Dear Dr. Jahn: I have lost about 75 pounds and have excess skin in my abdominal area. It is bothersome because it really distorts my figure and I have to constantly wear a girdle. I am considering having a tummy tuck but am concerned about how the surgery would affect my voice since the abdominal muscles are “tightened” during surgery. Another option would be a panniculotomy, which only removes the skin.
Do you know how these surgeries might affect the voice? I have searched everywhere for this information but can’t find anything. Any information or help you can give me would be great.
—Suddenly Svelte Soprano
Dear Suddenly: To get the full answer to your questions (and, certainly, if you are considering this surgery), you really need to talk to a surgeon who specializes in this kind of procedure, either a bariatric surgeon or a plastic surgeon. My experience with singers who have lost a lot of abdominal weight, either from surgery or drastic dieting, is that they have difficulty supporting the voice. They really have to rework the breath until the abdominal muscles have adjusted to their new “resting position.” Removal of just abdominal skin and fat (superficial to the muscles) should not have any effect on your voice. Suturing the muscles (primarily the rectus abdominis muscles in the front) would alter their range of contraction, but I suspect with adequate work you should be able to retrain these muscles to adequately support the voice.
—Dr. Jahn
Dear Dr. Jahn: My asthma was diagnosed about 10 years ago (I am 61) and I began using Azmacort and Serevent, which mostly kept my coughing at bay. A few years later I consulted a Marin County asthma specialist who recommended Advair, which I tried several times, each time being frustrated by hoarseness and the loss of about a sixth at both the top and bottom of my range. This doctor had never encountered anyone who complained about Advair and advised me to give up singing if need be rather than going back to the older medicine. (I have since read your article mentioning the same reaction to Advair by other singers [See “Asthma: What Singers Need to Know,” Nov. 2005].)
Unfortunately, my meds (I’m also now taking Singulair) no longer seem to be effective. Is there any newer or more effective medicine that you know of to control my asthma without impairing my singing voice?
—Breathless in Buffalo
Dear Breathless: I have seen many patients, both singers and non-singers, who have developed hoarseness from Advair. I advise them to discontinue this drug if at all possible. We believe the culprit is not the drugs in the spray, but the vehicle. In most cases, alternative inhalers may also work, either a combination bronchodilator/steroid or two separate sprays. If the only option you were given is to stop singing, I would get another opinion.
—Dr. Jahn
Dr. Jahn: I am a mezzo-soprano currently in between undergraduate and graduate school. I read your article “Mind Control” in February’s Classical Singer, and it pertains to a problem that I have had on and off since I began singing again five years ago. It has to do with swallowing. A couple of weeks ago, I almost choked on a piece of food and it seems that since then I have been overly conscious of swallowing. I am only able to swallow small pieces of food without making myself choke. Water is no problem, which tells me that there is nothing physically wrong with me.
I know this sounds crazy, but I have somehow trained the muscles of my throat to behave a particular way and don’t know how to retrain them to swallow without thinking about it. I know you wrote that we can consciously control things that are not normally controlled with the mind, and that seems to be what I am doing. Do you have any idea how I might get back to swallowing normally? Please help me if you can. Any advice would be greatly appreciated.
—Occluded in Oregon
Dear Occluded: This is an interesting problem. I would first make sure that there is nothing anatomically wrong with your swallowing mechanism. There can be situations, such as a partial obstruction or muscle spasm, where liquids go down okay but solids don’t. I would then make sure you don’t have acid reflux, which can irritate the sphincter at the upper end of the esophagus and make it too tight. Then, you need to get a cine barium swallow, which evaluates your swallowing process. If all of this is clear, I would see a swallowing therapist—this is a subspecialty of speech therapy that teaches patients (more often after a stroke or neurological problem) how to swallow. Of course, all of this should be directed and coordinated by a doctor, preferably a gastroenterologist.
—Dr. Jahn
Hi Dr. Jahn: I am a 21-year-old musical theatre singer (soprano and mix belt), and I wake up hoarse and breathy every day. The quality of my voice improves as I talk and as the day goes on (and sometimes when I eat—I feel that it warms up my cords), but I notice a constant delayed onset, particularly when I am creating a legit sound. I usually allow my voice to be breathy in order to reduce the pressure on my cords, and though I have been training for years, this breathiness is hard to overcome in my upper register. My voice doesn’t seem to have much stamina lately, either. I rarely lose my voice completely, but it feels and sounds weaker if I sing full out a few days in a row. I have to use a lot of breath to produce sound in my mix especially.
I am sure that this is a partially technical issue, so I have been trying rest, but I still wake up hoarse and feel like I spend the day coaxing my voice back into a full sound. I don’t think my voice has been at 100 percent in years. I have been scoped twice for nodules and have had an upper endoscopy in search of acid reflux, only to get negative results for both. I do have an allergy to dust, so I have tried a filtered humidifier, allergy shots, antihistamines (with tons of water), hypoallergenic covers, nasal rinses, you name it—nothing has worked.
I noticed that my stamina problem became particularly prominent after I sang on a cold four years ago. I suppose I must have formed some bad, sticky habits in that process. I warm up every day very easily, and I don’t do anything that hurts or feels strident. What can I do to improve this? Is there a problem here, or do I just need to let go of my frustration? I am beginning intense training to work in musical theatre, but if the condition doesn’t improve, I fear that my voice will be useless. That free, brilliant, full tone that I know it can have has become elusive and inconsistent.
One more thing: if I’m sitting on a bed or a couch, my voice gets raspier and a bit crackly. The delayed onset also gets worse, and I feel like I just woke up. This makes me think that the problem really is the dust allergy, or something related to it. However, I don’t sneeze, my nose doesn’t run, my eyes aren’t itchy. The only symptom is a raspy voice. But, as I said, since I’ve tried the strongest anti-allergy medication (shots) I know, I have no idea how to fix this problem or target whatever else might be causing it.
—Thoroughly Flummoxed Millie
Dear Thoroughly: This may be a stumper! This really is one that calls for a visit, not a letter, since there are many more questions. To review, you wake up hoarse and, based on your perception of delayed onset and vocal fatigue, you probably have some swelling of the vocal folds. The fact that this improves later in the day and with voice use makes me think that it has to do with either your reclined position or something in the bed or bedroom environment. On the other hand, you also noted similar problems when just sitting on a bed or couch.
You are a young woman, but you didn’t say anything about your weight. Are you overweight? What are your evening eating and drinking habits? You did say that you have no nasal obstruction. Do you have large tonsils? Do you snore? Are you a mouth breather?
The obvious two possibilities are nocturnal acid reflux and allergies. To completely rule out reflux, you need to have a 24-hour pH monitor study, since visual examination of the vocal folds may not give you enough information. Do you have a dry or sore throat in the morning? Do you sleep on your back or your side, elevated or not? Whether GERD is diagnosed or not, I would try a course of a proton pump inhibitor (like Nexium) before dinner plus a liquid antacid at bedtime, for a month.
The allergy issue: I understand you have taken some strong antihistamines. Do you take these at bedtime, since they can also dry you out and make you hoarse? Short of shots, you can hypoallergenize your bedroom environment (zip covers for the comforter, no shag rugs, no drapes), and try using an air purifier to remove any particulate matter from around the bed.
In addition to a full ENT evaluation, including stroboscopy, I would also check your thyroid and pulmonary functions.
—Dr. Jahn
