Hello Dr. Jahn:
I have been reading Classical Singer for about two years now and I have enjoyed your column, being very health conscious. I am writing to inquire about the supposed link between sinusitis and GERD [gastroesophageal reflux disease], which I read about in your article. I have also come across such implications in other publications and sites online, but no one has gone into detail.
I have always had extremely bad allergies, which had a bad flare up last summer, accompanied by sinusitis, which has lasted until now. I have done every nose spray, antihistamines, acupuncture, allergy shots, diet changes, nasal rinses, and I only see improvement with the latter. Western medicines are entirely too drying for me.
In relation to GERD, I began to experience the constant irritation and belching right around the time that the sinusitis took hold. I am very confident that in my body these are closely linked, and I was wondering if you could direct me to any publications or people who are knowledgeable about this and what to do about it.
I have gone to ENTs and had CAT scans, but no one has ever mentioned surgery. I know that my frontal and maxillary sinuses are clear, but my sphenoid and ethmoid sinuses have blockage. It is accompanied by a constant postnasal drip, which has never been alleviated by any sprays and is the cause of irritation and throat tightness. Is surgery even an option with those cavities?
I would appreciate any input you can give me, knowing what information I gave you.
To answer your question first, GERD has now been implicated in sinusitis, because it seems that in some cases the reflux can actually travel up to the nasopharynx at night, causing an irritation and blockage of the sinuses. This is uncommon, but may occur.
In your case, this might be one possible explanation for your symptoms. A second one would be that a chronic postnasal drip is creating irritation in the back of your throat, causing you to swallow frequently. Frequent swallowing (usually of air) is a common cause for belching. If you have significant sphenoid or ethmoid sinusitis, you should also experience some headache or facial pain. If you don’t have such pain, the CAT findings may not be significant. You should however obtain a consultation with an ENT doctor.
Yes, these sinuses can be cleaned out, but if you were my patient, I would like to have a convincing clinical reason for doing so.
Good luck!
Dear Dr. Jahn:
I have a question. Today I had a voice lesson, and I felt sick in the middle of the lesson. I couldn’t continue singing, so I had to go home.
I wasn’t sure what it was, because I had never had such a symptom. Now I am thinking it might have been from singing. I was dizzy and felt like [I was] lacking oxygen. I told my husband, who is a singer, and he said he has seen a few students get dizzy when they were singing.
Do you know if this happens often? When it happens, what does it imply? Does it have a positive meaning, like I was breathing very actively? (I recently started studying with a new teacher, and I did a lot of breath work—and my voice got twice as big, my husband says.) Or does it have a negative meaning, like I’m not using the air efficiently? Can this be harmful? I do not want it [to happen] any more in the middle of my lesson.
The most likely cause for your dizziness is that you were hyperventilating. When you do this, you blow off too much carbon dioxide, which changes the chemistry of the fluid around the brain. Try taking somewhat shallower breaths—more specifically, don’t exhale to the absolute limit when you breathe out. Incidentally, you can prove to yourself whether this is the cause of your symptoms by purposely hyperventilating: Take 20 deep, full breaths rapidly, in and out, and see whether the dizziness you feel is similar to what you experience while singing. If it is, you need to change your breathing technique.
Dear Dr. Jahn:
I have read your book and use it in my teaching. I am not only a voice teacher but also a singer.
I have a question. I have been having sinus problems, which affect my left ear in particular, and the Eustachian tube flaps around and blocks my hearing—not good for a singer/voice teacher. My doctor said it is thinner than the right ear tube. This creates some tenderness in the area of the ear.
I have been to a specialist ([I suffer] vertigo sometimes, too), and he has said to start my allergy injections again (I have [allergies to] dust, mold, and ragweed), and said that if things did not clear up he would make a small incision in the tube and allow air to pass. I am most hesitant about this surgery, since I am afraid it might change my perception of sound.
Also, my allergist—who is also an ENT—has put me on Allegra 180mg, Nasonex and now Singulair. Is this combination too much for the voice to function properly? I am concerned about the drying-out effect. I am keeping well hydrated.
Also, from time to time my allergist puts me on a Medrol pack and z-pack antibiotic. This seems to free up the ear until after the meds have worn off, then the problem reoccurs. Is it safe to take this steroid frequently? I would appreciate a general answer from someone of your expertise.
This is really not a general question, but more a specific and personal consultation, and I cannot treat you sight unseen. Let me however answer in general some of the issues you have touched upon.
For most of us, the two halves of our body are not exactly the same: one eye is better, one foot is bigger, etc. The same is true for the Eustachian tubes—one may open more readily than the other. I would have an audiologic test called an impedance test, and have them check your Eustachian tube function. This is a pressure measurement done while you yawn or swallow. It shows how readily (or unwillingly) the Eustachian tube opens. Sometimes the problem is not a sluggish tube, but one that is too open (called a patent or patulous tube). If you have this, your voice (speaking and singing) may echo abnormally into the affected ear.
If you do indeed have a blocked Eustachian tube, there may be many possible causes, including allergies, but also mechanical problems in the nose or nasopharynx. You need to sort out the cause. Treatment may include shots, antihistamines, nasal sprays, or even surgery.
Regarding the hole in the eardrum, you may suggest to the doctor that he put a temporary opening in the drum (myringotomy), minus the tube. These incisions normally heal within two weeks, and it will give you a chance to try how this feels before committing to a longer-term ventilation tube.
Dear Dr. Jahn:
I am a singer about to start a master’s program in the fall. I have also worn hearing aids since I was 5 years old (20 percent loss in each ear). I am in the process of purchasing new hearing aids and am finding that many of the new digital models are not conducive to singing. They automatically dim the resonant “ping” of the voice, producing a flat, muffled sound, to my ear. Additionally, they associate the higher frequencies of operatic singing with “feedback,” and automatically reduce the sound. Do you know of any audiologists who specialize in operatic singers?
