Your Health: Acid Reflux, Motion Sickness, and Warm-Ups

I have never heard of varicosity on the cords. How common is this? What are the chances that with some vocal rest and acid reduction medicine the vein will go away?

Hi Dr. Jahn,

I so enjoy reading your articles in CS Music. I was just diagnosed as having LPR [laryngopharyngeal reflux disease]. I am a professional singer as well as an adjunct teacher. I have been experiencing hoarseness, loss of range, and constant throat clearing and burping.

In an examination of my cords, [my ENT] found a varicose vein on my right cord, as well as pachydermia [abnormal thickness of the laryngeal mucous membrane], edema and a granuloma (not on the cord) [a nodule of inflamed, granulated tissue].

I have never heard of varicosity on the cords. How common is this? What are the chances that with some vocal rest and acid reduction medicine the vein will go away? Is it something I will always need to be concerned about? I am so concerned about it rupturing and bleeding into the cord.

I would appreciate any comments or suggestions you may have.

Dr. Jahn’s Answer

Your symptoms (hoarseness, throat clearing, burping) could be due to reflux, and should be manageable with appropriate medications. The varicosity, which is just a dilated blood vessel, is only significant if it is on the vibrating edge of the vocal fold (vs. the upper surface). Many singers have prominent blood vessels, and no problems. If it is on the vibrating margin, it could be a potential problem (if it ruptures). You can minimize this possibility by drinking lots of water, and avoiding medications that can clause bleeding (such as aspirin, vitamin E, niacin, and known blood thinners). Also, be careful not to strain vocally during your period.

The granuloma may be due to the reflux, or, at times, to excessive voice use, which can cause an abrasion on the posterior part of the vocal folds. This second possibility is more common in men, however. If the granuloma is not on the vocal folds, it is not significant in terms of your singing. You should get a second opinion if you do not respond symptomatically to anti-reflux medications. Good luck!

Dr. Anthony Jahn answers questions each month for CS Music. If you have a question, email support@csmusic.net.

Having allergies and asthma, I have been taking Advair once a day. Have you heard of any problems with that steroid spray?

Dear Dr. Jahn:

I’ve been having trouble with my voice phonating lately. When I put weight onto it, I become hoarse and end up marking. This is a problem now, since I’m in [opera] rehearsals. Having allergies and asthma, I have been taking Advair once a day. Have you heard of any problems with that steroid spray? My GP [general practitioner] mentioned the other day that Advair does affect the voice.

I had a sinus infection and he aggressively treated it with amoxicillin, but that drug has never caused a problem. So, I’m searching.

Ah, me—the ups and downs of a singer. Any ideas or input would be greatly appreciated.

Dr. Jahn’s Answer

Two possibilities: One, Advair does indeed cause hoarseness, and should not be used unless there is no alternative for asthma. Two, with any steroid inhaler there is a possibility of yeast infection. You should be checked for this, and given antifungal medications, if necessary. An early yeast infection can at times cause only dryness and redness, without the white patches, so it is easy to miss.

Should I fix something that is not really broken, or may this in fact help my singing?

Dear Dr. Jahn:

For as long as I remember, I have not been able to breathe effectively through my nose. I can breathe through my nose and smell, etc., but I can only do this for a while—eventually, I must breathe through my mouth.


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A couple of years ago I found out that I have allergies, so I now take Zyrtec-D and Rhinocort. This has helped my chronic stuffiness, but my nose-breathing did not get better. Recently I saw an ENT. After looking at me and having X-rays done, he determined that I have two problems: Mainly, that the adenoid—right where the nose meets the throat—is still there (I am now 21 years old), and secondly, that the tissue in my left nose passage is enlarged. So surgery has now been suggested.

I think the surgery will be fine and everything—I am not worried about that. I am worried, though, about my sound. He did say that my sound would probably brighten, because of more space and resonance. I currently sing fairly well. Should I fix something that is not really broken, or may this in fact help my singing?

A brighter tone would be fine, but I would like to think that I could change this sound slightly.

Dr. Jahn’s Answer

Based on what you have described, I believe the surgery is warranted, and will be helpful in terms of your nasal breathing. Regarding the voice, I suspect that with obstructing adenoids your voice may be a little hyponasal right now, and this should improve. The actual brightness of a voice is a subjective determination. Most of my patients tell me that after septal surgery their voice feels louder, and they find it easier to flip it up into the mask. Most of this is probably subjective (your sensation of the voice) rather than objective, but one patient told me that his teacher also commented on a bigger voice. I have recently written on this in CS, and you may wish to read that column. [Editor’s Note: Please see “The Singing Feeling: The Biofeedback of Singing” in the February 2005 issue.] Good luck!

