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Counterbalancing Necessary but Vocally Hazardous Medications with Healthy Technique

Phillip Hill, B.M. Vocal Performance (in progress)

UNC Charlotte
324 Waldo St.
Cary, NC, 27511
919-675-4946
PhillipLadru@gmail.com

Every person, at least once in his or her life, experiences an illness which can be treated
through the use of proper medication. Normally, one would take drugs; such as analgesics,
antihistamines or decongestants, and go back to life as normal. But, with any medicine, one
should be aware of possible side effects. Common side effects include dryness of the vocal cords,
sedation, or even a loss of high notes. Since minute changes in vocal function can alter vocal
quality, a singer should be aware of the roles that various medications have in vocal pathology,
and be especially cognizant of possible drug interactions. This awareness comes from a
physiological understanding of the respiratory system and how each part of it may be affected by
certain medications.
As all singers know, the health of the respiratory system is one of the most important
elements to a well-produced sound. Even non-singers are painfully aware when there is
something wrong with the vocal tract because it hinders the ability to breathe and often causes a
blockage of the nasal cavity due to mucus buildup in the sinuses. The respiratory system not only
serves to help saturate the blood with oxygen, but it also warms, humidifies, and filters the air
taken in. Depending on what sickness a singer is trying to treat, whether it be a psychiatric
disfunction or a common cold, the medication will have a certain effect on the voice such as
dryness or sedation resulting in swelling or, in severe cases, vocal fold hemorrhaging. It is
imperative that he or she take the necessary precautions to stay in good vocal health throughout
the course of an illness.
There are two types of phonatory disorders. One type depends on changes in the
laryngeal tissues such as swelling, the formation of nodules, and so on. The voice disorders

caused by these issued are called organic. Conversely, there are disorders which are not
associated with visible changes in laryngeal tissues, but which are caused by misuse of the voice.
These disorders are called functional.7
Among the organic voice disorders, there are illnesses such as acute laryngitis, which
often presents itself closely following a cold. Laryngitis can progress and become chronic if not
treated properly, and is
often caused by smoking
and excessive alcohol
consumption. Also in the
category of organic
disorders are vocal fold
polyps, or growths on
the vocal folds, shown
below9.
These are generally created by straining the voice during an infection; the voice will sound
breathy while polyps are present. Furthermore, a contact ulcer may occur near the arytenoid
cartilages due to an exaggerated adduction during phonation. Treating these organic disorders
mainly requires vocal rest, voice therapy, and, in the case of persistent growths that do not
resolve on their own, surgery. On the side of functional voice disorders, problems such as
hoarseness due to shouting or hyperfunctional phonation or support may occur. Phonastenia is
the term used to describe tiredness of the voice, or phonatory fatigue.7 It is largely the action of

the muscles powering the vocal cords, the thyroarytenoids in conjunction with the cricothyroid,
that brings about the constantly changing stiffness and thickness of their substance on which the
pitch of the notes produced partly depends. When these muscles become inflamed due to either
overuse or an illness such as laryngitis, they are weakened and the singer may find that his or her
voice becomes unreliable. A singer might experience fatigue as a functional voice disorder due to
high subglottal pressure or high activity in the vocalis muscles, often involving unnecessarily
added stress to the vocal folds. These types of functional disorders are unhealthy and should be
avoided.
Unfortunately, most singers cannot avoid either of these types of disfunction, which is
why they will turn to medication in order to remediate the symptoms causing the problems.
Perhaps there is a singer showing signs of a common cold or allergies, resulting in post nasal
drip(shown below) due to sinus blockage, thus creating a clogged or congested sound10. The first
thing that singer will want to do is take an over-the-counter drug to remedy the situation.
He or she would take something such as Benadryl or Zyrtec, which may alleviate the problem
at hand, but perhaps cause additional issues. Cold and allergy medications have a drying effect
and may thicken the mucosal secretions. Many drugs of this nature decrease the thin watery
component in mucus without decreasing the stickier lubricating component, leaving the singer
with a dry mouth that feels sticky.2 The buildup of this type of mucus on the vocal folds may
result in more friction between the vocal folds during phonation, which can irritate the folds and
cause quickly accumulating vocal fatigue. Instead of taking the decongesting medications, it is
recommended to use a topical steroid nasal spray such as Flonase to relieve the congestion. If

this is not effective, the singer should add an oral antihistamine on an as-needed basis. Should
the problem persist and a decongestant such as Claritin is needed, it should be taken earlier in
the day to prevent dryness in the event of an evening performance. In order to keep the vocal
folds moist from the inside, the singer should make sure to drink plenty of water. The vocal folds
move best when the body is well-hydrated and the folds may be less likely to become injured
from overuse of the voice. The mucus coating can be thought of as motor oil in the engine of a
car: if it is thin and slippery, the engine runs smoothly; if it is thick and glutinous, the engine
doesnt run well and can be damaged.8
The thicker mucus that often results from
colds and allergies can lead singers to clear
their throats with excessive frequency and
force in order to drive the mucus away from
the vocal folds. This is a very unhealthy
practice as clearing the throat forces a buildup of large amounts of subglottal pressure,
which then forces the folds to blow open,
expelling the mucus from the folds.2 When overly excessive pressure is put upon the folds, they
may swell, causing fatigue, hoarseness, or unstable vibrato. This swelling may cause pain and it
may lead a singer to try painkillers such as Advil or other non-steroidal anti-inflammatory drugs
(NSAIDs). It is important that these types of medications are used with caution by singers. These

