“Covid Voice” - Background and Recovery for Voice Professionals

Preface/Disclaimer:

Nothing in this guide is to be taken as medical advice. This is merely a brief culmination of some of the existing research in relation to the effects on the voice of contracting the Sars-CoV-2 virus, combined with Jim Chandler’s personal rehabilitation notes as a result of his experience rehabilitating his own voice after suffering vocal and physical difficulties from having Covid - as a professional singer for over 30 years and professional vocal coach for over 20 years. If you have any concerns about the information contained herein, please seek the advice of a medical professional. No claims are made by Rock Your Best Vocals, its owners or affiliates in relation to any of the information herein - explicit or implied. Any information provided herein is to be used at the sole risk and responsibility of the user. Rock Your Best Vocals, its owners or affiliates assume no responsibility in relation to any of the information provided herein. The reader of this document understands and accepts these terms and assumes the totality of risk involved in personal application of any of the information provided.

Introduction:

Your voice is your instrument and unlike other instruments musicians play, you cannot easily simply ‘change a string’ or other component, and you can’t simply buy a new one if yours is destroyed. Therefore, you must take care of it as best you can, so it can serve you well long into the future. The information in this document specifically addresses vocal health concerns in relation to what has been dubbed “Covid Voice”, the definition, causes, treatments and prevention.

I compiled all of this research because I wanted to do a full review of available information on “Covid Voice” and also document everything that helped me to (fortunately) recover my voice from a near career-ending battle with Covid in 2021 where I was coughing up blood, at 5% breathing capacity and couldn’t get off the couch for six weeks. I was unable to climb a flight of stairs without getting severely winded, and needed to recover my voice so I could get back to performing. When I eventually did, months later (after being unable due to lockdown for over two years), I was short of breath and putting too much pressure on my vocal cords. As a result, I kept doing further damage to my voice, setting me back, causing me to cancel shows, and be let go from certain bands with repertoire I could no longer perform due to changes in my voice.

I saw an ENT who assured me that my vocal cords were fine, and was ‘dismissed’ quickly although I knew something had changed in my voice. I wasn’t able to sing in the way I was used to prior to contracting Covid, and knew it was up to me to find out how to rehabilitate my voice. Subsequently, I haven’t seen enough from any voice professional who has suffered ‘covid voice’ so I feel like somewhat of an ‘expert’ because of; my own experience, and my need as a voice professional to get back to full vocal health.

If you would like to know more about my experience and recovery you can watch this video where I share my story and some exercises to help you recover: https://youtu.be/77JMSTQeX8M  

Section 1. What is covid voice?

• Definition: The term linking hoarseness (‘dysphonia’) as a symptom of having Covid.

• Background: According to this article by HSOA Journal of Otolaryngology, Head and Neck Surgery, “The association between COVID-19 and voice disorders seems to be a multifactorial result of mechanical traumas and metabolic alterations caused by the inflammation in COVID”. It also states, “Patients might undergo vocal cord trauma because a severe cough can change the voice quality”. It goes on to state, “the neurotropic behavior of Sars-CoV-2 was pointed out as a possible explanation of this association. The role of inflammatory cytokines, the psychogenic hypothesis, and the pulmonary function were evaluated as possible factors that could be involved in the pathophysiology of voice disorder COVID-related. Nonetheless, its impact on voice dysfunction is unclear.”

• Cytokines and what is a “cytokine storm”?: As this article explains; “Cytokine release syndrome (CRS) — sometimes called cytokine storm or cytokine-associated toxicity — is a condition that develops when your immune system responds too aggressively to infection.” and “Cytokine release syndrome may also occur in people infected with COVID-19. This is part of the reason why some people develop life-threatening complications.” It goes on further to state that “If CRS affects your lungs, you could develop cough or shortness of breath.” and since we know that Sars-CoV-2 attacks the respiratory system we may deduct that the lungs are particularly susceptible to this “cytokine storm”. It is, however important to add comments from this article that state: “No unifying definition of cytokine storm exists, and there is much disagreement about what the definition should be and whether specific conditions such as Covid-19 should be included in the spectrum of cytokine storm disorders.”

• Prevalence: There are many studies already done, and likely there will be more as this is appearing more common and widespread as we learn more about it. This publication states:  “Dysphonia was encountered in 26.8% of patients with mild-to-moderate COVID-19 and could be added to the symptom list of COVID-19. Dysphonia may appear in patients with a more severe clinical COVID-19 presentation. Only 3.7% of patients reported severe dysphonia characterized by aphonia (loss of voice). Future studies are needed to investigate the relevance of dysphonia in the COVID-19 clinical presentation.”

• Increasing awareness: There is ever-increasing information on the subject of “Covid Voice”, which is encouraging due to its prevalence. Here are examples of one vocal professional’s experience, and also of increasing awareness of Covid’s effect on the voice in the mainstream media:
• “Cincinnati native, Broadway star loses singing voice after COVID-19 diagnosis”: https://www.youtube.com/watch?v=rF2KZVdHgsk
• “Using your voice to test for COVID-19”: (machine learning to look for ‘vocal biomarkers’) https://www.youtube.com/watch?v=xuJnf9yv6OY 

Symptoms of Covid (and “Covid Voice”)

• hoarseness (‘dysphonia’):

A hoarse voice will sound “breathy, raspy, or strained, or will be softer in volume or lower in pitch. Your throat might feel scratchy. Hoarseness is often a symptom of problems in the vocal folds of the larynx.” https://www.nidcd.nih.gov/health/hoarseness 

• tired voice after short-term use

• dry throat (accompanied by cough)

Causes of hoarseness - In addition to the study by HSOA Journal of Otolaryngology, Head and Neck Surgery as cited above, the NIDCD lists the following:

• Laryngitis. “temporary swelling of the vocal folds from a cold, an upper respiratory infection, or allergies”. (note: swelling = inflammation)
• Misusing or overusing your voice. “Cheering at sporting events, speaking loudly in noisy situations, talking for too long without resting your voice, singing loudly, or speaking with a voice that's too high or too low can cause temporary hoarseness.”
• Gastroesophageal reflux (GERD). “GERD—commonly called heartburn—can cause hoarseness when stomach acid rises up the throat and irritates the tissues.“ See 5 Whole Food Supplements To Stop Acid Reflux Naturally
• Vocal nodules, polyps, and cysts. “Vocal nodules, polyps, and cysts are benign (noncancerous) growths within or along the vocal folds.” (these are metaphorically like a callous you might get on your hand/fingers from overuse)
• Vocal fold hemorrhage. “Vocal fold hemorrhage occurs when a blood vessel on the surface of the vocal fold ruptures and the tissues fill with blood. If you lose your voice suddenly during strenuous vocal use (such as yelling), you may have a vocal fold hemorrhage. Sometimes a vocal fold hemorrhage will cause hoarseness to develop quickly over a short amount of time and only affect your singing but not your speaking voice. Vocal fold hemorrhage must be treated immediately with total voice rest and a trip to the doctor.”
• Vocal fold paralysis. “Vocal fold paralysis is a voice disorder that occurs when one or both of the vocal folds don't open or close properly. It can be caused by injury to the head, neck or chest; lung or thyroid cancer; tumors of the skull base, neck, or chest; or infection (for example, Lyme disease). People with certain neurologic conditions such as multiple sclerosis or Parkinson's disease or who have sustained a stroke may experience vocal fold paralysis. In many cases, however, the cause is unknown. Vocal fold paralysis is treated with voice therapy and, in some cases, surgery.”
• Neurological diseases and disorders. “Neurological conditions that affect areas of the brain that control muscles in the throat or larynx can also cause hoarseness. Hoarseness is sometimes a symptom of Parkinson's disease or a stroke. Spasmodic dysphonia is a rare neurological disease that causes hoarseness and can also affect breathing. Treatment in these cases will depend upon the type of disease or disorder. For more information, read the NIDCD fact sheet, Spasmodic Dysphonia.”

Other causes. 

