The mucosal drying effects of both antihistamines and decongestants may be counteracted to some extent with mucolytic agents, which liquefy mucus and increase the output of thin respiratory tract secretions. Guaifenesin is an excellent mucolytic expectorant. It is available as a single agent or combined with a decongestant.

It is often necessary to experiment with several antihistamines, decongestants, or combinations in singers before finding a suitable balance between therapeutic effect and side effects. The clinician should be familiar with many different medications and drug classes, both to minimize side effects and because patients may develop tolerance to antihistamines with long-term use requiring changes in prescriptions. Professional voice users should generally avoid new medication shortly before a performance. Drugs are usually taken in small doses for short trial periods to determine both the level of allergy control and the effects on the vocal tract. If a singer obtains consistent control of allergic symptoms and does not suffer from excessive drying, sedation, or hyperstimulation, these medications can be used safely for both short- and long-term treatment.

Acute symptoms of allergic rhinitis are usually quite responsive to systemic steroids. Intramuscular or oral steroids can rapidly reverse allergic inflammation and can also result in mild mucosal drying and mild CNS stimulation. Steroids can be used to treat a singer or actor suffering an acute allergic “attack” or to rapidly initiate medical treatment because of a difficult upcoming performance schedule. In these instances, corticosteroids are usually administered as either a single intramuscular injection or a rapidly weaning course taken orally over 3 to 5 days. There is no evidence that inhaled steroids reduce vocal fold edema, whether it results from allergic or infectious etiologies. The use of long-term systemic steroids in the treatment of most patients with only allergic rhinitis is inappropriate due to the risk of serious side effects.

Allergy-Directed Therapy

Singers may be particularly sensitive to both the effects of their underlying allergy and the medications prescribed to control their disorder. For this reason, specific allergy-directed treatment is virtually always indicated. Serious singers should be referred to a physician with specialized training and expertise in the treatment of allergic disorders. The American Boards of Pediatrics and Internal Medicine supervise 2-year fellowship training programs in the evaluation and treatment of allergic diseases. Physicians who complete the fellowship successfully may sit for the certifying examination. Although other medical specialties including otolaryngology also offer training in this area, medical allergists generally focus exclusively on allergic disease.

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