Vocal Health and Aging for Choral Singers

This is a handout I made for the Colorado Symphony Chorus, and thought I'd share it on the blog!

Vocal Health and Aging
Kate A. Emerich, B.M., M.S., CCC-SLP
Clinical Voice Pathologist
Singing Voice Specialist/Voice Instructor

Coordinated activity in the brain, larynx, vocal tract, articulators, thoracic cavity and abdominal musculature is required for voice production. Impairment of any of the coordinated structures can impact phonation. Voice production is broken down into three main components:

power source 
sound source 
resonator 

• The power source is comprised of the muscular core (primarily pelvic floor, transversus abdominis and internal and external obliques), lungs, ribcage and diaphragm. The power source moves air from the lungs up to the vocal folds through an exchange of pressure from the abdomen (IAP), thorax (ITP), to just below the vocal folds (Psub), to initiate and maintain vocal fold vibration.
  The sound source is the vibrating vocal folds, which are housed in the larynx. The vocal folds vibrate and generate a sound similarly to blowing through a trumped mouthpiece.. This sound contains a complete set of harmonic partials.
• The resonators include the vocal tract, oral and nasal cavities and associated articulators. They filter and beautify the partials of the sound source.
  

The vocal folds are very small, approximately the size of a dime-to-penny in females
and a quarter in males. They are a multi-layered, complex structure consisting of the cover (mucosa and superficial layer of the lamina propria), transition (intermediate and deep layers of lamina propria) and muscle (vocalis muscle or thyroarytenoid muscle). Vocal folds do not have pain receptors, so it is possible to injure them without knowing it (until it is too late!). The best way to maintain vocal health is to prevent vocal fold injuries and prevent getting sick!

Vocal Health Tips
1. Hydration: Optimal hydration is important for normal vocal fold vibration. There are two types of hydration to consider:

• a) Systemic hydration is based on how much water or non-caffeinated or alcoholic beverages you drink. Drink alcohol and caffeine in moderation and pee pale.
  
• b) Direct hydration is achieved through steam inhalation ideally through the use of a Personal Steam Inhaler. 10-15 minutes of steaming 3 times a day is generally recommended.
  

2. Mindful Vocalization: The way you use your voice is paramount to your overall vocal health. Straining your voice causes vocal fold inflammation and/or injury because of trauma to the vibratory edges of the vocal folds from collision forces. Injuries such as vocal fold hemorrhage, vocal fold tear, vocal fold cyst or vocal nodules can happen from vocal strain. Straining behaviors include:

• Speaking without support and/or in glottal fry
  
• Speaking at a pitch that is not commensurate to your singing voice or physiologic pitch
  
• Prolonged loud singing
  
• Talking or singing over noise
  
• Screaming/yelling, e.g., cheering on your favorite sports team, etc.
  
• Singing or speaking with visible physical tension (jaw, head or other body parts shaking
  from tension)
  
• Using the voice to the point of hoarseness
  Instead....
  

• Sing with effective breath support and control
  
• Sing beautifully in a comfortable loudness level
  
• Avoid excessive glottal onsets
  
• Sing in your comfortable range
  
• Sing with proper body alignment and correct laryngeal position
  
• Sing without excess tension in the tongue, jaw, and throat tension
  

Remember, if you can’t hear your neighbor when singing in a choir, you are singing too loudly, probably causing vocal fold inflammation and risking vocal fold injury.

Interesting Fact!

When two choir members sing at a similar loudness level, the overall acoustic boost is 3 dB. When one singer sings at 91 db at the other is at 85 dB, there is only a gain of 1 dB for the choral sound (sometimes less if the disparity is greater). Singing to hear one another is not only good for your vocal health, but also for the acoustic output of the choir!

3. Listen to the sound of your voice. Hoarseness or a raspy vocal quality are signs of vocal fold inflammation and that you are singing with too much force and/or tension. It also may indicate you’re experiencing reflux. Consult a voice specialist (Fellowship-trained Laryngologist) if your hoarseness lasts more than two weeks or if you have pain with voice use. Breathiness indicates you are not getting good closure of the vocal folds. Voice therapy and/or voice lessons are good solutions to optimize your vocal production.
   
