain. Some medications stabilize the cell membranes that contain the packets of antihistamines, preventing their release. Sodium chromoglycate, found in some eye drops and nasal sprays, acts in this way. A new product, Clarinex, is touted as having some of this effect, in addition to the usual antihistamine properties. Sodium chromoglycate-containing products are not sedating, but they only work before

histamine is released. They are preventive, not curative. Conventional antihistamines, on the other hand, counteract the effects of histamine after its release. This is the group that includes the usual suspects: Claritin, Allegra, Zyrtec, and the stronger ones such as Benadryl. Each one is a bit different, some stronger than others, and theres the rub (actually, the rub also lies where the itch is, which is why you take this stuff in the first place!). The main complaints I hear about antihistamines is that either they are too weak or too strong. Efficacy varies, however,

counter multi-drug combinations, such as Tylenol Cold and Sinus. Orally taken decongestants, (which for all practical purposes is the same as saying pseudephedrine or Sudafed), constrict the blood vessels and decrease the swelling of the tissues. While superficially this may resemble the effect of antihistamines, it is quite different and carries with it its own side effects. These include palpitations, increased blood pressure, and again, dryness. So, while this combination of antihistamines and decongestants is less sedating, it is potentially doubly drying for singers.

Topical decongestants, found in Afrin-type nasal sprays, work quickly to shrink nasal membranes, but after a few days use are no longer effective.
not only by formulation, but also from patient to patient. One patient may say that Claritin is too strong, whereas another complains that Zyrtec (a more potent drug) doesnt touch her symptoms. So, despite all the scientific data, trial and error is the ultimate test when choosing an antihistamine. Equally important are the side effects. These are known to all, and are (going from weaker to stronger drugs): sedation, drying, blurred vision, and difficulty urinating (for those of you blessed with a prostate). For singers, the greatest problems are caused by drying of the vocal tract, which decreases control, particularly when singing softly and at the higher extremes of range. For the general population, however, sedation is an important issue; patients experience difficulty driving, focusing, and staying alert on the job. Unfortunately, the more effective (i.e. strong) an antihistamine is, the greater the sedative side effects. The pharmaceutical industry responds to this by adding decongestants to the formulation, as seen in Allegra D, Claritin D, and over-theTopical decongestants, found in Afrin-type nasal sprays, work quickly to shrink nasal membranes, but after a few days use are no longer effective. How is a singer to navigate this vocally treacherous course? My suggestions are the following: Find out what your allergens are, and minimize exposure to them. If you have perennial (versus seasonal) allergies, consider desensitization shots. If your allergies are localized (e.g. only nasal), consider using topical sprays rather than systemic medications. Look at alternative anti-allergy medications, such as stinging nettle, recommended by Dr. Andrew Weill and other alternative medicine experts. Again, how you personally respond to a particular medication is unpredictable and idiosyncratic. You may do very well with a drug someone else finds intolerable. So do experiment (with your doctors blessing), especially if you need to take these medications long term.

Question : Inspired by the brief CS article about Neti Pots [August 2003, Suzanne Jackson], I trekked to my local health food store to buy a neti pot, brought it home, and followed the detailed instructions. Knocked over by a big wave while swimming as a child, I first felt the sensation of salt water in my nasal passages. With the Neti Pot, I rediscovered that sensation. Its hard to imagine a more unpleasant daily cleansing ritual. Forcing salt water through my nose feels absolutely awful in every way. After the sordid ordeal is over, and the dust and impurities have been gently washed away, my mucous membranes protest at having been so impolitely violated, and react by producing more mucus. I actually end up more congested than before I began. Its been over a month now, and Im giving up. Some ancient yogi is having a good belly laugh at his practical joke. Dr. Jahn: Im sorry you have had problems with the Neti Pot. I have recommended it to my patients for years, and most of them find it very useful. A couple of suggestions for your next nasal adventure: First, adjust the concentration of salt so it is neither too strong nor too weak. If in doubt, try buying physiologic or normal saline at the drug store. This has the same concentration of salt as your body fluids, and should not be irritating. Second, when you pour the solution into your nostril, tip your head both to the side and slightly forward. This will assure that the solution goes into the other nostril, and not into your throat or ears. Also, pour slowly! You control the flow with your hand. Your experience, while not unheard of, is not typical. Give it another try. If it doesnt work for you, you may want to consult an otolaryngologist to see whether you might have a septal deviation, which misdirects the flow of the solution. And then, you can laugh back at the ancient yogi!

