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Keeping Vocal Cords Humming

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Susan Graham’s brown eyes are a little red this week. That’s because it’s pollen season in Houston, where the Grammy award-winning mezzo-soprano is learning eight arias and the rest of the leading role for Xerxes, the Handel opera. “I find I’m clearing my throat a little bit more,” Graham says in a slight southern drawl. “I sneeze more during the day than I’m used to.”

Runny noses afflict kings and knaves alike when spring is in the air. But for opera singers, allergies are no mere inconvenience. If the thought of spring pollen makes your eyes water, imagine singing unplugged to 3,000 people when dust from a 40-year-old costume has swollen your sinuses shut.

Luckily for singers these days, doctors are much more in tune than ever before with how an operatic voice should sound and what a singer’s vocal apparatus should look like. They also have new tools that let them see inside the larynx without causing lots of wear and tear. Years ago, doctors had to put patients under general anesthesia to examine their sinuses and vocal cords—which are not cords at all but two folds of mucous membrane stretched across the larynx; when the lungs expel air, the folds vibrate, producing sound. Now, patients can stay awake while doctors insert a variety of gadgets into their noses and mouths to scan for bruises, nodes or inflammations. If doctors find trouble, a host of remedies can help keep singers singing while they heal. And if worse comes to worst, new surgical techniques can sometimes save careers that would have been lost before.

Singers never want to see nodules on their vocal cords. Nodules can turn up when one's voice is overused or abused.

As the world gets busier and dirtier, the chances for respiratory stress abound, and airborne allergens are far from the only peril. Some vocal injuries are self-inflicted. Dr. Peak Woo, an ear, nose and throat specialist on Manhattan’s Upper West Side, says that unless singers are going for a “gin-at-midnight” crooner’s voice, they should avoid all irritants, including marijuana, cigarettes and alcohol. These strictures were unknown to opera singers in the days of Italian tenor Enrico Caruso, whose poison was Egyptian cigarettes that he smoked through fine tortoise-shell holders. Caruso said smoking made his voice rich and would not perform in any opera house where he couldn’t light up. The tenor had to stop singing shortly after a throat hemorrhage struck in 1920 as he performed Donizetti’s L’Elisir d’Amore at the Brooklyn Academy of Music. He died a year later.

Adverse reactions to food are another common plague for opera singers, and staying away from the bad stuff can be just as hard as giving up smoking. “There’s a famous Greek soprano who is allergic to goat milk,” says Woo, “and yet goat cheese was her favorite food.” The result for some singers is acid reflux, which can swell or damage the vocal cords. The doctor often advises singers to avoid performing on a full stomach; compressing the stomach muscles to belt out an aria can also bring on reflux.

But perhaps the greatest cause of injury to the voice is overuse, a byproduct of the same technology that helped turn three tenors into The Three Tenors (Plácido Domingo, José Carreras and Luciano Pavarotti) of intercontinental superstardom: the jet plane. “Two or three generations ago, singers had the luxury of being in one place for a whole season,” Graham says. “They traveled by ship or train. They would park themselves at the Metropolitan Opera for five months at a time, and they didn’t tax their bodies, and throats, in the same way.” With jet travel, singers can be in four cities in a week, with their throats subjected to the most hostile conditions as they travel from place to place. Joan Lader, a voice therapist in Manhattan, says, “Getting off a plane when they are dehydrated, singers get fatigued. Then they push through, and they can injure themselves.”

Flexible endoscopeBut technology contributes to the plus side of the ledger as well. Before the jet age, doctors could do little more for singers than station themselves backstage and paint vocal cords with elixirs and lubricants between scenes. Now when singers are struggling, throat specialists have a variety of exotic devices to help them identify the problem. Among the diagnostic instruments in the medical toolkit are flexible laryngoscopes and sinoscopes, which resemble the tubelike surveillance cameras that Hollywood spies snake under closed doors (doctors thread them through a patient’s nose to peer into the larynx, throat and sinuses). They can be used in conjunction with videostroboscopes, which, after insertion through the mouth, use strobe light to capture movements of the vocal cords as the patient sings at different pitches.

Susan Graham says one such implement saved her while she was touring South America a few years ago. “I contracted a terrible case of bronchitis,” she says, “and I was coughing so hard that I actually bruised one of my vocal cords.” She and her doctor saw the bruise with a laryngoscope. “A bruise is something you never, ever, ever want to see, and it was terrifying,” recalls Graham. “My doctor said, ‘It’s OK, but you have to be completely quiet for seven days.’” For the next week, she communicated via her laptop and didn’t utter a word.

Singers do what they can to keep from reaching that point, sometimes resorting to preventive measures that border on the baroque. Graham makes for a vivid example when she flies. “My face is covered with a wet washcloth the whole trip,” she says. “Sometimes I cover my head with a blanket to keep the dry air-conditioning from blowing on my face. I’m constantly drinking water. Many times I’ve kept the flight attendants busy bringing me glasses of hot water, and I make my own little vaporizer underneath a tent of a blanket. I’m just breathing the steam.”

Rolando Villazon

That sort of behavior may sound divalike, but in few other professions is the gulf between prevention and cure so vast, especially when the cure is surgery. There was a time when the discovery of a vocal node was the death knell for a singer’s career. But these days, most surgeries are relatively safe. Throat specialists often use long thin scissors and knives or laser treatment to remove polyps and scars. They also inject Botox into vocal cord muscles to fix folds that aren’t vibrating properly. Still, singers say voice box or sinus surgery isn’t to be taken lightly. After surgery last spring to remove a cyst on his vocal cords, Mexican-French tenor Rolando Villazon had to rest his voice for a year. When he resumed singing at the Vienna State Opera in March, some critics wrote that his voice sounded different; others detected no change. Natalie Dessay, the French soprano, had surgery on one of her vocal cords in both 2002 and 2003. She didn’t return to the stage until 2005.

Surgery has both psychic and financial consequences. Dwayne Croft, a 49-year-old American baritone who sings for the Metropolitan Opera, had surgery on his right sinus channel in 2002 to correct inflammation caused by allergies to milk products, cats, dust, mold, trees and blossoms. The allergies also made his voice sound more like a bass than the baritone he had always been. “There wasn't an upper resonance,” he says, remembering attempts to sing Ford in Giuseppe Verdi’s Falstaff that year. “It wasn't my voice anymore.” The surgery cleared his sinuses, but took a year to heal. Both his bank account and his confidence suffered a blow. “It stresses you out because you have no idea how long you have to cancel, how long you’re going to be out of work,” Croft says. “So it’s very hard to do what you really need, which is to relax.”

Julie AndrewsYet the pressure to keep performing is intense. No one wants to be known on the circuit as the singer who cancels because he or she is sick. “If you say you’ve had an operation, it’s as if you are cursed,” Rolando Villazon told the Telegraph in January. Still, most opera lovers say he, Dessay and Cross are surgical success stories; they all were able to resume their careers. Julie Andrews, the English movie star and Broadway singer, was not so lucky. She had a noncancerous nodule removed from a vocal cord at Mt. Sinai Hospital in 1997, when techniques were less sophisticated than they are now. The surgery failed, and she has still not been able to sing the high notes that helped make her career.

Fortunately for singers today, doctors have plenty of less extreme treatments if something bad shows up on one of their scopes. Steroids, either injected as cortisone or taken orally as prednisone, can reduce inflammation in the sinuses or vocal cords. Decongestants such as Mucinex let singers perform without the wrong sort of build-up in their vocal passages. And allergy medications such as Nasacort AQ and Zyrtec help singers survive those dusty sets and costumes, as well as high-pollution opera houses such as the Teatro Aguascalientes in Mexico City.

Dr. Woo, who is also the house physician for the New York City Opera, remembers one panicked call from a big-name singer who was scheduled to perform a sold-out show at Avery Fisher Hall. The singer had just gotten off a plane, which had left his throat parched. “He had barely an octave and a half of pitch-range in him,” Woo says. The doctor gave the singer a cortisone shot and lots of local treatment, which can include using a vaporizer and hydrating fluids to bring moisture back into a singer’s throat. By 4 o'clock that afternoon, the singer’s voice had returned, and at 8 o'clock he took the stage and sang to rave reviews.

Still, most singers try to minimize their exposure to drugs. “You don’t want to flood your body with steroids unless it’s absolutely necessary,” says Graham. She likes to tuck Ricola cough drops into her costume in case she needs to suck on them between arias. And to get through one particularly tough recital in St. Paul, she brought a goblet of slippery elm tea on stage. For the previous two weeks she had been flying across the country, performing six shows during that period. When she walked onstage in St. Paul, she told the packed house that her voice was still up at 35,000 feet, and that she would need to make some adjustments to the program. Then she asked the audience to vote on which songs she would sing. “It was like a reality show,” she says.

When I spoke to Graham nearly a month before the premiere of Xerxes in Houston, she was hoping for a bit of luck. “When we open,” she says just a little wistfully, “maybe the pollen season will have passed.”