Dear Dr. Jahn: I am a low-voiced male with a larger voice. I am actually singing pretty well and am lucky enough to be working in some major venues, but I could still use some help to reach my full potential.
I have both allergies and asthma, and I feel that my stamina and range could improve if my throat wasn’t always so irritated. An hour per day of singing is plenty for me. And that’s not really enough for the rehearsal process. I also wake up with about an added fifth on the bottom of my range. This thickness is fun to play with but bad for those early rehearsals!
Singulair is actually enough to beat back most of my problems rather brilliantly, and I have read that this is your preferred drug for my problem. Unfortunately, I am quite sure it has caused me to have reflux in the past. (I was not significantly overweight.) I have also read a lot online about it causing GERD by relaxing the LES. But let’s face it—there are scary stories about every drug online. What’s the truth?
If Singulair helps me, should I just take it and elevate at night, perhaps take an acid-reducer, and risk having GERD while doing a high-profile job? Or just “mark” more than sing out and feel vocally thick often but still be better off than I would be having had a bout of reflux? Coffee and pills such as ibuprofen or bromelain that reduce swelling help, but I know those are not a good idea due to the risk of hemorrhaging.
—Muffled Baritone
Dear Muffled: Lots of questions to address, but let’s start at the beginning. What are you allergic to? Can you minimize your allergy and asthma symptoms by identifying and reducing/eliminating these substances from your environment? A good allergy consultant can help you with this, and might even recommend desensitization shots. While tedious, these eliminate the usually drug-related side effects that allergy sufferers complain of.
Singulair is a good drug, and if it controls your symptoms, it might be a good one to continue. There are newer studies that recommend 10 mg twice a day rather than once a day, and my allergist colleagues tell me that the effect can be significantly enhanced. If you are convinced that Singulair exacerbates your reflux, you could consider a simple oral antacid, such as Gaviscon, rather than start on the more expensive anti-GERD meds like Nexium.
Other treatments for allergies include herbal medications such as stinging nettle capsules. A consultation with a Traditional Chinese Medicine (TCM) practitioner who is versed in herbal medication would be a different but potentially good avenue for you.
Regarding your asthma, you again need to diagnose whether it is allergic or not (other forms include exercise or cold-induced asthma, or infectious asthma). Acupuncture can be very useful for some cases and, again, has the benefit of no side effects. You could explore this with a good acupuncturist.
—Dr. Jahn
Dear Dr. Jahn: One of my students has used hiatal hernias as an excuse for poor breath management. Is there any validity to her complaint that a hiatal hernia would be a cause for difficulties with breath support?
—Deep Breather
Dear Deep: Thank you for this interesting question. There are different types of hiatal hernias, and different symptoms that may occur, depending on the amount of herniation and the competence (or incompetence) of the closing mechanism that separates the stomach from the esophagus. The hiatus is a normal anatomic structure, a small gap in the diaphragm that allows the esophagus to pass from the chest into the abdomen and connect with the stomach. If the hiatus is very large, which may occur with obesity, or a history of multiple pregnancies, then acid reflux is more likely. Since “support” involves contracting the abdominal muscles and pushing the abdominal contents inward (and upward), an incompetent hiatus may lead to a worsening of hiatal hernia symptoms, including reflux.
If your student has a significant enlargement of the hiatus, with a hiatal hernia, this may contribute to difficulties with support. She then should consult a GIU specialist for treatment options. While in the absence of other medically significant symptoms it is unlikely that the doctor would consider operating on the area (called an endoscopic fundoplication), a consultation may still be useful, especially if you and your student have done everything technically possible to overcome the support problem.
—Dr. Jahn
Dear Dr. Jahn: Do you have a recommended regimen for singers performing in arid climates? Twice while performing in the desert, I had situations where my upper register stop phonating and squeaked. I was sleeping with a humidifier in my room, drinking over a gallon of water a day, and even tried taking Mucinex. Nothing seemed to help me regain a feeling of being hydrated. I am scheduled to perform in Las Vegas soon, and want to have this problem tackled by then.
—Desert Singer
Dear Desert: This is a real problem. I remember several years ago one of my New York patients was singing with the Santa Fe Opera and, in addition to the three-hour time change, also had to battle the dryness of the air. I have a few thoughts for you.
First, increase your water intake. I would suggest 8-10 glasses a day, if your stomach and bladder can handle that. If you exercise, don’t forget to replace sweat with additional water.
Second, use saline nasal spray frequently. Since you normally breathe through your nose (although not while singing), you should take advantage of the humidifying ability of the nasal turbinates. Social talking usually is also associated with mouth breathing, so monitor this.
Third, minimize taking substances that can dry your mucous membranes. This includes alcohol, antihistamines, and any other medication that you don’t have to take. (Many drugs, such as antidepressants and diuretics you might take for blood pressure, are also drying). Spend time in the shower or steam sauna, if these are available to you.
And finally, you should think about getting some saline right down into the throat, either using an atomizer spray, a steamer, or a nebulizer. Be sure, however, that you use only sterile “normal” (a.k.a. “physiologic”) saline, which is 0.9 percent sodium chloride. You can buy this in bottles at the drug store.
—Dr. Jahn
Dear Dr. Jahn: A student of mine in his early 60s has suffered from chronic hoarseness for a few years. His vocal folds are healthy and reflux has been ruled out. He recently visited a new ENT who diagnosed that his larynx did not have enough muscle support to function properly, and suggested a procedure called thyroplasty. Can you tell me about this surgery? How invasive is it? Do you know about its success rate?
—Concerned Teacher
Dear Concerned: Thyroplasty is an operation where the position of the vocal folds can be altered, most frequently by inserting a small rectangular prosthesis from the side of the larynx. This is usually done by making a small opening in the side of the thyroid cartilage and inserting the prosthesis, which pushes the soft tissues inside the larynx (primarily the vocal fold) towards the middle.
This surgery is useful for cases of significant glottic incompetence, such as when one vocal fold is paralyzed and the other vocal fold is unable to approximate against it. These are patients who are quite hoarse, often unable to cough and clear their throat, and occasionally even aspirating.
Based on the information you have sent me, I would look at other treatment options before recommending thyroplasty. If the vocal folds look healthy (i.e., they move normally and have a healthy, smooth appearance), I would suggest a stroboscopic examination to see whether they approximate adequately and vibrate properly. Hoarseness can have many causes, and many of these patients can be improved with therapy. If all else fails, your student should inquire about an injection of saline of Gelfoam to the larynx, which would move the vocal fold over temporarily. This should give some idea about whether medialization would help the voice, and with no long-term consequences.
—Dr. Jahn
