Just the mention of the Ear, Nose, and Throat Doctor (ENT) can strike terror in the hearts (and throats of singers). However, a good ENT can be your voice’s best friend.
In this episode, John covers what to look for in choosing an ENT, when you should go, what to expect, and the main vocal issues you may encounter.
This episode is essential for all professional voice users.
Dr. Reena Gupta – An excellent resource website as well as a highly qualified voice specialist.
Dr. Curt Stock – A skilled ENT as well as a passionate supporter of vocal science and healthy singing.
Episode 51 – Seeing the Ear, Nose, and Throat Doctor
Hey, this is John Henny. Welcome back to another episode of the Intelligent Vocalist.
Alright, let’s talk about the Ear, Nose, and Throat doctor. This can strike fear into the hearts of singers – ENT. I’ve had students terrified to go to the ear, nose, and throat doctor and actually put it off worried about what they would find out. They didn’t want to hear the truth. And that’s unfortunate because the one thing that you have to realize about your voice is if you feel that something is going on, if something’s not right, the longer you wait the bigger the problem can be. So, I do want to encourage you to get to an ear, nose, and throat doctor right away.
Now, choosing an ear, nose, and throat doctor can be like choosing a voice teacher. Believe it or not, in the bigger cities especially here in L.A. and also New York, Nashville I’m sure has some of these – they get a little bit of a celebrity culture around medical professionals, just as you do around hair dressers and personal trainers, and yes, voice teachers. And when you start working with celebrities it raises your credibility because one thing celebrities are good at is picking medical professionals. All celebrities are medical experts. So you cannot be famous until you’ve proven that you are a medical expert, which of course is nonsense. However, celebrities are very very powerful thing in our culture and we’re all swayed by it. So the way it kind of works here in L.A. is celebrity voice teachers get in with celebrity ENTs. A lot of celebrities that voice teachers get actually come from the ear, nose, and throat doctor.
A lot of time singers don’t seek out voice teachers on their own or they don’t know who to choose so they get recommended by the ear, nose, and throat doctor. However, the ear, nose, and throat doctor recommends voice teachers that send them clients. It’s kind of a two-way street. And ear, nose, and throat doctors don’t always know who the best voice teachers are either. However, if a voice teacher is terrible, the ear, nose, and throat doctor would see that their students aren’t getting better. So if an ear, nose, and throat doctor recommends a voice therapist –that’s a little more regulated than voice teachers. Voice teachers are the wild west. If they recommend a voice teacher, you can be pretty sure they’re at least decent. And if your voice teacher recommends an ear, nose, and throat doctor, hopefully they kind of studied and vetted that doctor, and not just sending you because the doctor sends them clients.
Now having said that, let’s say that you need to choose a teacher on your own and you want to find an ear, nose, and throat doctor. Well, as the name implies, they work on the ear, the nose, and the throat. Some ENTs specialized more in the ears. Some ENTs specialized more in the nose or different cancers. And then there’s a branch of ENTs that are laryngologists and they specialized in the larynx or the voice, so they have additional training in voice disorders. And you do want to look for somebody if you can. If you’re in a bigger city you should be able to find – I believe they are called fellowship trained laryngologists. That means they’ve done, I think an extra year of training in laryngology, and then, even further specialized, if they really focus on professional voice users.
Professional voice users are not just singers. It can be public school teachers, sales people, attorneys, business people, public speakers – anybody who uses their voice primarily to make their living, so that encompasses a lot of people. It usually doesn’t encompass accountants – they don’t really use their voice too much – or computer programmers. But if it’s somebody that really focuses on professional voices, that is a great sign.
Now, when you go to an ear, nose, and throat doctor – hopefully your laryngologist, professional voice teacher, or voice teacher specialist, they will have different types of equipment. You may have these. Getting scoped is actually pretty painless. It’s where they take the little camera and they can see inside your vocal folds. This was first developed – oh I don’t know the date. It was well over a hundred years ago, and I’m sure someone listening to me is screaming it out. But I believe it was in the 1800s by Manuel Garcia, who is a voice teacher, who actually took a mirror and was able to look back and down in his throat and see his vocal cords in action. He was believed to be the first person to see the vocal cords actually working, not just from a cadaver.
So now we have sophisticated equipment. There are two main types of equipment; There is the soft flexible scope that goes up through your nose and then down and can see through your vocal cords from directly above. And then there is the hard scope that is solid and goes in your mouth and looks directly down. Of the two – they both have their uses, but in general, the hard scope that goes through the mouth is the one that you want. It gets a more accurate picture. I’m not an ear, nose, and throat doctor but my understanding is that it’s easier to misdiagnose what’s going on with the flexible scope. Things like phlegm can look like nodules, which is the word that freaks everybody out. And if you get misdiagnosed with nodules, you’re going to have a lot of sleepless freaked out nights for no reason. So the hard scope is better.