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Classical Singer Reprint: August 2000

The Singer and Yogic Health Enhancers: The Neti Pot
by Suzanne Jackson While many singers are starting to benefit from yoga, little is known or said about the health enhancing practices that yoga has to offer. This column will focus attention on these additions to your regular yoga routine. You may discover that these easy, practical and effective tips are the turning point for good health.
ealthy singing begins with clear sinuses and nasal passages. Singers must continually battle pollution, dust, pollen, viruses and other microbes to keep their singing mechanisms in top form. One way to do this is to gently cleanse the nasal passages with the aid of a Neti Pot. A Neti Pot is a small ceramic or metal

H
OR

A NETI POT IS A SMALL CERAMIC METAL TEAPOTLIKE

CONTAINER WHICH YOU WILL FILL WITH LUKEWARM SALT WATER. teapotlike container which you will fill with lukewarm salt water. The Neti Pot will come with specific directions on filling and using. Standing with your head over a sink, or in the shower, tilt your head horizontally while allowing the saltwater

to flow into the upper nostril and out the bottom nostril. Repeat with the other nostril after tilting your head to the opposite side. Some of my students prefer to use lukewarm distilled water with a teaspoon sea salt. Mix it together in a cup and use a straw at the very tip of each nostril to insert a small amount of water. When singers are traveling and do not have access to the Neti Pot, I recommend pre-packaged saline solution, which can be purchased in any drugstore. A few squirts up each nostril while flying or any time your nasal passages feel dry or irritated will help clean the sinus passages. My students have expressed only positive results from use of this yoga kriya. Neti Pots are available at most health food stores or may be ordered online. The price range for this valuable tool is approximately $14 for a plastic Neti Pot to $25 or more for a metal one. Note: This column is not to be construed as

specific medical advice. Readers should consult their physicians prior to adopting any of the techniques in the column. Suzanne Spangler Jackson developed YogaSing by combining her knowledge of the specific needs of singers and her yoga and dance training. She is currently on the faculty of The Washington Operas Young Artist Program of the Americas and Opera Delawares Artist Workshop. She can be contacted at YogaSing@juno.com. [Editors note: Dr. Anthony Jahn, Classical Singers resident ENT, also recommends the Neti Pot to his patients and has them available in his offices. As a substitute in a pinch, one can use a water bottle with a pull top, warm water and salt. The Neti Pot is much more efficient, however.]

Question : I think Ive got a broken blood vessel in my vocal cord. I got it from working a 14-hour day, not eating dinner, coming home exhausted and then practicing for an hour. I noticed nothing strange except I didnt sound very good. (Also, I was on my period and may have taken an aspirin that day.) I woke up hoarse and with a headache, kicking myself for being so dumb. Having been through this twice before, I know the remedy is vocal rest. I was hoarse for one day. I had sound the next but still did vocal rest. Today I tried the voice out very gently. It sounds fine but there is a little roughness on the E notes above middle C. Obviously, Im still doing vocal rest. Dr. Jahn: Before you start singing again, you need to make sure that the blood has completely reabsorbed from the hemorrhaged vocal fold. This may take several weeks, so if you cant see an ENT specialist, be sure you wait about a month before trying to sing. Also keep in mind that even if a doctor says your vocal folds look OK (i.e. no more visible blood), there is a period of persistent edema, which he cannot see, but you can feel and hear when singing. Thats the short answer, I guess. The longer answer is, if you do have recurrent hemorrhage, especially in the same vocal fold, you may need to see a voice specialist ENT, and have the blood vessel treated with laser. This seals the blood vessels and will hopefully stop future hemorrhages.

