The Dangers of the Flat or Retracted Tongue

Dr. Barbara Mathis is Professor of Music at Lamar University where she teaches studio voice, language dictions, structure & function of the voice, and graduate vocal methods. She received BM, MM, and PhD degrees from the University of North Texas and has taught at other universities and public schools in Texas, Alaska, and Florida. Dr. Mathis studied voice with Virginia Botkin and Alan Lindquest, coached with Regine Crespin, John Wustman, Harold Heiberg, and Berton Coffin, and served in a research internship with Van L. Lawrence, M.D.

She is an active soprano soloist, choral and vocal clinician and speaker. Dr. Mathis has presented research papers and lectures for universities, national and international medical conventions, and professional music organizations. Her specialties include vocal coaching, vocal pedagogy, and vocal health and rehabilitation. In her spare time, Barbara enjoys seasonal decorating, reading, swimming, and long walks with husband George and dog Dusty.

Good vocal health, of general interest to everyone, is a vital concern to the professional voice user, singers in particular. The voice is a precious commodity which cannot be replaced when worn out or damaged; therefore prevention can be the most important aspect of vocal hygiene. Vocal experts offer detailed suggestions for maintaining good vocal health and preventing serious vocal problems. Stemple states that people who make professional use of their voice must take special care to avoid risks to general health of the entire body as well as to the laryngeal mechanism, for the well-being of the voice is dependent on the well-being of the whole body.1 Brodnitz believes that among professional voice users the singer, above all, must practice intelligent hygiene, for the singer's profession requires the highest degree of specialization in the use of the voice.2 Unfortunately, as Stemple states, "the lifestyles of many professional voice users are not compatible with the maintenance of a healthy larynx. Not only may these lifestyles create vocal abuse and emotional stress, but they may also lead to less than adequate physical health."3 Luchsinger and Arnold further advise the professional actor or singer that psychological and physical conditions which concern everyone affect them to an even greater extent; and that singers, whose occupation requires a major form of physical activity, should preserve their health through temperance in every respect.4 The reviewed sources agree that professional voice users must attend to physical fitness and nutrition, prevention and prompt care of illnesses and allergies, environmental conditions, and speaking and singing habits.

Physical exercise and proper nutrition help keep bodies and voices healthy. Brodnitz states that the mucous membranes prefer a diet with limited starches, thus discouraging the overproduction of phlegm which interferes with free nasal breathing and clarity of the voice.5 The tendency to overindulge in starches and the lack of enough physical exercise often cause a corresponding tendency toward obesity, a condition associated with high blood pressure, higher levels of cholesterol, sugar diabetes, heart disease, and respiratory problems.6 Unhealthy for anyone, obesity is certainly detrimental for the professional voice user who must have a healthy respiratory tract; and, as Sataloff points out, obesity has significant disadvantages for the professional singer:

Today, most people involved in voice education and singing recognize that singing is athletic. As such, it requires good abdominal and respiratory conditioning, physical strength, and endurance. All of these are undermined by significant obesity. . . Even a moderate degree of obesity may adversely affect the respiratory system, undermining support.7

Bunch cautions against obesity but reminds singers that a good diet should include protein to combat wear and tear of tissues, and vitamins, minerals, carbohydrates and fat to insure vitality and energy as well as good health.8 Bunch also recommends physical activity which involves free movement and increased depth of breathing such as dancing, jogging, walking, calisthenics, tennis, and swimming. She states, though, that singers should refrain from diving and underwater swimming to avoid possible risks of nasal congestion and ear trouble, and further advises against weightlifting which tends to overdevelop the muscles of the neck and the adductors of the vocal folds.9