What medication do you suggest as an alternative for a singer who suffers from motion sickness and must perform shortly after, or the day after, plane travel?

Dr. Jahn,

When I fly, especially on smaller planes, nausea and vomiting are an absolute certainty. I normally take Dramamine, which works quite well, but it dries me out and makes me sleepy. Normally this isn’t an issue, but now that my calendar is starting to fill up, I suddenly find myself needing another option.

I have a performance on Friday in one city, and on Saturday in another, which means I will have to sing shortly after getting off of the plane. What medication do you suggest as an alternative for a singer who suffers from motion sickness and must perform shortly after, or the day after, plane travel?

Dr. Jahn’s Answer

Unfortunately, most anti-nausea medications are in the antihistamine family, and are drying.

I have a couple of suggestions, though. You could take some ginger capsules, or candied ginger; both are good traditional remedies for nausea. There are also a couple of good acupuncture points for nausea, on the forearm (also one on the ear). You should consider getting an anti-motion-sickness wristband, which puts pressure on one of these points, and might help you avoid throwing up. If you can find a good ear acupuncturist, they can implant a small stud into the ear’s acupuncture point (like the ones they use for weight loss or anti-smoking). Rubbing this during the flight might decrease your nausea.

You could also try some Valium, a drug that I sometimes give for vertigo. It is less drying than Antivert, Dramamine, or Bonine. If you absolutely need to take a Dramamine-type medication, drink as much water as you can—not huge quantities at once, but small sips throughout the flight. Cold water (or even ice chips) is better than warm drinks, in terms of nausea.

Finally, if the flight is a longer one, such as overseas, you might try a sleeping pill like Ambien. It is less drying, and if you are asleep, you may not get nauseous.

How do I know how much singing to try? Is there a special kind of warm-up I should do, given this history?

Dear Dr. Jahn:

I am likely what you call an “under-trained” beginning singer, having started my career as a cantorial soloist five years ago, at age 55. As a result of overuse—and too much travel and performance three months ago in dry climates over a short period of time, coupled with a minor chest infection and major laryngitis—I was left with “burn out,” a failing speaking voice, and diagnosed with reflux and fatigue.

I have been hydrating, changing my diet to a more alkaline one, drinking aloe vera and bitters, using homeopathic medication to change the bacteria in my stomach, using cold steam in the bedroom, and making minimal use of my voice. I have put off minor singing contracts for a few months, and a major concert and new CD until next year.

Currently, three months later, I am aware that talking on phone or in discussion for over 1.5 hours leaves me tired, so that is my limit. My main persistent symptom seems to be a throat irritation, as if there is pepper in it, or like a minor sore throat (no discomfort to swallow).
[Examination with an] ENT scope says my vocal cords, etc., are normal. On the odd day, it disappears, and when I am otherwise engaged (in my social consulting work), I don’t seem to notice it as much.

I appreciate that this is a whole body reaction. I am meditating and doing my best at “accepting” this condition, and appreciate that it can take even longer than three months. My questions are as follows:

1. I have been doing gentle singing for only 10 minutes a day —I started it last month. How do I know how much singing to try? Is there a special kind of warm-up I should do, given this history?

2. Is there anything else I can do?

3. I am aware that in the past I have had neck and larynx tension, so I need proper retraining, but I don’t know when I will be able to start this. I also realize that my voice and body need proper care and have ordered your book, hoping for insights.Sometimes I get the feeling that my throat has a message for me and is just trying to say: “Slow down, breathe, take care,” etc. That seems to be a kind of inner wisdom.

Please advise. Thank you in advance.

Dr. Jahn’s Answer

First, I commend you on your decision to pursue a career that you obviously enjoy, even at the age of 55. Many singers never do this, and spend their lives regretting it.

Based on what you’ve told me, I think you need to consider several possibilities:

1. Overuse, compounded by excess muscle tension. This, in turn, may be due to inadequate training in basic vocal technique. Lessons and practice should help.

2. Menopause and general mucosal dryness, which can compound muscle tension (trying to overcome vocal difficulties).

3. General health issues need to be checked, such as mild hypothyroidism, anemia, or chronic inflammation.
You may benefit from acupuncture and Chinese herbs. You should contact Dr. Steven Aung, an MD acupuncturist (and my teacher), who is in Edmonton, Canada. He has a website. If anyone can give you the best help in this area, it is Dr. Aung.

Good luck, and let me know how you fare!

Anthony Jahn, M.D.

Anthony Jahn M.D., noted author and professor of clinical otolaryngology at the Columbia University College of Physicians and Surgeons, has offices in New York and New Jersey and is a noted author of The Care of the Professional Voice.