SH OR T COM M U N ICATION

H idden respiratory allergies in voice users: treatment

strategies
Cristina A. Jackson-Menaldi1,2,*, Andrew I. Dzul1 and R. Wayne Holland 1
From the 1Lakeshor e Professional Voice Center, Lakeshore Ear, Nose and Throat Center, St. Clair Shores,
Michigan, USA, and 2Department of Otolaryngology, School of Medicine, Wayne State University, Detroit, Michigan,
USA
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Log Phon Vocol 2002; 27: 74 79

The treatment of the allergic voice patient may be somewhat different than other voice patients. Antihistamines are
generally avoided, though decongestants with G uaifenesin may be useful. Steroids are more useful in perennial allergic
systems. Steroids may be inhaled nasally, inhaled orally, or given systemically. Systemic steroids are especially useful for a
performer who needs quick relief. We strongly feel that vocalists with chronic laryngitis and dysphonia should be allergy
tested. A hidden dust mite or cat dander allergy is often found. A clean indoor environment can then be established.
Immunotherapy injections can also be initiated. Both of these treatments, desensitization injections and environmental
control, are especially useful in vocalists. These treatments are helpful in keeping a vocalists trachea, larynx, and nasal
cavity healthy. A careful search for mild asthma should be considered. Establishing good vocal hygiene and voice training
may also be necessary.
For personal use only.

Key words: allergy, professional voice.

Cristina A . Jackson-M enaldi, L ak eshore Professional V oice Center, L ak eshore Ear, N ose, and T hroat Center, P.C. 21000
T welve M ile R oad, S uite 111, S t. Clair Shores, M ichigan 48081, US A . T el. 1 (586) 779 -7610 ext 112. E -mail:
jmenaldi@aol.com

IN TR OD U CTION Inhalant allergy represents a common and treatable

It is the purpose of this article to clarify the role
hidden respiratory allergies can play in causing recur-
rent laryngitis, cough, and throat clearing in our
vocalist patients. Treatment strategies presented may
be unique for vocalists and may not apply to the
general public.
R epeated sinus infections, sore throats, laryngitis,
cough, and prolonged nasal congestion are very com-
mon symptoms througho ut the people of the world,
cf. Table 1. M any of us take these symptoms for
granted and live a good part of our lives with them
before we seek a physicians advice. These symptoms
can be magni ed and even disabling to the profes-
sional voice user. U ltimately, the treating physician
should recognize the roles hidden respiratory allergy
and subtle laryngopha ryngeal re ux can play in their
patients vocal dif culties. The treating physician
should be aware that hidden respiratory allergy might
be the fundamental cause of the patients vocal
dif culties or recurrent laryngitis.
* Web site: www.lakeshoreent. com
cause of respiratory disease, whereas many of the
other disorders listed here remain untreatable. F or
this reason, the physician treating these voice patients
should understand what allergy is, how to test for it,
and ultimately how to treat it. Jackson-M enaldi et al.
(1999) describe diverse tools to evaluate vocal edema
related to the allergies. One of the conclusions of this
article was that allergic reactions of the larynx might
exist. R ecurrent laryngitis, cough, and prolonged
hoarseness are common reasons why voice profes-
sionals seek consultation with an Otolaryngologist.
Laryngoph aryngeal re ux, vocal nodules or edema,
and poor vocal technique are common causes of such
vocal dysfunction. Inhalant allergy to perennial aller-
gens, such as dust mites, house dust, or animal
dander, must also be considered.
Inhalant allergies are caused by an unusual sensi-
tivity of the respiratory tracts to pollens, mold spores,
animal dander, or dust mites, cf. Table 2. The spec-
trum of symptoms caused by these allergens is
tremendously wide and can encompass the elds of
several medical specialties. R espiratory allergies in-

2002 Taylor & F rancis. IS S N 1401-5439 L og Phon Vocol 27

 H idden respiratory allergies in voice users: treatment strategies
volving the airways can be especially bothersome to
the voice user. The most sensitive target organs for
allergic respiratory reactions are probably the nasal
mucosa and bronchial tubes. Allergic reactions of the
nasopharynx (Eustachian tube dysfunction) or
oropharynx (sore throat) can be chronic and
vague. Speci c allergic reactions within the vocal
folds have not been described, but may exist. N ever-
theless, respiratory allergic reactions can affect the
voice in a number of ways, cf. Sala et al. (1996).
