Another Rock Singer With Injured Voice

On Sept 16, 2011, the Stone Temple Pilots had to cancel their tour because their lead singer Scott Weiland was placed on voice rest due to damaged vocal cords at risk for permanent damage. Specifically, the doctors at University of Cincinnati Voice Health Center determined that he had scarring on his left vocal cord and a tremendously inflamed right vocal cord.

The left vocal cord scarring is likely from past vocal trauma that did not heal properly and is now permanently damaged whereas the right vocal cord is at risk of also becoming permanently damaged if not aggressively managed. The picture shown here is an example with inflammation involving both vocal cords. Compare this with the picture below which shows one normal vocal cord and one inflamed vocal cord.

Without further information, beyond voice rest to allow the vocal cord inflammation to resolve without further injury, treatment may also include steroids as well as reflux medication.

It seems to be a continuing trend for singers of all genres to be pushed to the point where their vocal cords get injured resulting in show cancellations and at worst, become a one-hit wonder.

Other singers THIS YEAR alone who have cancelled tours due to voice injury include Kings of Leon, Duran Duran, Adele, The Vaccines, etc

And it's not just rockers, but also opera singers.

If you are a singer and you don't have a voice coach and supportive management, you need to remedy this immediately or you risk having a career that's a one-hit wonder.

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Steroid Inhalers for Asthma Can Cause Fungal Laryngitis

It is a big bummer to be an asthmatic. Not only is breathing a problem, but even the treatment for asthma can cause problems.

Take for example steroid inhalers like advair, symbicort, fluticasone, etc.

All asthma patients know to rinse their mouth out after inhaler use due to risk of oral thrush, but what about from the back of the mouth down to the vocal cords??? This nether region can't be gargled very easily. One can swallow water to rinse this area out, but the vocal cord region would still not be addressed (otherwise aspiration would occur).

And that leads to potential vocal problems... like fungal laryngitis (or thrush of the voicebox). Here's a picture of what that looks like. To compare, normal is shown in the smaller picture.

Note the white patches indicative of fungal growth. This fungal infection can lead to symptoms of a mild (if any) sore throat, but most patients complain of hoarseness as their only symptom.

Treatment is ideally to stop the steroid inhaler triggering the infection, but if an asthmatic needs it... than they need it. As I often tell patients, breathing is more important than voice. Often, anti-fungal medications like diflucan and nystatin can eliminate the fungal laryngitis, but problem is, as long as steroid inhalers are used, it comes right back. And repetitive anti-fungal treatment can place the patient at risk for a drug-resistant fungal infection.

So what to do???

There is one type of little-known (unpleasant) treatment an asthmatic patient can perform to minimize risk of fungal laryngitis while still maintaining steroid inhaler use.

It's called laryngeal washes and it takes a lot of time, patience, and period of discomfort. Think of it as gargling of the voicebox.

The patient takes a curved luer-lock cannula (picture shown) attached to a syringe filled with salt-water. While opening the mouth and sticking the tongue out, the curved end of the cannula is directed such that the end is pointed straight down into the throat. After taking a deep breath in, while saying "ah", salt-water is dripped down into the throat thereby "gargling" the voicebox. Coughing may be inevitable after performing.

This needs to be done after every steroid inhaler use. Or during an active fungal infection, at least 4 times per day.

Gagging is the biggest problem preventing correct usage of this technique. Coordinating the injection while saying "ah" is another issue since if it is incorrectly performed, can lead to aspiration and severe coughing. As such, it is not for everyone.

One can purchase such "luer-lock laryngeal cannulas" from any ENT medical supply company.

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American Idol Laryngitis Scare for Lauren Alaina

On May 24, 2011, US Magazine reported that American Idol Finalist Lauren Alaina "blew a vocal cord during afternoon rehearsal" and apparently completely lost her voice (aphonia).

Apparently, a doctor on set and ordered Lauren not to sing or speak which brought a very real possibility that she would not be able to perform that evening. Fortunately, "emergency" care was provided along with resting the voice and apparently sang quite well that night.

Without benefit of having examined Lauren's voice or being told what the exact emergency care that was provided, I have an idea of what might have happened and what care might have been provided.

Usually in the event of a sudden loss of voice during extreme voice use, it does suggest a blood vessel that might have ruptured. Blood vessel formation in the vocal cords is not unusual in the setting of heavy vocal use as shown in the picture to the left (normal is shown above for comparison). However, vasculature presence in the vocal cords is not a great situation as it does lead to a bit of unpredictability of how the vocal cords will perform in any given moment. Why? Because the vessel(s) may fluctuate in size leading to unintended pitch variation and at worst, raspiness. If you consider the vocal cord analagous to a violin string, a blood vessel is like adding the ability of the violin string to fluctuate in size.

In any case, once blood vessels are significantly present, the singer often has to continuously adjust the voice to achieve consistency in vocal quality. Often this leads to changes in vocal technique and even increased exertion in order to produce a consistent "good" voice.

However, with increased exertion to achieve that "good" voice, further irritation of the vocal cord vasculature may occur to the point it may rupture leading to a sudden loss of voice which is often accompanied with some transient pain. Here is a picture of what her vocal cord might have looked like after vessel rupture.

At this point, a few things can be done to try and resolve this situation as quickly as possible. By resting the voice, you reduce the repetitive trauma to the vocal cords that may further exacerbate bleeding into the vocal cord.

High dose steroids can be administered to reduce the inflammatory reaction to the vocal cord lining as well as swelling that is bound to happen.

Improvement can happen within hours... HOWEVER, injury is still present and vocal rest is mandatory to complete the healing process. Otherwise there is potential for permanent vocal cord injury that may require surgical intervention.



