Causes and solutions for Vocal Problems
"Lost in my thoughts I wandering find
a place in my mind to unwind,
it's a tiny dark corner with a stool and a loner who strums and sings in the night
no audience there to bear witness or share
in the melodies fair, only me
but I sing nonetheless in the darkness, abyss til the pestilence leaves me be. " -Mark Lincoln
Does singing come as natural to you as drawing a single breath and equally as important, rendering unto you a suffusion of novel ideas, fresh insights and exhilaration? Does it bring you life, energy, power, escape, peace and solace from a hostile world? Do you absolutely have to have music on at home, in your car, in your office or wherever you are and usually find yourself singing along to it, even when you don't really know the words? If you've answered yes to any or all of these questions then it's quite possible that you are a singer. Yes, a singer. What I mean to say is that you are one who is not content to sit passively watching others as they raise their heads and voices to the heavens and sing their hearts and souls out, but rather you are an active participator in the grand celebratory process of singing and the joy that it brings to your life. It doesn't matter whether you like the way you sound (most of us don't), or whether you're a professional performer, or this week's winner on American Idol. No. You simply love to sing simply for the pure and unadulterated enjoyment of pursing your lips together and releasing those lyrics from within, primal yet resplendent in nature and bordering on sublime.
Because you're a singer, your voice is central to your being and to who you are as a musical being, and as instrumental to your daily life as if it were an appendage, another finger, a third hand. But as many singers consider song a unique and particularly powerful form of expression that defines them, the loss of one's voice can be difficult on more than one level. Foremost, and most obviously of course, is the inability to hum-sing-perform, talk; the loss of which by itself can be utterly crushing to the singer, especially one who has incorporated singing into their livelihood in some manner or has a particular passion for song. Figuratively though the loss of voice can be equated with the loss of power, expression, communication, singularity in the crowd and worse, one's sense of individuality. Many of us define ourselves in terms of what we do (our careers, hobbies, passions) and when circumstances dictate that we must make drastic changes in our daily activities, especially when what we do is truly what we love to do, we're often forced to redefine who we are. Consequently the loss of voice, the inability to sing, express yourself with the same power and poignancy that you were once able can be utterly devastating and life-changing on many levels.
In lieu of the importance that many of us place upon our voices and the role that singing plays in many of our lives, it is of the utmost importance that we treat our voices with ultimate care and avoid or treat harmful agents that may cause vocal damage. There are numerous conditions that can cause damage to the vocal chords and to the voice itself although not all voice problems (or throat problems for that matter) will result in chronic long-term types of issues. In fact, some of the more serious types of conditions may have no symptoms at all or what the medical industry deems asymptomatic.
Let's take a look at various voice-related conditions beginning with the most benign and working our way into the more serious of the conditions.
1. Condition: Dehydration
Yes, believe it or not dehydration can cause the vocal chords, or folds to dry out reducing or eliminating the natural thin layer of mucus and making it more difficult for the folds to vibrate in the manner necessary to create sound, voice, song. Because the vocal chords are in effect rubbing against each other while in a state of vibration, they are more prone to dry out and eventually cause problems like hoarseness, soreness, lack of potential range/singing duration, and possible nodules (we'll talk more about these later).
The proper amount of water or other fluids needed will be different for each individual based on climate, career choice, exposure to the sun, and even what other fluids are being consumed as some will actually dehydrate the body (i.e. coffee or other caffeinated beverages, alcohol, beverages with artificial sweeteners). Relative air humidity in your home will also have an effect on your body's hydration level and many employ in-home humidifiers, even in the wintertime to counter the desiccating effects of dry air.
Fortunately the outlook for this type of problem is excellent if the proper steps are taken. As stated above, each person has different needs based upon numerous factors but 64 ounces of water a day is usually a safe bet. Obviously more is required if you're working out, working in the sun, drinking alcohol etc and coffee drinks can drastically deplete the body of precious moisture. To combat this problem the rule of thumb is to consume a 1-1 ratio of water to coffee so if you're drinking multiple cups a day, you will likely need to step up your water consumption to accommodate your caffeine consumption as well. If you're an entertainer and readying yourself for an important performance, or someone who uses their voice for long periods of time in the workplace, you'll need to be even more aware of the need for hydration in lieu of the fact that you are putting an increased level of demand and strain on the vocal chords and will subsequently be more prone to dry out the folds.
2. Condition: Acid Reflux
Many are unaware of how one's diet can affect the relative health of their voices and how changing what one eats can commensurately improve vocal health. Acid reflux is a process whereby weakened areas of the Esophagus (the tube through which food passes to the stomach) allow stomach acid to to move up and into the Larynx (voice box). Possible symptoms of Acid Reflux include frequent need to clear the throat, choking feeling, chronic cough, hoarseness, difficulty swallowing, sensation of having a lump in the throat, sour or acidic taste in the mouth and recurrent sore throat. This process may or may not cause heartburn and can, if left untreated, cause permanent damage to the Esophagus including cancer.
