Dear Dr. Jahn: Your articles in Classical Singer are always a blessing and appreciated. Thank you for being there for us and for the valued services you provide to the classical singer community.
I have had pain for several months and recently, severe pain. My doctor wants to do a cervical discectomy. As you know, this means going through the front of the neck and moving everything aside, including the vocal folds. As singing is my livelihood, I am naturally very concerned about the vocal folds. The doctor has said there is a 50 percent chance of losing vocal quality.
Can you please advise me whether to get a second opinion, contact an ENT, or give my doctor advice as to how to move things aside with the least amount of trauma to vocal tissue.
Do you know if there is another option available? The doctor has said that because of the structure of my neck bones they cannot go in from the rear.
Dr Jahn replies: I am happy to share what information I have. First, I would get a second and a third opinion. It may in fact be the case that this can be done only by the anterior approach, but there may be other options. If the consensus is that 1) you must have surgery, and 2) it can be done only by the anterior approach, then at least your options are clear.
I know many patients have this procedure, and I see in my practice very few patients with permanent damage to the laryngeal nerve from this procedure. So the 50 percent statistic may be a bit high. Most of these procedures do not cause vocal fold paralysis. Of course, there will be some edema in the surgical area, since the soft tissues of the neck (including the larynx) are temporarily retracted to the side.
Unless this is an emergency (and some of these cases are), I would look around carefully to find a surgeon with lots of experience in the area. Good luck! —Dr. Jahn
Dear Dr. Jahn: I am a 28-year-old baritone who finished a BM degree in vocal performance and MM and DMA degrees in choral conducting. My voice has always been very dependable and I have continually enjoyed strong vocal stamina and endurance. In September of last year, I was rehearsing a choir through some vocal exercises early in the morning and my voice just completely stopped in the middle of an arpeggio, and I felt a strange catch in my throat. I’d never experienced anything like that before and it made me very nervous.
I did my best to keep careful watch over all vocal production and to pay very close attention to my vocal condition. I had one solo/duet concert to sing one week later and I made measured preparations. During these preparations and during the concert I noticed that my voice became fatigued very quickly and my passaggio points were quite volatile. The concert was successful enough, but it made me concerned about my voice.
I tried to analyze the situation and identified what I thought were important events surrounding the incident. In August I had a severe cough—the worst, most difficult-to-control cough I have ever had. Often I would not be able to stop the cough before it began to hurt in my chest and I could feel it overload my vocal folds. I was also pushing hard to finish my DMA program by the end of October, so stress in my life was very high.
By the end of January I had been healthy continuously for over a month and still had the same vocal issues as before, so I had a scope done by an ENT. My diagnosis was reflux and the solution to take Nexium. I couldn’t afford the Nexium, so I’m on Prilosec.
I’m writing for two reasons. First, to see if you may have any insight on the accuracy of the diagnosis. I’m having a difficult time making it fit with the sudden trauma after which all the problems started. Second, to see if you may have any recommended therapy or treatments for reflux besides taking the PPI drugs.
Dr. Jahn replies: In the context of a prolonged, uncontrollable cough and vocal strain, sudden hoarseness in mid-performance to me would signal a vocal-cord hemorrhage as the most likely diagnosis. By the time you saw the ENT the blood had most likely reabsorbed, so there was probably nothing to see. Even after all the visible stain (red, then yellow) from bleeding is gone, you may still have some mild but persistent edema.
Regarding reflux, you may indeed have this, but I must tell you that it is a diagnosis often given when we can’t think of anything else. I would try the Prilosec—if you have ongoing symptoms, and not just because you had sudden loss of voice on one occasion. No harm in trying it for 4-6 weeks, and monitoring to see if anything improves. Good luck! —Dr. Jahn
Dear Dr. Jahn: Can the CPAP [Continuous Positive Airway Pressure] machine have any adverse side affects on the singing voice? I went in for a sleep study last night for sleep apnea. They put a CPAP machine on me, and I felt more rested when I woke up. However, my voice felt “tired,” and my range today is limited. Could the CPAP have caused this?
Dr. Jahn replies: I consulted Dr. Joseph Krespi, a fellow ENT specialist with specific expertise in sleep disorders. Here are his suggestions:
If it is a standard CPAP unit, consider reducing the air pressure from the therapeutic levels by 25 to 30 percent, to decrease potential traumatic impact to the vocal folds.
Otherwise, consider switching to Auto-CPAP to adjust the pressure as needed, as opposed to a constant pressure for all stages of the sleep cycle.
Be sure the CPAP includes a humidifier and in the winter, a heater. Do not use CPAP for at least 12-24 hours prior to an important performance unless it is a case of a very severe apnea.
If all fails, look into other alternatives to treat OSA [obstructive sleep apnea], such as an oral appliance, lifestyle changes (weight loss, alcohol, etc.) or surgery. Good luck! —Dr. Jahn
Dear Dr. Jahn: I am a 30-year-old spinto soprano with great promise. However, I am suffering from a most horrible performance anxiety. Please! I need your help. I am determined to fight this problem and empower myself, but I need your expert advice. Please tell me if you know any great teachers you can recommend that I work with.
I sing beautifully when I know I have no important engagements—no vocal issues, no hoarseness—but once I have a competition or any important engagement my body and voice seem to have a mind of their own! I am stubborn and try to be brave, but lately I have been forced to cancel my participation in competitions because I wake up hoarse and unable to properly support my middle to high notes. It is horrific—to say the least—to be passionate about your art and when you have an opportunity to share it, get sick.
Please enlighten me with a way to effectively confront my problem!
Dr. Jahn replies: First, you’re not alone! Some of the greatest performers (Rachmaninoff comes to mind) had to be literally pushed on stage because of stage fright. You have several avenues to explore. One would be to talk to a psychologist who deals with performance anxiety. Susan Gregory in New York is an experienced therapist who might be able to help you.
Two, you could consider trying Inderal, a beta blocker, one hour before your performance. This does take some of the “edge” off your performance, but many musicians use this drug.
Third, acupuncture, meditation, or visualization (not to clump all three together, because they are all very different) could be helpful.
Fourth, you may try hypnosis. A good hypnotist could help you to channel your excitement about performing into the performance itself, rather than into the negative feelings you develop.
—Dr. Jahn