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Womens Health

Question: I am a 31-year-old soprano still in the stages of developing my technique. I have discovered that in the days leading up to my menstruation and during it, the low and middle part of my voice do not phonate. It becomes an extreme effort to produce any type of sound. I would be very interested to know how a womans monthly cycle affects singing, and if it is typical for the voice to change. Colleagues have suggested going on the pill to manipulate my cycle so that I am not experiencing the above-mentioned problems, especially if I have a performance. This has been the cause of great frustration for me and I would appreciate any thoughts you may have on the subject and welcome any information and advice you can offer. Also, I take a small dose of Propranolol (5 mg) before a performance to help with nerves. To your knowledge, does this medication affect singing? Dr. Jahn: I think much of this has already been answered, but here are some thoughts. The middle- and low-voice difficulties you experience are likely not related to a swelling of the vocal folds themselves, but more to general fluid retention in the tissues of the pharynx, and even the muscles that move the vocal folds and raise and lower the larynx in the neck. You could try a mild diuretic about a week before your period; try the herbal ones first. Also, try to cut back your sodium (salt) intake. The pill can regulate your cycle, but Im not sure it would reduce your premenstrual vocal problems: it does help some women with premenstrual cramping and more systemic symptoms. The pill can, however, alter your voice a bit, and more significantly if you have a high voice. Propanolol is often used for performance anxiety. Five milligrams isnt a high dose and shouldnt affect you adversely. Some feel it takes the edge off the performance, but if for you that edge equates with terror, it might be a worthwhile tradeoff. Good luck!

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Question: Thank you so much for your informative and helpful articles in Classical Singer. I always read them first. There have been several articles concerning women and vocal health. The most recent article was about the thyroid gland. Very interesting! I was wondering if you might consider addressing the effect of PMS on the voice. Many singers such as myself suffer from this every month. Ive kept a journal each month for quite some time. Im positive that hormonal fluctuations during the month have a direct effect on my voice. PMS tends to take away the glow from my sound, the cords dont come together as cleanly, and there is a veneer of air around the sound. Sometimes its better than others, but for someone who depends on her voice for her livelihood, it can really get in the way. Do you have any suggestions on how to help alleviate the problem? I know that exercise and certain vitamins such as the B-complex help other PMS symptoms. I also know that some women find relief by taking birthcontrol pills. Can these methods also help the voice? I hope the subject is not too sensitive to discuss, but I would really be curious to hear what you had to say and Im sure that Im not the only one. Dr. Jahn : Again, let me preface this by saying that I am neither a gynecologist nor an endocrinologist. My understanding of premenstrual voice problems is that female hormones, progesterone in particular, lead to fluid retention. They also change the viscosity of the ground substance in the cells, causing a stiffening or thickening of the vocal folds. This typically will make the voice less flexible, more unwieldy, and takes some of the ring out of the voice. Treatment? It depends on how much this encumbers your singing. In the same way that some women have minimal premenstrual problems versus others who suffer greatly, the voice can also be affected a little or a lot. If you retain a great deal of fluids, you may consider a mild diuretic in the week before your period. If periods are heavy, crampy and uncomfortable, oral contraceptives may help. There is also a wealth of alternative-medicine-type herbs and vitamins that may be of benefit. I would suggest you consult a gynecologist or a naturopath. As a final point, the problems, both systemic and vocal, may be greater at the extremes of your reproductive span, i.e. shortly after the menarche and before menopause.

