Dear Dr. Jahn: First, thank you for taking our questions! I have heeded your advice over the years, and appreciate your dedication.
Secondly, I have rheumatoid arthritis and am taking a biologic drug (Humira), and sulfasalazine (2,000 mg per day). I am about to start taking methotrexate in place of the sulfsalazine, and I am concerned about the side effects this may have on me vocally. While I have resisted steroids for treatment, I have been forced to use them by injection on several occasions—better than oral I am sure, but still scary to have in my joints. Knowing that methotrexate is a chemotherapy drug and will suppress my immune system, I’m just scared in general.
I am hoping to have some guidance on this from you, in terms of potential hazards of any of my treatments. I also have a thyroid problem, for which I am also medicated. I have noticed that I cannot sing as high as I once could (I am 43 now), so I don’t know how much of what I’m experiencing is attributed to age.
Hope to hear from you, and thanks again.
Dear Reader: Based on your medications, I am assuming that you have a rather severe case of rheumatoid arthritis. As with all serious, and potentially debilitating, conditions, you need to weigh the pros and cons of aggressive treatment, no treatment, and your need to sing. Methotrexate is a medication that, years ago, used to be used for certain forms of cancer but is now commonly used for RA that fails to respond to other medications. I am not aware of it causing any specific problems with the voice—but, as an immunosuppressive drug, it might make you more prone to colds or other routine infections.
We have done studies years ago on RA and the larynx. In severe cases, the cartilages and joints of the larynx may develop arthritis, causing hoarseness and, rarely, even breathing issues. So my thinking is, you are better dealing with your medications and their potential nonspecific side effects than to let your RA continue uncontrolled. Certainly, discuss the potential side effects and any alternative treatments with your rheumatologist.
Your age, 43, is not an issue in terms of your voice. I’m not sure, however, whether any of these drugs may have an effect on the secretion of your female hormones.
A last point: if you are hypothyroid (this is seen more commonly in autoimmune patients than hyperthyroidism), be sure that you are adequately medicated (to a normal, or euthyroid, level), since even mild degrees of hypothyroidism can affect the voice.
—Dr. Jahn
Dear Dr. Jahn: I’m a classically trained singer and voice teacher, and I’m writing to ask you about some vocal difficulties I’ve been experiencing. For a little over a year, I’ve been having trouble producing a “free” and supported sound in head voice. I’m not sure why this started being so difficult, but seemed to happen all of a sudden. Prior to this I had very few problems with head voice, or high notes, or anything of that nature, and had performed whole opera roles comfortably. However, since last spring the problem has come and gone, always occurring in head voice, and sometimes to the extent that I’ve been unable to phonate entirely between the notes of G4 and A4. In order to try to produce any tone, I would have the sensation of air pushing its way through a very narrow passage, similar to squealing air escaping from the stretched opening of a balloon. As you might guess, the resulting tone sounds and feels very harsh, and the added breath pressure makes singing a phrase nearly impossible.
Last summer I decided to make the transition from soprano to mezzo-soprano because the tessitura of the soprano repertoire was too taxing. I’m not sure if this was a result of the vocal problem, or if I’ve always been a mezzo and never knew it, or if I might really be a soprano who has a vocal injury. The technical difficulties I’ve been experiencing I’ve assumed were from the voice transition. However, I’m not so sure anymore.
A few weeks ago, I felt a pain in my throat whenever I would sing, so I went to the ENT to make sure nothing was wrong. The ENT saw with a laryngoscope that while the cords themselves are fine, I had an edema on one of my arytenoids. He also said the vocal folds were closing in the manner of an accordion. His recommendation was to be quiet, take Advil, and drink Throat Coat tea.
My question is how does an edema occur, and is it different from vocal fatigue or other irritation? Also, could this be what caused me to start having issues a year ago and it just never really healed? Furthermore, what is the significance of the folds closing in the manner of an accordion?
Do you have any recommendation of how to treat it and how to proceed with singing so that my arytenoids close the folds completely to allow me to sing easily in head voice? Also, what can I do to avoid such problems in the future?
Dear Reader: Your problem is certainly perplexing and one of those cases where it is difficult to make a diagnosis, certainly not without an examination. You should understand that my ideas are only that, not a diagnosis, and based only on what you have told me.
Here are some suggestions to consider, though.
We are going first on the assumption that you might have some sort of “recurrent edema,” based on the fact that the arytenoid appears swollen and that you are having a problem in head voice. If we consider this possibility, we need to think about why you would get recurrent swelling. Certainly, the old standby of reflux should be looked at. I don’t know your height, weight, or body habitus, but I would first aggressively rule out reflux by taking an H1 inhibitor such as Nexium along with an antacid such as Gaviscon for a month.