drugs can increase the risk of vocal cord hemorrhaging for up to two weeks following their
consumption.1 Vocal fold hemorrhaging happens when a blood vessel on the surface of the vocal
fold ruptures and bleeds into the tissue of the vocal fold. It is considered a vocal emergency and
is treated with absolute vocal rest until the hemorrhage resolves.8 Factors predisposing a singer
to vocal fold hemorrhage include the presence of dilated blood vessels on the vocal folds,
menstruation, and the use of substances such as alcohol that further vascular dilation.1 If pain is
an issue, the singer should see a medical professional immediately. If medication is necessary,
Acetaminophen-based drugs such as Tylenol should be used as it is not a blood thinner and will
not cause hemorrhaging. If in need of a quick test to check for vocal swelling, try these

techniques developed by Bastian, Keidar, and Verdplini-Marston (1990)3:

(A) Staccato

(B) Twinkle Twinkle Little Star

The singer should sing these as quietly as possible and NOT in a low register of his or her voice.
Swelling should be suspected if the singer can only complete them by singing loudly. One may

also note a delayed phonatory onset as well as breathiness in the tone. If swelling is not present,
the singer should be able to complete the exercises as written.
In addition to colds and allergies, many singers also undergo treatment for psychiatric
disorders and should be aware of potential side effects from these medication. Many drugs used
in the treatment of depression, such as Prozac or Wellbutrin can cause dryness and fatigue as a
side effect. Anxiety disorder medications may cause the same side effects, but Xanax, in
particular, can cause a loss of muscular coordination/nerve function; which in turn may alter
pitch, timbre, and volume. These side effects may result from using drugs such as Adderall, or
other medications used to treat Attention Deficit Hyperactivity Disorder (ADHD). Because these
types of drugs are often over-prescribed, it is recommended that a singer only add them to his or
her regimen if the benefits outweigh the potential side effects.3
As all of these foreign compounds may have negative effects on the voice, so too can
everyday vitamins that many people believe are necessary to sustain a healthy diet. Some
vitamin supplements have the potential to alter ones voice or put one at risk for a vocal
pathology. Niacin, often used to prevent heart disease in patients with high cholesterol, can dilate
blood vessels and thin the blood, thus lowering the threshold for vocal cord hemorrhaging.
Vitamin C, which assists in the growth and repair of tissues in the body, can be a diuretic in
higher doses and therefore can dry out the vocal mechanism, creating danger of swelling or
hemorrhaging.
All of this information and more can be found in the table below6:

Medication

Side Effect

Antihistamine

Dehydration

Antidepressant

Drying, sedation

Antitussive

Dehydration

Antiemetic

Dehydration

Antihypertension

Cough

Decongestant

Dryness, tremor

Corticosteroid

Muscle weakness, yeast infection

Aspirin/Anti-inflammatory

Vocal hemorrhage

Sedatives

Dryness, sedation

Birth Control

Loss of high notes

Neurolepic

Vocal tremor

Anabolic steroid

Loss of high notes

Vitamin A

Vocal dryness

Vitamin B

Vasodilatation

Vitamin C

Diuretic in high doses - Dryness

Vitamin E

Vocal hemorrhage

The human body is not wired to fend off every form of bacteria or virus that crosses it;
therefore, staying perfectly healthy at all times is impossible and a singer should always know
his or her limits when it comes to vocal use. During times of illness, singers must strive to
protect their vocal mechanisms. It would be very convenient if a singer could simply take time

off from rehearsal to recover, but this is not always possible, and in the performance world he or
she must always be prepared to attend a rehearsal even in the worst of vocal situations. A
common method of participating in a rehearsal without damaging the voice is a technique called
marking. Marking is a method of sparing the voice during rehearsal where volume is reduced,
high pitches may be lowered an octave, and very low pitches may be raised an octave. At times
only the cues needed by ones colleagues or by the orchestra are sung, and especially high
pitches for males may be sung in falsetto. While this is typically a helpful technique, one must
exercise caution and make sure not to displace every pitch, as this can create bad performance
habits and make it more difficult to transition back into full voice.5 When marking, a singer
should strive to maintain proper support with the abdomen expanded and fully engaged as to not
damage the instrument further during sickness.
In the event of a performance while overcoming an illness or on any of the previously
stated medications, one should take the necessary precautions to ensure a good performance and
also remain vocally healthy. In the case of dryness due to a decongestant or other drying
substance, a singer should make sure to have plenty of water backstage for breaks between
scenes or an intermission in order to prevent further dehydration, leading to increased swelling,
quickly accumulating vocal fatigue, or even passing out on stage. Should the vocal folds already
be swollen due to irritation, a singer should take Tylenol prior to the performance instead of a
Non-steroidal Anti-inflammatory drug, as the acetaminophen will not cause the blood to thin and
will not raise the risk of vocal fold hemorrhaging. In addition to taking the proper medication,