Prompt attention to and care for illnesses, especially those affecting the upper respiratory tract, is important in the prevention of more lasting vocal disorders. The common cold, which may begin with a tickle in the throat, congestion, and/or sneezing, can lead to more serious infections of the sinuses, bronchial tubes, or lungs. Unfortunately, as Lawrence points out, the cold, or the URI (upper respiratory infection), "is a fever producing, sudden onset illness that attacks the respiratory tract, and which lasts about a week with treatment and about a week without treatment." 10 About all one can do when the cold strikes is to rest, increase fluid intake, and provide some relief for the affected tissues. Lawrence recommends steam inhalations, a decongestant, and antihistamine for the first few wet days; however, he cautions singers about the drying effects of antihistamine if used past the "pouring hot water" stages of the cold.11 Professional voice users should speak and/or sing as little as possible while under the effects of the cold and should avoid violent coughing or throat clearing, all of which may cause hoarseness long after other symptoms have abated. The best cold "medicine" is to avoid catching the virus in the first place, as some sources suggest. Lawrence believes that the best way to avoid a URI during the cold season is to wash hands often and to avoid touching objects which have been in contact with someone infected with a cold.12 Many sources recommend keeping the mucous membranes hydrated and keeping the atmosphere in homes and buildings at a high relative humidity level to help deter the spread of viruses.

Suggestions for adequate environmental and body hydration appear often as a preventive vocal health measure. Lawrence explains that water is extremely important in the normal functioning of the respiratory tract and of the vocal tract in particular. He advises the professional voice user to carefully monitor body water levels by noting the condition of one's urine: when well hydrated, urine is very dilute, nonodorous and almost invariably the color of tap water.13 Loeding advises vocal performers to avoid habits which dry out mucous membrane linings of the nose and throat, such as smoking and drinking alcoholic beverages, to drink eight to nine glasses of water a day, and to keep the air moist by using a vaporizer or turning on the hot shower.14 When outside temperature and humidity levels are uncomfortable, efforts to provide a healthy environment which contains a minimum humidity level of forty percent15 should often include running a vaporizer, humidifier, steamer, or hot shower, especially in homes or buildings which are centrally heated or air conditioned the year around. When outside humidity levels are too high, Stemple contends that the mucus of the respiratory tract may thin out, causing excessive drainage leading to throat clearing and coughing. He further states, though, that the presence of mucous drainage, or "postnasal drip," is a normal and natural function which should not be changed with over-the-counter "sinus" medicines which dehydrate the mucosal lining.16 Lawrence explains that normal mucus, which is watery, thin, and liquid, is rarely, if ever, perceived as being present. If overly aware of drainage, one is usually suffering from dehydration, although the thicker secretion can be the accompaniment of a problem such as sinusitis, upper respiratory infection, or a nasal allergy.17

Nasal allergies or sinus problems can make life miserable for the professional voice user, for these conditions can cause swelling of the tissues in the throat and larynx eventually leading to hoarseness.18 Severe or chronic allergies need specialized medical attention; however, if attacks are infrequent and mild and if problems are minimal, Sataloff advises the use of a mild antihistamine and/or decongestant. The drying effects of the antihistamine may be counteracted by mucolytic medications such as Entex, Organidin, Robitussin, or Humibid, which increase or thin upper respiratory secretions. These medications also help dryness caused by atmospheric conditions and overuse of the voice.19

Closely related to allergic reactions and general health of the laryngeal tissues is the unhealthy reaction of the voice to irritants such as tobacco, alcohol, and other recreational drugs. Almost without exception, voice experts advise against the habitual use of tobacco, marijuana, alcoholic beverages, cocaine, and other mood and mind altering drugs. Symptoms from habitual use are twofold: direct physical changes in the larynx and respiratory tract, and results brought about by changes in the sensory mechanisms. Sataloff warns that smoking not only may have eventual health consequences such as cancer, emphysema, and heart disease, but that the heat and consequent irritation of smoking also have an immediate effect on the larynx and the linings of the respiratory tract, producing inflammation that alters the vocal folds.20 Lawrence describes the effects of tobacco and marijuana ("weed" or "pot") smoking:

The hard palate is reddened. The soft palate and the uvula have that whitened surface look you see when you drop egg white into hot water and the protein first begins to coagulate. The edges of the vocal folds are reddened, and there is a slightly dry, nonproductive cough. . . .Pack-a-day smokers of tobacco will sometimes show those findings after a few months, but those on weed will be unmistakably there after a very short time. And the voice loses its brilliance and its cutting edge.21

Sataloff explains that marijuana smoke is particularly harsh, hot, and unfiltered and may alter sensorium thus interfering with intellectual awareness and fine motor control.22 In a later article Lawrence offers further concerns about marijuana usage and resultant attitudes and disregard for ethics. He states that excellent singing requires physical and mental discipline and daily practice and exercise, but that the "lovely, eased-out languid feeling of a marihuana high makes this so much less urgent, so much less agreeable to do. . . .I find pot eroding the work ethic, at least among several of my university voice majors."23

The professional voice user should carefully consider the consumption of alcoholic beverages. Wilson warns of these possible effects: excessive vascularization, a drop in fundamental frequency, and hoarseness.24 Sataloff reminds singers that alcohol opens up blood vessels and alters mucosal secretions while also altering awareness and fine motor control. He states that while very small amounts do not pose a major problem for people who are accustomed to drinking, singers who are not routine drinkers should be careful to avoid alcohol on the day of a performance.25 Bunch explains, though, that the habitual use of alcohol can affect the voice in several ways. As a depressant and muscle relaxant, alcohol may impair the control of the vocal folds and sensitivity of the throat, and the drying effect of alcohol can cause irritation in the tissues of the vocal tract eventually causing a raspy or hoarse voice.26

Like alcohol, other recreational drugs change the sensory mechanisms of the body, a pertinent fact for the serious voice professional who wishes to maintain good vocal technique at all times. Sataloff explains to singers the decreased awareness and impairment of accurate analytic abilities caused by "street" drugs:

They not only prevent a singer from making the instantaneous modifications that are intrinsic to good singing, but some street drugs also interfere with reaction time and motor control directly. In some cases, they may also decrease feeling (particularly narcotics) and allow a singer to injure himself without feeling pain. This can result in serious or permanent vocal fold damage as the singer continues to use his voice, perhaps remaining oblivious to the problem until the next day. Certain street drugs, particularly "uppers," may also cause a tremor that can be heard in the singing voice.27

Lawrence offers additional concerns about a particular recreational drug, cocaine, and its effects on singers:

As a laryngologist I see the residuals of the chemical and thermal burns of the vocal tract surfaces, and I'll hear the air escape during phonation, the harshness and breathiness, the loss of clarity of voice, the loss of high range voice.28

Lawrence also attests to the personality changes which may come about as a result of cocaine. The user most often experiences mood swings, from a sense of euphoria accompanied by a speeding up of thought processes and a tongue that cannot keep pace with mental activity, to the down phases, which can include attitudes of dejection, despair, and depression. Eventually true paranoia may result.29 The professional voice user may conclude from the opinions stated here that avoidance of smoking, alcohol, and recreational drugs will increase the chances for maintaining good vocal health and technique.

Another important factor in preventing serious vocal problems is sensible use of the voice in regard to time and demand. Unfortunately, many people who use their voices professionally are in job situations which require exhausting schedules of preparation, performance, promotion, and travel. These kinds of demands create tired bodies and tired voices. Lawrence feels that total voice use time should be a major consideration in vocal health and that vocal abuse may be a matter of "too much, too loud, and too hard."30 He further states:

I would say to any singer, to any voice user, that no larynx is infinite. None of us is made of cast iron or stainless steel. Each of us has a definite, a finite amount of vocal coin to spend. We should consider our priorities and then literally put our money where our mouths are.31