4. Don’t smoke. Anything. Smoking burns the vocal fold tissue and causes DNA changes in the vocal fold tissue, stunting normal cell regeneration. This results in swollen, fluid-filled vocal folds (think little breakfast sausages). Pot smoke is even hotter than tobacco smoke (hot enough to fry an egg!). If you use marijuana, edibles are a safer option to preserve your vocal health.
   
5. Don’t force your voice or sing when you are hoarse from laryngitis, a cold or the flu. When there is already inflammation of the vocal folds you are more vulnerable to damage. Until your hoarseness is gone, avoid prolonged speaking, singing, or straining your voice.
   
6. Avoid frequent throat clearing or coughing. A silent cough or strong burst of air past the vocal folds is effective in removing mucus to a place where you can swallow it. Otherwise, the body detects the vocal fold collision as a trauma and will send mucus to that area.
   
7. Vocal rest. Give your voice a rest after talking or singing extensively or too loudly.
   
8. Vocal warm-up. Warm up your voice before teaching, lecturing, or singing. This should include a physical warm-up, massage of tight muscles, gentle pitch glides (lip trills or straw phonation) or tongue trills.
9. Exercise regularly. Your voice relies on organs and musculature from your brain to the bottom of your torso. Overall fitness, including strength and flexibility of your muscular core, cardiovascular and aerobic conditioning, improves your energy, breathing, and posture, which are all important for voice production. Weight management is advised/ encouraged, as obesity is correlated with poor breath control.
10. Take singing lessons and/or sing in a choir! Good breath support is the foundation for healthy, flexible voice production. Singing has been shown to keep the voice healthy and young.
11. Support your speaking voice. It’s not uncommon for singers to have voice difficulties related to their speaking voice production.
12. Get your hearing checked. The brain relies on an accurate neural signal from the cochlea (auditory feedback loop) to coordinate muscles responsible for breathing, phonation and articulation. If you have hearing loss, it’s better to intervene early with amplification.
13. Manage your stress. Stress management can help you reduce overall physical tension, improve your sleep, and optimize your overall wellness.

Click on the link below to learn more benefits from singing: Health Benefits of Singing

Vocal Health-Prevention

These are a few items to have in a vocal health-prevention cabinet just in case you start feeling or get sick. One of the more challenging voice disorders can happen from getting sick with a viral infection. The superior laryngeal nerve (SLN) seems to be more susceptible in being affected by a virus, and when that happens, it doesn’t work optimally and results in a weak cricothyroid muscle, the only muscle that nerve innervates. The cricothyroid muscle is responsible for stretching and elongating the vocal fold and assists in vocal fold closure. When the SLN is weakened by a virus, one or both vocal folds cannot stretch normally and the weakness can result in a height disparity of the vocal folds (if there is a unilateral weakness). Singers are most affected by this kind of weakness, because we need the vocal folds to stretch for pitch and register change. Viruses can all create excess mucus and an associated cough. Coughing is really traumatic to the vibratory edges of the vocal folds and should be minimized when at all possible.

• Zicam is an anti-viral cold medication you take within 24-48 hours of symptoms of a cold until your symptoms go away
• Cold Snap is a concoction of Chinese herbs to help boost the immune system and helps to eliminate your virus in a SNAP.
• Delsym is an over-the- counter cough medicine recommended for singers to reduce coughing and subsequent vocal fold trauma.
• Gaviscon tablets are helpful in treating reflux symptoms by creating a barrier so acid doesn’t reach your throat.
• Vicks Personal Steam Inhaler is essential for direct hydration of the vocal folds. All singers need one for general voice care but especially when you are sick.

Medications and the Voice

1. Antihistamines. The are medications used to treat allergies. They thicken and dry the mucosa in the respiratory tract including the vocal fold mucosa. Singing on dry vocal folds requires more phonatory effort and can lead to vocal fold mucosal injury (vocal fold tear) and/or vocal fold inflammation. Both can cause hoarseness. Zyrtec, Claritin, Benadryl, Meclizine, Allegra, etc are examples of antihistamines.
   