And then, if they’re able to do a stroboscopy, they’ll get a strobe because vocal folds can move faster than the human eye can see. It’s a timed light that actually the vocal cord will go in slow motion. You can go on Youtube and just search for that, and you’ll see different stroboscopy there. And in that way they can see how the vocal folds is functioning, how it’s functioning within the wave, because sometimes there can be issues with vocal fold function and with muscular function, that the vibration of the folds is a bit of the problem. It’s not something obvious like a polyp or a blister on the vocal fold surface. So that’s what you want to look for.
Now, when should you go see an ear, nose, and throat doctor?
I’ve heard varying time frames where I’ve heard doctors recommend – you know, if you have a bit of a condition in the voice and after a couple of weeks it’s not getting better, you should go in. and then I’ve heard if it’s not getting better within a few days, you should go in. Between that, you know your own voice, especially if you’ve been singing for a while. So if you feel something’s not right, you should go see the ear, nose, and throat doctor.
Now, some of the common problems that we’ll be running into;
Everybody knows about nodules and everyone’s afraid of nodules. If they’re hoarse after singing, one night maybe they’ve over-sung, they think “Oh my gosh, I have nodules.” Nodules are actually a chronic condition and they take time to form. They form because of friction. So the idea is friction plus time causes most vocal issues. And as you stress the tissue of the vocal folds, it will begin to thicken and hardened to protect itself, much like the callous on your hands. When it does that, we have a problem. Because now, imagine if we have a big old callous on our lips and we’re trying to play the trumpet. You’ll begin to lose the flexibility that you need within the folds. And they also can’t come together properly. You can kind of know, if you have nodules, you’re going to start to have issues primarily in your vocal transition, your vocal break may become a little wider and a little more pronounced, you’ll have to work harder to not fall apart in your break. Your onsets are going to become a bit more breathy and squeaky as you try and hit them, even your speaking voice may tend to become more raspy. You’ll begin to lose your high notes.
Again, you have conditions that are acute and conditions that are chronic. Acute are conditions that come on right away. Those are laryngitis, which is any type of swelling be it from a virus or yelling too much. There are conditions like a vocal hemorrhage, those tend to be more acute, they come on quickly. But nodules are chronic. They take a while to come on. But if you start feeling those symptoms, you want to get to ear, nose, and throat doctor right away because the earlier to catch it, the easier it is to get rid of them. They don’t hardened as much so they would dissolve more easily. So you’d definitely want to get in quickly if you start to feel that that’s not going away. Again, you’re starting to lose some range, you’re getting a little wider, your speaking voice is maybe getting a little bit on the raspy side or breathy side. Go see an ear, nose, and throat doctor.
Now, some of the other condition that is less common is you can get polyps and cysts. They’re both like fluid-filled blisters, if you will, like a blood blister on your hand when you get those fluid-filled blister. The polyps are on the outside of the fold, and the cysts are on the inside.
Nodules these days, doctor don’t really do surgery on them. Doctors used to perform surgery much more often, but not so much today. I recommend you not to get surgery unless it’s some extreme circumstance and you’ve gotten at least a second opinion.
With polyps, they usually have to get surgery for those because even if they begin to diminish, they still have that lose skin from the blister. And the cyst inside the fold – in my understanding, the surgery is a bit trickier. It’s a bit more debatable. Some singers have polyps and they learn to sing around them. Polyp would actually move under the vocal fold, so they don’t have to have surgery. It’s not all the time.
Again, I like doctors who don’t go with surgery as their first choice.
The cyst, because it’s inside the vocal fold, is a little bit trickier. You have this kind of gelatinous tissue substance within the fold that you don’t want damaged. That’s what really gives the folds its pliability and its musical ability to vibrate. And if you mess with that and you lose too much of it, it can’t be replaced so you can suffer permanent voice damage, which we do not want.
Other issues are granuloma, which is like an ulcer irritation that’s back on the cartilages of the rear of the vocal folds. You have these little triangles that help the folds open and close. The vocal folds only open from the back and they’re attached together at the front. These little “door handles” if you will, these cartilages that open and close – if they’re closed forcibly and they begin to rub together and can be ulcerated, that can be a bit painful. It can also happen with extreme sneezing and coughing , so granulomas are a possibility. And then, you can get a hemorrhage, where you get a blood vessel that can burst and leak blood into the folds, which can cause some swelling.
You can get combinations of these issues where singers will be pushing and pushing on nodules, so they have to start squeezing harder and harder, which then causes the folds to slam together with more impact which raises the risk of a hemorrhage.
