This article discusses the use of an integrative approach in the evaluation and management of the voice. The article begins with a look at the larynx and antioxidant therapy, followed by methods to relieve the pain associated with myofacial trigger points, and the herbs and supplements that can be used by vocalists to replace conventional medications in allergies and reflux. The article concludes with a reminder of the reasons why many vocalists turn to complementary and integrative treatments.
Key points
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Voice professionals seek integrative care to minimize potential side effects on the voice.
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The antioxidant glutathione seems to reduce vocal fatigue and the effects of phonotrauma.
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Myofascial release and laryngeal massage are effective in improving vocal function and helping minimize throat pain.
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There are supplements that effectively modulate the immune system and prevent or treat allergies and upper respiratory infections.
Overview
Most benign voice disorders are the result of phonotrauma, infection, or inflammation. Voice professionals often seek integrative physicians because of concerns about the limitations and potential side effects of most conventional treatments for their voice disorders. The armamentarium of the conventional voice physician, for the most part, includes antibiotics for infections, steroids for inflammation, and stomach acid–reducing medications for reflux-related voice issues. I have more than 25 years of experience using an integrative approach in the evaluation and management of the voice. This approach includes both conventional and integrative modalities, with an attempt at restoring health and balance to the individual and managing any problems with the fewest possible side effects. I particularly focus on reducing oxidative stress to the larynx, eliminating all muscle tension issues, and using nutritional supplements and herbal therapies when possible to treat infections, allergies, and reflux. This article is a distillation of my experience based on the best possible evidence and empirical data.
Overview
Most benign voice disorders are the result of phonotrauma, infection, or inflammation. Voice professionals often seek integrative physicians because of concerns about the limitations and potential side effects of most conventional treatments for their voice disorders. The armamentarium of the conventional voice physician, for the most part, includes antibiotics for infections, steroids for inflammation, and stomach acid–reducing medications for reflux-related voice issues. I have more than 25 years of experience using an integrative approach in the evaluation and management of the voice. This approach includes both conventional and integrative modalities, with an attempt at restoring health and balance to the individual and managing any problems with the fewest possible side effects. I particularly focus on reducing oxidative stress to the larynx, eliminating all muscle tension issues, and using nutritional supplements and herbal therapies when possible to treat infections, allergies, and reflux. This article is a distillation of my experience based on the best possible evidence and empirical data.
Integrative treatment approaches and outcomes
Antioxidant Therapy
The larynx, being continually exposed to oxygen and irritants that promote inflammation, is a prime candidate for oxidative stress. Hydrochloric acid, pepsin, air pollution, toxic fumes, and allergens are all agents that promote laryngeal inflammation. Reactive oxygen species (ROS) are a wide variety of unstable molecules that cause tissue damage, which is known as oxidative stress. Glutathione (GSH), a tripeptide synthesized intracellularly from l -cysteine, l -glutamic acid, and glycine, has multiple functions, including protecting cells from ROS. It has a high electron-donating capacity and is found in high concentrations within cells, which allows it to be a potent antioxidant. The larynx naturally contains high levels of GSH and other antioxidants (superoxide dismutase) as protection against ROS. GSH depletion has been found in numerous disease states including:
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asthma
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neurodegenerative diseases
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diabetes
GSH levels are also found to decrease with:
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aging
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ultraviolet light and other radiation exposure
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viral infections
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exposure to environmental toxins
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after surgery
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among burn patients
Generalized inflammation also decreases GSH levels. When the cellular antioxidant defenses are insufficient to keep levels of ROS lower than a toxic level, then oxidative stress occurs. Oxidative stress is a product of either insufficient antioxidants or increased levels of ROS or both.
I have now used GSH in more than 150 patients with acute and chronic vocal fold inflammation. GSH is poorly absorbed orally, and intravenous administration is required to achieve an adequate dose. However, N- acetyl cysteine, undenatured whey protein, and α-lipoic acid seem to increase GSH levels in the body. GSH is available as a compounded intravenous nutritional supplement, which has been safely used in patients with Parkinson disease to their benefit. It has also been safely used for many years by integrative physicians for many chronic health problems. Voice patients receiving GSH report:
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increased vocal range and stamina
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less laryngeal mucus
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reduced burning sensations
GSH was also found to benefit some of my patients with refractory laryngopharyngeal reflux and laryngeal allergies. Some performers with phonotraumatic vocal fold lesions such as nodules, pseudocysts, and polyps have been able to maintain the high level of functioning required to continue performing even with these lesions. I have also seen phonotraumatic lesions disappear. The following case shows the benefit of GSH for acute phonotrauma.
