It’s All About the Mucosa: Healing and Preventing Vocal Fold Injuries

I rang in the New Year with ulcers on my vocal cords—no voice, furious, and terrified.

This happened to me once before, 25 years ago, when I was pregnant. I stubbornly and foolishly sang heavily into my eighth month, and gave myself a hiatal hernia. That unleashed a battle with reflux that nearly ended my singing career, and culminated in surgical repair. Afterwards, I published my 2001 article in the NATS Journal of Singing, “Treating Acid Reflux in the Professional Singer.”

Now, decades later, and still reflux-free, history repeated itself. This time it was the result of an upper respiratory infection that left me with violent coughing fits and incessant throat clearing.

Locked away in the solitude of vocal rest, I entered a dark night of the soul. In the silence, I opened my mind’s ear to my intuition. I started researching…and what I discovered astounded me. I had always been focusing on protecting the vocal folds, but totally overlooking the mucosa. It was like sending a knight into battle, and never once thinking about his armor.  

Let’s face it, mucus is not an enthralling subject. Yet the purpose of our mucus membranes is profound: they are the respiratory system’s first line of defense, the lubricant that keeps our tissues from drying out, and filters out harmful materials. The mucosa literally keeps us alive, and it definitely keeps us singing.

Elimination of Mucosal Threats

Most vocal fold traumas are direct injuries to the mucosa. Identifying threats to it prompts two key questions. What can be drying the cords? What can be irritating the cords?

Threat #1: Respiratory Infections

Respiratory infections inflame the mucous membranes. When we sing on an infection, we are singing on an existing inflammation. Full disclosure: I did this a lot in my youth, when I could get away with it. Now, it’s a different story. My advice: just don’t do it.

Threat #2: Reflux

Acid reflux literally burns the vocal folds. Because the esophagus is located behind the trachea, the back of the vocal folds is hit hardest, near the arytenoids. The mucosa in this area is also at its thinnest, making it especially vulnerable to injury. Dietary and lifestyle changes, as well as medications, and even surgery, can manage or correct reflux.

Threat #3: Post-Nasal Drainage

Post-nasal drainage triggers the urge to cough and clear the throat. Such trauma causes redness, swelling, and even ulcerations. Preventive strategies like saline irrigation and steroid or antihistamine nasal sprays are excellent lines of defense.

Threat #4: Medications

Certain medications are particularly drying to the mucosa. Singers need to be aware of such side-effects, and how to mitigate them, in consultation with their doctors.  

Threat #5: Air Quality

Smoky environments dry and irritate the cords. The increased prevalence of atmospheric wildfire smoke has lately exacerbated this threat. Pay attention to air quality, and use air purifiers to eliminate dust, pollution, and other harmful particulate matter.

Threat #6: Lack of Saliva

The salivary glands produce the secretions that cover the mouth, throat, and larynx. A dry mouth equals dry vocal folds. Keep the salivary glands stimulated with lemon lozenges and chewing gum, or by gently massaging them. They are located just in front of the ears, under the jaw beneath the chin, and under the floor of the mouth, below either side of the tongue.

Threat #7: Aging

Aging negatively impacts the mucosa, causing it to atrophy. Hormonal changes during menopause and andropause thin the mucosa, slow down healing, and decrease systemic hydration levels. Age with grace by tending more to your mucosa.

Threat #8: Sneezing or Crying

Sneezing and crying put a lot of strain on the larynx. During my injury, doing both hurt, a lot. I could feel my cords rubbing together and painfully chafing. Make a habit of voiceless sneezing, and not singing after crying, which swells the vocal cords.

Healing with Hydration

Healing a damaged vocal mucosa requires hydration, both systemic and topical.

Systemic hydration is the internal hydration of the whole body. Drink enough water so that you never feel thirsty, and so that your urine is clear, or very pale. A water intake calculator can give specific recommendations, based on age, height, and weight.

Topical hydration is the surface hydration of the vocal folds themselves. The mucosa must be protected from drying out, especially in cold, winter months. Scarves that cover the mouth and nose, or face masks, increase the humidity of inhaled air, as do indoor room humidifiers.

Steam inhalation is beneficial, although it only goes so far. Steam particles (15 microns) are too large to penetrate the bronchi and lungs, so they only humidify the upper respiratory tract. Because the larynx acts as a gateway between the upper and lower respiratory tracts, we often end up coughing when deeply inhaling steam.

Only particles of 10 microns or less will reach the lungs, bathing the vocal folds in the process. Many singers find that nebulized isotonic saline (3-4 microns) is a better laryngeal lubricant. Saline inhalation is indicated for colds and coughs, as well as for exposure to dry ambient air, pollution, dust, or smoke. It humidifies the mucosa, and stimulates the airway’s natural cleansing mechanism.

It is crucial to nebulize only with isotonic inhalable saline:  0.9% sodium chloride in purified water, with no preservatives. A higher salt concentration will have the reverse effect and dry out the mucosa. Any solution that contains preservatives will be highly toxic to the lungs. Simple and affordable handheld portable nebulizers, as well as inhalable isotonic saline, are easily purchased online.

Epilogue

This is the first time I have actively focused on mucosal healing, and my recovery was remarkably swift. Ulcerations normally take six months or more to heal, but mine were gone in three weeks. Under stroboscopy, my cords were healthy, and the doctor even mentioned how great the mucosa looked. My hope is that other singers can benefit from what I learned–it’s all about the mucosa!

Melanie Mitrano

Dr. Melanie Mitrano is a vocal performer, educator, and award-winning ASCAP composer. She holds degrees from the Eastman School of Music and New England Conservatory. She currently teaches voice at County College of Morris, and maintains an active private studio in New Jersey. To find out more and get in touch, visit www.melaniemitrano.com.