Maintain the Vitality of the Vocal Fold Mucosa

The analogy of the vocal athlete is appropriate, but it’s complicated by the presence of the vocal fold mucosa. Physical athletes have to think about their muscles and joints. Vocal athletes have to think about their muscles too, but they have to think even more about their mucosa.

Hydration is the most important concept.
The mucosal covering of the vocal folds must be wet and slippery in order to vibrate optimally. There are two kinds of hydration to maintain:

  1. Systemic hydration - the internal hydration of the entire body that keeps the skin, eyes, and all other mucosal tissue healthy
  2. Topical, or surface hydration - the moisture level that keeps the epithelial surface of the vocal folds slippery enough to vibrate up to 1700 times per second!

Systemic Hydration

Systemic Hydration is the internal hydration of the entire body that keeps the skin, eyes, and all other bodily tissue healthy. Systemic hydration comes from the fluid we consume, both what we drink and what we eat.

How much is enough?

The conventional advice used to be: Consume 64 ounces of water every day. In other words, 8 glasses a day of water. New research and more careful consideration of this gives more appropriate advice: consume enough fluids so that you are never thirsty or dry feeling, and your urine is clear, or very nearly clear.

Pee Pale!
Whiz White!
You get the idea.

Luckily, water is anything that isn't caffeinated or alcoholic. If you drink caffeinated or alcoholic beverages, it may be wise to increase your water to compensate. Obviously, there may be health risks with consuming too much caffeine or alcohol, but in moderate amounts they are not damaging per se. Rather, it is the dehydrating effects that can be damaging to vocal health.

Milk and sugared products should not be considered water if they create thickened secretions (make you feel phlegmy) and cause throat-clearing. Some scientists believe that sugared products aren’t as hydrating, because it’s more difficult for the body to use the water in the product.

Carbonated beverages may increase reflux in some individuals, in which case even non-caffeinated pop or sparkling waters should be used with care (e.g., avoid late at night).

Drink more if your physical demands require more, such as athletic endeavors on hot days or prolonged singing. But be reasonable. Too much water can be unhealthy, and too much in too short a time will not help you. A well-hydrated lifestyle will ensure much better vocal health than drinking a gallon of water just before a performance.

Myth vs Fact

Myth: Water must be room temperature, not too hot and not too cold. Cold water will make your laryngeal muscles tight, or will freeze your vocal folds.

Fact: Your larynx doesn’t care. The fluid races down the esophagus, in back of the larynx, and never touches those muscles. By the time the H20 gets back to the cells of the larynx, it’s 98.6 degrees.

However, if cold beverages make you FEEL cold, and that makes your muscles more tense, then don’t drink cold beverages. If you like the feeling of hot beverages, that’s fine. (We bet you won’t burn yourself too often!) Drink the temperature that makes you happy.

For your information

Here are three hints for ensuring that you're well hydrated.

1. Your urine should be clear or very pale. Certain medications and vitamins will cause a yellow tint to urine. Urine may be more concentrated and darker first thing in the morning. Other than that, your urine should be very pale and lacking in odor.

2. You shouldn’t feel thirsty or dry.

3. You should never have a desire to clear your throat. If you constantly feel "phlegmy", it may be because your secretions are thickened due to dehydration. Thickened secretions make it harder for vocal folds to vibrate. Throat-clearing is very abusive to vocal folds. Get more water.

If you drink plenty of water and still have thickened secretions (excess phlegm), it will be important to figure out why. Read the sections on reflux, post nasal drainage, and medications. It may be a good idea to schedule a medical evaluation to determine the source of the dryness.

Topical (surface) Hydration

The mucosal tissues of the entire respiratory system are covered with secretions (think: saliva), providing moisture that is crucial to proper functioning of the tissues and organs. Topical, or surace, hydration, is the moisture level that keeps the epithelial surface of the vocal folds slippery enough to vibrate. It’s the salivary glands that produce the secretions that cover the mouth, throat, and larynx (including the vocal folds) and keep them moist and slippery. Those secretions not only help the vocal folds to vibrate easily, they also help keep the mucosal tissues healthy. The secretions are typically swallowed many times per minute, and you are usually unaware this is happening. If you think you have too many secretions (too much phlegm) it is more likely that your secretions are too thick, often because they’re too dry. Friction and fast breathing can dry up the secretions more quickly than usual. Increased salivary stimulation can help. 

How do we promote topical hydration?

  • Keep your salivary glands stimulated. 
    • Sip on liquids all day long. 
    • Chew gum, suck on hard candies. (But beware of sugar!)
    • Don't bother with cough drops that have "vapor action" - they're rather drying. 
    • Beware of medicated cough drops with anesthetic effects that keep you from feeling the pain that tells you when to stop talking or singing. Anesthetics that help you sleep may be helpful, but anesthetics that let you talk through your pain may increase your disorder. 
  • Keep your environment humid. This can be very difficult in some climates. If your environment is dry, steam can help. Personal steamers are available in drugstores, though you can get the same effect from standing over a pot of simmering water or holding a hot, wet washcloth over your mouth and nose for a few minutes. 
  • A humidifier, especially in the bedroom, can be very helpful.  There are pros and cons to all the various kinds, and the best ones may be the most expensive.  It’s very important to keep your humidifier clean.
  • Keep swallowing to slough off the accumulated secretions. Don't clear your throat!

Special Threats to Hydration

Some classes of medications are particularly drying to the oral mucosa. These include antidepressants or antianxiety drugs, and blood pressure medications. The drying effect is actually related to the intended consequences of the drug. If you need to take these medications, you will want to be diligent about maintaining systemic and topical hydration as best as possible.

Menopause can result in systemic dehydration that can be acutely felt in the mucosal tissues. Hormone replacement therapy can be helpful, but must be carefully considered with your doctor. Diligent attention to systemic and topical hydration is also helpful.

Excessive use of Vitamin C is also associated with dehydration. Actually, it is best to avoid excessive use of anything.

Certain disease processes, such as Sjogren’s Disease, or diabetes, can also cause dehydration. If you have these problems, you will want to be diligent about your systemic and topical hydration as much as possible.

Maintain a nice environment for your vocal folds

Try to eliminate sources of irritation. The two most important are reflux and sinus drainage (post nasal drip). Allergies can be a problem as well.

Reflux
If you suffer from reflux, you may need medical intervention to manage it, though dietary precautions and over-the-counter medications may suffice (see LPRD in our section on Related Problems).

Post-nasal Drainage
Post Nasal Drainage (PND) is a common complaint that has a number of causes, including upper respiratory infection (URI), allergies, sensitivity to inhalants, and non-allergic rhinitis.  Individuals can usually feel the drainage and irritation in the back of the throat and larynx, and often complain of a sense of thickened secretions accumulating on the vocal folds.  This can cause noise in the voice quality, and a need to clear the throat, which is inflammatory if chronic.

  • The first level of relief from PND is saline nasal irrigation. Over the counter saline nasal sprays can be very helpful, and other forms are available.
  • PND may be chronic or serious enough to warrant medical intervention.  Discuss it with an otolaryngologist (Ear, Nose, Throat doctor) and let him or her know you're concerned about the hydration of your vocal fold mucosa.
  • Be wary of OTC (over the counter) antihistamines, which can be very dehydrating.  They can be helpful for reducing histamine reactions to an irritant, such as itchy, watery eyes and sneezing.  And they may help you sleep better when you have an URI (because you can breathe through your nose!).  But they won’t necessarily help you get over an URI faster, and their drying effect may leave you more vulnerable to repeated infection. 
  • OTC antihistamine nasal sprays are notorious for causing rebound congestion (congestion that returns as soon as you stop using the product) as well as being dehydrating.
  • Steroid nasal sprays may be a better option, because they can reduce inflammation without dehydrating the mucosal tissue.  Don’t worry about the steroids.  It’s a very localized effect, and won’t harm you systemically.
  • Some of the newer prescription decongestants or antihistamines may be less drying. For chronic conditions that cause PND, discuss these drugs with your ENT physician.  Take them with a large glass of water, and maintain excellent hydration.

Allergies
If you suffer from allergies, find a team of an allergist and otolaryngologist who are sensitive to your special needs. Managing the effects of allergies may be a long-term endeavor, but it can be done. Make sure you’re not over-medicating or drying your mucosa more than necessary. Also, make sure you maintain optimal vocal hygiene, so you don't exacerbate the effects of the allergies. Remember, it is often not the allergies themselves that cause hoarseness, rather, it is the irritation from PND, and sometimes even the reactions to allergy medications, that cause inflammation to the vocal folds.

The air you breathe, especially where you sleep, may be irritating to your mucosa.  A HEPA filter can be helpful in eliminating irritants in the air

Unfortunately, certain asthma medications can also be irritating to the vocal fold mucosa, and can even cause fungal infections that irritate the vocal folds. If you develop hoarseness associated with the use of an inhaler, it is best to see an ENT physician as soon as possible. A fungal infection can be diagnosed and treated medically. Other voice problems unrelated to fungal infections can also occur with the use of inhaled steroids, and they can be problematic. It can be helpful to work with your pulmonologist to find the lowest dose of steroid that is still helpful, and also to experiment with alternative inhalers. Voice therapy may be useful as well.