N asal congestion can impair the resonance pro-
vided by the paranasal sinuses, cf. Williams (1972).
Thick nasal mucus can ow from the nose down the
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throat and cover the vocal cords. Similarly, excess
tracheal mucus can cover or irritate the vocal folds
causing throat clearing and cough. A low-grade
asthma can reduce pulmonary function and decrease
voice support. Lastly, allergic mechanisms can
cause a primary edema of the vocal folds themselves,
D zul and Jackson-M enaldi (2002).
M ECH AN ISM OF ALLER G Y
The air we breathe is a suspension (or aerosol) of
For personal use only.
particles. M ost of these are inorganic dusts, yet the
atmosphere also contains signi cant amounts of bio-
logic particles (pollens and mold spores). When we
inhale air, these particles are also inhaled. The mu-
cosa of the nose conditions the air we breathe by
warming it, humidifying it, and ltering it of many
particles. The nose is a very ef cient lter and traps
particles 20 mm in diameter and larger. This size
includes all pollen grains. H ence, this helps us under-
stand why the nose is so dramatically and intensely
involved by pollen allergy or hay fever. Particles
smaller than 10 mm in diameter (many mold spores
and animal dander) can pass through the nose and
enter the lower airway. There they have the potential
for causing asthma or laryngitis.
Allergenic particles trapped by the noses mucus
blanket release a water-soluble protein that somehow
penetrates into the submucosa. Since the nose is the
rst organ to encounter these inspired particles, it is
endowed with a rapidly deployable host defense
Table 1. Common upper respiratory in ammations
Acute upper respiratory infection (viral)
Chronic sinusitis (bacterial or fungal)
Chronic or acute nasopharyngitis
Vasomotor rhinitis (post-viral)
Chronic allergies
R hinitis
Laryngitis
Asthma
75
Table 2. Environmental control of dust mites
Eliminate mite reservoirs
Cover pillows and mattresses with plastic
Wash bedding weekly in water140F (or 60C)
Remove carpets
Reduce upholstered furniture to a minimum
H umidity 2545%
Use air conditioner and dehumidi er
Avoid too-tight houses; use outdoor ventilation in
the spring and fall
Chemical control
Benzyl benzoate (Acarosan 1) kills mites
Tannic acid (Allersearch AD S2) denatures mites
Air ltration
Portable H EPA lters
Vacuum cleaning
Limit exposure to heat or cold
1
F isons Corp., Rochester, N.E.
2
Alersearch Laboratories, D ivision pf Alkaline Corp.,
Oakhurst, N . D J. Also available is Allerserch D M S, which
contains both types of agents.
system. It is an over-activity or over-sensitivity of
the noses immune system that causes allergic rhinitis.
What causes a persons T-cell lymphocyte to pro-
cess this antigen and stimulate plasma cell produc-
tion of IgE is not known, yet this particular step lies
at the heart of allergic disease. It is a well-known fact
that allergic individuals live from day to day with
high levels of IgE in their blood and nasal mucosa.
This IgE is speci c for such odd atmosphere de-
bris pollen grains, dust mite fecal pellets, and ani-
mal dander. N on-allergic persons have low levels of
IgE.
The allergic reaction has four major components:
(1) the allergens, (2) IgE, (3) mast cells, and (4) the
late phase reaction.
T he allergens
The respiratory allergens include various pollens,
mold spores, animal dander, and dust mites. Pollen
sensitivity typically causes an acute allergic reaction,
sneezing, and itching of the eyes. G eographic location
and the type of owering plant de ne this. Pollen is
the male part of sexual reproduction in plants. Pollen
is produced by the stamen of the ower. Its purpose
is to fertilize the egg of the ower, which creates
the seed. M ost of the owers we recognize are ente-
mophilous, relying on insects for pollen dispersal.
