Avoid Trauma to the Mucosa
Many things we do with our voice are perfectly normal, and not at all harmful for a healthy voice, in moderate amounts. But too much could potentially cause harm (swelling, see below), and they may certainly prevent a vocal injury from healing. Monitoring these behaviors is crucial for optimal vocal health.
- throat clearing
- screaming, yelling
- hard glottal attack
- extended loud talking (see below)
- extensive singing at pitch or loudness extremes
How loud do YOU talk?
Our patients are often unaware of some of these sources of loud talking:
- Is the TV or stereo on at all times in your household, and do you talk above it?
- Do you talk in the car? (Cars can be very loud, especially with the radio, etc. on)
- At home, do you talk to each other from different rooms?
- At work or school, is the noise level in the room increased by ventilation systems, electronic equipment, etc.?
Vocal Fold Edema
Edema means swelling. Extended high impact to the vocal fold mucosa can cause swelling or edema to the mucosa. Think of clapping your hands together very hard, for a couple of hours. The skin of your hands would become swollen and red. Similar processes can occur with your vocal folds. Edema in the vocal folds can also occur without high impact (such as when you’re ill). The following guide for managing vocal fold edema is aimed at singers, but the principles apply to all vocal athletes (and everyone else!).
Learn to detect edema early
Some individuals never seem to get hoarse, no matter what they do with their voices. Other individuals regularly get hoarse after parties, sporting events, and the like. By now, you probably know which kind of individual you are. Even if you never get hoarse, it’s a good idea to know how to detect swelling. But if you’re prone to hoarseness, you are prone to vocal fold swelling, and you should know how to detect it in your voice even when it’s very mild, in order to keep it from getting worse.
- High soft singing is your best way to detect early swelling. Try singing the first line of “Happy Birthday” very soft, at higher and higher pitches. Or try some scales or arpeggios very softly, very high, and staccato. If you experience delayed onset (a little rush or air before the voice suddenly “cuts in”), that’s a sign of swelling.
- The tasks to detect swelling are only helpful if your technique includes the ability to sing high notes very softly. Very simple, soft vocalizing throughout your entire pitch range should be part of your daily warm-up regimen.
- If you think you may have some swelling on the vocal folds, ask yourself “why?” There are some perfectly reasonable explanations for acute, temporary swelling:
- Premenstrual edema
- Upper respiratory infection, post nasal drainage, or very active reflux
- Recent loud voice use
- If you can’t think of a good reason why you might have some temporary swelling, and you can usually sing high soft notes easily, then you may want to think about your overall voice use in talking, singing, and other vocal behaviors (such as throat clearing), and try to identify why you may be getting some swelling.
- If you think you’re getting some swelling that’s related to your voice use, reduce your vocal fold impact for several days, and see if it starts to resolve. If so, you’ve just learned a very important lesson. If you can’t return to your previous vocal abilities in a week or two of very diligent attention to your technique, then perhaps you should consider calling your voice team (otolaryngologist and speech-language pathologist).
Deal with naturally occurring edema
Some kinds of edema are normal physical responses that you can’t actually override.
- If you have an upper respiratory infection (URI), your vocal folds are likely to become swollen, either from the infection itself or from coughing.
- Use a cough suppressant if you’re coughing. You really want to reduce the cough. Start with dextromethorphan; it’s OTC in cough syrup like Robitussin. Generic is fine. Don’t worry about not being able to cough up mucus in your lungs. You’ll still be able to do that if necessary. The cough syrup keeps you from needless reflexive coughing.
- Beware of medicated cough drops with an anesthetic effect that keeps you from feeling pain. Pain is a useful mechanism that tells you when to stop talking or singing. Anesthetics that help you sleep may be helpful, but an anesthetic effect that lets you talk or sing through your pain may increase the trauma to your vocal folds.
- Non-medicated kinds of cough drops, such as Ludens, are fine, and very helpful. Be careful of the Menthol-Eucalyptus combination, such as in Halls Metholyptus. It feels great, but can end up being drying. Halls Defense or Halls Fruit Breezers are considered more helpful. At the Lions Voice Clinic, we’re fond of Life Savers and Jolly Ranchers.
- Force fluids and inhale steam, just like your mother told you.
- Reduce your voice use as much as possible. Duh.
- Premenstrual edema is highly individual.
- If you’re prone to premenstrual edema, you’ll have to learn your own best way to deal with your singing. For most female singers, it’s a matter of warming up more carefully, and possibly avoiding certain parts of the pitch range, or altering technique slightly for a day or two.
- You may have heard precautions about the use of birth control pills. Many years ago, it was true that birth control pills caused chronic edema in some singers. Currently, the hormone levels in birth control pills are much less than they were in “the olden days.” Recent research shows that female singers generally do not often have singing problems due to the pill. Rather, they may do better because their hormone levels are more stable throughout the month, so they have fewer fluctuations in their voice quality.
Medicating Edematous Vocal Folds.
- If you’re sick and have vocal fold edema, there’s not much you can do to reduce the swelling except to wait it out. If you have a virus, antibiotics will not help you. As with most of the medical community, we do not support the use of antibiotics prophylactically.
- Some singers may want to reduce edema (or avoid edema) by the use of aspirin or ibuprofen. We do not support the use of these products prophylactically, or to reduce edema. These products are anticoagulants (they thin the blood) and therefore may make you more prone to hemorrhage. If you’re using a blood-thinning product for pain while you’re experiencing vocal fold edema, avoid yelling or sudden loud vocal behaviors that could possibly result in a hemorrhage.
- If you have vocal fold edema and have to perform, the edema can be reduced temporarily through the use of Prednisone or other oral steroids. This form of steroids should not be confused with the anabolic steroids used by athletes for performance enhancement. Steroids are powerful anti-inflammatory drugs that have many legitimate medical purposes, and also have side effects associated with long term use. Singers needing to take steroids to reduce edema quickly for a performance often take Medrol Dosepak (methylprednisolone), which is a burst of steroids that is then tapered over 6 days. Doctors sometimes prescribe a longer course of Prednisone to see if vocal fold edema will resolve permanently. At the Lions Voice Clinic, we are extremely cautious about advising the use of steroids to provide better voice quality, because:
- The effect may mask a legitimate case of vocal fold edema, and may make you think you’re better than you actually are, allowing you to do more harm to your vocal folds by overusing them when they should rest.
- With many legitimate causes of vocal fold edema, such as a virus, the edema will return as soon as the steroid effect is gone. While it may make sense to reduce a case of acute edema for a single important performance (followed by voice rest), it doesn’t make sense to try to reduce chronic edema for a week or two if you have a long run of performances with no possibility of rest. This could cause you to injure yourself further.
- It is not sensible to stay on steroids for a prolonged period of time, because the side effects can be worse than vocal fold edema.
Vocal Mechanism Quick Review
The voice is produced at the larynx (voicebox), a framework of cartilage that houses the vocal folds. Each vocal fold is composed of a muscle, covered by a sheath of pliable, moist mucosal covering (mucosa). The larynx has other muscles that make the vocal folds move.
Activities that cause high impact to the vocal folds used to be called vocal abuse. That implies some fault to persons who developed voice problems for normal behaviors such as coughing when they got sick. Now, many voice specialists prefer the term “phonotrauma. We like to say “high-impact vocal activity.”