Consequently, it is imperative that if you have any or all of these symptoms that you see a doctor specializing in Ear, Nose and Throat issues to have a proper diagnosis done and begin the necessary treatment. Most acid reflux issues are easily rectified with over-the-counter medication and a change in diet and eating habits. Spicy and fatty foods as well as acidic (i.e. tomato based) products can be catalysts for acid reflux as can chocolate and peppermint. One of the most common culprits for the condition though is eating late in the evening when you're body is readying itself for sleep, and the angle at which your body rests can be an avenue for increased acid prevalence in the larynx.
Many singers complaining of throat soreness and hoarseness have discovered that a change in diet and the habits that they have developed over time (many of them unhealthy in general), can help to reduce the presence of stomach acid in the larynx and allow the voice to heal. Other areas that should be considered in terms of acid reflux include consumption of aspirin and ibuprofen, smoking, tight fitting clothes (i.e. pantyhose, tight waste bands etc.), working out near to bed time, stress, and last but certainly not least, obesity.
The potential for recovery from acid reflux is good especially if the condition is recognized and treated early in the disease's progress, although it certainly can and will return if bad habits and corrosive foods are consumed. But along with proper hydration, and diet and life style changes acid reflux can be managed and the voice can be returned to its former glory.
3. Condition: Vocal Strain/Fatigue
In lieu of the fact that the voice box is composed of tissue it is prone to the unfortunate ravages of wear and tear and time. Overuse of any organ in the body will ultimately result in failure and the voice is no exception to this rule. There are a number of reasons why your voice may become strained and first and foremost among these is excessive talking. Individuals who rely heavily upon their voices, whether it be for their careers or simply because they have a tendency to express themselves more often through verbalization, are more susceptible to voice related problems. Teachers, for example, are at least 25 times more likely to develop voice fatigue than individuals whose jobs demand less speaking and verbal interaction. Actors, speakers, radio announcers, disk jockeys and therapists also merit inclusion in this unfortunate category as well and have higher incidences of voice-related issues. Speech-related activities that can lead to strain are clearing the throat, whispering, screaming/yelling, harsh coughing and of course singing.
Symptoms of voice strain are similar to those seen in cases of dehydration and acid reflux and include hoarseness, dryness, tickling sensation, tightness/pressure, general fatigue and lack of vocal energy, huskiness, croakiness (often heard in "older" voices but abnormal in "younger"), breaks in the voice, pitch changes, reduced range/projection and running out of breath while speaking.
Singing when done "correctly" and in combination with other healthy practices like proper breathing, hydration and thorough warm-ups shouldn't harm the vocal chords. Unfortunately many singers do not adhere to these notions considering themselves impervious to vocal damage and clinging fast to the illusion "that may happen to other people but it'll will never happen to me!" Every voice is prone to the same infirmities as the person next to you and should be treated with care in order to avoid strain. There are other steps though that we as singers can take as well to prevent the onset of vocal strain when we're singing.
A. Avoid singing in a key that is too high or too low for you! This is an extremely important element of voice care as many vocalists singing out of their natural range have ended up with career ending nodules on their vocal chords. Singing out of the natural range puts pressure on the vocal chords and can cause catastrophic problems for any vocalist.Awareness of your habits can be an excellent first step in bringing your tired voice back to life. Many people clear their throats continually throughout the day, seemingly without consciousness of their actions. Taking a sip of water instead of throat-clearing is a voice-friendly way of clearing the throat without overusing precious voice energy. The manner in which we speak can also cause strain to the voice. Here are a number of tips recommended by speech therapists that can help reduce the amount of pressure and strain that you may be exposing your voice to simply by speaking:
B. Arrange on-stage monitors (if you're a performer) so that you're able to hear yourself clearly. In loud environments it can be difficult to hear oneself sing which in turn causes the singer to sing louder and louder, which in turn can cause strain.
C. Reduce the quantity of singing-soloists are at particularly high risk for vocal strain since they're providing the only voice to the mix. One way to reduce the amount of voice being used is to include a number of instrumentals into the set's to give the singer breaks periodically. If you play with other singers see if you can swap vocal parts and include as many people as possible, that is if they know how to sing!
D. Resting the voice in between sets, between gigs, or anytime you can is important if you're a singer and want to keep singing for the long haul. Many professionals including opera singers won't as much as speak for weeks before a performance.