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Question: I am a 27-year-old soprano and am now almost 4 months postpartum. My pregnancy and delivery were easy and uneventful. During my pregnancy I experienced perfect vocal health; I sang recitals, sang a show and did an opera workshop. I am breastfeeding, and since the delivery I have run into a number of problems. I know there is a breastfeeding hormone that can effect the top notesmake the chords tight and not easily stretched, which I am experiencing. But the bigger problem is something else. Directly in my middle range, the B, C, C#, and D above middle C are rough, almost like radio static. I am wondering if you know anything about this and if I can blame the breastfeeding or the delivery on this problem. (I did groan like an animal during the delivery and was quite vocally tired and a bit hoarse for a couple of days.) My body has almost returned to normal, and I have been working diligently on my abdominal muscles to regain my support system. I have been offered a full scholarship to complete my Masters degree in vocal performance in the fall, and I am getting nervous about the condition of my voice. I did see an otolaryngologist about 6 weeks ago, and he could barely see down there, but he saw a little inflammation and maybe a little bit of swelling. Could that be the breastfeeding? Is this a common problem? I am sure that other singing mothers would find it interesting. Dr. Jahn: I dont have a clear answer to your question, but do have some thoughts. Problems in the middle range may be due to swelling on the vocal folds. However, if your top is clear, the problem is more likely one of muscular incoordination. By this I dont mean inadequate support, but more to do with the laryngeal muscle repositioning that is involved in the passaggio. My suggestion would be to undergo videostroboscopy with a good laryngologist to look for any incoordination in that range, and then you may need to work that part of the voice, even consider shifting your passaggio temporarily. Again, I am not a voice therapist, and these are just suggestions. The condition may improve significantly once you stop lactating. Good luck!

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Question: I have been on the birth control pill now for over 3 years straight (probably over 7 years total if you add up all the times in my life Ive been on them). I went off it for 3 months because I was on tour and away from my husband; it seemed the perfect opportunity to give my body a rest and see if it would change my voice at all. I have been on it so long I really wasnt sure if it has produced any vocal changes. Some people claim it makes a difference, so I thought Id find out if I qualified as well. I am a light soprano with nothing much (reliable) above a high C#. This hasnt been too much of a problem, but I have wondered if perhaps some of the very top notes would come in. Ive never been a true coloratura, but I have heard that the Pill can take a few notes off the top. My question is this: Ive been off it for three months now and have noticed no perceptible change in my voice. If there were going to be a difference vocally, would I have noticed it now? Or does it take more than 3 months for the hormones to truly clear out of ones system? I do like the Pill because it is nice having a predictable cycle and reliable birth control. Should I give my body more time to adjust to being without it? Dr. Jahn: Hormones do affect the voice. Although there are no specific estrogen receptors on the vocal folds, many singers have noticed that once they start oral contraceptives, they lose a little bit off the top. They may also gain a bit on the bottom, but usually less. This effect is probably related to the specific hormone preparation, but is also to some degree idiosyncratic. The important point for you, however, is that this effect is not reversible. Going off the Pill will not change your voice, and your range will remain the same whether you give the Pill a rest or continue. Unless your voice is still developing, your next possible voice change should not occur until the menopause. If you are comfortable with the oral contraceptive preparation you are taking, from the vocal point you should stay with it. If you change your Pill, there may be additional voice changes. In general, take the least amount of hormone you need to regulate your cycle and achieve contraception.

