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Allergies and the Voice
Dr. C. Gaelyn Garrett
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Voices6/1/2004

Editor's Note: This volume of Voices offers important information on the care and maintenance of your most important tool — your voice. We’ve invited expert physicians from the field — doctors recommended to us and used by our OPERA America member companies — to share their knowledge with you. In the following article, vocal health expert C. Gaelyn Garrett, M.D. of the Vanderbilt Voice Center explores the effects of allergies on the voice and gives recommendations for treatment.

Advisory Note:
Patient education material presented here does not substitute for medical consultation or examination, nor is this material intended to provide advice on the medical treatment appropriate to any specific circumstance.
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Healthy voice use should first begin with a basic understanding of voice production. Normal voicing begins with airflow from the lungs moving past the vocal folds (also known as vocal cords), triggering vibration and resultant sound. The sound is then modulated by the structures above the vocal folds, which include the tongue, mouth, lips, and nasal and sinus cavities, producing what we recognize as the human voice. The vocal folds vibrate very quickly, from 80 to 800 times a second, depending on the vocal pitch. You can imagine that a significant amount of friction can be produced by this amount of vibration, unless there is something to reduce that friction, which, in this case, is mucus lubrication provided by glands in and around the larynx.

Normal mucus is a thin consistency and is clear and glistening. Alterations in the usual thin consistency can affect the protective mechanism of the mucus on the vocal folds. Any vocalist who has visited a laryngologist (an ENT physician/surgeon who specializes in voice disorders) has probably been counseled on the importance of mucus lubrication. We encourage our professional singers and voice users to maximize water intake and minimize caffeine intake to enhance mucus consistency. Keep in mind that water you drink does not directly lubricate the vocal folds but keeps the body wellhydrated. Alternatively, a person who is dehydrated will produce thick, sticky mucus that may interfere with normal vocal fold vibration. Caffeine also contributes to dehydration and should be avoided as much as possible. Certain medical conditions also cause alterations in mucus consistency. The most common of these is allergy. Allergies can also cause other symptoms within the vocal tract, such as nasal congestion, throat irritation, and cough. Depending on the specific allergens involved, these symptoms can be seasonal or year-round. Often, the symptoms of allergy can be mistaken for an upper respiratory infection. The presence of fever or discolored mucus is more commonly associated with infection, either viral or bacterial.

Many different types of medications are available to treat allergies and the symptoms of allergy. One approach is to prevent the release of histamine, the substance that triggers the symptoms of an allergic reaction. Both prescription and over-the-counter antihistamines are available. Common side effects of antihistamines are sedation (more common with over-the-counter antihistamines) and drying of the mucous membranes. A prescription topical antihistamine nasal spray is also available which may minimize the systemic drying effect.

Decongestants are another class of medication frequently used in the treatment of allergy. Rather than preventing the allergic symptom from occurring, decongestants are used to treat nasal congestion once it has already occurred. Decongestants can also be used to treat congestion associated with other non-allergic conditions such as cold symptoms and sinus infections. Decongestants are available in both pill form and in topical preparations. Topical nasal sprays affect just the area within the nasal cavity. These sprays should not be used for more than two to three days to prevent rebound nasal congestion and possible mucosal overdrying and irritation. Oral decongestants also treat nasal congestion but can also affect other mucosal surfaces because of their systemic effect. All decongestants work by causing shrinkage of the dilated blood vessels involved in mucosal swelling. Keep in mind, however, that blood vessels bring nutrients to tissue and therefore, excessive use of decongestants should be avoided. Decongestants can also cause thicker mucus throughout the vocal tract.

An alternative to the antihistamines and decongestants for allergy treatment is immunotherapy, or allergy shots. Allergy testing will identify the specific allergens, commonly dust mites, mold, grasses and trees, and animal dander. Immunotherapy is designed to “reprogram” the body’s response to an allergen, minimizing symptoms. Unfortunately, this process of immunotherapy may take months or years to make a significant impact onallergies and usually requires weekly or biweekly injections.

Other medications are often recommended for allergy sufferers. Topical nasal steroid sprays reduce the inflammation within the nasal cavity, thereby reducing nasal congestion and overproduction of mucus. The effects of these sprays are not specific to allergies and are also used for people who have recurrent sinusitis and hypersensitivity to environmental irritants. One disadvantage of the nasal steroids is that they must be used on a daily basis and may take one to two weeks for onset of action. I recommend them for people who have chronic symptoms for at least several weeks out of the year. They are safe for year-round use if indicated.

Mucolytics may also be beneficial in the treatment of allergy. They reduce the consistency of mucus, optimizing its lubricating effect. The main mucolytic is guaifenesin and it can be found in many of the over-the-counter cold and allergy medicines. Mucolytics can help counteract the drying effects of allergy medication as well as the drying effects of the allergy itself. This medication can also be used for general mucus optimization, even in the absence of allergy or infection. Guaifenesin alone is available overthe- counter, and there are no significant side effects.

Professional singers and voice users who suffer significant allergy symptoms will probably benefit from allergy treatment. For these, the drying effects on the mucosal surface of the vocal folds and the thicker mucus are outweighed by the benefits provided by the various medications. Maximal hydration is even more important in this case. The use of allergy medicine should, however, be symptom-directed with as little medicine as possible. For example, combination antihistamine-decongestant medications are available in a single pill form. If your allergy symptoms do not consist of nasal congestion, you might overmedicate yourself unnecessarily and cause excessive drying of the vocal fold and nasal mucosa. An antihistamine alone would be a better choice and may prevent nasal congestion from occurring.

As outlined above, allergy symptoms can often be managed with over-the-counter medications. Many times, however, a medical evaluation is indicated. Most primary care physicians, usually a medical internist or family practitioner, can manage routine allergy symptoms. Medical specialists in allergy who have additional training are another option, especially if allergy testing is indicated. Most general otolaryngologists (ear, nose, and throat specialists) are also trained in allergy, though not all practices will offer allergy testing and immunotherapy. Otolaryngologists are able to examine the entire vocal tract, including the nasal cavity, oral cavity, and laryngeal structures. This is helpful if symptoms do not respond to routine treatment and further evaluation is indicated.

In summary, allergies can have a significant adverse effect on the quality of the speaking and singing voice. However, many options are available to address the symptoms of allergy. In most cases, the side effects of the medications can be managed and are fewer than the benefits gained by the symptom relief.
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About the Author: C. Gaelyn Garrett, M.D. began her career with the Vanderbilt University Medical Center as a fellow in the Department of Otolaryngology in 1994. Following her fellowship, she was invited to join the distinguished staff of the Department of Otolaryngology where she has excelled in the field of laser surgery, care of the professional voice, and laryngology. Dr. Garrett has served in various capacities on many national committees, boards, and societies, including the councils of the American Laryngological Association and the Triological Society. She is a senior examiner for the American Board of Otolaryngology. She has been involved in multiple research projects and has held various lectureships in America and abroad, including the national meeting of the Sweden Society of Otolaryngology Head and Neck Surgery in Stockholm. As medical director of The Vanderbilt Voice Center, Dr. Garrett oversees the operation of a nationally renowned treatment center for laryngology and care of the professional voice. She has been a faculty participant in many instructional courses including Country Radio Seminar in Nashville, Tennessee. Dr. Garrett is also on the staff of St. Thomas and Veterans Hospitals in Nashville. She is currently licensed in the state of North Carolina as well as Tennessee.
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