2. Mucolytics-can be helpful in counteracting the drying effects of antihistamines, dehydration from athletic events, flying on an airplane or high altitude dryness. . Musinex, Guaifenisin, etc thin mucus and increase secretions
   
3. Non-steroidal anti-inflammatory medications (NSAIDS)- Advil, Motrin, Alleve, Aspirin, Naprosin, etc. change the platelet function and can lead to vocal fold hemorrhage, one of the most impactful vocal fold injuries a singer can experience. AVOID regular use.
   
4. Vitamins-are not always safe. High doses of Vitamin C (1000 mg or more) can actually be drying. Fat soluble vitamins A, D, and E and fish oil in above normal doses can thin the blood over time and cause vocal fold hemorrhage.
   
5. Inhalers for treatment of asthma-Many people develop contact inflammation from oral inhalers and they also may cause drying. Steroid inhalers can cause a fungal infection (candida laryngitis). They can also cause bowing of the vocal folds with prolonged use. Inhaled cromolyn sodium has the fewest problems for singers.
   

Singers can use nasal sprays such as Flonase, Rhinocort, or Nasacort for effective treatment of allergies without systemic drying .

You must be systemically hydrated for mucolytics to be helpful.

Tylenol, Celebrex, Meloxicam and Tramadol are safe alternative pain medications for singers.

Oral medications would be ideal for asthma control with only limited inhaler use.

6. Steroids- Occasionally it is necessary to undergo corticosteroid treatment for inflammation in the body. They are given for acute inflammation of the vocal folds in rare cases.
   
7. Hormones- may cause changes in voice quality due to bound fluid in the superficial layer of the lamina propria or structural changes. Androgens must be avoided in female singers as they can permanently lower the fundamental frequency (pitch) of the voice. Birth control pills high in progesterone can cause a lowering of the pitch of the voice (usually temporarily).
   

Singers should not sing while taking corticosteroids for vocal fold inflammation to prevent further vocal fold tissue injury.

Estrogen-progesterone balanced pills are better choices for singers, as are non-hormone birth control options.

Click the link below for a comprehensive list of medications and potential impacts to the voice:
Medications and Voice Affects

Aging Voice Issues:

• A decrease in estrogen in women increases the thickness of the vocal fold tissues which can decrease overall range and can cause hoarseness and also lead to compensatory muscle tension patterns or hyperfunction.
  
• A decrease in testosterone in men increases pitch of the speaking voice and decreases the low range a small amount.
  
• The laryngeal cartilages ossify over time which can affect range and flexibility.
  
• Laryngeal muscles can atrophy resulting in a breathy or hoarse vocal quality.
  
• Abdominal and rib muscles atrophy negatively affecting breath support.

Aging Voice Symptoms: 

• Hoarseness
  
• Pitch breaks
  
• Delayed onset of voicing
  
• Muffled voice
  
• Difficulty projecting
  
• Register transition challenges
  
• Decreased control of pitch
  
• Reduced breath support
  
• Wide vibrato
  
• Vocal tremor
  
• Breathy voice
  
• Decreased vocal range
  
• Increased warm-up time
  

Aging Voice Tips:

• The good news is that vocal aging can be delayed! Regular singing, exercise, both aerobic and strength training along with a well-balanced diet and weight control can allow us to sing well into old age. Obesity negatively impacts reflux, breathing and support.
  
• Use good breath support! Exercises to optimize efficiency of breath help keep the muscles of the power source younger and stronger.
  
• Avoid excessively pressed phonation that can cause phonotrauma to the vocal folds. Also avoid breathy phonation. Strive for a balance of airflow and vocal fold entrainment.
  
• Always warm up the voice prior to singing and cool down the voice after long sessions of singing.
  
• Use techniques to optimize resonance which increases efficiency of singing
  
• Use good vocal technique when speaking and singing
  
• Steam and stay well hydrated systemically
  
• Don’t smoke
  
• Hormone replacement can help with depleted hormone levels. It’s best to know your physiologic levels when you’re young to know the minimum replacement your body needs.
  
• Voice lessons or voice therapy can be effective in strengthening your particular voice issues.
  