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Question : My first question is about birth control pills and the singing voice. I am a soprano, I am 37 years old, and I have one six-year-old daughter. My husband and I are trying to have another child. After I had my daughter, I experienced some vocal problems very similar to those brought about by PMS (hoarseness, voice catching, etc.). In addition to that, I had terrible mood swings. My doctor recommended going on the Pill after delivery if I encounter these problems again next time I have a child. Taking the singing voice into consideration, what sort of birth control pill would you suggest? I know that taking the wrong thing could be detrimental to a singer, especially a high soprano. I was on the Pill only once when I was 26. It did not bother my voice. In fact, if anything, it may have helped vocal PMS. However, I was only on it for a short period of time, so I dont know what the long-term effects would have been. My second question has to do with IVF [In Vitro Fertilization] and the voice. One of the problems I have is early miscarriage due to a genetic translocation. My doctor suggested doing IVF to better my chances for a fullterm pregnancy and delivery. My question to you is, how can IVF affect the voice, and are any of these effects permanent? Should I choose this route, is there anything in particular that you might caution me about with regards to vocal health? I would appreciate any helpful feedback you may have for me. Thank you. Dr. Jahn : Regarding your first question, you may wish to read CSs recent survey on the effects of the Pill on the voice [Feb 2003]. A significant number of singers, particularly high sopranos, did report changes in the voice. This is less likely if you are a dramatic or spinto voice, or a mezzo. The fact that you took the Pill before with no untoward effect is a good prognostic sign. If you were to go back on the same medication you took earlier, it seems to me this would minimize any potential effect on the voice. You are right, by the wayone benefit of the Pill is that it can reduce the normal PMS effect on the voice. On occasion we have even advised singers to delay their period using the Pill, so that it doesnt coincide with an important engagement. Regarding IVF, you need to ask your doctor what hormones are used to induce ovulationthis is beyond my expertise. The culprit in the Pill is synthetic progestogen, which metabolizes down to a testosterone analogue and can darken the voice. While being placed on hormones to induce ovulation will very likely affect the voice temporarily, it should have no long term effect providing synthetic progestogens are not used. Please check with the fertility expert, however!

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Classical Singer Reprint

February 2003

Survey Results
Age: 19 and under 20 - 29 30 39 40 49 50 and over er taking the Pill, If the voice changed aft I first noticed this: ning Within a month of begin 8.9% ence the following vocal I experi oral contraceptive Voice type: beginning ies premenstrually: s of 26.0% difficult 32.5% Within 3 month 14.6% Coloratura Soprano 37.8% None at all oral contraceptive 47.1% no Lyric Sopra after beginning 8.2% Mild changes 16.4% Within a year 7.1% Spinto derate changes tive 5.0% Mo 3.9% oral contracep ra Mezzo Coloratu beginning 15.0% Major changes More than a year after 6.3% Lyric Mezzo tive 5.7% oral contracep 63.9% traceptives, I tic Mezzo l con Drama 0.3% After taking ora Not applicable al changes: Alto noticed the following voc 0.7% change) Other nged or reverted on (select most prominent 58.5% If the voice cha the Pill, I noticed this: None at all traceptives 12.1% discontinuing have been taking oral con m the top I of discontinuing 8.2% Lost notes fro 6.0% Within a month on the bottom (the Pill) for: 12.5% Gained notes Within three months of 9.2% ge but change Less than six months .9% No change in ran 23 17.1% discontinuing 3.2% Six months to two years tinuing discon 26.7% in quality 6.0% Within a year of 2-5 years er 23.9% Other More than a year aft 0.7% 5-10 yrs 12.8% discontinuing ceptives, the rs tra 78.5% Over 10 yea When I stopped oral con Not applicable on my voice was effect s primarily for: ice stayed same as on I take oral contraceptive 28.9% None at all (vo 27.5% l irregularity Menstrua 71.0% the Pill) but not ption Contrace Voice changed back, 7.5% completely 2.1% 65.0% 28.9% 3.2% 0.7% nts: 280 Total Number of Responde contraceptive I have changed my oral escription): formulation (pr taken) 42.1% Not changed (only kind 39.6% 1-2 times 15.3% 3-5 times 2.8% More than 5 times al Voice recovered to origin voice (pre-Pill) Other Not applicable 9.2% 4.6% 51.0%