Sundberg advises singers and other people who rely heavily on their voices to note an important fact: the endurance of the vocal mechanism varies considerably among individuals. Even when using the voice economically and well, some people cannot perform as long as others. Endurance is affected by factors other than individuality, such as a cold, alcohol consumption, or dry air. What is harmless under normal conditions may be twice too much under unusual circumstances. Sundberg concludes this idea by stating that the more the voice is used, the more wisely and economically it must be used, and, that the risk of developing a voice disorder using one's normal vocal technique increases during adverse conditions such as a cold.32 Thus, if it is up to the individual to discover his own vocal limits in regard to time and demand without experiencing health problems, then the professional or future professional voice user should know recommendations from experts along these lines. In 1894 Manuel Garcia advised his students that the "practice of singing three or four hours a day will ruin the most robust organ;" and he recommended three half hours a day at long intervals as the maximum of study.33 Coffin also tells us that the master teachers of singing recommended four practice sessions of thirty minutes a day for "the most robust vocal organs." Coffin also cautions singers about the demands from opera and chorus conductors, and places the responsibility for limiting rehearsal and performance hours on the singer, who must "protect himself by any guise."34

Luchsinger and Arnold advise the professional singer to rest the voice at regular periods and, as a general rule, to limit major performances to three per week.35 Sataloff reminds singers that just as the eyes burn and get "bloodshot" after staying up too late, similar changes in mucosal lubrication and irritability occur throughout the vocal tract: "When we wear ourselves out, we interfere with the body's ability to repair, replenish and balance the components of our vocal mechanisms."36 Sataloff and Roberts further advise singers, who must deal with both the physical and psychological stress of performance, that rest periods are essential for muscle recovery, and that it is essential to condition and build up strength and endurance before rehearsing long hours prior to a performance.37 Tucker supports this advice, and he lists singing for excessively lengthy time periods as one factor sometimes associated with vocal dysfunction. He also states that even the well trained singer may experience alteration of the voice during peak points of a career due to behavioral factors such as stress, extensive rehearsal, and the need for precise control and exquisite conditioning.38

This need for precise control, exquisite conditioning, and athletic endurance is another aspect in prevention of vocal disorders, as the professional voice user must certainly attend to speaking and singing habits and techniques to avoid vocal health problems. Speaking techniques have been discussed earlier in the chapter, but sources do offer hints for prevention. In his vocal hygiene program for professional voice users, Boone lists twelve "commonsense application" steps, among which are the following speaking habits or techniques: identify and reduce or eliminate vocal abuse and misuse; develop an easy glottal attack; use an appropriate speaking level; keep the speaking voice at the lower end of the loudness range; take an easy, relaxed breath; reduce vocal demand as much as possible; avoid talking in loud settings; and avoid making odd sounds with the voice.39 Cooper agrees that one should talk with moderate volume, even in noisy situations. He also warns against habitual cheering and yelling.40 In her ten commandments for vocal health, however, Loeding says one should never scream, not at a basketball or football game, not even for joy. She also warns against overuse of the voice, speaking too rapidly, and speaking or singing in the wrong tessitura or pitch range.41

Most sources agree that vocal efficiency and excellence are related to fine control in certain vocal areas as listed by Reich, who offers ways to prevent dysphonia in vocal artists involved in performance speech and concert singing. He believes that vocal efficiency relates to control in the areas of intensity (regulation of pulmonary flow and glottal resistance), fundamental frequency (isometric "tension" tuning of vocal folds), vibrato (frequency modulation accompanied by some amplitude modulation), tone quality (noise-free phonation with lots of energy in the higher harmonic frequencies), respiration (maximum utilization of lung capacity and precise control of expiratory muscles), and resonance (low laryngeal position, pharyngeal dilation, lots of energy in the 2800_3200 Hz range, some nasal resonance, and lots of jaw opening at high frequencies).42 Further, George Antolik III feels that hyperfunction of the singing voice may be prevented by using correct techniques of posture, breathing, vocal attack, registration, and resonance. However, he does not seem to agree with other sources reviewed earlier in the chapter, such as Boone and McClosky, that once hyperfunction occurs it can be removed with the same techniques, as demonstrated by the following statement:

Since few laryngologists, singing teachers, or speech therapists are qualified to formulate techniques successful in removing vocal hyperfunction, it seems that its prevention offers a more logical approach to both singer and teacher. It should also be noted that once the laryngeal muscles are damaged, the prognosis for a complete recovery of the singing voice is extremely guarded."43

Evidently some sources agree that, although cures for vocal faults are possible, they are never absolutely certain, and prevention through proper training is infinitely more vital. In 1894, Garcia, for example, offered corrections for vocal faults such as guttural or nasal sounds, tremolo, and slurring the attack of a sound; however, he stated that some of the faults are distressing and extremely difficult to correct.44 Today, according to Bunch, the prognosis is still not good for "restoring battered vocal folds to normal function."45 If a singer suffers severe muscular fatigue, a condition she thinks is the most difficult to detect or remedy, or hoarseness after every practice or performance, it is a clear sign that the voice is improperly used or that something else is seriously wrong. Bunch believes that hoarseness caused by misuse is usually one of two things: putting excessive air pressure on the vocal folds or using too much muscular effort in the larynx to produce sound. When this type of misuse continues until muscles have had more strain than they can take, sometimes the voice stops working "overnight" and thus surprises the singer who has probably abused the voice for months or even years.46

All people in the voice professions would agree that prevention of vocal disorders through proper training and techniques is desirable, and many would agree that therapy is the most important treatment for vocal problems. Unfortunately, as Sundberg states, "The dispute among singing teachers and other voice experts as to what is the best method or therapy and what is the best vocal technique has gone on over the centuries, and probably there is little hope that the issue will be resolved in the near future. . ."47 He goes on to say that although it is difficult to judge what is a good method or technique, objective measurements on voice characteristics should help; and even though one method probably could not suit all voice types or musical styles, he prefers a method which is in close agreement with physiology. Sundberg believes that it is easier for the majority of students to understand instructions that reflect what is actually happening within their bodies.48 Perhaps Luchsinger and Arnold best summarize good vocal hygiene and preventive measures by stating that good vocal hygiene is based upon knowledge of the physiology and pathology of voice production; and two types of measures may be taken to avoid vocal disease: promotion of physical health and prevention of vocal misuse or overexertion.49

For singers, this means careful attention to the following recommendations for good laryngeal
health and the prevention of serious vocal problems:

1 Joseph C. Stemple, Clinical Voice Pathology, (Columbus, Ohio, 1984), p. 158.
2 Friedrich S. Brodnitz, Keep Your Voice Healthy, (New York, 1953), p. 88.
3 Stemple, p. 158.
4 Richard Luchsinger, M.D. and Godfrey E. Arnold, M.D., Voice-Speech-Language, (Belmont, California, 1965), p. 157.
5 Brodnitz, p. 94.
6 Dalia Sataloff and Robert T. Sataloff, M.D., "Obesity and the Professional Singers," The NATS Bulletin, Vol. 44, No. 5 (May/June 1988), pp. 26-27.
7 Ibid.
8 Meribeth Bunch, Dynamics of the Singing Voice, (New York, 1982), pp. 110-111.
9 Ibid, p. 111.
10 Van L. Lawrence, M.D., "U.R.I.'s," The NATS Bulletin, Vol. 37, No. 4 (March/April 1981), p. 41.
11 Ibid, p. 42.
12 Ibid.
13 Van L. Lawence, M.D., "Sermon on Hydration (The Evils of Dry)," The NATS Journal, Vol. 42, No. 4 (March/April 1986), p. 23.
14 Rosalie Loeding, Loeding's Ten Commandments For Vocal Health, "Vocal Stress," workshop presented at Delta Omicron 1987 Triennial Conference, Jefferson City, Tennessee, August 1, 1987.
15 Lawrence, p. 23.
16 Joseph C. Stemple, Clinical Voice Pathology, (Columbus, Ohio, 1984), p. 159.
17 Van L. Lawrence, M.D., "Post-Nasal Drip,' The NATS Bulletin, Vol. 39, No. 1 (September/October 1982), p. 27.
18 Meribeth Bunch, Dynamics of the Singing Voice, (New York, 1982), p. 112.
19 Robert T. Sataloff, M.D., "A 'First Aid Kit' For Singers," The NATS Journal, Vol. 43, No. 1 (September/October 1986), p. 22.
20 Robert T. Sataloff, M.D., "Ten More Good Ways to Abuse Your Voice: A Singer's Guide to a Short Career (Part II)," The NATS Journal, Vol. 43, No. 1 (September/October 1986), p. 22.
21 Van L. Lawrence, M.D., "Cigareets and Whiskey and Wild, Wild Women," The NATS Bulletin, Vol. 38, No. 3 (January/February 1982), p. 27.
22 Sataloff, p. 23.
23 Van L. Lawrence, M.D., "Marihuana and Cocaine," The NATS Journal, Vol. 43, No. 2 (November/December 1986), p. 27.
24 Frank B. Wilson, Ph.D., Speech course presented when visiting professor, North Texas State University, Denton, Texas, Spring, 1985.
25 Sataloff, p. 23.
26 Bunch, p. 117.
27 Sataloff, p. 23.
28 Lawrence, p. 27.
29 Ibid.
30 Van L. Lawrence, M.D., "Handy Household Hints: To Sing or Not to Sing," The NATS Bulletin, Vol. 37, No. 3 (January/February 1981), p. 25.
31 Ibid.
32 Johan Sundberg, The Science of the Singing Voice, (DeKalb, Illinois, 1987), p. 185.
33 Manuel Garcia, Hints on Singing, (New York, 1894, 1982), p. 18.
34 Berton Coffin, Coffin's Sounds of Singing, 2nd ed., (Metuchen, New Jersey, 1987), p. 220.
35 Richard Luchsinger, M.D. and Godfrey E. Arnold, M.D., Voice-Speech-Language, (Belmont, California, 1965), p. 157.
36 Robert T. Sataloff, M.D., "Ten Good Ways to Abuse Your Voice: A Singer's Guide to a Short Career (Part I)," The NATS Journal, Vol. 42, No. 1 (September/October 1985), p. 24.
37 Robert T. Sataloff, M.D. and Barbara-Ruth Roberts, "Stress in Singers," The NATS Journal, Vol. 42, No. 3 (January/February 1986), p. 26.
38 Harvey M. Tucker, M.D., The Larynx, (New York, 1987), p. 156.
39 Daniel R. Boone, The Voice and Voice Therapy, (Englewood Cliffs, New Jersey, 1983), p. 206.
40 Morton Cooper, Ph.D., "Be Good to Your Voice," Prevention, (May, 1979), pp. 142-144.
41 Rosalie Loeding's, Loeding's Ten Commandments For Vocal Health, "Vocal Stress", workshop presented at Delta Omicron 1987 Triennial Conference, Jefferson City, Tennessee, August 1, 1987.
42 Alan R. Reich, Ph.D., "Evaluating and Preventing Dysphonia in the Vocal Artist/Athlete," Short Course presented at Annual Convention of American Speech-Language-Hearing Association, Toronto, November, 1982, pp. 9-10.
43 George Antolik III, "The Prevention of Vocal Hyperfunction in Singers," Doctoral Dissertation, Louisiana State University, School of Music, August, 1978, p. 88.
44 Manuel Garcia, Hints on Singing, (New York, 1894, 1982), pp. 17-19 and editor's note, p. 18.
45 Meribeth Bunch, Dynamics of the Singing Voice, (New York, 1982), p. 116.
46 Ibid, pp. 113-116.
47 Johan Sundberg, The Science of the Singing Voice, (Dekalb, Illinois, 1987), p. 193.
48 Ibid, p. 194.
49 Richard Luchsinger, M.D. and Godfrey E. Arnold, M.D., Voice-Speech-Language, (Belmont, California, 1965), p. 156.

(c) 2003 by Barbara Mathis

You may contact Dr. Barbara Mathis at:
Please direct other questions to: