Vocal Health and Care of the Voice

As a singer, you are essentially a vocal athlete. You’ll push the coordination and strength of muscles that can be no bigger than your thumbnail. When trying to get your most controlled sounds, high or low, loud or soft, you’ve got to maintain a vocal balance that doesn’t push beyond your muscles ability to handle it.

Usually the misuse, abuse or overuse of your voice is the cause of hoarseness, irritation, fatigue, and the like. Sometimes, your vocal problem can be the result of outside factors such as sickness, allergies, acid reflux, or other disorders. Whatever the problem, let’s discuss some simple ways to deal with them, and get your voice “back on its feet”! These articles should be very helpful:
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Disorders of the Voice

For years I've specialized in working with singers with vocal disorders. I've worked in conjunction with ENT’s, Vocal Pathologists and Speech Therapists to help singers with vocal disorders regain their vocal range, strength and control.

Unfortunately, most singers to a certain extent have an imbalance between the airflow and the use of the “right” singing muscles in the larynx. The result of this imbalance is tension, strain, vocal “breaks”, sudden register shifts, pitch problems, weak tones, breathiness, hoarseness, or strident, pushed, harsh tones, and all to often, vocal disorders.

Many vocal disorders stem from the use of poor speaking and/or singing technique. A few common vocal disorders caused or agitated by improper singing technique are:


VOCAL PRE-NODULES
A vocal cord pre-nodule is an inflammatory area that develops on the vocal cords of people who constantly strain their voices. Pre-nodules have not yet progressed to the true vocal nodule. Pre-nodules respond well to good singing technique, general vocal health care, and conservation of the voice (no straining, overuse or talking/singing to loudly). For singers, treatment requires modification of voice habits, and referral to a knowledgable vocal technique teacher. Resting the vocal cords a bit by allowing little speaking/singing for several weeks may permit the pre-nodules to shrink.

VOCAL NODULES
A vocal cord nodule is a small, inflammatory or fibrous growth that develops on the vocal cords of people who constantly strain their voices. These are also called screamer's nodule, singer's nodule and teacher's nodule. For singers, treatment requires modification of voice habits, and referral to a knowledgable vocal technique teacher, and in more advanced cases, surgery may be required to remove the growth area. Resting the vocal cords by allowing little speaking/singing for several weeks may permit the nodules to shrink.

VOCAL POLYPS
A vocal cord polyp is a small swelling in the mucous membranes covering the vocal cords. As they grow, they take on a rounded shape. They may run the whole length of the vocal cords or be localized. Polyps are lesions that develop from voice abuse, chronic laryngeal allergic reactions and chronic inhalation of irritants, such as industrial fumes and cigarette smoke. It may also be seen in hypothyroidism. Polyps can make the voice become breathy-sounding and harsh. The person may complain of hoarseness. Sometimes biopsy and surgical removal are necessary. They can be removed during the course of a special examination (a laryngoscopy) in which a metal tube with a light on the end is passed through the mouth and into the throat. A small, sharp, cup-shaped punch is threaded through the tube and used to clip off the polyps. Biopsy of the polyp may be performed in order to be certain that there is no cancer. Removal of a polyp should be followed by voice therapy to correct the underlying cause.

VOCAL FOLD HEMORRHAGES
Vocal fold hemorrhage is a fairly rare occurrence that usually is caused by aggressive or improper use of vocal folds (e.g. cheerleading). It is a result of rupture of a blood vessel on the true vocal fold, with bleeding into the tissues of the fold. Weakness of tone, incomplete range and hoarseness are common complaints. Total and complete vocal rest recommended.

VOCAL FOLD BOWING
Vocal fold bowing, can result from neural, muscular, traumatic, congenital, or functional causes, with or without vocal fold atrophy, and can result in vocal weakness. Singers will need to first work with an ENT familiar with the special needs of the professional voice.

MUSCLE TENSION DICORDER
Excessive laryngeal muscle tension squeezes the vocal folds and surrounding muscles, preventing air from moving through the vocal folds. The voice is often reduced to a “squeak”. Singers will need to work with a knowledgeable vocal technique teacher, and quite possibly a Vocal therapist.

Our thanks to the Texas Voice Center
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Maintaining Vocal Health
Article by David Otis Castonguay, Radford University

For many school-aged singers, the choral director is the only significant source of professional instruction and advice they willever receive about their voice. The choral director is their first line of defense for vocal health. A conductor's skill at diagnosis of vocal faults must be matched by a willingness to refer students to the proper health care professional. This is a copy of a handout presented to students in choral conducting and vocal pedagogy classes at Radford University. In addition to the sources cited in the bibliography, and my own experience, this material is drawn from the work of Van Lawrence, M. D., Otolaryngology and Paul Brandvik.

1. Try your best to maintain good general health. Avoid viral colds (a regimen of washing hands hasbeen shown to reduce the transmission of cold viruses). Some advocate vitamin C and zinc lozenges, while I find these effective I would recommend their use these only after the student has consulted a physician.

2. Emotional and physical stress both contribute significantly to vocal distress. Exercise regularly. Using your major muscle groups in jogging,etc. is an excellent way to diminish stress. NOTE: extensive power weight lifting will place some wear on the vocal folds, this should be avoided during times of extended vocal use or vocal fatigue.

3. Eat a balanced diet. At times of extended vocal use avoid large amounts of salt and refined sugar, spicy food such as Mexican, Szechuan Chinese, as well as excessive amounts of food and/or alcohol. One may note hoarseness in the larynx or dryness of the throat after drinking significant amounts of alcohol, caffienated, as well naturally or artificially sweetened beverages. The body needs water to metabolize these foods and beverages, excessive consumption of these items will reduce the amount of water available to hydrate the voice.

4. Maintain body hydration (7-9 glasses of water a day) and avoid known dietary diuretics such as caffeine and alcohol. Moisture is a necessary lubricant of the vocal folds. When one's body is dehydrated laryngeal lubrication diminishes and wear takes place at a much greater rate than normal.

5. Avoid dry, artificial interior climates. Laryngologists recommend a humidity level of 40-50%. Much body moisture is lost while breathing air in low humidity climates, i.e., air conditioned or heated rooms (routinely 10-20% moisture), cars, buses, etc.

6. Avoid smoking cigarettes, cigars, pipes. These are bad for the heart, lungs, and vocal tract of not only yourself, but others around you as well. Avoid other irritant inhalants, i.e., marijuana. In addition to the debilitating effect on the vocal tract, you need your head on straight when you sing.

7. Avoid breathing smoggy, polluted air, i.e., car exhausts, smoky bars and lounges when you are vocally tired.

8. Avoid the use of local anesthetics when you are singing. The anesthetic effect masks any signs of injury, therefore encouraging further abuse of the folds. Additionally, singing under their influence is like playing the piano with gloves on (Chloroseptic, Parke-Davis Throat Discs, etc.).
9. Question the use of progesterone dominant birth control pills. These cause a virilization of the female larynx and a decrease of range in your upper register. There may be no other solution for your particular situation, however. The treatment of endometriosis often includes pharmaceuticals which cause permanent vocal changes. Inform your doctor that you are a singer if you are undergoing treatment for this disease.

Vocal Use Practices

1. Avoid hyperfunctional use of your voice, i.e., learn to use your voice with as little effort and tension as possible. A high school or collegiate singer in training should be able to sing for 3-4 hours per day (when healthy) without debilitating the next day's singing activity. If one cannot sing for this length of time without some disablement, then one should consider a reevaluation of present singing or speaking habits.
2. Keep in mind that the degree of individual vocal conditioning and innate vocal capacity to endure wear and tear relate directly to the amount of singing or speaking one can do each day.
3. Avoid singing in a tessitura which is continually near the extremes of your own range (both high and low). Carefully pace the use of register extremes (such as pushing the chest voice into the upper range for effect, i.e, belting).
MISUSE OR OVERUSE HERE CAN BE VOCAL SUICIDE.
4. Before singing or using the voice in unusual ways (public/dramatic speaking), do some vocal warm-ups. As in any physical activity, the warm-up should proceed from general stretching through less strenuous to more strenuous usage. Loud volume and high range are the most strenuous of usages,therefore, begin in the mid-range with easy production. At every stage along the way, evaluate your present day vocal condition, and adjust your rehearsal activity accordingly. Every voice is different, but 7-10 minutes of warm-up is usually the minimum.
5. Reduce general voice use prior to a concert. While riding the bus to the program, have a quiet period when everyone can conserve energy for the task that is at hand.
6. Avoid shouting, screaming,loud laughter, and heavy throat clearing. Necessary coughing and sneezing should be as gentle and as nonvocal as possible.
7. If it feels bad, don't do it.


Common Signs of Significant Vocal Abuse

1. Throat is tender to the touch after use.
2. Voice is hoarse at the end of singing.
3. Throat is very dry, with a noticeable "tickle" that is persistent. Check dehydration.
4. Inability to produce your highest notes at pianissimo volume.
5. Persistent hoarseness or an inability to sing with a clear voice after 24-48 hours of vocal rest.
Treat your voice and body sensibly when you feel vocally run down. This necessitates the development of accurate perceptions by the singer of why the voice is feeling tired. Accurate self-evaluation will lead one to therapeutic practices which will return you to vocal health in the shortest period of time. In doubt? seek professional help.

Recommended Reading
Brodnitz, Friedrich S., M. D.
Keep Your Voice Healthy . 2nd ed. Boston: College Hill Press, 1988.
McKinney, J. C.
The Diagnosis and Correction of Vocal Faults. Nashville: Genevox, 1994.
Sundburg, Johan.
The Science of the Singing Voice. Translation of Röstlara. Dekalb, Illinois: Northern Illinois University Press, 1987.
Thurman, Leon. "Putting Horses Before Carts: A Brief On Vocal Athletics."
The Choral Journal (March 1983): 15-21
Thurman, Leon. "Putting Horses Before Carts: When Choral Singing Hurts Voices."
The Choral Journal (April 1983): 23-28.
The chart on the following page illustrates many of the points outlined above. While the chart is largely self-explanatory, three factors contributing to vocal distress taken from Thurman's articles perhaps need some explanation.
Disease Circumstances (such as allergies or viral colds) and
Aggravating Circumstances (such as lack of sleep, and spending time in smoky or polluted air) are factors which can cause vocal distress. Predisposing Circumstances include Psychological Stress Reaction - becoming emotionally upset. The emotional tension often associated with such distress has a negative impact on the voice. Persons who suffer from what is commonly called "stage fright" experience the shortness of breath, "lump in throat" and other symptoms which impair good vocal production. Under Heredity, Thurman includes individuals whose vocal mechanism tires at an abnormally fast rate.
 
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Vocal Health
Article by MEWSIC

You have to make your own choices about what to do to take care of your voice and weigh them against other parts of your life. There are all kinds of theories and opinions about what is good and bad for singers. Here are some common beliefs on care of the voice:

Bad For Your Voice:

Alcohol dries vocal folds, Don't drink and sing!

· Don't use Antihistamines if you can avoid them, they dry the respiratory system.

· Anesthetic sprays - they just numb you into thinking everything is OK when it's not!

· Diuretics (including caffeine!) these deplete the body of excess fluids and as a singer you NEED fluids! So if you drink caffeine - drink lots and lots of water to counteract the drying effects.

· Beta blockers - tranquilizers, valium, alcohol, these aren't good for your voice. To overcome stage fright try some of the
techniques covered in my other workshop: yoga, visualization, preparation, exercise, breathing... and remember that nervous energy gives you an edge in performance!

· Don't shout! - Singing, speaking, shouting or screaming too loudly is bad for your voice. Get out of the habit of yelling if you do it often. If you sing in loud venues or with a rock band, use proper amplification for your voice and make sure you can hear in a monitor well enough to not oversing.

· Lack of Good Vocal Technique - using poor or injurious habits.

· Inadequate Sleep · Inadequate Hydration - drink LOTS and LOTS of water! ("Pee Clear")

Good For Your Voice:

· Drink - Drink LOTS of water! - herbal teas without caffeine and avoid hibiscus (it's also a desiccant) this can be tricky because lots of teas have it, but I've heard that just following the herbal tea with lots of water works. If your throat feels tired I suggest Traditional Medicines "Throat Coat Tea" it has slippery elm in it and tastes pretty good as well as making your throat feel soothed.

