Dear Dr. Jahn: My question is about the risks involved in having RAI treatment for a hyperactive nodule causing hyperthyroidism. My internist has recommended this and the RAI uptake and scan test. But I read that this could cause dry mouth and/or vocal cord damage. What is your opinion about this? I don’t feel comfortable with this approach at all and would be very grateful to get your input before I proceed further.
Radioactive iodine treatment of benign thyroid nodules is a very effective method of obliterating functioning thyroid tissue (thyroid tissue that is normal or overactive). It is occasionally also used for certain low-grade malignancies, but in most cases the disease treated is benign. So, that’s the first good news. Secondly, the advantage of the isotope is that it goes specifically to thyroid tissue. It is therefore not like other forms of “radiation,” where an entire part of the body (such as the neck) is irradiated, including all of the tissues present. It is highly specific. This is also good news, since it does avoid damage to the mucous and salivary glands, the major cause of dryness in other forms of radiotherapy. The third advantage of this treatment is that it automatically shuts down the entire thyroid, which theoretically could include other smaller areas of abnormal activity which were perhaps not palpated on examination, or biopsied when your diagnosis was made. And finally, RAI treatment avoids a surgical procedure, which may on occasion present complications to the larynx.
The main disadvantage of RAI is that it makes you dependent on oral thyroid medication for the rest of your life. This medication, usually Synthroid, replaces the thyroid hormone that your body manufactures and needs to be taken daily. It also needs to be monitored periodically by your internist or endocrinologist.
To specifically answer your questions, I am not aware that this treatment causes a significant dryness or damage to the voice. Beside surgery and RAI, you may have one other treatment option available. Some hyperactive thyroid tissue can be suppressed with Synthroid alone, without ablating the thyroid using RAI. You may wish to explore this with your endocrinologist.
Dear Dr. Jahn: I am a cardiologist at the Minneapolis Heart Institute caring for an opera singer for whom I have prescribed Propanolol in doses of 5-20 mg before performances. She read your article in Classical Singer and noted that anti-anxiety drugs might affect voice quality. She is very concerned that the Propanolol falls under that category because it affects the central nervous system. Can I reassure her? Thank you for your response.
If she has had no problems so far, you can certainly reassure her. The main issue in our experience is that it takes some of the excitement out of performance, which in a patient with stage fright is exactly what you may want to do. Some singers feel that it flattens the performance, since they lose the “adrenaline rush,” which may be important to the drama of the performance. It should have no significant effect otherwise (in terms of pitch or range). She should try it before a less important performance or audition and see how it affects her before using it for an important engagement.
Dear Dr. Jahn: I have a problem where I am always clearing my throat. I always have mucus on my vocal cords. I don’t have any allergies that I know of. Any suggestions?
I have several thoughts. Do you drink enough water? You need 8-10 glasses a day (two with each meal, two between each meal), in addition to any coffee, tea or other drinks. Try to avoid milk products for a few weeks. Irrigate your nose twice daily with salt water to reduce any post-nasal drip. Try to avoid drying medications, such as antihistamines, antidepressants or decongestants. And finally, if you have any heartburn or gastroesophageal reflux, have it treated. There is a column addressing this in our magazine, about three years back, called “High Notes, Hydration and Humibid.” You may be able to get a copy from the Classical Singe archives. [November 1997]
Dear Dr. Jahn: I remember you talking about ephedra, but unfortunately I cannot find the article. I am an opera singer and I wanted to know what kind of effect this herb could have on your voice.
Ephedra is a vasoconstrictor and has an effect somewhat similar to ephedrine, sudephedrine, and adrenaline. It can be drying and can make your heart rate pick up. In general, the effect is similar (although different in degree) to taking a Sudafed tablet. While the drying effect is important for all ages, the effects on the heart may be significant in older singers, particularly ones with hypertension or cardiac disease. Older men may also experience difficulty with urination, particularly if they have an enlarged prostate.
Dear Dr. Jahn: I have been a subscriber to Classical Singer for quite some time and have always looked forward to your informative and helpful articles. My first question is about birth control pills and the singing voice. I am a soprano, I am 37 years old, and I have one six-year-old daughter. My husband and I are trying to have another child. After I had my daughter, I experienced some vocal problems very similar to those brought about by PMS (hoarseness, voice catching, etc.). In addition to that, I had terrible mood swings. My doctor recommended going on the Pill after delivery if I encounter these problems again next time I have a child. Taking the singing voice into consideration, what sort of birth control pill would you suggest? I know that taking the wrong thing could be detrimental to a singer, especially a high soprano. I was on the Pill only once when I was 26. It did not bother my voice, as I recall. In fact, if anything, it may have helped “vocal PMS.” However, I was only on it for a short period of time, so I don’t know what the long-term effects would have been. By the way, I was very glad to see the recent article by Fiona Chatwin in Classical Singer about problems associated with monthly cycles.
My second question has to do with IVF and the voice. One of the problems I have is early miscarriage due to a genetic translocation. My doctor suggested doing IVF to better my chances for a full term pregnancy and delivery. My question to you is, how can IVF affect the voice, and are any of these effects permanent? Should I choose this route, is there anything in particular that you might caution me about with regards to vocal health? I would appreciate any helpful feedback you may have for me. Thank you.
Regarding your first question, you may wish to read CS’s recent survey on the effects of the Pill on the voice [Feb 2003]. A significant number of singers, particularly high sopranos, did report changes in the voice. This is less likely if you are a dramatic or spinto voice, or a mezzo. The fact that you took the Pill before with no untoward effect is a good prognostic sign. If you were to go back on the same medication you took earlier, it seems to me this would minimize any potential effect on the voice. You are right, by the way—one benefit of the Pill is that it can reduce the normal PMS effect on the voice. On occasion we have even advised singers to delay their period using the Pill, so that it doesn’t coincide with an important engagement.
Regarding IVF, you need to ask your doctor what hormones are used to induce ovulation—this is beyond my expertise. The culprit in the Pill is synthetic progestogen, which metabolizes down to a testosterone analogue and can darken the voice. While being placed on hormones to induce ovulation will very likely affect the voice temporarily, it should have no long term effect providing synthetic progestogens are not used. Please check with the fertility expert, however!
Dear Dr. Jahn: I’ve had a bad cold, then laryngitis, but I still have it after five weeks! I sound terrible. I’ve been doing the normal vocal rest, plenty of fluids, etc. I think I’m getting a little better. I’m on Biaxin. Have you ever heard of laryngitis going on this long?
Persistent hoarseness after a cold could be due to several factors. If all of the cold symptoms have resolved except for the hoarseness, the most likely cause is abnormal posturing of the larynx. During the cold, if the singer continues to try to sing, he or she may need to “muscle” the voice more to try to get an acceptable sound. This excess muscle tension usually involves squeezing or grabbing at the laryngeal level. After several days, this adaptation becomes “the norm,” and the singer unconsciously uses excessive laryngeal pressure. As the cold resolves, adaptation becomes maladaptation. It must therefore be consciously un-learned, concentrating on releasing tension in the neck, lowering the larynx and opening the back of the throat. A good voice therapist can be helpful with this. We also see this situation after colds which involve a lot of coughing.
Less common causes of persistent hoarseness are hemorrhage of the vocal fold from coughing and gastroesophageal reflux (GERD), particularly when the illness involved gastrointestinal symptoms such as regurgitation and vomiting.
Disclaimer: The suggestions given by Dr. Jahn in these columns are for general information only, and 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.