A. Use plenty of breath while speaking-some voice therapists say to "create a pillow of air around the voice" while speaking (or singing) in order to cushion the vocal chords from harm.Prognosis
B. Leave plenty of space in your throat and mouth and keep your facial muscles loose, rather than squeezing out the words with the vocal cords. Yawning periodically is a good way to remind yourself of how your mouth should feel. In general, you want to have a relaxed feel in the tongue and jaw as well and not have any tightness in the neck region.
C. Enunciation - Open your mouth and speak clearly rather than muttering or "swallowing" the words. Swallowing can be equated with speaking in the back of the throat which puts considerable pressure on the voice and can lead to strain. One way to alleviate pressure related to this is to practice speaking at a slightly higher range than you usually do, perhaps a whole step (one tone). This can increase awareness about word-swallowing and reduce potentially damaging pressure in the larynx.
D. Avoid starting a word before beginning to let breath out through the vocal cords. Ultimately, you want to have speech and breath release occurring at the same time in order to keep pressure to a minimum.
E. Warm-up your voice in a fashion similar to a singing regiment (if you have any questions about a good warm-up routine please see my voice and performance series on the JamPlay site).
F. Articulate your words while talking and incorporate pitch and inflection. Speaking in a monotone energy-less fashion actually puts more strain on the vocal chords.
G. Balance - Avoid situations where you might be yelling, screaming, or otherwise pushing your voice beyond its capacity. This can be a difficult one to avoid for some especially if you're prone to express yourself in a vocally demonstrative fashion, or use yelling and screaming as a dynamic performance tool. Talking and singing in general when suffering from strain should be kept to a minimum and many doctors recommend vocal rest as long as two months to their patients suffering from vocal fatigue. Just keep in mind that overuse and abuse of the voice will likely result in problems and ultimately, failure.
The prognosis for recovery from vocal strain is good unless permanent damage (i.e. nodules) has been done due to continual and prolonged abuse. By combining hydration with good speech and vocal practices, and even considering seeing a vocal coach or speech therapist, the voice is likely to return to its healthy state of being. Again, if you're concerned about any symptoms you're having and want to pinpoint the causes and courses of action it's always in your best interest to see a doctor who specializes in the treatment of throat and voice-related issues.
4. Condition: Allergies
Having a familiarity with the physiology of the sinuses and their relationship to the throat and voice can be very insightful, especially if you're suffering from a voice disturbance. Because the nasal passages drain directly into the larynx, the voice is especially prone to problems resulting from post-nasal drip and inflammation, symptoms of allergy related infirmities. This can cause the same or similar symptoms as dehydration, acid reflux and vocal strain so it can be difficult to know for sure exactly what's causing your problem and how to treat it effectively.
There are different approaches to allergy treatment including holistic types of medications that can be quite effective at alleviating symptoms. One product that is being heralded as a wonder-substance in the relief of symptoms associated with hay fever is called European Herb Butterbur or Petasites Hybridus. Butterbur has been proven in clinical studies to be as effective as some antihistamine drugs at symptom alleviation but without the drowsiness often associated with such medications. Saline Nasal Irrigation is another effective non-invasive treatment for certain types of allergies which can cause or contribute to vocal distress and fatigue. Of course there are steroid-based products like Nasonex or Flonase which can help to reduce inflammation in the nasal passageways and commensurately decrease the amount a drip occurring in the larynx. Unfortunately there may be side effects associated with steroid based products including the tendency for some of them to lose their effectiveness over time.
Prognosis for recovery from allergy related voice issues is excellent especially when treatment is continued over time and adhered to during peak allergy seasons. Keep in mind though that some medications can actually do more harm than good to the voice, so it's important to consult with a professional about the appropriate medications for your particular situation. Also, increasing levels of hydration can aid in recovery as allergies tend to dehydrate the tissues in the throat contributing to dryness, hoarseness and soreness.
5. Condition: Nodes and Cancer
Probably the most frightening news that a singer (or anybody for that matter) can hear is that he or she has a mass of some sort in the larynx. There are a number of different types of growths that can occur in the throat ranging from simple benign nodules, to cysts, to the dreaded cancer. On the bright side, all of the conditions including cancer are treatable and usually have relatively positive prognoses depending on the severity of the condition. Let's take a look at each of the types of growths as these are likely the most ominous of potential debilities that can befall the human voice.
