Laura Claycomb's Young Artist Corner

A Singer's Health

I thought to write a little about health. After talking to most of my singer friends, I found they didn't get the same information from their specialists. These are some tips and some ideas I have gathered - my translation of what I've heard from numerous doctors and colleagues over the years.

Choosing your Doctor
Drugs to avoid when you're a singer
Nasal Rinse
GERD - REFLUX
Hiatial hernia
Allergies
Women's particular problems
Edema
Plane
Preparation for yourTrip
Arrival at your destination
Hotel
Emergency measures

Choosing your Doctor

Find an Ear-Nose-and-Throat doctor who has a stroboscope (with video) IN HIS/HER office and uses it on all singers. If you are nervous if "it's ok to sing or not" and he/she does NOT look at your vocal chords with this contraption (either with the hard metal tube through your mouth, or the teensy fiber-optic one through your nose), then the doctor is not a serious "opera singer" doctor. I have had doctors tell me they "see opera singers all the time" and "they can tell if the chords are swollen without that machine" etc etc. and I have found it patently A BIG FAT EGOTISTICAL LIE. My throat has been totally pristine white (no redness) and yet my chords have been swollen. If it feels hoarse, trust your instinct. But go to someone who has specialised in the singing voice, NOT JUST SOME ENT (Ear/Nose/Throat doctor) WHO'S FRIENDS WITH SOMEONE AT THE OPERA HOUSE OR WHO JUST LOVES OPERA.

One of my favorite ENT's (Ear /Nose/Throat doctor) - - Dr. Richard Stasney in Houston, Texas, has a website. Check out the advice on the Texas Voice Center . It has LOTS of helpful advice from a wonderful doctor who is a HUGE opera fan.


I will start with some topics that all singers need to know about. Many (probably all!)of these topics are covered on ClassicalSinger.com :

Drugs to avoid when singing - and alternatives


- check out the vocal rx part of this site

Things you can do:

To fully rinse out your sinuses, either to avoid a cold you can feel coming on, or to re-hydrate tissues, lay on your back on a bed, with your head hanging over the side, leaning it back as far as possible. Apply a salt water rinse and let it sit thus in your upper sinuses for 2-5 minutes, then sit back up and spit it out, or blow it out. This helps reach the upper part of your sinuses where many bacterium grow unchecked, since it easily dries out and does not always get re-hydrated with a salt-water rinse standing up.

Recipe for Salt Water Rinse for the Nose from Dr. Stasney

(Buffered Hypertonic Saline Nasal Irrigation)


IMPORTANT WORD ABOUT VITAMIN C INTAKE:

Although some people advocate taking enormous amounts of Vitamin C per day for longevity, staving off a cold, etc... Please use with caution, as use of more than 1000mg per day can affect muscle coordination (in your throat, especially.) Someone explained exactly how to me once and I've since forgotten the details, of course, but the gist of the matter is that if you're going to use more than 1000mg per day, you should not do it on a day you are performing. If you're on a day off and feel a cold coming on, be my guest to tank up on Vitamin C. Beware that it can have gastric repercussions, as well. If you get diarrhea, then you have taken too much ascorbic acid. I advise Zinc lozenges, as well, as these seem to have a big effect on getting rid of colds more quickly. Never take Zinc or vitamin C on an empty stomach. They can upset your stomach and make you feel nauseous by themselves.


ACID REFLUX, GERD (Gastro-entestinal-reflux-disease), hiatial hernia and the reflux--allergy connection

Most professional singers I know have had problems with acid reflux or allergies. Read on for the connection between the two and what to do about it.

What is acid reflux?


Acid reflux happens when the stomach either makes too much acid, and it seeps up the aesophagus, and/or the valve at the top of the stomach does not close as it should and allows stomach acid to flow back up the aesophagus, washing stomach acid up over the back of the throat and around the vocal cords. Eating certain foods (read below) seems to open up that valve and allow the acid to backwash up. Dr. Stasney is convinced many singers have reflux problems AS THEY'RE SINGING, not necessarily while they sleep or are reclining. I tend to agree with him. Symptoms: burping up stuff, hoarseness, feeling of a lump in the throat in the morning or when you swallow, a dry cough, dryness of the throat (in the evening and morning especially), bad taste in mouth, and redness and swelling of the chords. and heartburn. Most doctors won't think it's that big of a deal, because it's just a little gas! But it is a big deal for your throat, and usually should preclude singing on it for at least 48 hours. (This is my experience, coupled with a few friends' experiences: you could be the miraculous one who heals more quickly, but I doubt it.) It can be light or intermittent reflux and still have huge repercussions on a singing voice. You could only have one or two of the symptoms but still have reflux. I am also convinced that there does not have to be actual ACID liquid flowing up, but that the gas from burping can contain enough acid to damage your throat. After all, this is the acid that digests your steak dinner - why shouldn't it digest your throat, too, if it comes into contact with it?