• According to this medical publication by NIDCD  “Thyroid problems and injury to the larynx can cause hoarseness. Hoarseness may sometimes be a symptom of laryngeal cancer, which is why it is so important to see your doctor if you are hoarse for more than three weeks. Read the National Cancer Institute fact sheet, Head and Neck Cancer--Patient version. Hoarseness is also the most common symptom of a disease called recurrent respiratory papillomatosis (RRP), or laryngeal papillomatosis, which causes noncancerous tumors to grow in the larynx and other air passages leading from the nose and mouth into the lungs.”

• Inflammation: According to this article “What Is “COVID-19 Voice” and What Causes It?” “Any upper respiratory tract infection is going to cause inflammation of the upper airway,” says Dr. Khabbaza. “That includes the vocal cords.” “The virus itself causes inflammation,” he says, “but it’s a lot of the secondary symptoms that worsen what’s going on.” “That inflammation affects the flexibility of those vocal cords, making them swollen and stiff. That means they can’t vibrate as much. This can affect the pitch and depth of your voice, causing it to sound raspy or even reducing it to just a whisper.” “If the vagus nerve isn’t working well, the vocal cords may not work the way they are supposed to and may stay closed when they should open,” he says. “That can also cause additional sensations of breathlessness and coughing which perpetuates this cycle of irritation.”

• Vagus Nerve: “Covid-19 Era Post Viral Vagal Neuropathy Presenting as Persistent Shortness of Breath with Normal Pulmonary Imaging”  https://juniperpublishers.com/ijoprs/pdf/IJOPRS.MS.ID.555641.pdf “vocal folds were not moving in normal synch with their breathing, that is, they were closing more than 50% of their glottic airway during quiet respiration when they should be opening” “This vocal fold dysfunction, or paradoxical vocal fold movement disorder [1], is a vagal neuropathy, often occurring after a viral illness” “cohort was treated successfully with a combination of physical therapy - respiratory retraining - and diet modification techniques.”

• Stress: Linked as a cause of both reduced immunity and inflammation

Section 2. What can you do about it?

• Some treatments for hoarse voice as per Dr. Khabbaza: 
• Stay hydrated. “Dry cough receptors promote more coughing which causes more irritation, so staying well-hydrated can keep those cough receptors from being activated.”
• Cough drops. Yes, these can help you out with COVID-19 just like other respiratory diseases. “I recommend these with any kind of upper respiratory issue,” he says, “because cough drops, especially menthol ones, numb the nerves of the cough receptors and make your trigger a little less sensitive.” 
• Speak less, speak softer. “It’s a more extreme approach, but avoid speaking and avoid speaking loudly,” he suggests. “The more you use your voice, especially often and at a loud volume, the more irritation that can occur.”
• A healthy diet. “A healthy diet is important across the board,” Dr. Khabbaza says, “but it also minimizes those acid reflux issues that can worsen the situation in your throat.” 

• Other methods of treatment:
• Increase support muscles (diaphragm and abdominals) so you aren’t focusing on using your larynx or ‘voice box’ to power your voice, which will cause further strain on the vocal cords and tire you out more. Become more aware of supporting your voice as you speak and it will be easier when you go to sing.
• Homeopathic remedy: Lemon water, or warm water, with honey and thyme

Section 3: Recovery and prevention Some things you can do to ensure a speedy recovery and prevent recurrence. (again, these are based on my experience and not intended as medical advice or a substitute thereof - see disclaimer above)

• Increase/improve Lung capacity:

• Breathing (breathing for Vagus Nerve / Nasal Nitric Oxide breathing through nose)
• Supplement known to benefit lungs, Covid recovery, and immune support: NAC, 
• Nebuliser (with Saline solution): This is the one I use: A&D Medical UN-014  (affiliate link)

• Strengthen singing support muscles (Sssss exercises to strengthen diaphragm)
• Exercise; yoga (breathing and body strength), planks, cardio (walkin, cycling, swimming, running, mountain climbers, etc)
• Strengthen Pharyngeal muscles (to assist ‘open throat’ or widen so the tissues aren’t collapsing causing tension or a ‘squeezing of the vocal cord area’) 
• Nasal clearing (in the case of sinusitis) - use Nasal Nitric Oxide breathing through nose, and/or Saline rinse

• Diet: 
• Reduce Inflammatory foods: Sugar (causes direct cytokine release), Vegetable oil, rapeseed oil (in most processed foods!) Gluten/Carbs, Dairy (congestion, allergies, inflammation), Artificial Colours/flavours, Nitrates in processed meats, Saturated fats (cheeses), Fried foods - (white flour is stripped of slow digestive fibre/nutrients)
• Increase Anti-Inflammatory Foods, and Herbs Here is a video on the top 15 Anti-Inflammatory Foods so you can move toward an  Anti-inflammatory diet
• Intermittent fasting 

• Vocalizing Exercises When you’re ready to sing, start back singing slowly. Limit the duration and volume to gently ease your vocal cords back into being worked - such as with any type of physical training, for example you wouldn’t run a marathon your first day back running!). Start with ‘SOVT’ (Semi-Occluded Vocal Tract) exercises such as; Lip trills, yawn, sirens, etc. for 5-10 minutes at a time, and maybe sing some light, easy songs for a few minutes just to warm your vocal cords up and coax them back to health. Do not attempt anything too vocally athletic or aggressive until you are sure you’re ready. Even then, pay attention to your body and any warning signs of pain, or pushing too hard. NOTE: This was my biggest mistake - trying to get back to singing a full 2-hour set at full volume before my voice was ready, which ended up setting me back by weeks if not months!

• Boost Your Immune System: (Vitamin rich foods and supplements): 
• Essential Vitamins and nutrients to boost the immune system: D3(with K2), C, A, Zinc, Garlic, etc. Watch: how to make your immune system ‘bulletproof’
• Turmeric: (by Dr Suneel Dhand) “TURMERIC as an Anti-Virus Therapeutic: Why didn’t we use MORE during Pandemic?” 
• Wild Oregano oil: Watch “14 amazing benefits of Oregano oil” 

• Things to avoid to protect vocal health and prevent damage:
• Avoid throat clearing - especially ‘excessive’ or ‘aggressively’ which strain your voice. Here is an example of a very light, yet effective way to clear mucus.
• Avoid whispering, as this puts greater strain on the vocal folds. According to Lesley Childs, M.D. “Whispering is OK in principle, but most people do not whisper in a way that is good for the voice. When most people whisper, they want to be heard, so they strain to produce sound. It can be as bad for your voice as shouting. There is a type of whispering, called an “open throat whisper,” which is fine, but the problem is no one will hear you! If you are trying to rest your voice, we recommend you not talk, not even in a whisper.” 
• Avoid smoking or vaping - including second hand exposure to either.
• Avoid cold medications such as ‘Sudafed’ that dry out your vocal folds. Others include Benadryl, Zyrtec, allegro, Claritin, and any other antihistamine.
• Avoid loud, excessive talking, talking for long periods of time, or shouting to reduce strain on your vocal cords

Other articles/resources:

“How can COVID affect the Voice?” https://www.centerforvocalhealth.com/blog/covid-effects-on-the-voice 

“Coronavirus (COVID-19) recovery”: https://www.guysandstthomas.nhs.uk/health-information/coronavirus-covid-19-recovery ***important to note that this advocates high Carbohydrate diet and high consumption of dairy!!!! (Because it’s the NHS?)***

“Voice Disorders Associated to Covid-19: A Theory Domain Review” https://www.heraldopenaccess.us/article_pdf/54/voice-disorders-associated-to-covid-19-a-theory-domain-review.pdf 

Conclusion:  

“The association between COVID-19 and voice disorders seems to be a multifactorial result of mechanical traumas and metabolic alterations caused by the inflammation in COVID”

“Furthermore, non-intubated patients might undergo vocal cord trauma because a severe cough can change the voice quality.“

“The mechanical ventilation with endotracheal intubation was found as the most important factor associated with a vocal alteration”

“the neurotropic behavior of Sars-CoV-2 was pointed out as a possible explanation of this association. The role of inflammatory cytokines, the psychogenic hypothesis, and the pulmonary function were evaluated as possible factors that could be involved in the pathophysiology of voice disorder COVID-related. Nonetheless, its impact on voice dysfunction is unclear.”