Dear Dr. Jahn: I am a high school junior studying to be an opera singer (tenor). I am also an International Baccalaureate Full Diploma Candidate, and I have ADD. I have been tested, so I know for a fact that my inability to focus is legit, and I’m trying to find a medication that could help me focus to improve my grades and focus on my music (I have until this point been dealing with it without medication). That having been said, what potential effect could medications such as Adderall have on the voice?
Dear Reader: In my experience, you should not have any difficulties. Other laryngologists have reported a tremor that may develop in the voice. Like with so many other medications, how you as an individual respond is rather idiosyncratic. I would suggest you try the drug and see how it affects you. There are other ADD drugs on the market, so you and your doctor can try various ones to find the one with maximum benefit and minimum downside.
—Dr. Jahn
Dear Dr. Jahn: I recently have been snorkeling in a pool at a local rec center. I love swimming. It is the only exercise that I can do and, as you know, one gets very dry when snorkeling. I purchased very good equipment ($180) and the breathing is easier, etc.—however, I am getting very dry during the workout and my voice seems challenged lately. The swimming is a new variable in my life, so it seems plausible that there is a cause and effect. However I thought I would get your opinion.
Dear Reader: I am not an expert on diving or snorkeling, but my first thought would be that breathing through your mouth (using the snorkel equipment) would cause the vocal tract to dry out. Normally, we are not meant to breathe through our mouth, but our nose. The nose is designed to take in air and, in a matter of a couple of inches, warm it to body temperature and fully humidify it—the mouth cannot do this.
Something similar occurs in patients who mouth breathe or snore at night—they wake up with a throat that is dry and even sore. This occurs even during sleep, when we are at rest and not exerting ourselves. Add to this the increase in airflow as you exert yourself under water (and the additional effort imposed by having to clear the “dead space” of the snorkel tube with each breath), and you have a problem. A still further consideration is the fact that the air just above the pool surface may contain some chlorinated water aerosol, which is an irritant to your mucous membranes.
The most logical solution is to drink lots of water and perhaps consider a steam sauna to humidify the vocal tract and dilute out any chlorine ions that you may have inhaled.
—Dr. Jahn
Dear Dr. Jahn: In August 2010, I had my tonsils removed in response to chronic tonsillitis. Fast forward to now, and as I’m working with my voice teacher, a consistent issue has been the lowering of the soft palate, especially as I sing descending scales, causing me to lose resonance and vibrato and even sag in pitch. I’ve noticed since the operation that there are small areas of scarring in the back of my throat where the incisions were made. Could these be inhibiting the free movement of the palate and causing these problems? What can I do to remedy this? Is additional treatment necessary to alleviate this if this is indeed the case?
Dear Reader: When the tonsils are removed, they are separated from the two sides of the pharynx, leaving a raw area that heals over time. During the healing process, there is of course swelling and some stiffness of the palate, but this healing should be complete, with a return to normal, within three months. Naturally, after any surgery there is some scar, but your question pertains to whether this scar is functionally significant.
In my experience, if the surgery is done carefully and without any unexpected complications, such as bleeding (which requires cauterization or suturing), there should be no difficulty lifting the palate. Keep in mind that every time you swallow you need to lift your palate to completely occlude the nasopharynx (i.e., the palate must close against the back of the pharynx), otherwise you would reflux your drink into your nose. So your palate obviously moves, and moves well. It is possible that your proprioception in the area has changed, but this should not affect actual movement.
You may wish to consult a speech pathologist to assess how effectively you are able to lift the palate and to see whether both sides of the palate move equally well. She may even give you exercises to strengthen the palate—exercises that they use to treat patients who have true velopharyngeal incompetence. I would not have any further surgery done to loosen the palate. Keep also in mind that cortisone injections can cause the muscle to weaken or atrophy.
—Dr. Jahn
Dear Dr. Jahn: My 74-year-old mother has recently been diagnosed with spastic dysphonia. She has taken statins for cholesterol for years. Is there any connection between statins and this condition? She is currently seeing a speech therapist. I would so appreciate your input.
Dear Reader: I discussed your question with Dr. Andrew Blitzer, who is an international expert on spasmodic dysphonia. If the diagnosis is indeed correct (meaning that your mother does not have another form of vocal tremor or some other movement disorder of the larynx), statins have no effect, either in terms of causation or worsening of the dysphonia. In your mother’s age group, the new onset of SD may be the sign of a mini-stroke, and she should be evaluated by a neurologist to make sure everything else is OK.
—Dr. Jahn
Dear Dr. Jahn: I was diagnosed with strep throat about two weeks ago. The sore throat was gone after about five days on antibiotics, and after one week, I started singing again. I was hoarse from the start. I stopped and tried again one week later. Again, I was hoarse after about 15 minutes.
I’ve always had a very healthy voice. Can strep affect the vocal cords? I’m worried I might have done damage.
Dear Reader: Normally strep should not affect the vocal cords. If you had a strep infection of the larynx, you would have much more severe symptoms, so this is not due to the strep. It is however possible, if you were singing with an infected throat, that you were straining to phonate, and this muscled type of phonation has persisted now that the infection is gone. I would have your larynx examined and then work on lowering the larynx and opening the throat, singing with as little neck tension and as much support as you can.
—Dr. Jahn
Dear Dr. Jahn: Yesterday one of my returning voice students had her first lesson of the new academic year. She became lightheaded and things began to go black as we were vocalizing. She sat down immediately and as the minutes passed, she said her ears felt as if they needed to pop—as if she had been flying. Last spring in her lessons she became light headed once or twice, but it was weeks into the term when she was run down and lacking sleep, so I was not overly concerned. Since yesterday was only the second day of classes, there wasn’t time to be exhausted yet, and the need for her ears to pop was a new experience. Could you share with us your thoughts on this situation?
Dear Reader: This is an interesting problem, which may have several causes. Let me ask you a couple of questions first. Does your student have low blood pressure? Has she lost a lot of weight over the summer or is she dieting aggressively? The clinical picture you are so clearly describing suggests primarily that your student is hyperventilating when she is singing. If she does not breathe well through her nose and is gasping for air or going through the breath too quickly, she may be hyperventilating—blowing off too much carbon dioxide when she is singing. A simple test for this would be to ask her to breathe quickly and deeply through the mouth 20 times, and see whether this reproduces her symptoms. If she tells you that her lips and fingertips tingle as she is about to black out during singing, this would also support the hyperventilation theory.
Regarding my questions above: low blood pressure may cause a sensation of fainting, especially when she stands for longer periods of time. General weakness from excessive dieting and weight loss is another possibility. Sudden excessive weight loss impairs abdominal support and can change breathing patterns. Finally, with excessive rapid weight loss, the Eustachian tubes of the ears can become floppy (they also lose support!), and a sensation of ear blockage can develop.
What to do? Ask her to see her doctor to check blood pressure while sitting and also standing to determine if there is significant postural drop. Ask her to do a blood count to see whether she is anemic. If everything mentioned above checks out, she should do some vocal exercises where she sings slow, soft, and sustained passages, to train a gradual release of the breath without pushing too much air. This may help.
—Dr. Jahn