It tends to be exacerbated by hot, spicy, or greasy food, and can more easily travel upwards over vocal cords if one is lying down. (duh!) So having as little acid in your stomach as possible is helpful before lying down. Keeping your upper body elevated while sleeping can also help.

More information on Voice Disorders and GERD (acid reflux)

Histamine's role in acid (over-)production:


The body sometimes uses one substance for two different purposes. Histamine is what your body puts out when you have an allergic reaction (- thus, anti-histamines calm down the effects of histamine.) Your stomach's cue to release acid for digestion is also the release of histamine into your system. It needs a very small amount - micrograms - of histamine to be released in order to make enough stomach acid to digest your food. BUT when you are having an allergic reaction, you are releasing MILLIGRAMS into your system (so no wonder people with allergies can have big problems with acid reflux.) Proton-pump inhibitors like Nexium and Prilosec (Losec) inhibit the release of histamine into your body. Antacids such as Zantac, and non-prescription Maalox and Gaviscon neutralise the acid that's already in the stomach.

Good rules to go by if you suspect you have acid reflux:


Hiatial Hernia

Also involved with your acid reflux could be a hiatial hernia. Your diaphragm is bisected by your aesophagus, which goes through the middle like a tube through a tight hole. Sometimes, the "hole" around the aesophagus gets "stretched out," to put it in layman's terms, and when the diaphragm goes down, it presses the stomach up through the gap now around the tube... To use a very scientific term, this squishes the stomach's contents back up the aesophagus and backwashes acid into the throat. Singers tend to be prone to this, as we are overextending our diaphragms all the time with singing. There are also certain diets that can exacerbate a hiatial hernia. However, most stomach doctors will not think there is a problem unless there is a GROSS problem of tons of acid washing up on your chords, and the hernia is obvious, and heartburn is extremely painful. You can have hiatial hernia (and reflux, for that matter) without having heartburn. There used to be simple drugs to take for a hiatial hernia, to close up the space, also drugs to help "tighten" the valves at the top of the aesophagus. I don't know if they're still available, as they found they had side effects. I thought it worked very well for mine, years ago, and didn't have any side effects. (yet?) In more extreme cases, a small surgery can be done to fix the problem.

Sometimes unexplained problems that are attributed to acid reflux are NOT. There are sometimes dryness and hoarseness, and oedema of the chords related to hormonal changes and imbalances (due to pregnancy, the pill, hormonal imbalances, thyroid problems, change of life, even..) If aggressive reflux treatment does nothing after a few months, look into other causes for your problems.

Allergies and the Vicious Circle with Acid Reflux:

Singers take in more air than "normal" people when we sing, in dusty, moldy old buildings most of the time. So we end up breathing in more air, and thus, more pollutants and allergens than others. And we lose more moisture from singing all the time. And we notice the effects that allergens and pollutants have on our voice, whereas most average people do not. Singers may not necessarily be more prone to allergies (although I think they do because of my "more air theory," but you can agree or not - it's just an idea, not proven...) but we do notice it more! Combine with allergies, the effects that a histamine reaction has on your stomach and its overproduction of acid: it will make even more acid, wash up even more over the cords and sinuses, thus creating even more irritation, which then creates more histamine... What a vicious circle! Cut the circle by treating acid reflux with an aggressive treatment of behavior modification (when you eat and what you eat) and drugs (proton-pump inhibitors and antacids). And maybe even find an antihistamine that works for you without drying you out too much. My favorite throat doctor recommends a sinus spray called "NASONEX" (mometasone furoate monohydrate) Nasal Spray, 50 µg, to keep irritation down in my nose, to try and stem the vicious circle. Or take a Clarityn in the evening before bed, if that doesn't dry you out too much. Or use NasoChrome sinus spray. Steam with a warm vaporiser (a cheapo 15$ at Walgreen's) and if you even suspect acid to be a problem, glug a bit of Gaviscon before going to sleep. If acid is a problem, at least that way, some of it will be neutralised.

Women

- Having a baby and your voice/ to Pill or not to Pill and many more questions - to be addressed soon?
  • IVF - TAKING HORMONES TO HAVE A BABY - I can not stress enough the huge and mostly irreperable damage to your cords that can be caused by the flood of hormones required to do in-vitro fertilization. Hormones can totally change the structure of your vocal apparatus. (Think men that have had sex change operations!) I don't know any singers who have done these rounds of hormones who have not had major problems with their voices as a result. Please think about your priorities, and know that you could lose your voice in order to have a baby with this method. If it is that important, then of course, do it (although I think there must be other repercussions on your overall health as a result of this flood of hormones that doctors have not fully addressed in their rush to fulfill a wish that is very lucrative for them.) If singing is also important for you, or your only livelihood, think about adopting! Some foreign countries have more streamlined and simplified adoption procedures than the U.S. and maybe shorter waiting periods - adopting there can have its benefits, and there are certainly many needy children who need loving homes.
  • hormones (i.e. the pill) - ask your THROAT doctor what effects it can have on your voice, not your gynecologist, who will say "of course not" because he/she doesn't sing. I DO believe they can have adverse effects on the singing voice. Try to take the lowest dosage possible without "bleed-through" and avoid the mini-pills that only have progesterone. Pills with synthetic progesterone can cause darkening in the voice - - it metabolises down to a testosterone analogue in your body. Instead try barrier methods and/or IUD together with rhythm to be extra sure. Meanwhile, Check out OPERAMOM.COM Advice most of all - for (prospective) singer moms but also some advice for singers trying to avoid pregnancy.

    Oedema

    - how to know your cords are swollen without them being necessarily RED
    Your vocal cords can be swollen, full of water (much like a blister on your heel when you've walked in shoes that are too tight for too long) and YET not be red. Most doctors will look down in your throat and say "you're fine to sing, your cords are not even pink." This is misleading, as the pink may have gone away, or your cords could be swollen with water because of hormonal changes, etc.. without ever having been red. If you feel hoarse, the voice does not warm up no matter how long and how slowly you warm it up, you have a big break in your voice when you slide down supporting, you feel a lump in your throat or like you need to clear your throat all the time (this could also be due to acid reflux) and you have air escaping in your voice that is not normally there, you may have swelling on your cords. It is usually in the same place about a third of the way up the cords, on both sides. This could be called a PRE-NODE, or a SOFT NODE. Very scary words, and most singers think their careers are over. They are not, but care must be taken to let the swelling go down, and to get to the root of the problem that has caused it so it doesn't happen again. Most of the time, it is from too heavy a schedule, and it was caused by singing while sick. I also find swelling to be a big problem for me after air travel. I'm trying more and more to have at least one to two days of rest in my destination before having to sing. ESPECIALLY trans-Atlantically. My new rule is that if the flight is over 3 hours, I have to wait two days until I sing. And I try to SHUT UP talking when I get there, as speaking is the hardest thing on my voice.

    When we're sick, the right kind of mucus is not protecting our throats, and we are more prone to injury. Sometimes oedema is not visible, however, with a normal laryngyscope, but only when the doctor makes a film of your cords while you're singing with a strobe light to slow down the beats of the cords recorded on the video. Sliding slowly down a fifth in a few places in your range should give the doctor enough to see. If the chords, instead of "kissing" each other symetrically, "dance" with each other (i.e. not meeting up but moving autonomously on each side), there is water in the cords. Sometimes a soft node is only seen on a sliding scale because it is on a part of the cord that is not easily visible on one note, but will show up when you slide. Strange but true. The best remedy for oedema is VOCAL REST. This means absolutely no singing and very minimal talking, if any. NO whispering, as that's worse for the voice than talking. No laughing, as that is so percussive on your cords. I know this is a toughie. Crying ain't too great either.

    I know lots of professional singers who have had this problem, usually for reasons above, not necessarily because they were singing ill-suited repertoire or that their technique was bad. Because they dreaded that phrase "Janey's having VOCAL PROBLEMS," they did not tell people that they had oedema. Nobody forgets how to sing overnight. But you can mess up your voice overnight if you're sick, are singing on a cold or on reflux, or are singing too much, no matter how well. There should be no stigma, but for some reason there is the implication that they don't have a good technique if they have oedema. It can even be caused by hormonal changes (especially in women), so I don't see why there is this stigma attached. It should be as valid and innocuous a reason not to sing as a cold or the flu, but since you don't end up with a red nose and outward signs, I guess it seems suspect. It should not. Nobody tells a runner or a tennis player they have bad technique if they pull a muscle while running: it is an injury. However, if you let it go, and do not address the problem head-on with vocal rest...