What speaks against this is the fact that you are not complaining of any problem in the primo passaggio, which is where irritation, such as with reflux, would first manifest.
A much less likely consideration would be a recurrent swelling, such as a small polyp, on a vocal fold. This might cause a problem in high head voice—but your problem is not really at the top, but closer to the second passaggio. Also, a swelling or lesion should be apparent to your doctor on examination.
This leaves us with two other possibilities. One would be some minute scarring, perhaps from a previous injury or hemorrhage. Such a hemorrhage may have happened without you being aware of it (i.e., without having had it medically documented). If this left some scarring, this may not be visible, except possibly with stroboscopy. Speaking against this possibility, however, is the fact that your hoarseness is intermittent, not constant.
This leaves one final possibility, which is a neurological problem, such as a partial superior laryngeal nerve palsy. Some laryngologists believe that this can occur intermittently and cause only a partial weakness. In support of this diagnosis is the following: we know that the superior laryngeal nerve is most important in head voice (i.e., cricothyroid contraction) and not chest voice. Again, the fact that you have no primo passaggio problems suggests an isolated phenomenon, not something generalized such as reflux. Also, it is likely not primarily a technical problem, since with technical problems, such as muscle tension dysphonia, we would expect squeezing, yodeling, or skipping notes around E or E-flat (primo passaggio).
I am not sure what the “accordion” analogy is. Having grown up with two parents who were professional accordionists, I am familiar with that instrument and would assume the doctor saw some sort of pleating action as the vocal folds approximated? This could be due to asymmetric contraction, compensatory over closure on one side, or possibly edema and redundancy of the tissues. I am not clear what he meant.
In any case, if you do have a nerve weakness, the problems are that this cannot be definitively diagnosed (although some laryngologists believe they can do quantitative electromyography of the larynx, most of us don’t agree) and, more importantly, there is no specific treatment. This condition is caused by a virus, and most often it resolves over time. Aggressive and focused voice therapy may be of benefit; however, if your voice continues to be unreliable in that range, you may indeed be more comfortable as a mezzo.
—Dr. Jahn
Dear Dr. Jahn: I have a history of snoring and some sleep apnea. I went to the ENT a while back to get something checked out in my throat, and he told me that my tonsils were larger than they should normally be and it may be the cause of my snoring. He advised I have them removed to see if that helps with the apnea. As a singer, I would like to know the risks associated with having this surgery performed and if the benefits outweigh them.
I am well aware that sleep apnea is very serious and should be handled properly, so doing nothing is simply not an option. Would a better alternative to surgery be
a breathing device for my sleep?
Dear Reader: We did a column on tonsils recently, and you might wish to read that—it should answer most of your questions [see February 2010]. Certainly, massive tonsils can obstruct the oropharynx, and it can fall back into the throat at night (especially if you sleep on your back), causing snoring and exacerbating a possible sleep apnea. In general, a tonsillectomy, properly done, should have no adverse effect on the voice. Some singers actually feel there is more room in the back and the voice sounds less covered once large tonsils are removed.
—Dr. Jahn
Dear Dr. Jahn: I had my appendix removed Friday, Sept. 23. I am still recovering, but I noticed my voice does not seem the same. I do not have the same sensation when I am singing as well. Can you please explain why this is happening?
Dear Reader: I received your question on Sept. 28, so I will assume you wrote it on the 27th. Your question is why does your voice feel not normal four days after a general anesthetic and an abdominal operation?
I am purposely restating your question to make a point: four or five days after this sort of surgery, it would be unusual if your voice were normal! And there are many possible reasons, including the intubation during anesthesia, some dehydration, and some of the medications you may have been given, which could be drying. A second group of possible causes have to do with difficulty supporting after an abdominal incision and possible change in bowel habits. All of these are temporary. I would recommend patience, lots of fluids, and allowing your body to return to its normal state.
When should you start to sing? I suggest 7-10 days after your surgery. Although your appendectomy was probably done laparoscopically, which is a much smaller incision with fewer postoperative consequences on your bowel habits, you still need to wait this long for swelling, dehydration, etc., to correct themselves. When you do start singing, work on getting your larynx back down, and focus on your abdominal support, which may be temporarily impaired. Don’t push and don’t be impatient. Give your body time to heal. Of course, if you continue to have problems that are not improving after two weeks, you should consult an ENT doctor for a look at your vocal tract.
—Dr. Jahn
