The Jahn Report

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  • 8/6/2019 The Jahn Report


    Spec ia l Report

    A Vocalists Medicine Cabinetby Dr. Anthony Jahn, MD

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    2/42C l a s s i c a l S i n g e r S p e c i a l R e p o r t2

    Special Report: Singers Ask Dr. Jahn.

    This Special Report features Anthony Jahn M.D., noted author and pro-

    fessor of clinical otolaryngology at Columbia University College of

    Physicians and Surgeons. He currently has offices in New York 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 Voice.

    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@classica lsin 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, whichshould be obtained only following a visit and consultation with your own physician.

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    A V o c a l i s t s M e d i c i n e C a b i n e t 3

    Hernia, Hoarseness and Overweight . . . . .4

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

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

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

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

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

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

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

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

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

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

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

    Smoking . . . . . . . . . . . . . . . . . . . . . . . . . .17

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

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

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

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

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

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

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

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

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

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

    Womens Health . . . . . . . . . . . . . . . . . . . .31PMS Menopause

    Menstruation Thyroid

    Hormones Birth Control


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

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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t4

    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.

    A lso, 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 amI 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.)

    A lso, 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? T hanks 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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    A V o c a l i s t s M e d i c i n e C a b i n e t 5

    Question: My question is about the risks involved in having RA I 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. W hat 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 ofobliterating 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 ofradiation,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 yourinternist 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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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t6

    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? T hank you for your response.

    Dr. Jahn:If she has had no problems so far, you can certainly reassure her.The main issue in ourexperience 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 post-

    nasal 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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    A V o c a l i s t s M e d i c i n e C a b i n e t 7

    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 isimportant 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 musclethe

    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 musttherefore 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 hoarsenessare 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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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t8

    Question: Have you ever heard of any voice changing effects from using the drug Advair? W hat 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. W hat 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 theesophagus, 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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    A V o c a l i s t s M e d i c i n e C a b i n e t 9

    Question: Ive recently become a serious runner. I ve 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 greatlyappreciated.

    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


    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


    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 SingersMarch 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? T he 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 numberof non-vocal symptoms.

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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t10

    If there were a competition for the glandwith the most significant impact on the

    singing voice (although I frankly cannot

    imagine who in his right mind would sponsorsuch 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 glandsof the body, glands that secrete their

    hormones directly into the blood stream.

    Exocrine glands secrete their products, suchas tears, skin oils and mucus, outward, onto

    the inner and outer surfaces of the body. The

    thyroid consists of two ovoid lobes that areconnected by a short bridging center portion

    called the isthmus. The gland is curved

    around the front part of the upper trachea likea shield. (In Greek, thyreos means shield-like.)

    A list of all of the effects brought about by

    thyroid hormones would be very longthethyroid affects almost every part and tissue of

    the body. Most importantly, the thyroid sets

    the metabolic thermostat of the body. If thethyroid 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 thestereotypical clinical presentations of hyper-

    thyroidism 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 itsmore subtle manifestations. Why are female

    singers at risk? Because thyroid disease, be

    it over-activity, under-activity or tumors, isalmost exclusively a condition of women. And

    as women grow older, the incidence of thyroiddisease (usually under-activity) increases.

    There are forms of thyroid disease that affect

    both sexes equally, such as goiter, which mayresult from inadequate iodine intake but with

    the wide availability of seafood and iodized

    salt, it is rare. Still, thyroid disease in men isrelatively uncommon.

    Occasionally, a mass grows within the

    thyroid. These nodules (or tumors) are mostoftenalthough not alwaysbenign. Their

    true nature can usually be diagnosed by a

    painless fine-needle biopsy performed in thedoctors office. It is for masses like these that

    the doctor feels for when he examines your

    neck. At other times, the entire thyroid, or apart of it, may be diffusely enlarged. This

    condition is usually associated with hypo-

    thyroidism, rather than a tumor.Acute inflammation of the thyroid, more

    common in women, presents with pain,

    discomfort on swallowing, and tendernessover the mid-portion of the neck. Although