If you listen carefully to Lauren Alaina's voice right before her performance in this video, you can hear a slight rasp to her voice especially when saying the word "fine" indicative of a persistent vocal cord injury. I believe that if she sang a song containing  passages requiring a very quiet upper-range pitch, her voice would have sounded quite bad. As it is... by singing loudly, she would be able to "power" past any vocal cord imperfections. Indeed, she "beat" her laryngitis, though she'll have to be careful in the days to weeks after her performance.

Read the US Magazine article here.

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Is Whispering Bad for Your Vocal Cords???

For most people, the answer is yes according to research publicized in a New York Times article on Feb 7, 2011.

In the mentioned study, out of a group of 100 patients, 69% exhibited increased supraglottic hyperfunction with whispered voice (ie, it was bad for the voice). 18% had no change and 13% had less severe hyperfunction.

As such, though whispering is not bad for everybody, it is for most people and as such, the safest thing to do if the vocal cords are damaged whether by infection or trauma is to rest your voice. If you have to talk, do not whisper, but rather talk in a soft voice.

The best way to think about injured vocal cords is to talk in an analogy. Laryngitis is like a badly sprained ankle. In this scenario, talking is like walking and screaming is like running. So just like you would rest the sprained ankle and not walk on it in order for it to recover as quickly as possible, you should refrain from talking in order for the laryngitis to recover as quickly as possible. Where does whispering fall in this analogy? Probably equivalent to running on a sprained ankle.

Read the NYT article here.

Read more about voice problems here.

Reference:
Laryngeal hyperfunction during whispering: reality or myth? J Voice. 2006 Mar;20(1):121-7.

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Miley Cyrus "I Cut My Uvula"! ...NOT!

I was recently made aware of this video Miley Cyrus made in January 2009 when she reported that she cut her uvula (according to a nurse) after swallowing a slippery piece of chicken causing her voice to sound quite hoarse. Watch the video here:



However, based on how her voice sounds, I seriously doubt that her hoarseness is due to a cut uvula. When the uvula gets cut, or swollen, or gets injured one way or another, it would cause her voice to sound muffled... NOT raspy like her voice sounds. Though it is possible that her uvula may have been injured, it certainly is not the cause of her poor vocal quality.

Rather, I suspect that her voice sounds bad the way it does due to a vocal cord injury. Often, when people swallow a piece of food (like a chicken) that either gets stuck or goes the wrong way, the person automatically coughs severely in order to expel it.

If the cough is severe enough, it'll cause traumatic injury to the vocal cord resulting in a hoarse voice. The injury itself may not be that bad (usually a mild vocal cord submucosal hemorrhage), but the voice does sound bad. Here are two mild examples of laryngitis due to blood accumulation here and here. A more severe example of traumatic laryngitis can be found here.

In this situation, if the person persists and tries (forces) to talk and sound normal in a setting where the vocal cord is injured, compensatory behavior sets in whereby the vocal quality will fluctuate and go in and out as Miley's voice does in the video (listen to an audio of another patient with this problem here). This condition is called "compensatory muscle tension dysphonia," and in her case, secondary to acute traumatic laryngitis.

This diagnosis can be confirmed on fiberoptic laryngoscopy. Treatment is high dose steroids that will bring the swelling down as well as strict voice rest for a few days (depending on severity of the injury). Resolution of her voice would be expected within 1 week with this treatment. Voice therapy may be required, though usually not.

Read more about traumatic laryngitis here.

Read more about muscle tension dysphonia here.

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NCIS Character Tony DiNozzo Gets Acute Laryngitis

On October 19, 2010, there was a CBS episode of NCIS (Naval Criminal Investigative Service) called "Cracked" in which Special Agent Tony DiNozzo developed acute laryngitis.

The show's chief medical examiner, Dr. Ducky Mallard, examined Special Agent Tony DiNozzo and instructed him on strict voice rest for 24 hours which Tony ignored.

If I was on the show, I would have performed a much more thorough examination that would include fiberoptic laryngoscopy (and/or stroboscopy) in which the vocal cords could be directly examined as shown in this video:

Based on his hoarseness, lack of productive cough, and acute onset, I suspect Tony developed acute VIRAL laryngitis. Here's an example of what I suspect I would have seen on laryngoscopy if one was done (video is actually stroboscopy, a much more intensive examination than laryngoscopy):

This exam is different than acute BACTERIAL laryngitis in which pus on the voicebox would be seen as shown in this video (also stroboscopy):

Overall, treatment for acute viral laryngitis is strict voice rest as the esteemed Dr. Mallard recommended, though 24 hours is a bit optimistic. I probably would have prescribed a course of steroids to help with the swelling as well as hydration.

Should Tony keep on talking in setting of acute laryngitis, he runs the risk of developing muscle tension dysphonia.

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TV Show "Glee" Character Rachel Has Laryngitis? Tonsillitis?

On May 11, 2010, Glee aired its eighteenth episode titled "Laryngitis". In this episode, Rachel suffered from a lost voice which was attributed to tonsillitis or is it laryngitis.

It was a bit confusing as it would seem her lost voice was attributable to laryngitis (title of the episode), but than she was diagnosed with tonsillitis by the TV doctor which really has nothing to do with laryngitis. I guess it is possible that she had TWO conditions going on at the same time even though she did not mention a sore throat at any time.

I can say for certain that the TV doctor was not portraying an otolaryngologist mainly because he was wearing a stethescope around his neck (our profession does not carry a stethescope on our person).

In any case, I doubt Rachel had tonsillitis. The main complaint with tonsillitis is a sore throat and not a lost voice. As such, she probably had a mild case of laryngitis which in most cases, only time, voice rest, and hydration should have been adequate. Antibiotics do not play a role in most cases of laryngitis which are virally induced.

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