Case 1
A 60-year-old male voice teacher presented with acute onset of hoarseness after holding back a sneeze. Initial strobovidolaryngoscopy revealed a small hemorrhagic polyp of the right posterior true vocal cord along the free margin of the fold ( Fig. 1 ).
The patient was given 2 g of intravenous GSH weekly for 8 consecutive weeks and his voice completely returned to normal, with a vocal range that was better than before the injury. A proton pump inhibitor was recommended, but the patient did not take it. Examination of the larynx at the end of 8 weeks showed complete resolution of the polyp ( Fig. 2 ).
Myofascial Pain
Muscle tension dysponia
Muscle tension often plagues vocalists, and circumlaryngeal massage has been shown to be effective for muscle tension dysphonia (MTD). MTD can often mimic spasmodic dysphonia. MTD is considered to be a functional voice disorder. Symptoms include nondystonic laryngeal or paralaryngeal muscle tension, with impaired, strained vocal quality. Other symptoms of MTD may include pain, hoarseness, and burning in the throat. The pathophysiology of MTD has yet to be characterized. Roy has suggested that MTD is the result of a central conditioning of the laryngeal and paralaryngeal muscle groups, which function in an inhibitory fashion to restrain voice production. Roy and others have described the use of circumlaryngeal massage in the successful management of this disorder. The mechanisms for the beneficial results of this therapy have yet to be completely understood. Most theories have postulated that the manual reduction of extralaryngeal musculoskeletal tension results in reduced laryngeal hyperfunction. In my personal experience, patients with MTD and other function laryngeal complaints such as diminished vocal range, vocal fatigue, and throat pain are often suffering from a subset of myofascial pain.
Myofascial trigger points
The concept of myofascial pain and myofascial trigger points was developed by Dr Janet Travell in the middle of the twentieth century. She recognized that patients who had been bedridden with tuberculosis often suffered from severe pain in the shoulders and arms. She noted that the origin of this pain appeared to be coming from trigger areas in the chest muscles and scapula. She went on to postulate and then to identify focal points in muscles that referred pain to distant locations. These points were termed trigger points. Myofascial pain and trigger points have been understood and researched by physiatrists, pain specialists, physical therapists, and massage therapists, but the concept is not taught to otolaryngologists and speech pathologists.
Trigger points are hyperirritable spots in skeletal muscles that give rise to referred pain, referred tenderness, motor dysfunction, and autonomic phenomenon. Trigger points may be active or latent. Active trigger points usually cause pain locally on compression but also refer pain in a characteristic pattern. Latent trigger points, on the other hand, cause symptoms other than pain, such as increased muscular tension, restriction of motion, and autonomic phenomenon. Trigger point pain distributions and the effects of latent trigger points have been well delineated by Travell and Simmons. Each trigger point has a characteristic pattern of pain, specific to individual muscles. An active trigger point in the sternal division of the sternocleidomastoid muscle, for example, refers pain to the occiput, the parietal region, the supraorbital rim, the submandibular area, and the mentum.
Trigger points arise from multiple causes; they may be activated indirectly by:
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other trigger points
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acute or chronic overload stress
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exposure to cold
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visceral disease
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arthritic joints
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emotional distress
Once a trigger point is created, if it is not treated, it has a tendency to propagate further trigger points, further aggravating symptoms. Activation of trigger points in the neck often gives rise to neck pain, facial pain, throat pain, and shoulder pain. Activation of trigger points in the muscles supporting laryngeal function gives rise not only to pain, but also to several other symptoms, including burning, hoarseness, and autonomic dysfunction. Active myofascial trigger points vary in irritability from hour to hour and day to day. Signs and symptoms of trigger point activity long outlast the precipitating event.
In general, myofascial pain and trigger points should be suspected when the symptoms arise shortly after acute overload stress or there is a history of gradual onset of symptoms with chronic overload of the affected muscle. Other characteristics of myofascial pain include:
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characteristic patterns of pain, specific to individual muscles
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weakness and restriction in the stretch range of motion of the affected muscle
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a taut palpable band in the affected muscle
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exquisite and focal tenderness to digital pressure in the taut band
Trigger points are diagnosed by direct palpation. Palpation of a trigger point may cause a characteristic twitch response. With palpation, pain may also be experienced at the trigger point or in its distribution pattern. The distribution pattern of myofascial pain does not follow neural pathways. The pathophysiology of myofascial pain is not completely known.
Treatment is directed to the trigger point. Treatment techniques vary, including:
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injection of the trigger point with lidocaine or saline
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dry needling the trigger point
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spraying the trigger point with a cooling agent, such as ethylene chloride
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ischemic massage.
The affected muscle must always be stretched after the trigger point is treated. Treating a trigger point without stretching the muscle does not eliminate the symptom.
I find that massage and stretching are my most effective tools in the treatment of vocal fatigue and throat pain. The following 2 cases are examples of patients with throat and voice symptoms, who were treated successfully with myofascial release.
Case 2
N.H. is a 47-year-old woman, who presented with the sudden onset of pain in the base of her tongue. Although on initial examination, there were no physical findings, she was treated by another otolaryngologist for an infection with a course of antibiotics, which were ineffective. She also did not benefit from proton pump inhibitors. Head and neck examination was normal, except for finding exquisite tenderness in the left scalenes, trapezius muscle, and her supralaryngeal musculature. She was treated with myofascial release of the affected muscles on 3 separate visits and her symptoms were eliminated.
Case 3
I.R. is a 48-year-old woman, who developed persistent throat pain and vocal fatigue after a bout of shouting. She also complained of a right hemicranial headache and pain in the right posterior neck. She had a normal laryngeal examination. She had exquisite tension in the right posterior neck along the nuchal line and suboccipital muscles. She was also tender along her right scalenes. Myofascial release of the affected areas eliminated her pain and improved her vocal fatigue.
Herbs and Supplements
Herbs and supplements for the vocalist may be used to replace conventional medications in allergies and reflux, often with fewer side effects. Immune-modulating herbs and supplements are available to prevent and treat upper respiratory infections (URIs) and have no conventional counterpart.
Butterbur
In the management of seasonal and perennial allergic symptoms, natural and nutritional products have been researched. Perhaps the most well-researched herb is butterbur. This herb has been found in head-to-head trials to be as effective as cetirizine in the relief of allergic symptoms and has less of a drying effect on the voice. It seems to work as a leukotriene inhibitor.
Stinging nettle and quercetin
Less rigorous studies have shown that plant sterols balance the T helper type 1 (Th1) and Th2 lymphocytes and thereby reduce the allergic response, and daily use of probiotics reduces allergy symptoms. In vitro studies of the herb stinging nettle and the antioxidant quercetin provide a theoretic basis for allergy relief. Stinging nettle has antagonistic and negative agonist activity against the histamine 1 (H 1 ) receptors and causes inhibition of mast cell tryptase, preventing mast cell degranulation. It also inhibits prostaglandin formation through inhibition of cyclooxygenase 1 (COX-1), COX-2, and hematopoietic prostaglandin D 2 synthase.
Quercetin is a natural antioxidant that blocks substances involved in allergies and acts as an inhibitor of mast cell secretion, causing a decrease in the release of tryptase, monocyte chemotactic protein 1, and interleukin 6 and the downregulation of histidine decarboxylase mRNA from a few mast cell lines. Quercetin and stinging nettle are often together in many herbal allergy products.
Chinese herbs
A combination of Chinese herbs for asthma has been compared with prednisone in a double-blind placebo-controlled trial, and it was shown that the herbs were as effective as prednisone in improving pulmonary function; they increased serum cortisol levels rather than suppressing the adrenal glands.
Other natural treatments
Natural treatments for reflux abound, but there are no studies validating their efficacy. In my own practice, I find that they help some people and do recommend them in cases that are not severe. Digestive enzymes and calcium citrate powder are used with each meal to theoretically increase gastric emptying time and slightly buffer the stomach acid. Other products used include:
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d -Limonene
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Betaine hydrochloride (HCL)
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Magnolia extract
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Black raspberry
The mechanism of action of d -limonene is unknown, but it does relieve symptoms in some patients. Betaine HCL purportedly increases stomach acid, and those who use it once again believe that it increases gastric emptying time by speeding up digestion. Magnolia extract purportedly increases the sphincter tone to the lower esophageal sphincter, thereby reducing reflux. Black raspberry has been shown to protect the esophagus against stomach acid and convert Barrett esophagus to normal mucosa.
URIs
Supplements
Supplements for immune modulation for the prevention and treatment of URIs, which are the bane of most vocalists, have been well researched and have been shown to be effective. CVT-002, a proprietary North American ginseng extract, has been shown in several double-blind placebo-controlled trials to both prevent and enhance recovery from viral URIs. Ginseng has multiple known effects in vitro on immune function. The Cochrane database has reported that evidence supports the use of zinc supplements in the treatment of URIs, even although the exact dose has not yet been established. Zinc can cause nausea as a side effect and caution is advised. The African herb Pelargonium sidoides has also been shown in double-blind placebo-controlled studies to be an effective nonantibiotic treatment of acute bronchitis and sinusitis. The active ingredient is EPs-7630. It seems to modulate salivary secretory immunoglobulin A and serum and nasal inflammatory cytokines. This herbal treatment is also supported in the Cochrane database ( Table 1 gives the product names of these supplements).