· Don't eat too much. Wait two hours after a full meal before singing. (Due to interaction of diaphragm and digestive system.) Bring along healthy light snacks to eat if you get hungry. Fruit is excellent because the natural sugar energy it provides gives you a boost when you may need it most!

· Don't PUSH the sound! Avoid situations where you must force your voice. Don't yell to be heard. If you are singing along with many instruments or people in a casual setting either use a microphone or use your hand cupped between your mouth and your ear to help you hear yourself better and remind yourself not to shout. Insist on being properly miked if performing with a band or in a loud setting.

· Avoid Smoke. Don't smoke. Try to avoid smoky places.

· Get plenty of rest. This really is very important.

· Warm up vocally and physically before singing. Get in the habit of it. Make it a badge of being serious about singing. It's very important. Warming up with
vocal warm-ups is better than just "singing a song" because the warm-ups generally help you get you focused on proper technique, which makes you sound better and protects your voice.

· Steam - Take hot showers and take deep breaths and even gently warm up in the shower. Use a humidifier in your house/bedroom/practice room. Consider traveling with a humidifier or steamer. (Hotel rooms get very dry!) Steam anytime but especially when clogged up from sinus congestion, a cold, smog etc.

· Use Saline Nasal Spray - This works! It actually helps your body avoid colds etc, and also opens clogged nasals, and hydrates.

When should I see a doctor? Here's some information on vocal nodes.

Vocal cords aren't really cords, they are actually folds, which is why the term vocal folds has come into use. The vocal fold is where polyps or nodes (nodules) occur. Nodules are most frequently caused by vocal abuse or misuse. Polyps may be caused by prolonged vocal abuse, but may also occur after a single, traumatic event to the vocal folds, such as yelling at a concert. Long-term cigarette smoking, hypothyroidism, and gastroesophageal reflux may also cause polyp formation. Vocal abuse takes many forms and includes: Allergies, Smoking, "Type A" personality (person who is often tense or anxious) Singing, Coaching, Cheerleading, Talking loudly, Drinking caffeine and alcohol (dries out the throat and vocal folds) I am not in any way trained in this area but the following is excerpted from an article in "Vocals Newsletter" and will at least give you an idea:

Here are symptoms that are warning signs of nodes or polyps: Auditory Signs: acute or chronic hoarseness; reduced vocal range; inability to sing at length; recurring laryngitis; a tonal change from a clear voice to one that's breathy, raspy, squeaky, foggy or rough; and the inability to project clearly. Sensory Signs: repeated throat clearing (to no avail); progressive vocal fatigue after speaking or singing; pain in or around the larynx; the sensation or a foreign substance or lump in the throat; recurring throat soreness; tickling, a burning sensation, tension or tightness in the throat; the feeling that talking or singing is an effort; frequent mucus formation; and unusual swelling of veins or arteries in the throat during speaking or singing. Visual Signs: You can't see nodes, only an otolaryngologist or speech pathologist has the training and equipment. in an exam what they see is benign callus like growths that are the body's reaction to undue friction of the vocal fold mucous membranes. Always get a second opinion! There are other things that can have similar symptoms and before ever letting anyone perform surgery on your vocal folds make sure it's really necessary. Nodes can be cured without surgery depending on the severity.

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Acid Reflux
Article by the Texas Voice Center

Laryngopharyngeal Reflux Disease and Recommendations to Prevent Acid Reflux


What is Reflux?

When we eat something, the food reaches the stomach by traveling down a muscular tube called the esophagus. Once food reaches the stomach, the stomach adds acid and pepsin (a digestive enzyme) so that the food can be digested. The esophagus has two sphincters (bands of muscle fibers that close off the tube) that help keep the contents of the stomach where they belong. One sphincter is at the top of the esophagus (at the junction with the upper throat) and one is at the bottom of the esophagus (at the junction with the stomach). The term REFLUX means "a backward or return flow," and it usually refers to the backward flow of stomach contents up through the sphincters and into the esophagus or throat.

What is GERD and what is LPRD?