    the treatment is usually simple, acute

    thyroiditis can damage the gland and leave itunder-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 feelin the neck and the diagnosis is made on

    clinical suspicion. Even a mildly under-active

    thyroid can affect the voice. A singer maycomplain that the voice feels heavy,

    unresponsive, and has lost its color. There

    may be some loss of range (particularly thetop) 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 moreobvious stages, myxedema). The vocal folds

    become swollen and sluggish. The voice that

    is generated by the larynx will then encounterpharyngeal walls, palate and tongue, which

    are also edematous, heavy, and acoustically

    altered. Hypo-thyroidism can also affectmuscular 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 thyroiddisease: if your mother had thyroid problems,

    you need to be on the lookout. There is one

    form of hypo-thyroidism which is associatedwith autoimmune diseases, or those that

    develop when the body mistakenly damages

    its own components. This condition is calledHashimotos thyroiditis (also known,

    depending on your cultural ancestry, as

    Graves disease or Basedows disease). It isparticularly prevalent in middle aged women.

    It may be associated with decreased saliva and

    mucus (another bane of the singers life), dryeyes, and occasionally arthritis. Other, non-

    vocal 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 hypo-thyroidism is anything but obvious. It can be

    heralded over months by a gradual

    deterioration in vocal quality, fatigue andother nondescript symptoms. As a (female)

    singer,you need to be aware of this condition,

    since your physician, trained to look for themore classic manifestations of thyroid disease,

    and you may not hear these subtle changes.

    Once the suspicion arises, a simple set ofblood tests may uncover the problem and put

    you on the therapeutic road to thyroid (andvocal) health.

    Classical Singer Reprint : March 2002

    Your Thyroid Gland:

    A Singers Primerby Dr. Anthony Jahn

    As a group, singers

    are particularlyprone to thyroid

    disease and

    affected by its


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    A V o c a l i s t s M e d i c i n e C a b i n e t 11

    Question: I am a 29-year-old singer in my third year of voice studies. I will be taking part in a physician-

    supervised 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. T he fast will also include a regular exercise routine of walking, cycling and

    some swimming. W ill this rapid weight loss adversely affect my singing?

    Dr. Jahn: I congratulate you on this difficult undertaking. From the point of view of your generalhealth, 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


    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 T hursday. T he

    alcohol isnt out of my system yet and my voice sounds terrible. How can I get the alcohol out of my system by

    T hursday? 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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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t12

    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 legitvoice 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 properdomain for chest voice. Beltingrefers 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 allergiesare 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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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t14

    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 allergiesand 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, butcertainly your vocal performance may be affected. To the best of my knowledge, none of these

    effects are permanent.

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    A V o c a l i s t s M e d i c i n e C a b i n e t 15

    Question: I have sung professionally for the past nine years (I am now 37). T hree years ago I had vocal cord

    surgery to remove a cyst on my right cord.

    Due to a resulting stiffnesson 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, andpersistent 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 that thus 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


    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 alwayspossible 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 re-

    accumulation 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 mucus-

    thinning medication such as Humibid or SSKI drops, and nasal irrigation. Find a yoga shop andbuy yourself a Neti pot, which is a device for washing your nose out. Do this twice a day. Good


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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 EN T that the cords were dry but notrefluxed. For this reason, he put me on Humibid and Vancenase. An EN T 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. T hat is why I doubt the reflux idea. Any thoughts would be greatly


    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


    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 bloodcount, 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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    A V o c a l i s t s M e d i c i n e C a b i n e t 17

    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 havebeen 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, smokinginvolves 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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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t18

    Question : I live in Oregon, famous for allergens molds and pollens of all kinds. I take a daily

    antihistamine/ decongestant combination, A llegra-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. Suckingthe 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?

    W hat 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, usingair 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 thisorally ingested L-cysteine.

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    A V o c a l i s t s M e d i c i n e C a b i n e t 19

    Question : T hank you for your valuable contribution to Classical Singer. T he 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. T he 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 singingin 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 entirelength. 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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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t20

    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.