Resources:
Top Clinical Fellowship-trained Laryngologists in Denver area:
Drs .Mona Abaza or Matt Clary- University of Colorado Anschutz Outpatient Pavilion 720-848-2820 http://www.ucdenver.edu/academics/colleges/medicalschool/departments/ Otolaryngology/patientinformation/adultservices/Pages/Laryngology.aspx
David Opperman, Colorado Voice Clinic 303-844-3000 https://www.coloradovoiceclinic.com
J. Michael King- Peak ENT Golden/Broomfield 720-401-2139 https://peakentandvoicecenter.com
References:
McCoy, Scott (2012). Your Voice: An Inside View (2nd Edition) Delaware, Inside View Press.
Sataloff, Robert Thayer (2017). Vocal Health and Pedagogy (3rd Edition), San Diego, Singular Publishing Group, Inc.
LeBorgne, Wendy D., Rosenberg, Marci (2014). The Vocal Athlete, San Diego, Singular Publishing Group, Inc.

Direct Massage Tasks:
Often when there is some kind of weakness or change in entrainment or closure of the vocal folds there is also secondary tension present in the extrinsic laryngeal muscles. This tension is often a biological response to the change in vocal fold closure or a compensatory technique used to manipulate voice production.These muscle tension patterns impede normal voice production and need to be restructured. Along with retraining the vocal production, direct massage release is an important tool to decrease the overall tension in and around the vocal mechanism. Massage 1-2 minutes MAX per muscle. Steam/massage.
Tongue-base
Because of the close proximity of the tongue to the larynx (pictured partially in blue above), tongue tension can cause a compression of the larynx or, in combination with the hyoid complex of muscles, result in a raised larynx.

• .  1) Tongue base massage: using your thumb or finger(s), press and massage the genioglossus and hyoglossus with a gentle circular massage. 

  
• .  2) You can also do tongue stretches- but make sure you support your jaw joint by pressing the hands firmly next to the TMJ so it doesn't pop with mouth opening. 


Stretch the tongue to the chin. Breathe.

Slowly slide the tongue across the chin to the corner of the mouth. Breathe. Slowly slide across the chin to the other side of the mouth. Breathe

Slide the tongue back into the mouth. Wipe chin.
Anchor the tongue tip behind the front teeth. Keeping the tongue tip behind the teeth, slide the rest of the tongue forward. Feel the back of the tongue stretch. Breathe.
Repeat a few times during the day.

Jaw
We want to focus on the muscles that impact the jaw joint the most, so we will massage the chewing muscles. There are two; the masseter and the temporalis. Bite down gently and you will feel the muscles press out against your fingers.
To release, press the pads of your

fingers into the muscle, hold for a few

seconds and release into a circular massage. Move around to release the entire body of the muscles.

Laryngeal Massage
Using your first finger bent over at the knuckle and your thumb, gently stroke downward along the body of the larynx. Be careful not to squeeze or press. It should feel soothing. Laryngeal massage

can be performed to release a high, tight larynx, sooth sore extrinsic laryngeal muscles or to restore a neutral laryngeal posture prior to speaking or singing.

Hyoid complex massage
Using your middle finger, work gently with an up and down motion to release the hyoid complex of muscles. When tight, these raise the larynx and can actually keep the larynx too high.
Make sure the finger is perpendicular to the neck and between the body of the larynx and the body of the SCM. Work the vertical distance of the larynx.

Sternocleidomastoid (SCM)
The diagonal muscle in this image, the Sternocleidomastoid is a large neck stabilizer but when tense can negatively impact the voice because of its approximation to the larynx.
To release, use your thumb and press into the muscle and do a circular massage, pressing and massaging through the entire course of the muscle.

Skull-base

Using the pads of your fingers, press and do a circular massage of the fascia. Press-circular massage-move to another spot until you've accessed the entire skull-base.

Neck joint/upper trapezius
Using your first two fingers, press into the muscle at the indent of the neck and perform a circular massage. Press and massage all the way down to the shoulders and across shoulders. 

In honor of Labor Day! (I know, wrong kind of labor) Strengthen your Pelvic Floor Muscles for a Stronger, Healthier Voice: A look at the anatomy, biomechanics and exercises to get you singing at your best!

Exercises to promote awareness, flexibility and strength of the pelvic floor

• 
  *  Sit on a hard surface and make sure you are sitting on your sit bones or ischial tuberosities. Find a neutral pelvis by gently rocking the pelvis back and forth and side to side. Once you have found neutral, inhale through your nose and feel the body expand to breathe into the lateral ribcage, back and pelvic floor (downward). Inspiratory diaphragm also moves downward as you inhale. As you exhale on a "hum" feel and encourage the pelvic floor to move up and inward, toward your head.  Release pelvic floor at the end of the utterance.  Your breath should return automatically.  Repeat.
  
  
• *  Lean forward with your elbows on your knees and repeat the inhalation/exhalation exercise. Feel the deeper course of the inspiratory diaphragm and the pelvic floor expansion in this position and the upward and inward motion of the pelvic floor on the exhalation/ hum. Repeat with different h-syllables, e.g., /ha/, /he/, /hi/, /ho/, /hu/.
  
  
• *  Move into child's pose making sure you are not tucking your pelvis first before you stretch your torso forward and away from your hips. Inhale and exhale, noticing your breath and with an increased awareness of the pelvic floor. Perform a lift followed by a release of the pelvic floor muscles. Repeat 10 times. This is an agility exercises and will help you have more control of engaging and releasing PFM.
  
  
• *  While in child's pose, transition to lifting the pelvic floor and sustaining that lift.  Increase progressively, releasing the pelvic floor musculature for equal counts after each lift/sustain.  Work up to 10 counts each of lift/sustain and release.  This is an endurance exercise and will translate to the pelvic floor musculature strengthening.  A strong pelvic floor can engage and support phonation through a long spoken or sung phrase easily. E.g., lift 1, release 1; lift 12, release 12; lift 123, release 123, etc.
  
  
• *  Repeat the process with your favorite sung vowels.
  
  * Inhale and on your exhale slowly stand. Feet stay hip distance apart and pelvis restores to neutral as your body straightens. Release your knees as you inhale and go into a feet parallel plié.  Inspiratory and pelvic diaphragms move downward. Lift pelvic floor upward as you exhale and slowly stand. Couple this with sustained speech or singing in place of exhaling air. 

• 
  
  The role of the pelvic floor: considerations in voice production
  
  
  
  
  Breathing
  

  • *  The inspiratory diaphragm works in a symbiotic, phase-locked relationship with the pelvic floor (pelvic diaphragm).
    
  • *  As the inspiratory diaphragm courses downward during inhalation, so does the pelvic floor and the larynx
    
  • *  If the pelvic floor is not released, it compromises the inhalation by limiting the course of the inspiratory diaphragm
    *  The pelvic floor descends and expands as the vocal folds open during inhalation

• 
  

  
  

  
  Phonation
  
  *  The pelvic floor and transverse abdominis co-contract during forced expiration/phonation.
  

  
  

  *  Support must come from dynamic, coordinated musculature of the pelvic floor and transverse abdominis.
  *  Inhalation expansion ends at pelvic floor and support for forced exhalation and phonation begins at pelvic floor. 
  
  
  
  Physical Considerations
  
  
  • *  Globally, alignment of the body is impacted by the pelvis
  • *  The jaw mimics the pelvis; too much tension in the jaw can obstruct the pelvic floor
  • *  Pelvic floor, inspiratory diaphragm, 1st rib, glottis and soft palate need to be stacked
    above one another in alignment
  • *  Because of the central position of the pelvis, small shifts can result in big changes, e.g., a
    big twist in the neck
  • *  Pelvic floor supports almost every movement we make
  • *  Knee and feet movements are connected to pelvic floor; if the pelvic floor is balanced, so then are the feet
  • *  Tension in the upper body can obstruct pelvic floor function
  • *  A tight pelvic floor can lead to constipation; vice versa
  • *  A weak pelvic floor can lead to urogenital dysfunction
  • *  Glottic insufficiency can lead to pelvic floor dysfunction
  • *  Of note, hormone receptors are identical in larynx and urogenital region (Abitbol)
  • *  Wearing high heels can obstruct pelvic floor function 
  • 
    
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