March 13, 2012

TV Show SMASH Portrays Ivy With Vocal Issues

In last night's episode (Episode 106: Chemistry) of the new hit TV drama SMASH, the main character Ivy who plays Marilyn Monroe in the show developed laryngitis that affected her ability to sing clearly, especially in the high registers. However, her speaking voice did sound normal.

To treat this condition, she was given prednisone which did help her voice, but suffered unfortunate side effects of mood lability, hallucinations, insomnia, etc.

Did the show accurately portray what actually happens in real life?



Ivy probably did suffer laryngitis, but more in the sense of pre-nodule formation (otherwise known as vocal cord swelling) from vocal overuse given how much singing she has been doing. With such "pre-nodule" formation, the singer is able to sound perfectly normal when talking, but suffers from pitch breaks and onset delays in the high range, especially when singing quietly. Watch a video and audio demonstrating this phenomenon.

I should also point out that this problem is also under-recognized by medical professionals including ENTs... When such singer/patients with vocal cord swelling present complaining of hoarseness, they sound normal... talk normal... and for all intensive purposes seem to be making up their perceived raspy voice.

A simple test to demonstrate vocal cord swelling is to have the singer sing a song at a high pitch (octave above middle C), but to sing the song very quietly. I typically have patients sing Happy Birthday. Listen for any vocal quality problems.

Even though the vocal issue is only in the high range, for professional (and amateur) singers, such "minor" vocal raspiness is a HUGE problem. Consider this... if this patient is singing a solo for a performance where there's several hundred people in the audience... it's hard enough to sing a solo just from nervousness. Now add the concern that you have no idea what your voice is going to do in that one part of the song where it goes high. Confidence is key to a good performance and with an undependable voice, confidence is lost and the performance overall suffers.


Is prednisone really as good as the show suggests? Yes... including the side effects, though they did stretch the side effects some.

Typically steroids provide almost immediate (within 4-12 hours) resolution of vocal cord swelling and inflammation. Problem is, it only works for a short period of time.

I typically prescribe decadron rather than prednisone as I feel it works faster, better, and more reliably than prednisone. I also prescribe it judiciously.

Judiciously means I prescribe it if there's a single major concert or single audition that is very important to the singer. I typically prescribe a single large dose to be taken the night before.

If it is a singer who is undergoing a series of auditions over a short period of time, I may prescribe a week long course of steroids to maintain its good effects.

The USUAL common side effects are reflux, insomnia, mood lability, and jitteriness. However, for those who are sensitive to medications can suffer many of the side effects experienced by Ivy.

NOW... for the problem with steroids beyond the side effects... Its effects are temporary and the better way of treating vocal cord swelling is behavioral changes as one can't just keep prescribing steroids indefinitely. It is much like giving morphine to a football player to mask the pain of a sprained ankle so he can still keep playing football. MORE vocal injury can occur while taking the steroids!

With steroids, I usually also recommend restricted voice use (strict voice use is even better). What this means is talk ONLY when you MUST talk and with low energy if you do. NO social talking, no whispering, no yelling, no raising voice, etc. Strict voice rest is when you are not even talking at all.

Also, work with a singing voice therapist.
Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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