The short answer is, I don’t know of any audiologists who specialize in singers, but that doesn’t mean you shouldn’t be able to find someone. Depending on where you live, you should be able to contact a larger teaching institution where a senior audiologist may be experienced and flexible enough to help you. But let me share some thoughts on hearing aids with you.
Several issues may plague singers who need to wear hearing aids. First, the digital processing technology (versus analog processing) is not kind to music. Most hearing aids are designed to make speech more intelligible. They do this by emphasizing short transient sounds, and enhancing the onset/offset of such sounds. This enhances the “contour” of speech and suppresses the softer background sounds. In audiologic terms, it increases the signal-to-noise ratio. Music (and singing) is not a series of short transients, but often a sustained line with gradual changes in loudness (crescendo/diminuendo). Digital aids can make music sound tinny and choppy. They may be even worse for orchestral music.
So digital aids may in fact not be ideal for you. You may do better with analog hearing aids.
The second issue is how to keep the aid in your ear. Many hearing aids sit in the outer ear canal. As you widely open and close your mouth, the hinge of the lower jaw pushes into the ear canal. (You can feel this by putting your little fingers in your ear and opening and closing your mouth.) So a deeper insertion aid (called a CIC, or completely-in-the-canal aid) may be better. These aids are not as powerful, but should be adequate for a 20 percent loss.
The final issue is one of cosmetic appearance. Again, a CIC aid would be the answer, since these are completely hidden within the ear canal.
Just remember, when trying hearing aids you have a state-mandated free trial period (in New York and New Jersey, you have one month) during which you can decide to keep or return the aids. So don’t get stuck with aids that aren’t the best they can be for your needs as a singer.
Dear Dr. Jahn,
I was very excited and heartened to see your response to an asthma medication (ADVAIR) in the June issue of CS.
I am likewise being treated with ADVAIR, and am experiencing hoarseness, as I have with other inhaled asthma medications such as QVAR. I’m getting desperate, as I have had to cancel several performances recently, and have nowhere to turn. My doctors, although they are aware that I’m a singer, do not seem to take hoarseness that seriously. They are content as long as I am breathing better, and I can’t seem to make them understand.
Are there any medications for asthma that you know of that do not affect the voice? Are there any oral treatments besides steroids in tablet form? Any advice you can give would be greatly appreciated.
I’m glad you found my comments on ADVAIR relevant. It does cause hoarseness, which is not usually an issue for non-singers, but a big problem for singers, particularly sopranos. I wasn’t aware of a similar problem with QVAR.
What can you do for your asthma? First, you need to figure out what kind of asthma you have. Some cases are triggered by allergy, infection, or exercise, and these may be controllable by managing the cause (controlling infections, shots, avoiding allergens, etc.). If your asthma is chronic, intrinsic, and requires ongoing treatment, consider the following options.
Singulair, a non-steroidal tablet, may be helpful for mild cases. I have seen no adverse reactions in singers, although it may not be strong enough for some cases. Inhalers such as albuterol do not affect the voice, but this is normally used only for acute flareups, not for long-term management. Serevent, one of the components in ADVAIR, may also be useful, and not as harmful to the singing voice.
You may also consider acupuncture. A number of acupuncture points can open up the lungs, decrease airway resistance, and reduce asthma.
Now, it may be that you absolutely have to use ADVAIR or QVAR. Asthma can be a serious condition and its treatment may need to take precedence over other issues, but often, ADVAIR is used only because it is convenient—it is a combination of two drugs, easy to prescribe and easy to use. So, you may need to talk to another doctor who is more sympathetic to your singing and willing to spend the time to fine-tune your asthma management.
Dear Dr. Jahn:
For years I have suffered from reflux, which I do not feel, but it definitely affects my voice (I am a 30-year-old lyric soprano, singing lead roles in regional houses), and I’m afraid that by continuing to sing on swollen, irritated cords, I have done some damage …[trying] to compensate for what is not working.
I have taken a month off from singing, but even so, when I visited my doctor the other day for a scope, it appears that I have what he called two small “blisters” on my cords, which are [having a major effect on] the ease with which I sing. I have been singing with these blisters for a few years, but my doctor has insisted that lots of singers have them, and they either find a way to sing around them, or they have them removed.
Well, I am at a point in my career where I cannot afford to just be “getting through” every performance by the skin of my teeth! It is too stressful, and uncomfortable, and tight, and makes singing just too difficult. Now that the reflux seems to be under control, he has suggested the option of having surgery to “pop” the blisters and release the fluid (when I sing, the blisters come together, but they prevent the actual cords from vibrating together) when I [can find] a period of about three weeks to go on a total vocal rest and allow [the cords] to heal properly. He has assured me that this is a very simple and common five-minute procedure that he has performed on a number of professional singers with a 100 percent success rate, and that they are all extremely happy they did it. Naturally, the thought of him going in with a knife to “pop” these things makes me extremely nervous and anxious to get a second opinion.
It’s not clear from your doctor’s description what these “blisters” are. Normally, these would be nodules, cysts, or polyps. None of these conditions is ordinarily treated by “popping,” but rather, where necessary, by microscopic removal. If a cyst (the closest thing to a “blister”) is drained, it is very likely to recur by reaccumulation of fluid. You should obtain a second opinion regarding your problem, since often the vocal difficulties are due as much to excessive laryngeal muscle tension (which develops from an attempt to compensate and “overcome” the hoarseness) as from the lesions themselves.