Just as a side note; Be very careful with anti-inflammatories such as Advil because they can actually, though they will reduce inflammation on the cords because we don’t like inflammation. It makes us harder to sing. They can actually make us more prone to a hemorrhage. And women, here’s another area in life where you get the short straw because you’re more prone to this. So there you go. Just as the other thing that’s not quite fair is, they think they’ve discovered in female voices, you tend to have drier voices because your tube, if you will, that the air passes through is shorter than a man’s. So, there’s less time and distance for it to become moist and humidified by your body, if you will. So you get your own special voice problems.
But it’s made up for by the fact that because men have thicker longer vocal folds and more chest voice, that when their transition comes, it can be a real difficult area. Not that it’s easy for everyone, it tends to be a little easier for women than for man.
Now, you want to, if you can, let your voice teacher know the doctor you’re going to and ask the doctor to give permission for the voice teacher to being contacted and seeing your records. If you’re suspecting that there are vocal issues, you kind of want to have a team behind you. And if you really trust your voice teacher, let your voice teacher speak with your doctors so they understand what’s going on and they can work together or at least communicate in how best to help you. If you’re put on vocal rest by your doctor, that usually means vocal rest – you need to be quiet. However, they don’t do vocal rest the way they used to because they don’t want those muscles to atrophy. So a good voice teacher will be able to help you with rehab in that way. Now, if you don’t have a voice teacher in general, when you vocalize you want to be very careful and take your time. Don’t go in and start trying to belt and sing big tones if you can just do gentle narrow vowels not to loud. Don’t start trying to get to the higher pitch kind of singing because that’s going to likely cause too much stress on the folds.
Now, let’s talk about nodules again. If you are diagnosed with nodules and you followed the doctor’s instructions, and your nodules dissipate, here’s the bad news; If you go back to what you were doing before and engaging in the same behaviors, your nodules will likely to come back. So if you do get nodules you’re going to have to do a little bit of self-reflection as to what you were doing vocally. If you’re not studying with a really good voice teacher, you really should think about it. If you’re studying with a voice teacher, and you feel you’re doing everything they tell you to do and you’re getting nodules, you might want to think about trying another voice teacher. I know it’s a delicate subject but your voice is the most important thing after coffee.
So you need to just take care of yourself. Do not be afraid. Get in there and get the information. The quicker you get the information, the quicker you diagnosed, the quicker you can stop the problem from growing. You can fix the problem. And then you can know what to do in the future to not have that problem come back.
Now, the other thing that people often are diagnosed with is reflux, which is that pepsin in the stomach, your digestive acids coming up and burning the folds, kind of digesting your vocal folds. Of course the stomach acids are in our system. I wouldn’t have designed the voice this way. I wouldn’t have the voice sharing digestion, and swallowing, and eating, and having this vat of caustic dissolving material sitting below it, that can travel up and burn your cords. But what can we do? That’s the system we’re given. So you just want to be careful with what you eat. If you do have reflux, follow the doctor’s orders with diet, etc.
Sometimes, it’s now starting to be, what I’ve heard, a bit over diagnosed if, ear, nose, and throat doctors just see redness or swelling, they kind of jump to the reflux diagnosis. So you might want to get a second opinion. Again, if you’re really dealing with a specialist or laryngologist who deals with voice professionals, you’re in better hands. And if they’re using the top-end equipment, and if they get the stroboscopy, make sure that you get a copy of the stroboscopy video because you can send it to other doctors. There are some great great doctors around the world who can give you a second opinion just by looking at that. Dr. Kirk Stock in Salt Lake City is absolutely fantastic. Dr. Reena Gupta here in Los Angeles of the Osborne Head & Neck Institute, she is great as well. You can reach out to them and get second opinions, and keep yourself healthy.
Hey, I just actually finally launched my Contemporary Voice Teacher Academy. Right now it’s gone out to my email list. But by the time you hear this, I think it should be open to the public. You can go to johnhenny.com and click on the PRODUCTS tab. And if you see it there, well then it’s open for business. You can jump in. This will take you – I’ve designed this course to take you from never having taught a voice lesson, to being a really good solid Contemporary voice teacher. It goes step-by-step, gives you all the vocal tools and pedagogue, you had a diagnosed voice, vocal science, etc. And there’s a certification test. I’m really happy with this. And the beta testers we have going through it are really really enjoying it as well.
So there’s my little commercial. Until I decided to get sponsors, I’ll be my own sponsor and do my own commercials, thank you very much.
Again, thank you so much for listening. You can get this podcast, if you want to read the transcript, look at the show notes. It’s johnhenny.com/51. I’ll have the full transcript of the episode up there as well. If it’s not there when you go, it should be there within a day or two. That means you’ve just jump on this thing right away. I have people working on these.
Until next time. To better singing! Thank you so much. Bye.