Most singers have, at some crucial moment, resorted to the use of cortisone. This is often a crisis, an impending important performance or audition that simply could not be cancelled.
Cortisone seems like a panacea to some. Others, however, have had bad experiences and will stipulate to their physician in no uncertain terms that they do not want anything—pills, injection or inhaler—that contains steroids. Both these extremes may be wrong, yet cortisone is something about which every singer seems to have an opinion, whether based on personal experience or the experience of a colleague.
In this column, I would like to outline some of the legitimate uses of this powerful drug, but also caution against its casual or habitual use in other circumstances.
Cortisone and steroids (other drugs in the cortisone family) are normally present in our bodies, and are formed by the adrenal glands. They work in many powerful ways: suppressing swelling and inflammation (which in turn often cause pain) increasing energy, appetite, and endurance. The generally positive effects of cortisone are exemplified by our image of an athlete “on steroids” (although athletes are usually not on cortisone, but other steroid analogs).
Let’s examine some of these effects a bit more closely.
Swelling, such as may be seen with an overused knee, is the body’s signal that trauma has occurred, trauma that must be repaired. It is the body’s way of temporarily putting that body part out of commission. Pain, mediated by local swelling compressing the nerve endings, is the body’s reminder to let the particular body part rest. Similarly, inflammation often accompanies infection, and represents the body attacking a bacterial or viral intruder. In both of these situations, cortisone may cause symptomatic relief of pain or swelling, but undermines the greater purpose of repair and restitution.
The above paragraph shows both sides of this powerful weapon, and the caution that is implicit in its use, even in acute situations. Long-term use of cortisone is a serious medical decision that should be undertaken with even more forethought.
Chronic illnesses that are treated with steroids are often allergic or autoimmune illnesses, where the body’s immune response is turned against itself, and causes damage to normal body parts. Asthma and rheumatoid arthritis are two illustrative conditions. Such long-term use of cortisone can result in many serious side effects, including suppression of the user’s own adrenal gland, diabetes, GERD [gastroesophageal reflux disease], glaucoma, osteoporosis—the list goes on.
Turning from chronic illness to the typical healthy singer, when, if ever, should the vocalist consider using cortisone? In my opinion, cortisone should be given to vocalists rarely, selectively, and for a specific purpose only.
Steroids could be offered to decrease swelling when the cause has been diagnosed and addressed. If the swelling is due to a bacterial infection, cortisone can prolong the healing process by inhibiting immune defenses, and should be given only rarely, and always with a powerful antibiotic to destroy the bacteria.
Swelling may also be due to acute trauma, oversinging or strain. The background for these situations is typically a performing commitment (one, or several in a short period of time) that cannot be cancelled without significant financial or professional repercussions. While the quality of the voice on cortisone is often not normal, it may get a singer through a performance that would otherwise have been impossible. If the performance can be cancelled, if the role is covered and the fate of the show is not compromised, it might be a valid option to notify the theater.
Traveling singers, who depend on “the kindness of strangers,” are at particular risk. I worry about a singer who is in town for three performances, then moves on to another city, since I don’t know what treatment she received last week, nor what she will get next week. Broadway singers are even more vulnerable: Eight shows a week for several months or even years cannot legitimately be supported with cortisone.
So, what can you, as a singer, do to make optimum use of this powerful drug? First, get a reasonable diagnosis, and a plan of treatment. Chronic hoarseness in an otherwise healthy singer should almost never be treated with cortisone alone, although a short course may be useful as an adjunct to measures that truly treat the underlying condition.
Then, look at your schedule, and weigh the risks of canceling versus the risks of chronic cortisone. Not every performance or audition is vital. At times I will advise singers to consider postponing auditions or canceling smaller or covered performances, so that they can excel two weeks later in a recorded or reviewed performance that is important to their career.
Know what you are taking! Your physician should be willing to discuss the medications he is giving you. If a medication contains cortisone, how much does it contain, in what formulation, and how long will it stay in your body? Chronic cortisone treatment for hoarseness, whether from one physician or 20, is just as dangerous and never justified.
Finally, know your physician and his philosophy of management. There are a number of “performance arts specialists” (often not otolaryngologists) who hand out cortisone like candy, “just to get you through the show.” But what happens when that performance is over and the next one looms?
Disclaimer: The suggestions given by Dr. Jahn in these columns are for general information only, and are not to be construed as specific medical advice or advocating specific treatment which should be obtained only following a visit and consultation with your own physician.
