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Allergies and the Voice
C. Gaelyn Garrett, M.D, Medical Director, Vanderbilt Voice Center, Associate Professor, Department of Otolaryngology, Vanderbilt University Medical Center
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ArtistLink7/9/2009

Editor's Note: 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 well hydrated. 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 on allergies and usually requires weekly or bi-weekly 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 over-the-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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