Dear Dr. Jahn: I have an issue and I’m not sure what is causing it or why it is happening.
Three years ago I was performing in a concert and it was five days after returning from Europe (so perhaps I was exhausted). Toward the middle of the concert, I sang “Vissi d’arte” and when I sang the high notes toward the end of the aria, I had a shooting, stabbing pain in my head. After the aria, I had a few moments backstage and put a cold bottle of water on my forehead. It seemed to subside within several minutes, and I was able to continue singing without incident for the rest of the evening. At that time, my mother had seen me from the audience and saw that my face turned just about purple. She thought that it was just because I was holding the high notes for a long time. When I told her about my head pain, she had much more concern.
Three years have passed now and just this past weekend I was performing in concert, and during “Mi chiamano Mimì,” once again when I sang the high notes, the stabbing pain just about knocked me off of my feet. Honestly, no exaggeration! Only this time, I was unable to escape to a backstage and had to continue singing until the end of “O soave fanciulla.” There was such pain in my head that I could barely stand. I had about seven minutes to recuperate and that helped a bit—but any song that I sang after that, singing high notes caused pain.
When I finished the concert, the discomfort slowly abated, but the next morning I had a bit of a throbbing ache still on the right side of my skull. The pain seems to be located from my temples throughout the entire front of my forehead.
Now, I am so apprehensive to sing high notes; however, I have performances up and coming and I have to force myself to try and see what happens during vocal exercises. I thought the first time was an anomaly, but now after a second instance, I need to know if I have need to be concerned—or, if it’s a physical thing that I am doing while I’m singing, I need to understand and correct so that I don’t do it again.
I hope that perhaps you can help to shed some light on my plight. Thank you, and I hope to hear from you soon!
Dear Reader: What an unusual problem! I was thinking about your story and, as usual, have some ideas for you to consider.
You didn’t say where the pain was, although it sounds like it was over your forehead. If that’s the case, I would consider that your frontal sinuses may be responsible, especially since the first episode involved an airplane flight also. As you know, the focus of resonance in the body varies with the pitch of the note, and head notes typically resonate in the mask. As you go up higher, however, the focus of resonance shifts, and I’m told by high sopranos that the very high notes feel like a column of sound that comes out the top of your head. It would then make sense that with your higher notes, the area of vibration in the head would shift from the maxillary and ethmoid sinuses (“the mask”) up into your frontal sinuses. If the sinus problem is intermittent, then you might experience pain only intermittently.
Much less likely is that the increased pressure from singing high and loud increases intracranial pressure, and the pain comes from distention of the meninges by increased pressure from the cerebrospinal fluid. You could sort these two possibilities out by experimenting to see whether the pain is there with high notes even when you sing more softly or just when you push for a prolonged amount of time. If it’s present only with hard pushing, you should see if it also occurs when you push hard in other situations, like in the bathroom.
The third, and least likely, possibility is that this is some form of neuralgia. I’m thinking of a form of “brain freeze” that you get from eating ice cream. Brain freeze is sphenopalatine neuralgia, and triggered by cold ice cream touching the soft palate. If what you have is neuralgia, then the pain should not be just localized, but should radiate along the distribution of the nerve. Other nerves in the nose (like the anterior ethmoid nerve) can cause radiating pain over the face.
Most importantly, however, please see a doctor—either an ENT for sinus evaluation or a neurologist. While this is unlikely to be something serious (apart from the impact on your singing), you should try to get a diagnosis based on physical examination and imaging studies.
—Dr. Jahn
Dear Dr. Jahn: Thank you for your reply. If you don’t mind me asking, I have another follow-up question. I had a sinus CT yesterday and have narrowed maxillary sinuses with infection, according to the CT findings. My ENT has recommended balloon sinuplasty dilation at this time. Is there any negative affects on the singing voice from having the maxillary sinuses dilated in this manner? Again, I’m unable to find any substantive information online regarding BSD and its affect (positive or negative) on the singing voice.
Dear Reader: In response to your second question, balloon sinuplasty is the latest gadget in the field of sinus surgery. Rather than enlarging the sinus openings surgically, this procedure involves slipping a catheter through the openings and then blowing up a balloon, expanding the narrow connection between the nose and the sinuses. Although there may be some advantage to this office (rather than OR) procedure, in my opinion this is a rather limited surgical technique which has limited applications. It is certainly not as versatile or as broad in its efficacy as conventional endoscopic sinus surgery.
The effects on the voice should be minimal. If anything, it may improve resonance and volume, although not to the same degree as conventional endoscopic sinus surgery, especially if the latter is combined with septoplasty.
—Dr. Jahn
Dear Dr. Jahn: I recently read an interesting article you wrote in Classical Singer on “Rhinoplasty and the Voice” [December, 2012].
I was recently diagnosed with chronic sinusitis, a 50 percent deviated septum on the left, and extremely enlarged turbinates primarily on the right. My ENT put me on antibiotics as a first step before doing a CT scan, which is a requirement of my insurance provider.
My situation is that, as a singer, I have always struggled with finding my head voice and placement in the mask. At times it’s as though I don’t even have a head voice—and at other times, I can find it but have a limited upper range, even as a female singer.
Is it possible or likely that enlarged turbinates and deviated septum are causing my singing issues in addition to the chronic sinusitis? I actually quit singing a few years ago because of my struggles, but am taking it up again. I’m considering corrective surgery if it will help my sinusitis and am cautiously optimistic that this may also help my singing voice placement. I don’t want any additional issues on my singing voice, so would appreciate any feedback you might be inclined to share.
Thanks in advance for considering this request.
Dear Reader: I suspect not much has been written on this in the medical literature, but let me share with you my personal experience, after 36 years of clinical practice and many hundreds of septoplasties.
The sensation of being “in the mask” is related to the resonance generated by the voice in the nasal cavities. This in turn is a function of the size of the two nasal chambers. My singer patients have told me that a septoplasty and turbinate reduction has improved their voice in several ways. I pass these on to you without, of course, being able to personally verify them:
-It is easier to put the voice into the mask.
-The voice has moved forward.
-It is easier to access higher notes.
-There is a greater depth (richness) to the voice.
-The voice is bigger.
When I suggested to a patient that the last “improvement” above may just be a subjective perception due to increased skull resonance, this patient (a tenor) said that his teacher also said that his voice sounded bigger.
If there is a good medical reason to get the surgery (remember, the insurance company will not pay otherwise), you should also benefit vocally. This may not solve all of your technical problems, but there is very little downside.
—Dr. Jahn
Disclaimer: The suggestions Dr. Jahn provides 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.