They are also perfect owers because both stamen
and pistil are on the same ower. These owers are
showy and emit fragrance. They are designed to
attract insects, which then y from ower to ower
carrying and dispersing the pollen with them. These
recognizable owers are not important in allergy.
L og Phon Vocol 27
 76 C. A . Jackson-M enaldi et al.
M ost allergenic plants, however, are anemophilous,
relying only on the wind for pollination. Their ower
structure is specialized to produce large quantities of
pollen and releasing it randomly into the atmosphere.
F ertilization occurs on the sheer chance that the
pollen will land on a pistil of another plant of a
similar species. It is within this random process, the
seasonal massive production and dispersion of pollen,
that pollen encounters our respiratory systems.
Some pollen are more allergenic than others, some
are produced in greater quantities and some less. F or
a pollen to be a public health problem it must be
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both very allergenic and very numerous. The exact
pollen season in ones area may or may not be well
known. U nfortunately, we cannot rely on textbooks
or other generalized publications because pollen types
and seasons are really very speci c to the local geog-
raphy and plant growth. Pollen is the best-known
and most studied allergenic particle. Pollen grains are
generally tiny spheres, about 20 30 mm in diameter.
Though pollen allergy seasons have been described in
allergy textbooks for the past century, these descrip-
tions may not be accurate today as our botanical
urban landscape in ever changing. Collecting and
For personal use only.
counting daily pollen samples remains a tedious job.
Several pollen and mold spore reporting networks
exist in the U nited States. The best known is the
A eroallergen M onitoring N etwork sponsored by the
A merican A cademy of A llergy, A sthma, and Immunol -
ogy. The academy publishes a yearly Pollen and
S pore R eport (Pollen and Spore R eport, 2001).
Indoor allergens are also very important. D ust
mites are actually insects that live in bedding, carpets,
and furniture, but they do not y around our bed-
rooms like mosquitoes or ies. Their body parts and
fecal pellets are very allergenic and are inhaled when
we are sleeping in bed. Cat dandruff and saliva
contain several highly allergenic proteins. Cat aller-
gen is far more potent and problematic than dog
dander allergen. F or a more detailed and thorough
discussion of indoor allergens and mold spores, the
reader is referred to any standard textbook of allergy:
immunology.
IgE
IgE is the antibody responsible for triggering the
allergic reaction. IgE is normally an unimportant
antibody responsible for the bodys immune response
to parasitic infections; however, in the allergic person
IgE becomes important. IgE speci c for ragweed and
dust mites is circulating in the bloodstream and pene-
trates into the soft tissues. M ast cells are coated by
this IgE, setting the stage for the damage and
pathology of the allergic reaction to take place. IgE is
L og Phon Vocol 27
also of immense importance in the diagnosis of al-
lergy. All tests (R AST, skin tests, etc.) commonly in
use to diagnose a speci c allergy measure speci c IgE
levels. If there is no antigen speci c IgE measurable,
the diagnosis of allergy cannot be made.
M ast cells
M ast cells are normally present in the nasal epithe-
lium, submucosa, and other soft tissues (skin, gas-
trointestinal tract, lungs). Their location around
blood vessels, nerves, and lymphatics suggest they
may play a role in regulating regional blood ow. IgE
has a special af nity for mast cells. The mast cells of
an allergic individual are covered with IgE, while
those of a non-allergic individual are not. M ast cells
contain granules lled with a variety of irritating
substances, including histamine. These noxious bio-
chemicals presumably play a role in the normal func-
tioning of the mast cell. U pon exposure to allergen
and contact with the surface IgE, these sensitized
mast cells explode or degranulate and release
their contents into the soft tissue. These granule
contents are extremely irritating to the soft tissues.
Among them is histamine. Together these substances
cumulatively account for the symptoms of acute aller-
gic respiratory in ammation, also known as the
early phase reaction. H istamine is an especially
important substance within this reaction, as many of
our pharmaceuticals (antihistamines) are targeted at
it. H istamine is probably much less important in the
late phase reaction.
