Vocal health: managing post-nasal drip

Post-nasal drip can be a singer's nightmare. I have recently sent several students to ear-nose-and-throat (ENT) doctors for allergies issues, which I suspected were causing vocal problems. In both cases, their throats were so swollen from post-nasal drip that their vocal cords couldn't fully close! Below are a few tips on combatting symptoms. 

Use a nasal rinse

Many singers use neti pots, but I recently discovered two options that I like even better:  

Each of these kits comes with squeeze bottle and small packets of salt mixed with soothing aloe. You dissolve the salt in warm distilled water, squirt it up one nostril, and it flows out the other. Repeat on the opposite side.

As with a neti pot, the saline rinse cleans out the nasal passages by loosening and removing debris, allergens, and mucus. However, unlike a neti pot, the bottles gently squirt a stream of solution into the nostril allowing it to pass through quickly. If you hate the feeling of salt water up your nose, you'll want to trade in your neti pot! These kits do the job better and get it done more quickly!

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Use a nasal spray

Your physician may prescribe a steroid nasal spray like Flonase or Nasonex (prescription only) or Nasacort (over-the-counter). Steroid sprays work by reducing inflammation in the nose. They are safe for the vocal cords, as they are non-drying.

If you'd prefer a natural alternative, I like Pretz Nasal Spray. It will help thin out nasal mucus, although it will not flush out the nasal passages as well as a nasal rinse can. However, I consider it a good alternative for people who strongly dislike nasal rinses.

Avoid antihistamines

Antihistamines are generally considered a first line treatment for allergies, and they are used in many allergy pills and nasal sprays. (In sprays, they are sometimes combined with corticosteroids.) However, antihistamines are drying and can therefore pose problem for singers. (Dry vocal cords are particularly prone to injury.) For that reason, singers may be better off using steroid sprays or getting allergy shots. 

Seek treatment

If you are having vocal trouble and you think you may have allergies, seek advice from an ENT who can examine your vocal cords and see how allergies may be affecting them. (See my post on finding a voice doctor.)

Please do not assume that allergies will resolve on their own, and do not attempt to sing through them if they affect the quality of your sound. It may simply not be possible for you to improve your voice until your allergies are under control. If your throat or your vocal cords are swollen, you may end up straining to produce sound. These bad habits can be difficult to correct even after your voice is healthy. So get your allergies treated before bad habits set in!

Disclaimer: This blog post does not constitute medical advice, professional diagnosis, opinion, treatment, or services. It simply provides general information for educational purposes only. This information is not a substitute for medical or professional care, and you should not consider it a substitute for a consultation with a physician or other healthcare provider.

Vocal health: tips and resources for keeping your voice healthy

I recently had several students come to me who I suspected might have vocal nodules. With fall allergies on the rise and flu season around the corner, I thought now would be a good time to revisit some thoughts on keeping the voice healthy. 

vocal health tips

Drink plenty of water. Aim for 64 ounces (or eight 8-ounce glasses) daily. Caffeinated beverages do not count towards this total, but the following beverages do: juice; decaffeinated coffee, soda, and tea; herbal tea; and milk. 

Get 7-8 hours of sleep each night. We tend to fall back on bad habits when we’re tired. Getting enough rest will keep your body energized so that it can properly support your voice. 

Practice nasal irrigation: use saline drops or a neti pot. This is especially important if you are prone to allergies or sinus infections. 

Avoid speaking over background noise. We easily learn to “tune out” background noise, but speaking over other sounds can fatigue the voice. Common examples of background noise include talking at parties or restaurants and traveling by car. 

Maintain proper humidity. If the humidity levels in your home or office fall below 40 percent, consider using a humidifier, especially at night. (It is important to use a humidifier that can easily be cleaned, as the bacteria build-up can make you sick.)

Practice healthy and efficient speaking habits.

Avoid clearing your throat. 

Get acid reflux treated. Stomach acid can literally burn the vocal cords. See a doctor if you experience reflux several times a week.

Rest your voice when it feels fatigued. Listen to your body. Warm up your voice before speaking extensively or before singing.

Avoid excessive use of Aspirin and non-steroidal anti-inflammatory drugs (Advil, Ibuprofin, Motrin, Anaprox, Naproxin, etc.) 

Practice relaxation techniques if you tend to experience physical tension. Examples include meditation, yoga, visualization, and hypnosis.

Keep your body strong and flexible and maintain optimal posture. There are many physical disciplines that can help: yoga, Pilates, tai chi, Alexander technique, dance, etc.)