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Classical Singer Reprint: February 2003 Oral Contraceptives and the Voice
by Dr. Anthony Jahn
his was a useful and hopefully applicable piece of clinical research, and I want to thank each respondent for participating. Because we tried to maximize response, we kept the questions few and brief. As with most surveys, this one was also imperfect, and led me to want to ask many more specific questions, which, if reader interest and CS editorial planning permit, we could do in a future issue. Looking at the data, the following information is significant: 1. Over 2/3 of all female singers normally experience some vocal difficulties premenstrually. 2. Almost 1/2 of those on the Pill experienced voice change. 3. Of singers who took and then stopped the Pill, only about 20% recovered their original voice. Over 1/2 in this (voicechanged) group experienced no improvement at all after stopping the Pill. 4. The onset of voice change can occur as early as one month after beginning the Pill. 5. Reversion of the voice after discontinuing the Pill occurs most frequently within the first three months, and then less and less over one year. Voice changes during the normal menstrual cycle are well known and documented. The condition even has a medical name: laryngopathia menstrualis. The voice becomes husky and loses focus, the top notes are impaired, and the singer is fatigued and has difficulty sustaining. These changes are due in part to fluid retention associated with the fluctuation of estrogen and progesterone and are most marked in the progesteronedominated pre-menstrual phase. These changes, caused by hormones secreted by the body, however disconcerting, are temporary, and are due to the effect of these hormones on blood vessels and mucous membrane. How do oral contraceptive hormones differ? After all, these are also estrogen and progesterone preparations. It appears that nearly 80 percent of singers who experienced voice change after oral contraceptives had some permanent change. The answer to this question has to do with the chemistry of the synthetic hormones. There are basic differences between natural (secreted by a womans own body) vs. synthetic (taken into the body as an outside substance) hormones. It may surprise you to know that women form not two, but three sex hormones: estrogen, progesterone and testosterone. Although we normally think of testosterone as a male hormone, a small quantity is normally formed by the ovaries and has a number of functions, including regulation of sex drive. The fluctuation of hormones during a normal menstrual cycle involves primarily estrogen and progesterone, not testosterone. It has been shown, however, that SYNTHETIC progesterone-like chemicals, such as are found in oral contraceptives, break down to form testosterone-like substances. What this means is that, when a singer takes oral contraceptives which contain progestins, she is actually taking a certain amount of testosterone. And we know that, unlike the temporary effects of estrogen and progesterone, the darkening or masculinization of the voice brought on by testosterone can be permanent. Unlike the female hormones, testosterone acts on cartilage and muscle and thus brings about structural changes in the skeleton of the larynx and its muscles. How do we then explain the fact that some women experience no deleterious voice change, some find mild or temporary changes and some are significantly and permanently impaired? We dont understand all of the parameters involved, but here are a couple of possible reasons. One has to do with the presence of testosterone receptors in the muscles of the vocal apparatus. Some women have more and hence are more sensitive to the effects of the hormone. If there is a way to determine this prior to taking oral contraceptives, and thus predict the vulnerability of the individual singer before beginning the Pill, I am not aware of it. Secondly, given the fact that there are dozens of oral contraceptive preparations on the market and the metabolism of these substances may also vary from person to person, it would be almost impossible to put together a statistically meaningful report on who can safely take which pill. What should you do? Here are a couple of suggestions. It is a reasonable generalization that higher voices would be more prone to damage. If your income resides in the high C region, and you are considering the Pill for contraception (rather than menstrual regulation), you may wish to consider other methods of birth control. If your voice is dramatic or spinto, you may be able to tolerate or incorporate minor color changes more readily, but always weigh the consequences of possible voice change. If you have been advised to take synthetic hormones for other reasons (excessive bleeding, fibroids), explore other possible treatment options with your gynecologist. Monitor your voice carefully, especially around mid-cycle, since any change you hear or feel at that time will not be confounded by normal premenstrual changes. If you perceive any negative effect on the voice, consider discontinuing the Pill. Three final thoughts: As you may see by the survey, we did not separate oral contraceptive effects by voice type, and this is probably one of the most important issues for individual singers. Secondly, there are many singers out there who have had no deleterious effects at all from oral contraceptivesour survey is not a sampling of everyone who is singing, just of those who replied. The respondents could represent a higher incidence of contraceptive-damaged voices than is the general prevalence. And lastly, I am a laryngologist, so I beg forbearance from any readers who might be gynecologists. A complete version of this paper, coauthored by Dr. Y.J. Cho, will appear in the future in The Journal of Voice.

It is a reasonable generalization that higher voices would be more prone to damage.

Question : Im having a lot of depression and other symptoms, which are not being fixed with antidepressants. The doctor just tested my hormones because he told me this could cause depression. Result: estrogen was high. Progesterone and testosterone were so low, they were not detectable. He said this could be the reason depression is so resistant to therapy. He wants to supplement both the progesterone and testosterone. I remember reading that you said both testosterone and DHEA [Dehydro-epiandr-osterone] (which turns into testosterone) can lower the voice permanently even after discontinuing the hormone. My doctor told me he has women taking as much as 8 mg. a day of testosterone with terrific results and wants to start me on 1 mg. He claims this small amount could not possibly have an effect on my voice. Im scared to take it. At what dosage does testosterone or DHEA become dangerous for a singers high notes? (Im assuming progesterone is OK, since you havent mentioned it.) Dr. Jahn: First, progesterone is fine, but synthetic progesterone apparently can metabolize down into testosterone analogs (one of the points in our Oral Contraceptives and the Voice article). The effects of both testosterone and synthetic progesterone are variable. Some of the variability has to do with your voice type (mezzos are less likely to be affected than high sopranos), and how receptive your larynx is to these hormones. The number of receptors varies, and there is no way of finding this out short of administering the drugs. It seems to me however that the change, if any, would be dose related, and thus a very low dose of testosterone might be safe, particularly in view of the positive effects that the treatment of your depression would have on your singing and your life. The hormone story, incidentally, continues. A recent scientific article claims that most of the deleterious effects were due to older preparations with higher doses of hormones. It also suggests that a low-dose birth control pill is actually good for the voice, since it smoothes out and stabilizes vocal fluctuations due to the normal endogenous fluctuation of estrogen and testosterone during the menstrual cycle!

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Question: I have a student who is a coloratura soprano and in her fifth month of pregnancy. She experienced severe vomiting and nausea during her first trimester and is presently demonstrating a huskiness much more apparent in her speaking voice than in her singing voice. She has been to see a laryngologist and has been diagnosed with GERD [Gastroesophageal Reflux Disease].. The anterior portion of her vocal folds is clear but there is irritation and some swelling on the posterior portion. Her doctor prescribed Gaviscon but is understandably reluctant to prescribe any of the stronger prescription remedies. He has restricted her to one hour of singing a day and vocal rest as much as possible outside of that hour. She is entering the Masters Program in Vocal Performance at the university next week and I am wondering if you have any additional recommendations for her. Is there any research out on the safety of Nexium or Prilosec for pregnant women? Should she be singing at all with irritated vocal folds? She is still able to sing clear, ringing unforced high Es but has little stamina, especially in middle-voice singing. I very much appreciate your time and advice. Dr. Jahn: I have several suggestions in response to your question. As you know, it is common to have reflux with pregnancy, and for your student it may actually increase into her seventh month, which is the time when the uterus presses up highest in the abdomen (after that, it starts to descend and protrude). She should certainly explore the use of one of the prescription anti-reflux medications, and information regarding their use in pregnancy should be available, either on the product insert, the doctors PDR book, or the pharmaceutical companys website. Your student should also consider singing in the morning, on an empty stomach, rather than after a meal. Regarding her inability to sustain, this is not so much due to reflux as to decreased pulmonary function, due to the uterus pushing up on the diaphragm. While many singers can sing through pregnancy, this depends not only on stage of pregnancy but body habitus (size of pelvis, size of uterus, how the baby is carried). The muscles and ligaments can also be more relaxed in late pregnancy (in rabbits, the ligament holding the two pubic bones together anteriorly actually becomes so loose that the bones separate to allow delivery!). I would recommend continued singing, but within the limitations that her temporarily altered body allows. Please pass these suggestions on to your student, and have her discuss them with her obstetrician.

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Question : I am a 53-year-old light lyric coloratura. I began singing lessons at age 9 and have studied and performed for 40 years. Even at this age, people think Im a teenager when I answer the phone. However, I am developing a widening vibrato, kind of a shake in the voice. Also, I have put on a great deal of weight since age 45, and I am in menopause. Should I take hormone replacement? Will TSH [Thyroid-Stimulating Hormone] effect the singing voice negatively? Does weight effect vibrato? Will medications to assist in weight loss effect the voice? I want to save the delicacy Im known for, or perhaps I should say get it back. Please advise me on what to do. Dr. Jahn: I dont know if there is a simple solution to your problem. Normally a widening vibrato is a sign of muscular fatigue. I dont know your repertoire or performance history, but we often see this in voices that are wearing out, not necessarily from age. Certainly, if your estrogen level is low (as it might be postmenopausally), you should consider hormone replacement, if there are no specific contraindications. Thyroid medication does not normally cause the voice to wobble. Im assuming that you would be taking this to correct low thyroid output (hypothyroidism), and in appropriate amounts. If the thyroid is low, you may get a huskiness to the voice, and if it is overactive, you may develop a tremor, but not a widening vibrato. Certainly, loss of excess weight is a good thing, particularly if it makes you prone to acid reflux. You may, however, need also to consider reworking your technique to try to address the wobble.

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Index
Acid Reflux . . . . . . . . . . . . . . . . . . .8, 15, 24 Advair . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8 Alcohol . . . . . . . . . . . . . . . . . . . . . . . . . . .11 Allergies . . . . . . . .6, 9, 13-14, 18, 20, 26-27 Alternative medicine . . . . . . . . . . .23-24, 27 Anthistamines . . . . . . . . . . . . . . . . . . . . . .27 Antidepressant . . . . . . . . . . . . . . . . . . . . .14 Anxiety . . . . . . . . . . . . . . . . . . . . . .6, 14, 32 Asthma . . . . . . . . . . . . . . . . . . . . . . . . . .4, 8 Belting . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 Birth Control . . . . . . . . . . .32, 33, 35-37, 39 Broken Blood Vessel . . . . . . . . . . . . . . . . .30 Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Diet . . . . . . . . . . . . . . . . . . . . . . . . . . .11, 20 Ephedra . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Fatigue . . . . . . . . . . . . . . .10, 16, 19, 24, 41 GERD . . . . . . . . . . . . . . . . . . . . . . . .7-8, 40 Habits . . . . . . . . . . . . . . . . . . . . . . . . . . . .25 Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4 Hoarseness . . . . . . . . .4, 7-8, 12, 16, 21-22 Hormones . . . . . . . . . . . .10, 25, 33, 35, 39 Hyperthyroidism . . . . . . . . . . . . . . . . . . . . .5 Laryngitis . . . . . . . . . . . . . . . . . . . . . . . .7, 22 Menopause . . . . . . . . . . . . . . . . . . . . .33, 35 Menstruation . . . . . . . . . . . . . . . . . . . . . . .32 Mucus . . . . . . . .6, 10, 13-15, 18, 20, 26, 28 Neti Pots . . . . . . . . . . . . . . . . . . . . . . .28-29 Nodule . . . . . . . . . . . . . . . .5, 10, 12, 15, 21 Overweight . . . . . . . . . . . . . . . . . . . . . . . . .4 Phlegm . . . . . . . . . . . . . . . . . . . . . . . .20, 24 PMS . . . . . . . . . . . . . . . . . . . . . . . . . . .33, 36 Pregnancy . . . . . . . . . . . . . . . . . . . .4, 34, 40 Running . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Smoking . . . . . . . . . . . . . . . . . . . . . . . . . .17 Thyroid . . . . . . . . . . . . . .5, 9-10, 20, 33, 41 Tonsils . . . . . . . . . . . . . . . . . . . . . . . . . . . .26 Whisper . . . . . . . . . . . . . . . . . . . . . . . . . .19 Womens Health . . . . . . . . . . . . . . . . . . . .31