    W hen this mucus gets on my cords, they simply do not phonate properly and, in the worst case, I can lose myvoice. 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.

    T he 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 EN T has now suggested non-

    allergic 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 mucusquite effectively. Let me know how you make out.

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    A V o c a l i s t s M e d i c i n e C a b i n e t 21

    Question : My doctor says my larynx is normal, but Im still slightly hoarse. W hat 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


    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 asnodules, 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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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t22

    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 minordegrees 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 laryngitisoften 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, non-

    functional 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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    A V o c a l i s t s M e d i c i n e C a b i n e t 23

    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 ever-increasing 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 consumersto take an active role in their well-

    being. 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 offeel-goodliterature,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,

    herbalor 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 supplementindustry is driven for the most part by consumer whim.Althoughmany 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 phlegmor fatiguemay not be effective for specific

    diseases such as acid reflux or anemia.

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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t24

    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 harmingourselves.

    How should alternative medicine be used?

    I see three general benefits, which may not be as readily available through conventional medical


    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 self-treatment.

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    A V o c a l i s t s M e d i c i n e C a b i n e t 25

    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. W hat 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


    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


    Finally, if you have any heartburn or gastroesophageal reflux, have it treated.

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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t26

    Question : W hat effect do the tonsils or the removal of the tonsils have, 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 isusually 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 potatovoice.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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    After our mild winter and global-warming type spring, allergies havebeen worse than ever. Even patients

    who seldom have allergies, or who sufferonly for a few weeks, are complaining. Thepharmaceutical industry, ever ready forchallenge and opportunity, is bombardingthe airwaves, and our offices, with newermedications, each of which is easier to take,more effective, and less sedating. What tomake of the wealth of information?

    Antihistamines, as their name implies,

    counteract the effects of histamines releasedby the body. Histamine is one of manyinflammatory substances that cells release toreact to physical insult. The insult may betrauma, such as a scratch to the skin, orcontact with foreign substances, such asallergens. Histamine is contained in smallpackets, or granules, within some of ourcells. When the cells release the granules,inflammation resultsredness, swelling, anditching. One of the effects of histamine is tomake blood vessels leaky. This allows bloodcells and other blood products to move out

    of the vessels and to the area of inflammationto address the injury and deal with theinvaders,whether pollen,poison ivy resin,orinsect bite. This is all good. What is NOTgood is the bodys inappropriateoverreaction to benign bits of dust, pollenand your cat. This is allergythe bane ofmillions of otherwise perfectly healthypeople.

    Antihistamines counteract inflammationby blocking the effect of histamines.This canbe done at many different levels, beginningwith the point of histamine release, tosedating the brain. Some medicationsstabilize the cell membranes that contain thepackets of antihistamines, preventing theirrelease. Sodium chromoglycate, found insome eye drops and nasal sprays, acts in thisway. A new product, Clarinex, is touted ashaving some of this effect, in addition to theusual antihistamine properties. Sodiumchromoglycate-containing products are notsedating, but they only work before

    histamine is released. They are preventive,not curative. Conventional antihistamines,on the other hand, counteract the effects ofhistamine after its release. This is the groupthat includes the usual suspects: Claritin,Allegra, Zyrtec, and the stronger ones suchas Benadryl.Each one is a bit different, somestronger than others, and theres the rub(actually, the rub also lies where the itch is,which is why you take this stuff in the firstplace!).

    The main complaints I hear about

    antihistamines is that either they are tooweak or too strong. Efficacy varies, however,

    not only by formulation, but also frompatient to patient. One patient may say thatClaritin is too strong, whereas another

    complains that Zyrtec (a more potent drug)doesnt touch her symptoms. So, despite allthe scientific data, trial and error is theultimate test when choosing anantihistamine.Equally important are the sideeffects. These are known to all, and are(going from weaker to stronger drugs):sedation, drying, blurred vision, anddifficulty urinating (for those of you blessedwith a prostate).

    For singers, the greatest problems arecaused by drying of the vocal tract, whichdecreases control, particularly when singingsoftly and at the higher extremes of range.

    For the general population, however,sedation is an important issue; patientsexperience difficulty driving, focusing, andstaying alert on the job. Unfortunately, themore effective (i.e. strong) an antihistamineis, the greater the sedative side effects. Thepharmaceutical industry responds to this byadding decongestants to the formulation, asseen in Allegra D, Claritin D, and over-the-

    counter multi-drug combinations, such asTylenol Cold and Sinus.

    Orally taken decongestants, (which for allpractical purposes is the same as sayingpseudephedrine or Sudafed), constrict theblood vessels and decrease the swelling ofthe tissues. While superficially this mayresemble the effect of antihistamines, it isquite different and carries with it its own sideeffects. These include palpitations, increasedblood pressure,and again,dryness.So,whilethis combination of antihistamines and

    decongestants is less sedating, it ispotentially doubly drying for singers.

    Topical decongestants, found in Afrin-typenasal sprays, work quickly to shrink nasalmembranes, but after a few daysuse are no

    longer effective. How is a singer to navigate this vocally

    treacherous course? My suggestions are thefollowing:

    Find out what your allergens are, andminimize exposure to them.

    If you have perennial (versus seasonal)allergies, consider desensitization shots.

    If your allergies are localized (e.g. onlynasal), consider using topical sprays ratherthan systemic medications.

    Look at alternative anti-allergymedications, such as stinging nettle,recommended by Dr. Andrew Weill andother alternative medicine experts.

    Again, how you personally respond to aparticular medication is unpredictable andidiosyncratic. You may do very well with adrug someone else finds intolerable. So doexperiment (with your doctors blessing),especially if you need to take thesemedications long term.

    Topical decongestants, found in

    Afrin-type nasal sprays, work quickly to

    shrink nasal membranes, but after a few

    days use are no longer effective.

    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

    Classical Singer Reprint : August 2002

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    The Singer and Yogic Health

    Enhancers: The Neti PotWhile 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.

    Healthy 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

    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 Potsare 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

    [email protected].

    [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,






    Classical Singer Reprint : August 2000

    by Suzanne Jackson

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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t30

    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 soundthe 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 ( 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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    W omens H ealth

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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t32

    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 theabove-mentioned problems, especially if I have a performance. T his 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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    A V o c a l i s t s M e d i c i n e C a b i n e t 33

    Question:T hank you so much for your informative and helpful articles in Classical Singer. I always read them

    first. T here have been several articles concerning women and vocal health. T he 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 hormonalfluctuations during the month have a direct effect on my voice. PM S 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 birth-

    control 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 beaffected 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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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t34

    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 notes make 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 M asters 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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    A V o c a l i s t s M e d i c i n e C a b i n e t 35

    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 sopranowith nothing much (reliable) above a high C#. T his 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 occuruntil 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


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    C l a s s i c a l S i n g e r S p e c i a l R e p o r t36

    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. A fter 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 havea 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 full-

    term 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. T hank 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 normalPMS 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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    A V o c a l i s t s M e d i c i n e C a b i n e t 37


    dents: 280





    3039 28.9%
















    Sixmonthstotwoyears 23.9%




    Itakeoralcontraceptives primarilyfor:





    Notchanged(onlykindtaken) 42.1%
















    Gainednotesonthebottom 6.0%




























    Withinamonthofdiscontinuing 8.2%



    Withinayearofdiscontinuing 3.2%




    Classical Singer ReprintFebruary 2003

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    This was a useful and hopefullyapplicable piece of clinical research,and I want to thank each respondent

    for participating. Because we tried tomaximize response, we kept the questionsfew and brief. As with most surveys, thisone was also imperfect, and led me to wantto ask many more specific questions,which, if reader interest and CS editorialplanning permit, we could do in a futureissue.

    Looking at the data, the followinginformation is significant:

    1. Over 2/3 of all female singersnormally experience some vocaldifficulties premenstrually.

    2. Almost 1/2 of those on the Pillexperienced voice change.

    3. Of singers who took and thenstopped the Pill, only about 20% recoveredtheir original voice.Over 1/2 in this (voice-changed) group experienced noimprovement at all after stopping the Pill.