Seek medical attention. See a doctor if you are experiencing vocal problems and are not otherwise ill. (Read more information on the reverse page.)

vocal health resources

when to see a voice doctor

Vocal problems can develop at any time, but they most often occur following an illness or after times of extended voice use. However, the voice generally recovers on its own within a week or two. See doctor if you are experiencing the following symptoms and are not otherwise ill:

• change in vocal quality, such as hoarsness, breathiness, vocal fatigue, loss of volume, or decreased vocal range (high or low)

• throat pain or discomfort

• recurring voice loss (full or partial)

finding a voice doctor

Look for a doctor with experience working with “professional voice users.” Other specialists - even ear, nose, and throat (ENT) doctors - may not fully understand voice use or vocal problems common to people who speak or sing frequently. If you’re looking for a voice doctor, or are curious about problems related to the voice, I highly recommend www.voiceproblem.org. 

voice doctors in the Philadelphia region

These two highly-experienced teams of ENTs and speech therapists specialize in treating professional voice users.

Joseph Spiegel Thomas Jefferson University
925 Chestnut Street, 6th floor Philadelphia, PA 19107 215-955-6760

Philadelphia Ear, Nose and Throat Associates
www.phillyent.com 219 N Broad St, 10th Fl Philadelphia PA 19107 215-762-5531

CHOP operates a world-class voice clinic for children. The staff is sensitive to the needs of children who perform at avocational and professional levels.

Children's Hospital of Philadelphia - Voice Clinic
www.chop.edu 215-590-1000 • 34th Street and Civic Center Boulevard Philadelphia, PA 19104

This large group practice treats a broad range of ENT issues, including voice problems of children and adults. 

Ear, Nose and Throat Associates of Chester County
www.entacc.com 610-363-2532 • offices in Exton, Coatesville, West Chester, and Kennet Square

other professionals

A voice doctor may recommend that you work with a speech and language therapist (SLP) as part of your recovery. Like ENTs, SLPs often specialize in various areas of their field. You will want an SLP who specializes in voice. If you are a singer, you may need a singing (or voice) teacher. Look for someone who has experience with injured voices and who teaches the vocal style you wish to sing.

Download this handout as a PDF.

Disclaimer: This blog post does not constitute medical advice, professional diagnosis, opinion, treatment, or services. It simply provides general information for educational purposes only. This information is not a substitute for medical or professional care, and you should not consider it a substitute for a consultation with a physician or other healthcare provider.

Guidelines for voice work

Teaching has taught me a lot about the average person’s conception of vocal training. Beginning students expect a teacher to talk about breathing, tone, and projection. Yet many of them - even those who have had vocal training before - are surprised by certain aspects of my classes.

They don’t expect me to ask questions about their health, talk about relaxation, inquire about their earliest vocal memories, or assign yoga exercises. Many are surprised that they feel uncomfortable talking about or exploring their voices. Others only want a few simple tips they can use on their own to suddenly bring their vocal skills from an amateur to a professional level.

As I have learned more about the expectations of my students, I have slowly developed some guidelines for beginners.

Guidelines for Voice Work

  • The voice is deeply personal. Along with our physical appearance, our voice is one of the primary ways in which we express ourselves to the world. Our voices reflect our upbringing, social influences, and self-image.
  • Voice work involves releasing tension and engaging the breath. Most voice problems are caused when some muscles are too tense and others are not working hard enough. Voice training can help you retrain your muscles, relaxing some and engaging others.
  • Voice work takes time. Be patient with yourself, and do not expect a quick fix. Poor vocal habits may take years to develop, and they will not disappear overnight.
  • Voice work involves replacing habit with choice. This requires 1) knowledge 2) attention 3) change and 4) repetition.
  • Voice work requires regular practice. You will get the most out of vocal training if you practice regularly. It is more effective to practice for 10-20 minutes several times a day than to practice for one hour once a week.

Download my Guidelines for Voice Work as a PDF.

Taking voice problems seriously

US News & World Report recently published an article on common causes of hoarseness. They include:

  • a cold
  • allergies
  • acid reflux (which, by the way, can actually burn the vocal cords!)
  • cancer of the larynx, thyroid, or lungs

The article gives five tips for dealing with a hoarse voice:

  • Talk to your doctor about getting a larygeal exam.
  • Protect your voice by drinking enough water, avoiding smoke, and not clearing your throat, coughing, shouting or yelling. 
  • Avoid decongestants, which can dry out the vocal cords.
  • Remember that the degree of hoarseness doesn’t correlate with the seriousness of the problem.  Don’t assume a really hoarse voice indicates cancer or that a little hoarseness isn’t an issue. 
  • Get voice training. If your speaking voice fatigues easily, you may be unintentionally misusing it. Just a few sessions with a speech and language pathologist can teach you how to use your voice more effectively. And your health insurance may pick up the bill. If you fatigue quickly while singing, look for a voice teacher with experience in working with injured voices.

Read the US News article here!

Finally, keep in mind that issues that affect the speaking voice often show up more dramatically when we sing. Even if you’re a casual singer, look for a doctor with experience in dealing with “professional voice users.” Any other specialist probably won’t understand the singing process and how problems that seem minor to a speaker can really hinder a singer. Read this previous post on how to find a qualified voice doctor.

My laryngoscopy (updated)

I recently completed a major rite of passage as a singer: I had my very first laryngoscopy (March 2009). In case that sounds like Greek to you (which, actually, it is) a laryngoscopy is an examination of the interior of the larynx. It allows a doctor - and the patient - to see the vocal cords in action. I went to the doctor because I was seeking answers to vocal problems that began when I was a high school senior:

  • vocal fatigue
  • difficulty projecting the voice
  • breathiness
  • sensations of tightness in the throat
  • loss of upper range
  • Increased warm-up time
  • increased vocal effort
  • occasional choking on liquids

This is the video monitor where I was able to view my vocal cords in action.

The process was less uncomfortable than I had expected and every bit as fascinating as I had hoped. The office I visited - Philadelphia Ear, Nose and Throat Associates - has a reputation for restoring damaged voices. The practice has two locations: one in an old brownstone (whose walls are lined with autographed photos of famous singers) and the other in a generic looking medical building.

My appointment was in the generic medical building. I remembered to bring my “homework” - a 10-page questionnaire about my medical and vocal history. A medical assistant met with me to go over the history and ask additional questions. He even wrote down my vocal range - in musical notation! The doctor met with me and asked more questions, then sent the assistant back to do the actual procedure.

The vocal exam

They sprayed some kind of numbing medicine up my nose. Then the assistant inserted a long, black tube with a strobe light on the end into my left nostril. It hurt a bit going in, but once it was there it wasn’t that bad. He had me sing a series of exercises, plus “Happy Birthday” and a few lines from an aria I’ve been working on.

Then he removed the tube and had me stick out my tongue. He held my tongue and put a telescope tube into my mouth. (This allows for a closer view of the vocal cords.) He had me say “eeeeeeee” - not an easy or comfortable task when someone is literally holding your tongue!

I couldn’t see the video screen during the exam - probably so the sight of my vocal cords wouldn’t distract me. When it was over, the doctor came in to review the video footage with me. It was amazing to watch my vocal cords in action. The pictures look incredibly clinical, and yet for me there’s so much emotion associated with my voice. I’ve invested so much time, energy, hope, and money in those tiny bands of tissue, but I’d never actually seen them before. I almost felt like a mother viewing a sonogram of her unborn child.

My vocal cords: the left cord is slow to meet up with the right, due to a slightly weakened superior laryngeal nerve.

Diagnosis

So what did we see? The right vocal cord looks fine (it’s active and moves quickly), but the left one is slow. It moves, and it even meets the right cord, but it’s sluggish. As my voice teacher suspected, I probably have paresis (partial paralysis) of my left vocal cord.

The next step is to have a laryngeal electromyography (LEMG), a medical procedure that will measure the nerve input to the muscles that control the vocal cords. The results will tell the doctor which nerves - there are two, the recurrent laryngeal nerve (RLN) and the superior laryngeal nerve (SLN) - may have been damaged and to what degree. At that point, my doctor will be able to give a more complete diagnosis.

The treatment will most likely involve more of what I’ve already been doing - voice therapy (my voice teacher specializes in vocal rehab) along with yoga and other relaxation techniques. (People with vocal weakness often develop a lot of unhelpful laryngeal tension to compensate for the muscles that aren’t working properly.)

For now, I feel relieved to have some answers and grateful to have found a doctor who takes my voice as seriously as I do.

UPDATE: I had my laryngeal electromyography (LEMG) in June 2009. The doctor told me that my recurrent laryngeal nerve is fine, but that the superior laryngeal nerve (SLN) has only 80% function. (I guess that explains why I lost an octave off the top of my vocal range.) The results were not surprising, and I am lucky to have made wonderful progress with voice therapy. 

There's no way to know what weakened my SLN, but viruses are a common culprit, and my vocal symptoms began after I got the flu several times during my senior year of high school. Additionally, I strongly suspect that I am genetically prone to these issues. My father, who is not a singer, does a fair amount of public speaking and has similar issues with his speaking voice.

How to find a voice doctor

My journey as a singer with vocal problems has been emotionally (and vocally) exhausting. One of the many lessons I’ve learned is the importance of seeking out qualified specialists.


Finding a voice doctor

It’s not that I didn’t try. But for years the doctors and voice teachers I went to never recognized what was going on. I realize now that most doctors (even ENTs) don’t have the experience it takes to treat singers. This may seem ignorant to anyone who has spent years training the voice, but think about it this way. ENTs treat disorders of the ears, nose, head, neck, and throat. Many choose one or more specializations like:

  • pediatric otolaryngology (children)
  • otology/neurotology (ears, balance, and tinnitus)
  • allergy
  • facial plastic and reconstructive surgery
  • head and neck
  • rhinology (nose)
  • sleep
  • laryngology (throat)

Even laryngologists may choose specialties, such as swallowing disorders or throat cancer, that focus on more than the voice. Singers will want to find a doctor who specializes in treating professional voice users. He or she will understand, for example, that a little breathiness can be a big deal. Or that losing the very top of your vocal range (notes most people don’t know the human voice is capable of) is a tragedy. Or that vocal fatigue can be an occupational hazard.

If you’re shopping for a voice doctor, or if you’re just curious about the voice, I highly recommend www.VoiceProblem.org.


Finding a teacher who rehabilitates voices

It’s understandable that not all doctors are sensitive to the needs of singers, but surely voice teachers should be able to recognize vocal problems, right? Yes … in an ideal world. But the reality is that most voice teachers have little to no experience with vocal disorders. They are typically trained first as singers, and may or may not receive training in vocal pedagogy (the art of teaching singing), much less vocal pathology (disorders of the voice) or vocal rehabilitation.

Today I feel very lucky to have found an excellent teacher who specializes in rehabilitating damaged voices. If you suspect you’ve had vocal damage, look for a teacher who has similar experience. Wondering where to start? Call up the nearest ENT who specializes in treating professional voice users.

Photo: bcostin

Why every singer should get a voice exam

I recently made my very first appointment with an otolaryngologist (also known as an ear-nose-throat doctor, or ENT), and it’s something I think every singer should do.

Even if you aren’t sick or aren’t experiencing vocal problems, having your vocal cords examined is still a good idea. Here’s why:

1) It gives you a baseline from which to measure any future vocal health problems. Identifying the source of vocal problems can be a long and circuitous process. It can only help to know what your vocal cords look like and how they function when your voice sounds healthy.

2) It could identify issues you aren’t aware of. Just because you’re not aware of having vocal problems doesn’t mean you don’t have them. Acid reflux can burn the vocal cords, even without noticeable symptoms.

3) It could identify causes for problems you thought had a different source. So many things affect the voice: lifestyle, weather, allergies, medications, hormonal fluctuations, food, exercise (or lack of it), almost any illness, and – of course – a person’s vocal technique. For years, I – and the voice teachers I worked with – thought I simply had poor technique. But my current teacher, who is a specialist in vocal rehabilitation, suspects that the problems were caused paresis (partial paralysis) of the vocal cords due to a virus. If something seems off, consult a specialist right away.

Not sure where to find a voice doctor? Look for my next post, or visit www.VocalProblem.org.


RESOURCES

www.VocalProblem.org - You can’t trust everything you read on the web, but this site is a trustworthy resource by top vocal physicians. The guide to finding a vocal physician is especially helpful. (The site is run on a volunteer basis and is sometimes unavailable. If you experience problems, check back later. It’s worth the wait.)

www.ENT.org - This is an excellent resource for anyone looking for more information on what to expect when visiting an ENT. The site includes detailed fact sheets about a variety of vocal disorders.

British Voice Association - Singers in the UK will find information on finding a UK voice clinic. Singers everywhere can read the BVA’s voice care tips and browse the article archive.

National Center for Voice and Speech - NCVS’s website is a wonderful place to begin exploring the science behind vocal technique. Check out the list of 200 commonly prescribed medications and how they affect the voice.

GET A FREE VOICE EXAM!

In honor of World Voice Day, the Voice and Swallowing Institute of the New York Eye and Ear Infirmary is offering free voice screenings for professional singers. A full voice work-up can run over $1,000, so this is an incredible offer. Call 212-245-7840 or inquire by email.