This column is in response to a reader’s request—a simple enough question—when should a singer see her ENT? But like many simple questions, the answer is more nuanced. While the absolute indications for a medical visit are clear, the relative indications are less self-evident—and open to discussion.
One absolute indication for a laryngeal examination is a sudden loss of voice. I refer to a sudden and painless onset of hoarseness, which may occur while singing or straining. This is the clinical presentation of a vocal fold hemorrhage, and it needs to be identified and managed as early as possible. It is different from a gradual hoarseness or discomfort after excessive singing, or hoarseness in the context of an upper respiratory infection.
Another indication for a visit is hoarseness that persists after a cold or viral infection is over. If you are still hoarse one week after all of the other viral symptoms have resolved, you might benefit from having the vocal folds examined. Conditions such as vocal fold paralysis can develop in this environment. A confounder here is that vocal fold paralysis might be partial and, as with other types of laryngeal impairment, a singer can compensate to a degree. So, if your voice is hoarse, even after maximal compensatory posturing (such as increasing muscle effort in vocalizing), a medical visit may be helpful.
Gradual onset of hoarseness that persists or grows worse may be due to vocal fold nodules. Here, the timing of your visit is not crucial, but there comes a point when—even with adjustments of technique, repertoire, and schedule—you are simply no longer able to do what you used to or what your job requires. Time to see the doctor then.
Infections of the vocal tract are, as a rule, more likely to be viral than bacterial. You need not run to the doctor for every sniffle or sore throat. On the other hand, once a bacterial infection develops, antibiotics can be beneficial. I would recommend initial self-treatment with vitamin C (or one of the vitamin C-containing preparations), nasal washing, and oral zinc gluconate tablets. The presence of green or yellow mucus, whether from the nose or the chest, is evidence of pus in the secretions, the result of a bacterial infection. At this point, you are still not obligated to see the doctor. But if the bacterial infection persists beyond a few days, or if your symptoms progress (e.g., from the nose to the throat and to the chest), a visit may be in order.
Pain in the throat that persists beyond three or four days, especially in the absence of other symptoms, is another reason to see the doctor. Oversinging, due to inadequate technique or other reasons, frequently causes discomfort during performance. I am referring here, however, to pain that occurs in the absence of vocal effort—pain that is present on swallowing or that radiates to the ears should be investigated. When persistent pain is associated with difficulty (as well as discomfort) on swallowing, you definitely need to see your ENT.
In general, then, if you are sick and not getting better, vocally or otherwise, you should see your doctor—either your primary physician or a specialist in the area where your symptoms lie.
One final absolute indication for a visit is if your doctor tells you something that doesn’t make sense to you, if your symptoms are not improving, or if surgery has been recommended. This is the time to consider a second opinion, which involves seeing another specialist—hopefully one who has experience in the management of singers.
Relative indications are more nebulous, but should also be discussed. In general, if you feel you are not getting your normal sound even though using good technique and observing all the usual health measures, at some point you may feel better to have your vocal folds examined. The occasional “preventive” visit, prior to an important audition, performance, or tour, is not inappropriate. Similarly, some singers stop by for an examination after returning from a strenuous tour abroad, especially if they had to sing under difficult conditions or with a cold.
While I am always happy to see my patients, especially when I can give them a clean bill of health, I don’t advocate “routine” visits, which can encourage an emotional dependence. As singers, you know best when the voice is not doing what it should do. You need to remain master of the voice and make decisions regarding medical visits based on your own auditory and proprioceptive perception of the voice, rather than outsource that control to someone else, even if he or she wears a white coat.