    Long plane rides

    Long plane rides (and sometimes even short ones) can have detrimental effects on the voice. The plane is an environment drier than a desert, so adding humidity to your throat and sinuses is a must. The plane can also be a great breeding ground for bacteria and virus - - you are stuck in a box with many people for hours... If you are seated next to a sniffing, coughing person, ask them if they're sick or coming down with a cold (it could be their allergies), and then ask to be moved! You are not being rude - you can not afford to be sick once you get to your destination. A cold has a gestation period of about 10 days, so you may be fine once you get there, but come down with a nasty bug your second week of rehearsals. I am also a big goober and bring a hospital mask with me on long flights. I also bring spray salt water (Sterimar in Europe - great stuff) and mist my face, nasal cavity and the inside of the mask with it periodically (about once an hour) , and wear it to keep the humidity in. I also drink at least one small bottle of water every hour, to try and hydrate from the inside out. Do NOT drink alcohol or any kind of caffeine or carbonated drinks if you can avoid it (they don't hydrate that well), and avoid milk products, as they tend to thicken mucus membranes. Try to get up every now and then and walk around to keep your circulation going, or do exercises in your seat. The plane's pressurized cabin also has detrimental effects on your soft tissues - it makes them swell (guess what your cords are - soft tissue). AND the air quality is oxygen-poor because of the altitude and re-circulation, so get as much fresh air as possible once you get to your destination. I've had good results with an "air-ionizer," one of those snazzy gadgets from Sharper Image. I find that I feel more refreshed after a flight wearing one, but maybe it's psychological. I always bring it on long-haul flights. I also goop up my face with moisturizer on a flight, and put vaseline or chapstick on my cuticles, nails and the base of my nose. Those are body parts that seem to really dry out on the plane. Boy, am I a fun passenger to watch! Who cares if they think you're a total weirdo? And I usually keep my blanket over my entire seat and head and just try to sleep and to keep moisture in the air I breathe. I'm a real fun row-mate to have, obviously. But who cares? My main objective is to be in good shape when I get there. I also do some of those little isometric exercises in my seat to keep my blood moving. Heck, after all that, who has time to get bored on a long flight? I am also the big geek on the plane who wears a surgical mask DO NOT TALK on a flight - tell the enthusiastic, nosey lady next to you that you're a plumber or something, so you don't have to tell her ALLLLL about your "Fascinating Career!" ARGH. Talking in that loud and dry of an environment is horrible for your voice.

    BEFORE YOU LEAVE


    ONCE YOU GET THERE

    I advise not singing the day you arrive nor the day after you get there because of swelling from the flight. You can knock yourself back a week by singing too early on swollen cords.
    Jet lag!

    Jet lag is when your inner body clock doesn't understand what time it is. You need to get it on the right schedule. If you arrive in the morning, go out during the day and get some sun - in the places you have receptors exactly for your clock - - in your eyes, on the back of your knees (yup!), and get some exercise. Try valiantly to stay awake at least until the sun goes down, and then DO NOT get up when you wake up at 5 a.m. the next morning - stay in bed with the lights off and tough it out until at least 7 a.m. If you get there in the evening, it's easier - eat a light meal and go to bed. If you have trouble sleeping, I bring along Melatonin, which I buy in the U.S. It is the substance your body starts to make in the absence of light to tell your body to go to sleep. Take one small tablet at sundown. And then stay out of the LIGHT! Act like Dracula or something...

    In your hotel room

    Hotel rooms are notoriously DRY. You can usually buy a cheapie humidifier at a drugstore, if you're going to be there very long, or you can leave wet towels hanging over the gas radiator to add some humidity in the room. (Don't leave them there all day - could start a fire!) I usually run myself a bath by stopping up the tub, turning on the SHOWER with only hot water to steam up the place, then add cold water to the mix out of the regular spicket. Soaking in a tub is also great for you to recapture some moisture after a long flight - your largest organ is the skin, after all. Moisturize afterwards to keep in the moisture!

    Tips of the trade:

    EMERGENCY HELP FOR HOARSENESS from water or swelling on/around cords - when you have a cold and know that you just have to sing and that swelling is the direct culprit for your hoarseness: Use the decongestant "AFRIN 12-hour decongestant" in the burghundy box - not any other brand or with any other additives. Inhale while spraying it in your MOUTH, trying to get it on your cords (if it makes you cough a little, you're doing it right). This will bring down swelling temporarily, but you will need to see a doctor and SHUT UP after the concert. The stuff tastes horrible, by the way.

    If you have a very important engagement and there is no way to cancel - you must sing, and hopefully you have some time afterwards to recover: you can use methopredosone. You should discuss the repercussions with your doctor. It is a prescription medicine and needs to be used sparingly in your entire career (if at all) and with much caution. Steroids like this will take down swelling, but can open you up to injury (like running on a broken leg), open you up to infection, and slow down the actual healing process your vocal chords need. If the swelling is not just from a too-busy schedule or an illness, and is instead from incorrect singing, you are risking a lot by singing on steroids. This steroid, taken orally 30 minutes before you need to sing, can temporarily bring down swelling. HOWEVER, I would not recommend its continued use, nor would I really recommend using it at all, unless it is really dire straights and you have to sing. You can not sustain a career and good singing if you need steroids in order to keep your schedule. I would not recommend using this for the OPENING of a run of shows, as I think you need lots of quiet time after having used steroids to let your body heal itself properly. In using steroids, you've slowed down that process in some ways. More soon with links on all these subjects....

    Disclaimer: all information on this site is given as a NON-PROFESSIONAL in the doctor business! These are home remedies. Laura Claycomb takes no responsability for damage nor legal responsability for advice taken from this site. Please see a health professional for serious throat/nose problems!

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