One evening a few years ago during an opera performance, I was called backstage to see a singer who couldn’t sing or breathe. Expecting some true emergency, I found a soprano with severe menstrual cramps and spasm of the abdominal muscles which incapacitated her normal breathing mechanism. After 10 minutes of acupuncture, her cramps subsided and both breath and voice returned.
Singers and singers’ doctors spend a great deal of time focusing on the larynx. Apart from being obviously the generator of vocal sound, the larynx has also become more and more visible. Over the past 150 years, we have come from a tantalizing glimpse in a mirror reflecting sunlight into the throat to xenon-illuminated Technicolor recordings of the vocal folds, to be admired and analyzed almost ad nauseam.1
It is equally important, however, that we consider the 500-pound gorilla of vocal production that sits, invisible but ever present, in the room. I refer, of course, to the lungs. In this column I would like to talk about how the lungs and larynx interact and how disorders of the lungs can affect the singer.
The body is an entity which represents an almost incomprehensible universe of subspecialized cells and organs. These elements cooperate and collaborate every second of our lives and, therefore, it makes no sense to consider any part in isolation. In the case of the lungs, functional capacity depends not only on the lungs themselves, but also on anatomic structures that are above, below, and around the bellows.
An example is the nasopulmonary reflex. It was shown years ago that when air is inhaled through the nose, the lungs are more compliant and have greater capacity. Mouth breathers, whether due to a cold, adenoid enlargement, or other causes of nasal obstruction, have a decreased ability to fill the lungs, no matter how widely they open their mouth to inhale. Yoga practitioners have used this phenomenon to good advantage for centuries with nasal breathing exercises.
But let’s look south of the diaphragm. The contents of the abdominal cavity and the tone of the abdominal muscles and pelvic floor also affect thoracic expansion and contraction. As mentioned above, something as trivial as menstrual cramps can cause splinting of these muscles and impede smooth pulmonary function. Even temporary abdominal distension, such as with overeating or drinking carbonated beverages, might stretch the muscles of the abdominal wall beyond their optimal contraction point, resulting in impaired control during expiration and phonation.
The lungs are basically a set of soft sponges that expand and contract as they are pulled open and squeezed by the walls and floor of the thoracic cavity. Impairment of free movement of these walls (the rib cage and intercostal muscles) or the floor (the diaphragm) will interfere with lung function, no matter how flexible the lungs themselves may be.
Impairment may be due to many conditions. In addition to what has already been mentioned, here is a partial list:
• Chest wall injury, contusion, or rib fracture: Even a slight bruising causes pain on movement of the thoracic cage and a protective “splinting” on inhalation.
• Costochondritis (Tietze’s syn-drome): Inflammation of the area where the ribs articulate with the sternum (breast bone). There is tenderness on pressing on the sternum.
• Pleurisy: Inflammation and irritation of the lining of the lungs and the thoracic cage (pleura) causes a sharp pain on inspiration.
• Kyphoscoliosis (lateral or anter-oposterior curvature of the spine): Curvature of the spine can crowd the ribs together on one side and cause decreased expansion of the lungs. Mild degrees of thoracic scoliosis are common in women and often undiagnosed.
• Abdominal surgery, inflammation, or enlargement of abdominal organs: Distention of the abdomen makes it more difficult to contract the diaphragm and expand the thorax. Irritation or scarring of the abdominal wall muscles limits abdominal expansion during inhalation.
• Endometriosis, fibroids, and other gynecologic problems: Distention of the abdominal and pelvic cavity, pressure on the pelvic floor, and irritation of the abdominal lining due to endometrial bleeding impair full range of motion during breathing. Even in healthy women, menstrual cramps or ovulatory pain (“mittelschmertz” or mid-cycle pain) can cause problems.
• Urinary incontinence: OK, you get the idea.
While none of these conditions directly involves the vocal tract, indirectly they all might affect pulmonary function, the ability to easily expand and contract the lungs and, of course, the ability to sing longer phrases with wide dynamic range and good support.
Disorders of the lungs themselves may, from the singer’s point of view, be classified into conditions causing decreased flexibility of lung tissue (such as emphysema) and those causing decreased caliber of the bronchial tubes (such as asthma). In the case of the first, you cannot get enough air into the lungs, and in the case of the second, it takes more work and more time to fill and empty the lungs.
Apart from the overriding importance of getting enough oxygen, singing with such conditions presents specific problems. The voice may be weak and phrasing may have to be reworked to accommodate the need for more frequent breaths. The singer needs to work harder to move the bellows and needs to adjust glottic tension to reflect decreased subglottic air pressure and airflow. In a more general sense, he needs to continue to keep the pharynx and supraglottic resonators open and “relaxed,” all the while he is increasing muscle effort just below the vocal folds.
When this rebalancing is achieved, the voice will still be adequate, although less powerful or dynamically agile. If the rebalancing is not successful, the singer may complain of vocal problems on top or in the passaggio, difficulty sustaining a phrase, or other technical issues. Since singers with chronic but stable pulmonary disease learn to downsize and accommodate vocally, we more frequently encounter complaints among singers who have acute, temporary, and intermittent problems. They might not be aware of what the cause of their vocal difficulties is, let alone have the time and finesse to compensate, since they are aiming at a moving target.
The main point here is this: while a vocal complaint might direct both the singer and her doctor to focus on the larynx (which is usually found to be normal), they might overlook the many other conditions that can affect the breath and the lungs. Even in the absence of obvious pulmonary problems such as coughing or wheezing, the lungs may not be working to their optimal capacity—and the voice is affected. When these problems, which are outside the vocal tract, are identified, they can be treated, and the singer who is worried about her larynx can be reassured.
Endnotes
1 For the historically curious, an enlightening article on the development of laryngoscopy over the centuries can be downloaded from my website, www.operadoctor.com.