T he late phase reaction
After several years of chronic allergic exposure, B-cell
stimulation, IgE production, and mast cell reactions,
the allergic reaction switches gears into the late phase
reaction. Eosinophils and neutrophils in ltrate the
soft tissues and secrete their own types of irritating
substances. These include several metabolites of
arachidonic acid, including prostaglandin D 2 and the
leukotrienes. Pharmaceutical inhibitors of
leukotrienes (antileukotrienes) have recently become
available to treat this chronic in ammatory response.
The late phase reaction occurs at least four hours or
longer after the initial antigen exposure, and is thus
much less obvious to the patient. This reaction can
also occur in tissues some distance away from the
initial antigen exposure within the nose.
SYM PTOM S
G enerally speaking, allergic rhinitis causes two clini-
cal syndromes, depending on the duration or the
chronicity of the allergic exposure, cf. D zul (1998).
 H idden respiratory allergies in voice users: treatment strategies
We initially see the acute allergic reaction sudden 3. H as the patient ever had a reaction when cleaning
bouts of sneezing, itching, rhinorrhea, or wheezing that
occurs with sudden exposure to allergen. We might see
this when a cat sensitive individual enters a cat resident
home. Immediate sneezing, pruritus, and even wheez-
ing occur. The individual soon leaves the house and the
allergic symptoms immediately improve. Similarly, in
our M ichigan climate in late August, the Ambrosia
owers and releases great quantities of pollen. Individ-
uals allergic to ragweed promptly begin sneezing.
About 3 weeks later, when pollen levels drop, these
allergic symptoms quickly improve.
A second type of allergic syndrome occurs after
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prolonged, daily allergen exposure. This syndrome is
caused by the predominance of the late phase reaction,
and re ects a prolonged, daily allergen exposure.
Examples would be a cat sensitive individual living
with a pet cat, or a mite sensitive individual sleeping
on an old mattress. The allergen exposure is daily and
has occurred for years, perhaps a lifetime. These
symptoms are usually less intense, more prolonged,
and dif cult to interpret. These include daily conges-
tion of the nose upon awakening in the morning,
wheezing or coughing at night, and frequent sinusitis.
For personal use only.
Since histamine itself is an early phase reactant directly
released by the mast cell granule, antihistamines are
often of little help in the treatment of late phase
reaction. Inhaled steroids are of best use here.
U sually it is just these late phase reaction disorders
of the upper airway that bother voice users, causing
unexplained bouts of laryngitis, bronchitis, or causing
copious post-nasal drainage.
D IAG N OSIS
H ow do we decide that a patient with recurrent
laryngitis, sinusitis, cough, or wheezing has allergies as
the cause? Speci c allergy testing is the only way to
pinpoint allergy as the cause. F irst, there are several
important questions that can be asked during the
patient history taking.
1. H as the patient ever had, or do they now have,
yearly hay fever during any of the predictable
pollen allergy seasons? M any patients may recall
having had this as a child, but have now grown
out of it. If the patient answers yes, a hidden and hence high R AST scores. H ouse dust or molds
allergy to dust mites or a pet is probably causing
their current problem.
2. H as the patient ever had a violent reaction around
a cat? This only pertains to those without pet cats.
Patients can answer this question easily. Again,
this is just a clue, but if they have had such a
reaction, they probably are allergic to dust mites
and :or animal dander.
77
out a basement, garage, or when vacationing in an
old cottage? This question is more open and an-
swers can be vague, but if such reactions have
occurred, a mold allergy is suspected.
4. Is there a family history of allergy? The capacity
to recognize allergens and to mount an IgE im-
mune response is a genetic trait inherited from
ones parents, and passed from generation to gen-
eration. Typically, a parent, brother, or sister may
have had hay fever, cat reactions, or have been
allergy tested. About 75% of children with whom
both parents had allergies eventually develop aller-
gies themselves.
Certainly, allergy history taking can be exceedingly
complex and prolonged. We have found these four
simple questions to be very useful. If the patient
answers positively to any one of them, allergy may be
present and further skin testing is recommended. If
answers to these questions are all negative, then
extensive allergy testing is probably not necessary.
H ow can we test a patient for allergy? There are
speci c tests (R AST, prick, or intradermal) and non-
speci c tests (total IgE and nasal cytology). We prefer
the speci c tests. These tests not only will tell us if a
patient has allergies, but they tell us what the patient
is allergic to. F or example, it is important to tell a
patient if they are allergic to dust mites, cat dander,
or both.
The R AST test is a simple blood test that measures
allergen speci c IgE in an individuals serum. This
test involves incubating allergen coated discs in a
patients serum and then measuring the IgE that
collected on the discs. Since the R AST test is charged
per disc, and hundreds of antigens can be tested from
a single tube of blood, it is important to exercise
economy when selecting the number of tests done.
N ormally, very low levels of IgE are present in the
serum, but none of the IgE should be directed at
birch pollen or dust mite allergen. The presence of
even low levels of anti-dust mite IgE is suggestive of
dust mite allergy. The R AST test results are in
counts, which have been calibrated into scores
1 5. Typically, pollen allergy seems to induce large
amounts of IgE production, high serum levels of IgE,
generate much lower R AST scores and speci c IgE
levels, but are much more important in the chroni-
cally ill patient. A class 4 to grass and a class 2 to
dust mites does not mean this individual is more
allergic to grass that to dust mites. The dust mite
exposure is a daily perennial exposure and hence very
important, while the grass pollen exposure occurs
only once a year for a 2-week period.
L og Phon Vocol 27
 78 C. A . Jackson-M enaldi et al.
Scratch, prick, and intradermal tests are commonly
used and are the traditional techniques of skin testing
for allergy. Skin testing is a physiologic test that
actually measures a tiny allergy reaction that takes
place when tiny amounts of diluted antigen solution
are dropped on a skin scratch or injected intrader-
mally. This test is a measure of G ell and Coombs
Type I or immediate hypersensitivity, and is a direct
measure of IgE coated mast cells in the skin. It is
assumed that IgE coated mast cell degranulation is
proportional to serum IgE levels, and this has gener-
ally been found to be true. In other words, R AST
scores and intradermal skin tests seem to correspond
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to each other accurately. Whether either technique
measures the actual allergic reactivity of the nose is
controversial. But these techniques (R AST and skin
testing) are universally accepted by allergy societies as
the most accurate and practical means of allergy
testing.
At this time, videostroboscopy cannot give a pre-
cise indication of allergy as an underlying cause.
At our Professional Voice Center we have observed
pooling of uids on the lip of the epiglottis and an
accumulation of frothy uid on the undersurface of
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the epiglottis, cf. F ig. 1. These characteristics have
caused initiation of a referral for a complete allergy
workup. The allergy characteristics and the improper
speaking or singing techniques negatively affect the
larynx in our professional voice users. A curious
decrease in the fundamental frequency has been
found in our allergic patients. This has resulted in a
general lowering of the speaking pitch and a coarse
voice quality. This was especially true in females.
Positive identi cation of allergens has been con rmed
in most cases, cf. Jackson-M enaldi et al. (1998
Fig. 1. Post-nasal mucous secretion and edema of the
vocal folds.
L og Phon Vocol 27
Table 3. Pollen avoidance
1 U se air-conditioning
2 Close windows and doors
3 Avoid use of fans
4 Wear loose, light clothing outdoors; shower, change,
and wash clothes in hot water after each use
5 Avoid vacation during peak pollen season
6 Avoid indoor owers and direct contact with plants
7 Avoid going outdoors on hot, dry days
1999), D zul and Jackson-M enaldi (2002), Chodwick
(2002). Our experience demonstrated that voice users
who have allergies might increase vocal abuse when
the laryngeal mucosa is in amed. These characteris-
tics have clearly contributed to frequent throat clear-
ing behavior by the patient and con rmed edema of
the true vocal folds.
TH ER APY
Once allergy testing has de ned an allergy to house
dust, dust mites, pollens, or animal dander, speci c
therapy can be started. The rst therapy is known as
environmental control, decreasing or limiting the
individuals exposure to the allergen, cf. Table 3. We
recommend this only after speci c allergy testing has
con rmed the presence of this particular allergy. An-
tihistamines are usually the rst medication to be
used in treating allergies. Antihistamines can have an
anticholinergic side effect that dries respiratory
mucosa, and most vocalists nd this bothersome.
This anticholinergic effect varies between different
antihistamines. These medications can still be of great
bene t with seasonal pollen allergies and should be
tried.
Topical nasal sprays are also very useful in treating
nasal or sinus dif culties that voice patients may
have. Several types of medications can be sprayed in
the nose or inhaled through the oropharynx into the
lower airway. M ost commonly used are inhaled
steroids followed by cromolyn solution, anticholiner-
gics (Ipratropium), and antihistamines (Azelastine).
When these same sprays are inhaled through the
throat for treatment of asthma or bronchitis they can
have side effects on the vocal cords, and therefore, be
less desirable. Theophylline (systemic bronchodilator)
may be a preferred bronchodilator over Albuterol
(inhaled bronchodilator). In acute situations, periodic
use of bolus steroids are helpful. These are one to
two week courses of prednisone or methylprednisone.
Systemic steroids must be avoided in diabetic pa-
tients. Side effects include anxiety reactions and skin
ushing. Allergen immunotherapies, or allergy
shots, again are an excellent treatment option for
 H idden respiratory allergies in voice users: treatment strategies
the professional voice user. They are free of any
drying or irritating effects the medications may
have, and they keep the patient in close contact with
their allergist for frequent treatment changes that
may be necessary. The extremely rare anaphylactic
reaction can complicate allergy shot therapy. A
trained technician must give immunotherapy injec-
tions. D osage escalation must proceed carefully and
beta blockers should be avoided. Voice therapy in-
volves analyst and reduction of vocal abuse and
misuse, vocal hygiene, proper use of optimal pitch
level, and changing improper speaking and singing
techniques in order to reduce chances of muscular
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strain or vocal fold trauma.
CON CLU SION
H idden respiratory allergies to pollen, dust mites,
indoor molds, or animal dander can be the primary
cause of recurrent laryngitis and other respiratory
complaints in the vocalist. In the past, allergy testing
has not been part of the medical evaluation of the
vocalist. We think it should be.
Once the diagnosis of allergy is made, speci c
For personal use only.
allergy therapies may be different for the vocalist
than for other patients. F or instance, vocalists may
be prone to side effects from antihistamines (drying
or sedation) or topical steroids (drying). Treatment
79
strategies may include short bursts of oral steroids.
Allergy therapies must, however, be individualized
for each speci c patient. Professional voice users have
a vocally demanding career. F or this reason, lifestyle
factors may need to be adjusted.
R EF ER EN CES
Chodwick S. In: K rouse JH , et al. (editors). The Pharynx
and Larynx: Allergy and Immunology, An Otolaryngic
Approach. Philadelphia: Lippincott Williams and
Wilkins, 2002. pp. 249 69.
Dzul A. Selecting allergenic extracts for inhalant allergy
testing and immunotherapy. The Otolaryngologic Clin-
ics of N orth America 1998; 31: 11 25.
Dzul A, Jackson-M enaldi C. Voice and Allergies: La voz
patologica. Buenos Aires, Argentina: M edica Panameri-
cana, 2002. pp. 61 71.
Jackson-M enaldi, C, D zul, A, H olland, W. Inhalant Al-
lergy in Professional Voice U sers. IALP Abstract. Am-
sterdam. August 1998.
Jackson-M enaldi C, D zul A, H olland W. Allergies and
vocal cord edema. Journal of Voice 1999; 13 (1): 113
22.
Sala E, H ytonen M , Tupasela O, Estlander T. Occupa-
tional laryngitis with immediate allergic or immediate
type speci c chemical hypersensitivity. Clinical Otolar-
yngology 1996; 21: 42 8.
Williams R. Allergic Laryngitis 1972; 81: 558 65.
AAAA1 Pollen and Spore R eport. American Academy of
Allergy, Asthma & Immunology. M ilwaukee, WI. 2001.
L og Phon Vocol 27