Some people have an abnormal amount of reflux of stomach acid up through the lower sphincter and into the esophagus. This is referred to as GERD or Gastroesophageal Reflux Disease. If the reflux makes it all the way up though the upper sphincter and into the back of the throat, it is called LPRD or Laryngopharyngeal Reflux Disease. The structures in the throat (pharynx, larynx, and lungs) are much more sensitive to stomach acid and digestive enzymes, so smaller amounts of reflux into this area can result in more damage.

Why don't I have heartburn or stomach problems?

This is a question that is often asked by patients with LPRD. The fact is that very few patients with LPRD experience significant heartburn. Heartburn occurs when the tissue in the esophagus becomes irritated. Most of the reflux events that can damage the throat happen without the patient ever knowing that they are occurring.

Common Symptoms of LPRD:

“ Hoarseness “ Asthma-like symptoms

“ Chronic (ongoing) cough “ Referred ear pain

“ Frequent throat clearing “ Post-nasal drip

“ Pain or sensation in throat “ Singing: Difficulty with high notes

“ Feeling of lump in throat

“ Problems while swallowing

“ Bad / bitter taste in mouth (Especially in morning)

Diagnosis of LPRD:
The following signs seen by the physician are strong indicators of LPRD.

1. Red, irritated arytenoids (structures at the back of the vocal folds).

2. Red, irritated larynx

3. Small laryngeal ulcers

4. Swelling of the vocal folds

5. Granulomas in the larynx

6. Evidence of hiatal hernia (May or may not be associated with reflux)

7. Significant laryngeal pathology of any type

Definitive diagnostic testing for LPRD:

The 24-hour Pharyngo-Esophageal pH monitoring is the gold standard for monitoring reflux events associated with LPRD. A small tube is passed through the nose into the esophagus in order to monitor the amount and type of reflux during a typical day. One of the biggest advantages is that it allows the testing of the patient's system while performing his/her daily routine. In LPRD patients, it is important that the upper channel is placed at the level of the laryngeal (voice box) inlet. A newer test is the combination test of a 24-hour pH probe coupled with an impedance device in the same tube. This gives information about non-acid reflux which some Esophagologists believe in an important factor in many cases of LPRD.

Treatment for LPRD:

1. Stress: Take significant steps to reduce stress!

Make time in your schedule to do activities that lower your stress level. Even moderate stress can dramatically increase the amount of reflux.

2. Foods: You should pay close attention to how your system reacts to various foods. Each person will discover which foods cause an increase in reflux. The following foods have been shown to cause reflux in many people. It may be necessary to avoid or minimize some of the following foods.

A. Spicy, acidic and tomato-based foods like Mexican or Italian food.

B. Acidic fruit juices such as orange juice, grapefruit juice, cranberry juice, etc...

C. Fast foods and other fatty foods.

Caffeinated beverages (coffee, tea, soft drinks) and chocolate.

Peppermint

3. Mealtime:

A. Don’t gorge yourself at mealtime.

B. Eat sensibly (moderate amounts of food).

C. Eat meals several hours before bedtime.

D. Avoid bedtime snacks.

E. Don't exercise immediately after eating.

4. Body Weight: Try to maintain a healthy body weight. Being overweight can dramatically increase reflux.

5. Nighttime Reflux: If the 24-hour pH monitoring demonstrates nocturnal reflux, elevate the head of your bed 4-6 inches with books, bricks or a block of wood to achieve a 10 degree slant.
Do not prop the body up with extra pillows. This may increase reflux by kinking the stomach. Recent studies by the Texas Voice Center have shown that reflux occurs much more often during the day when upright. Therefore, this suggestion may be much less important than once believed.

6. Tight Clothing: Avoid tight belts and other restrictive clothing.

7. Smoking: If you smoke, STOP!! This dramatically causes reflux and many other evils to your body!!!

Medications for LPRD:

Medications such as H2 Blockers (Axid , Pepcid , Tagamet , Zantac), have been used in the past and may serve as useful additions to proton pump inhibitors; however, the drug class known as proton pump inhibitors (Prilosec , Prevacid , Axid , Protonix, Zegerid or Nexium ) are the most effective and may be prescribed or recommended by your physician.

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