A. Nodules - Also known as nodes, singer's nodes or screamer's nodes. This type of growth is caused by overuse of the vocal cords and usually appears on each side, in the middle of the vocal cords, facing each other. There are two types of vocal cord nodules: soft or young nodules and hard or old nodules. Younger nodes are much easier to treat and are far more likely to go away without surgery, so it's important to diagnose them as early as possible in their stage of growth. Many times, nodules diminish or disappear when the trauma or misuse of the vocal cords stops but this is less likely to occur with older, harder nodes that have been in place for a long time. Large, fibrous or chronic nodules may require surgical removal and may leave scar tissue that can affect the voice's quality, or contribute to drastically decreased duration of voice. Consequently many who have undergone node surgery may still be able to talk and sing, but only for short periods of time before they become hoarse and often loose their voices completely. Symptoms for both soft and hard nodes are similar to dehydration, acid reflux and allergy disorders.After reading this treatise on the potential evils that can befall the human voice you have likely become more aware that the symptoms for dehydration, acid reflux, vocal strain, allergy issues and Cancer are similar if not identical in some cases. Likely as not, if you are experiencing problems with your voice, simple solutions like drinking more water or making small changes in your lifestyle will help you to maintain and keep your precious voice. But if you cherish your voice like I do, and value your means of artistic expression, your ability to speak out and communicate with the world, your persona and individuality as a singer, then it may very well behoove you to take the necessary steps to improve your vocal health and the life and longevity of your singing voice.
As stated above, prognosis for recovery from nodules depends upon the severity of the condition. If diagnosed early in the life of the node, voice rest and speech therapy can often eliminate the node or at least reduce it in size. But once the node has been in place for a longer duration and has hardened over time, it becomes more difficult to treat and may very well require surgery. Many professional singers have undergone node surgery including Robert Plant, Stevie Nicks and Julie Andrews, the latter of which has never fully recovered her singing voice.
B. Polyps and Cysts
These are firm masses of tissue often located near the surface of the vocal chord but sometimes deeper in the tissue nearer to the ligament. Polyps and cysts usually occur on one chord only, contrary to the occurrence of nodes, and the size and location of the growth directly affects the severity of the symptoms. Cysts can also produce unusual side affects in the voice as diplophonia, a condition where the voice produces multiple tones at once, or dysphonia where voice quality is compromised and takes on a hoarse and breathy quality. Females are far more likely to develop cysts and interestingly enough, the menstrual cycle can affect the growth o the cyst.
Outlook for voice recovery from polyp and cyst issues is questionable especially in lieu of the fact that most cysts will not simply go away by themselves and often require surgical intervention before the voice can recover. Many who undergo surgery are left with compromised levels of voice quality as well as duration.
C. Lesions - Also known as a reactive chord growth, lesions are masses found opposite another growth (often a cyst) and are postulated to be an internal reaction to the growth on the opposite vocal fold. What is unusual about this type of lesion is that there is little or no voice disruption on the side of larynx affected by it.
Outlook for this condition is good in lieu of the fact that often no voice disruption is experienced by its presence and voice rest and speech therapy will likely eliminate it.
D. Throat and Neck Cancer.
Obviously this is a topic that most people would rather not think about but in lieu of the fact that Cancer can cause the exact same symptoms as the conditions aforementioned, or be completely asymptomatic, its discussion merits inclusion in this article. Throat Cancer can occur in any number of areas including the larynx or voice box, the pharynx (the hollow tube inside the neck that starts behind the nose and ends at the top of the windpipe and esophagus), the nasopharynx (the upper part of the throat behind the nose), the oropharynx (the middle part of the pharynx), and the hypopharynx (the bottom part of the pharynx). Most Cancers in these areas present themselves in the form of squamous cell carcinomas or thin, flat cells resembling fish scales. Those at higher risk for the disease include people over the age of 55, men (ten times more likely to develop it than woman), those with a history of throat and neck cancer, smokers (especially those who smoke and drink alcohol excessively), African Americans, and workers who are continually exposed to sulfuric acid, asbestos and nickel. Other studies have shown that a diet low in vitamin A can contribute to the onset of the disease, as can the presence of acid reflux disease which when left untreated can allow stomach acid to continually irritate the lining of the esophagus. Evidence of higher incidences of throat and neck Cancer have also been witnessed in countries where higher levels of cigarette smoking and alcohol consumption are recorded.
Cancer symptoms depend upon the size and location of the growth, much like a cyst, and include hoarseness, a lump in the neck, a sore throat or feeling that something is lodged in the throat, chronic cough, labored breathing, earache and unexplained weight loss.
As with any form of Cancer the earlier it's diagnosed the less likely it will have spread to other areas of the body, and the more likely it can be treated effectively. Most sufferers of the disease are in the intermediate to advanced stages and consequently have less of a chance of surviving. As stated previously and at the risk of becoming painfully redundant: please see a medical professional if you have any or all of the above symptoms especially if you have been experiencing them for more than a week or two. Surgery and radiation treatments are the main courses of action often coupled with diet and lifestyle changes and many who undergo treatment for throat Cancer need to relearn to speak. This can perhaps be one of the more difficult facets of the treatment process, especially for those who rely heavily upon their voices for their careers.