    4. The onset of voice change can occuras early as one month after beginning thePill.

    5. Reversion of the voice afterdiscontinuing the Pill occurs mostfrequently within the first three months,and then less and less over one year.Voice changes during the normalmenstrual cycle are well known anddocumented. The condition even has amedical name: laryngopathiamenstrualis. The voice becomes huskyand loses focus, the top notes are impaired,and the singer is fatigued and has difficultysustaining. These changes are due in partto fluid retention associated with thefluctuation of estrogen and progesteroneand are most marked in the progesterone-dominated pre-menstrual phase. Thesechanges, caused by hormones secreted bythe body, however disconcerting, aretemporary, and are due to the effect ofthese hormones on blood vessels andmucous membrane.

    How do oral contraceptive hormonesdiffer? After all, these are also estrogenand progesterone preparations. It appearsthat nearly 80 percent of singers whoexperienced voice change after oralcontraceptives had some permanentchange.

    The answer to this question has to dowith the chemistry of the synthetichormones. There are basic differencesbetween natural (secreted by a womansown body) vs. synthetic (taken into thebody as an outside substance) hormones.

    It may surprise you to know that womenform not two, but three sex hormones:estrogen, progesterone and testosterone.Although we normally think of testosteroneas a male hormone, a small quantity isnormally formed by the ovaries and has anumber of functions, including regulationof sex drive. The fluctuation of hormonesduring a normal menstrual cycle involvesprimarily estrogen and progesterone, nottestosterone. It has been shown, however,that SYNTHETIC progesterone-likechemicals, such as are found in oralcontraceptives, break down to formtestosterone-like substances. What thismeans is that, when a singer takes oralcontraceptives which contain progestins,she is actually taking a certain amount oftestosterone. And we know that, unlike thetemporary effects of estrogen andprogesterone, the darkening ormasculinization of the voice brought on bytestosterone can be permanent. Unlike thefemale hormones, testosterone acts oncartilage and muscle and thus brings aboutstructural changes in the skeleton of thelarynx and its muscles.

    How do we then explain the fact thatsome women experience no deleteriousvoice change,some find mild or temporarychanges and some are significantly andpermanently impaired? We dontunderstand all of the parameters involved,but here are a couple of possible reasons.One has to do with the presence oftestosterone receptors in the muscles ofthe vocal apparatus. Some women havemore and hence are more sensitive to theeffects of the hormone. If there is a way to

    determine this prior to taking oralcontraceptives, and thus predict thevulnerability of the individual singerbefore beginning the Pill, I am not aware ofit. Secondly, given the fact that there aredozens of oral contraceptive preparationson the market and the metabolism of thesesubstances may also vary from person toperson, it would be almost impossible toput together a statistically meaningfulreport on who can safely take which pill.

    What should you do? Here are a coupleof suggestions. It is a reasonablegeneralization that higher voices would bemore prone to damage. If your incomeresides in the high C region, and you areconsidering the Pill for contraception(rather than menstrual regulation), youmay wish to consider other methods ofbirth control. If your voice is dramatic orspinto, you may be able to tolerate orincorporate minor color changes morereadily, but always weigh the consequencesof possible voice change. If you have beenadvised to take synthetic hormones forother reasons (excessive bleeding,fibroids), explore other possible treatmentoptions with your gynecologist. Monitoryour voice carefully, especially aroundmid-cycle, since any change you hear orfeel at that time will not be confounded bynormal premenstrual changes. If youperceive any negative effect on the voice,consider discontinuing the Pill.

    Three final thoughts: As you may see bythe survey, we did not separate oralcontraceptive effects by voice type, and thisis probably one of the most importantissues for individual singers. Secondly,there are many singers out there who havehad no deleterious effects at all from oralcontraceptivesour survey is not asampling of everyone who is singing, just ofthose who replied. The respondents couldrepresent a higher incidence ofcontraceptive-damaged voices than is thegeneral prevalence.

    And lastly, I am a laryngologist, so I begforbearance from any readers who mightbe gynecologists.

    A c