Feder,R.J.(1990). Vocal health: A view from the medical profession. Choral Journal (February), 23-25.

      A View from the Medical Profession

      by Robert J. Feder

      Vocal music educators are on the front line of defense against their students' vocal misuse. They see their students regularly and are aware of obvious and sometimes subtle changes in their health and lifestyle. Vocal instructors and choral directors, both of whom are especially sensitive as to how voices should sound, are encouraged to listen to their students' voices in normal conversation --to pay particular attention to how students use their voices in their daily lives. This can be a factor in recognizing potential vocal abuse and in taking steps to prevent or remedy it.

      The potential for the abuse of vocal cords is always present, regardless of the age of the student, his or her talents, or level of ability. To help protect their students' voices, teachers can caution children (and adults) against such common abusive activities as yelling, loud stage whispers, and gargling, and instruct them in the basic, common sense elements of good vocal hygiene.

      Young, elementary school-age children are especially vulnerable to a variety of colds and infections which often result in sore throats, hoarseness, and laryngitis. Teachers should be especially alert to their students' voices when they return to school after an absence due to colds and flu. Hoarseness can be caused by croup and epiglottis (an infection of the larynx), or any number of typical childhood diseases. The hoarseness should disappear as the child recovers from the causing ailment. However, if a child speaks with a roughened voice that appears to improves, only to worsen several days later, the problem may be "screamer's nodules" --calluslike nodules on the vocal cords. The child should exercise complete vocal rest for two to three days. If the hoarseness persists, a physician should be consulted.

      In general, children with vocal-related problems should be referred to a physician more quickly than adults with vocal ailments. This is so because a child's airways can be compromised more quickly than an adult's, and a child can suffer possible damage if a problem is not treated in a timely fashion. Children usually do not develop polyps on their vocal cords--probably because their vocal cords are small. However, respiratory papillomas, which are wartlike growths, are more common to children than to adults. Perhaps one percent of child patients who are seen for persistent hoarseness have developed papillomas. They are dangerous to the vocal development of children, and can be avoided with proper vocal care.

      As children grow older --as they approach and go through the adolescent years-- their voices are subject to remarkable changes that make them extremely vulnerable. In addition, the opportunities for vocal abuse during these years are probably the most prevalent of any in their lives. General exuberance, yelling at sporting events or at any social gathering, and improper singing can all, if done to excess or during a period of illness, cause damage to a youngster's voice.

      The teacher should encourage students, especially during the critical period of voice change, to speak without yelling, to vocalize (speaking and singing) in a comfortable middle vocal range, to sing without straining, and to rest if they become hoarse. If it is possible, the teacher should also advise parents of proper vocal production --especially parents of children who demonstrate poor habits and a predilection for hoarseness.

      If proper habits are developed during the adolescent years, vocal cords are generally able to withstand the rigors of adult life and to operate freely and efficieintly. High school and college students should avoid prolonged yelling or forcing their voices. (The voice usually becomes fully mature after age 28). Even prolonged speech can be problematic. Speaking in a higher vocal range, singing and speaking with considerable breath flow --especially at high volume level, and frequent pauses or rests during extended speaking or singing can all help maintain good vocal health. If hoarseness or laryngitis persist for more than a week, a physician should be consulted.


      Hoarseness is often the first sign of more than an upper respiratory tract infection; it can indicate a number of different vocal problems. Primarily, they are:

      1. Malignant and benign tumors. Squamous cell carcinoma of the larynx, nearly always due to smoking and excessive consumption of alcohol, is by far the most common of malignant tumors. Benign growths commonly include nodules, polyps, and Reinke's edema (swelling). The latter is a form of polypoid degeneration that runs the entire length of the vocal cords. Contact ulcers often result from reflux of stomach acid, but also can be caused by other forms of chronic irritation and by hypothyroidism. Other, but less common causes of benign growths, are respiratory papillomas and granulomas. Granulomas form when, as a result of the constant banging together of the cords, the mucosal covering of the vocal cords becomes irritated. This usually is caused by people who talk excessively, are under tension , or are chronic throat-clearers.

      2. Vocal cord paralysis. Some people have voice problems when a vocal cord becomes fixed in an inappropriate position. The degree of hoarseness is determined by the position of the cord; the voice may be reduced to a whisper or may have difficulty phonating at a loud volume. Paralysis can occur as the result of a virus, heart surgery, thyroid survery, or intubation (the placing of a tube down the throat).

      3. Trauma. External neck injury is another source of hoarseness. Frequent causes are sports mishaps and motorcycle, trail bike, and automobile accidents involving trauma to the Adam's apple. Medical diagnosis of laryngeal fracture is critical because damage can cause total obstruction and even death.

      4. Functional voice disorders. Various forms of abuse of the vocal apparatus or psychological disturbances are often the source of this problem. They stem from:

      a. vocal misuse and abuse syndrome. This can be a cause of hoarseness if it comes on unexpectedly or if the voice gives out after speaking, even when examination reveals the larynx to be normal. Often, such patients have poor breath control and pitch their voices so low that a great deal of energy is required to produce sound; they may be straining to emulate th low tones so admired in our society. Similarly, nodules and polyps on the larynges, analagous to calluses on the hand, are due to abusive, non-organic causes.

      b. conversion reaction. Some patients experience a hysterical truama, or conversion, losing their voices after an upsetting event.

      c. falsetto disorders. Males sometimes begin to speak in an unnaturally high voice after an upsetting event.

      d. relapsing aphonia. People with this condition lose their voices repetitively, such as at a stressful time every year.

      e. habituated hoarsenes. Hoarseness in people having had laryngitis may persist long after the illness has passed. The patient has adapted a mechanixm of speaking and stayed with it; they have adapted to the low pitch and gruff tone of hoarseness.

      The cause of hoarseness has many sources. While not a substitute for experienced medical examination and advice, being able to spot the non-medical source may avert further damage and point to the need for a change in behavior or environment, medical attention, or speech therapy.

      Obviously, hoarseness resulting from heavy use of tobacco and alcohol can be the first symptom of laryngeal cancer. Smoking frequently leads to the formation of benign polyps on the vocal cords.

      Recent usage of drugs also contributes to hoarseness. The drying effect of antihistamines and decongestants on the laryngeal and broncial mucosa can cause or worsen hoarseness that accompanies a respiratory condition. Taking these medications typically results in throat irritation and a cracking voice pitch, especially on awakening after sleep, although the medications do not harm the larynx. Read medication labels carefully. Corticosteroid sprays such as nasal and oral beclomethasone dipopionate contain liquid fluocarbon (Freon) radicals that may cause yeast infections and pain in the throat.

      Other drugs that can cause hoarseness and therefore vocal damage are birth control pills (especially those of an older vintage; they can cause enlargement of the larynx), steroids (which cause a deepening of the voice), and marijuana and cocaine.

      In addition, common colds, respiratory infections, and throat-related diseases can cause hoarseness. Such connective tisue disorders as rheumatoid arthritis and scleroderma can affect joint movement, adversely affecting the vocal cords, and hypothyroidism can manifest itself in the larynx first. In fact, people who are hoarse have a comparatively high incidence of previously undetected hypothyroidism.

      Gastric disorders are being increasingly considered as a major cause of hoarseness. Heartburn, solid belches, regurgitation, or choking on awakening may suggest that stomach acid is backing up, bathing the vocal cords and causing chronic inflammation of the arytenoid (cartilage of the larynx). Such conditions are often traced to an over-abundance of or low tolerance to spicy foods in the diet.

      The vocal music educator should be aware of the above conditions and should listen for such everyday occurrences as habitual clearing of the throat or coughing. Males who are chronic throat clearers run the risk of developing ulceration and granulomas. If speech is in a rough, low tone, it is a clue to a possible ganuloma.

      Where your students are and what they do during the day or week can affect their vocal quality and performance. School yard yelling, office noise, air environments, and certain professional voice user occupations (such as clergymen, lawyers, auctioneers, choir directors, and aerobics instructors) contribute to vocal problems ranging from simple strain to chronic nodules on the vocal cords.

      To deomonstrate the potential causes, one new patient, a full-time choral director, had suffered a continual problem of nodules for several years; this was despite every previous remedy attempted, including voice rest. Some detective work revealed that the school room heating/air conditioning system was releasing an irritant to her voice. After some mechanical alterations to the system, her vocal nodules shrank and her voice returned to normal.

      Persistent hoarseness, the symptoms of many possible causes, whould be a warning bell to teachers. At the first sign of something amiss, music educators are well-advised to heed the warning and suggest remedial action to their students. Don't forget to safeguard your own voice, too.


      Dos and Don'ts for keeping a voice healthy. Some commonsense rules you can share with your students...and keep in mind for yourself.

      1. Drink 10-12 glasses of fluids a day, preferably without ice. (The temperature range between iced beverages and the larynx is too great). Ice cream is not as cold and is therefore permissible. The best beverage for singers is plain hot water with dashes of lemon and honey.

      2. Avoid alcohol and all forms of smoke. Limit spicy foods. 3. Avoid all forms of whispering, including loud "stage" whispers. Whispering puts too much strain on the voice.

      4. Avoid throat clearing, yelling , or gargling; the vibrations irritate the vocal cords.

      5. Keep environmental temperatures comfortably constant.

      6. Avoid drying medications. If they are necessary, increase intake of fluids.

      7. For hoarseness, sore throat, or laryngitis:

        rest the voice completely

        inhale steam five minutes every three to four hours

        avoid aspirin or gargles. Take only Tylenol.

        suck on glycerin-based lozenges (Only black currant pastilles, Pine Bros. honey or cherry).

        avoid mint, menthol, or medicated ones as these are drying and irritating.

      8. While traveling--land or air--be aware of road or cabin noise which is often louder than you think.

      Keep your conversation to a minimum. Also, be aware of temperature and drafts. Keep warm, drink warm fluids (preferably herb teas) or drink a glass of water every hour, sit as far away from smokers as possible, and stretch and walk around frequently.

      9. Avoid travel the day of performance, especially before difficult or repeated performances, so that the body can rest.

      10. See a doctor if throat problems last more than five days, especially if a fever develops, if there is a loss of appetite or lethargy, or if the small glands under the jaw become swollen, tender, or painful.

      Note: After reading this article you may want to view the Gallery of Laryngeal Pathology and other voice- care related webpages from The Center for Voice Disorders, Wake Forest University.