the singer must maintain an appropriate level of hydration and should maintain a solid technique
without harmful subglottal pressure. Here are some tips for maintaining healthy technique6:
1. Avoid glottic shock (coup de glotte). There are two main sets of factors causing the
vocal cords to resist a steady passage of air from the trachea. The first is the stiffness present
on the cords themselves, and the second is the force of the muscles which close the glottis.
The more powerfully these two groups of muscles contract, the higher the pitch of the note
formed when the air pressure does manage to overcome this resistance and sets the cords
vibrating. If this resistance is mainly due to cord stiffness, no harm is done to the cords
surface. However, if to obtain the desired high note the singer excessively increases the force
of the closing muscles, the vibrating cords become opposed and consequently strike against
one another with too much force. This can inflict significant damage, resulting in vocal
nodules of attrition or, in extreme cases, vocal hemorrhaging.
2. Do not Sing too Loud or too Often. The majority of muscles in the human body, when
overused, will begin to ache. This ache should be treated as ones signal to rest.
Unfortunately, the muscles surrounding the vocal mechanism do not trigger this ache,
therefore leaving singers to their own devices when dealing with the dilemma of vocal rest.
Because the singers voice does not ache, he or she will not know exactly when to begin
resting until the voice has been completely overworked and can no longer produce an easy or
pleasing sound. It is because of this that singers must constantly restrain themselves from
singing too much and overworking their instruments. It is always recommended that singers

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refrain from forcing unnecessary strain on the vocal cords through actions such as yelling or
using the voice for extended periods of time without taking appropriately timed breaks.
3. Avoid Further Vocal Complications. In order to reduce negative side effects from
medication, one must maintain a healthy lifestyle. This means that overuse of tobacco and
alcohol must not take place excessively. One must also avoid overly cold or moist climates
as well as dangerous fumes such as paint, as these may further irritate the pharynx due to
toxins present in the fumes.
There are many environmental dangers that a singer may be susceptible to. While it is
important to counterbalance these dangers with common over-the-counter drugs and healthy
technique, it is no substitute for true vocal rest. If a singer is confronted with an illness or
disability that should cause the need to take such medications, it is imperative that he or she pace
himself or herself when in rehearsal or performance. Once enough damage is done to the vocal
mechanism, it becomes much more difficult to recover and could result in permanent damage.
Singers should always take medications based on the advice of a physician and not take more
than the recommended dosage. If further medical attention is required, one should not wait to
seek help as damage to the voice can become irreversible at a certain point. Even though there
are exercises that can show the presence of vocal swelling, they are no true substitute for an
examination by a medical professional and should be used to help a singer decide when to seek
help for an issue.
Notes:

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1. Youngness Jenny Cho, The Singers Guide to Complete Health: Medications and the Voice
(New York: Oxford University Press, 2013), 255-262.
2. Rachael Gates, L. Arick Forrest, and Kerrie Obert, The Owners Manual to the Voice: A
Guide for Singers and Other Professional Voice Users (New York: Oxford University Press,
2013).
3. Anat Keidar and Nancy Kleemann Menges, The Singers Guide to Complete Health: SelfScreening for Vocal Injuries (New York: Oxford University Press, 2013), 355-365.
4. Richard Miller, Training Tenor Voices (New York: Schirmer Books, 1993), 26-30.
5. Richard Miller, On the Art of Singing (New York: Oxford University Press, 1996), 273-275.
6.

Norman A. Punt, The Singers and Actors Throat (London: William Heinemann Medical
Books, 1979).

7. Johan Sundberg, The Science of the Singing Voice (DeKalb: Northern Illinois University
Press, 1987), 182-194.
8. "Vocal Health Information." Dukevoicecare.org. Accessed December 5, 2015. https://
www.uu.edu/dept/music/library/safety/VocalHealthInformation.pdf.

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Bibliography
Jenny Cho, Youngness. The Singers Guide to Complete Health: Medications and the Voice. New
York: Oxford University Press, 2013.
Rachael Gates, L., Forrest, Arick, and Kerrie Obert. The Owners Manual to the Voice: A Guide
for Singers and Other Professional Voice Users. New York: Oxford University
Press,
2013.
Keidar, Anat and Nancy Kleemann Menges. The Singers Guide to Complete Health: SelfScreening for Vocal Injuries. New York: Oxford University Press, 2013.
Miller, Richard, Training Tenor Voices. New York: Schirmer Books, 1993.
Miller, Richard. On the Art of Singing. New York: Oxford University Press, 1996).
Punt, Norman A. The Singers and Actors Throat. London: William Heinemann Medical Books,
1979.
Sundberg, Johan. The Science of the Singing Voice. DeKalb: Northern Illinois University Press,
1987.
"Vocal Health Information." Dukevoicecare.org. Accessed December 5, 2015. https://
www.uu.edu/dept/music/library/safety/VocalHealthInformation.pdf.