Carolyn,

I have wanted to reply to you ever since I read your original posting, but
"urgencies" have prevented me. Regardless, Cindy Pribble (whom I've never
met, but would like to) provided a lot of the essential information that you
need about your condition. In case you're interested, here's some more.

"Thrush" is the "folk label" for tissue infection by a yeast-like fungus,
the genus name for which is Candida [kan'-dih-duh] There are several
species of Candida, and many of them are always present on the outer skin
and the interior mucosal surfaces of all our human bodies (e.g., mouth,
throat, intestines, the female vagina; a bit more info below). The
infective process is called candidiasis [kan-dih-deye'-uh-sis]. The most
common species that infects us people in the mouth and throat is called
Candida albicans [al'-bih-canz ("al" as in the diminutive name for a male
named Albert)].

Candida is normally kept in check by its predator bacteria, and they are
among what Cindy accurately referred to as the "good" bacteria. Several
medical therapies can contribute to a reduction of those predator bacteria,
such as corticosteroids (an antiinflammatory medication that can contribute,
in some degree, to suppression of immune system function), chemotherapy and
radiation therapy in the treatment of cancer, and, as you now know,
antibiotics. Antibiotics are indiscriminant killers of all types of
susceptible bacteria, both "good and bad". When the predator bacteria are
reduced in sufficient numbers, we become more susceptible to infection by
one of the species of Candida, and in the mouth and throat that's usually
albicans. The immune system then produces inflammation in the infected
tissue so that it becomes swollen and reddened, but in addition, a creamy
white material exudes to the surface of the infected areas (exudate) and
aggregates into visible "patches" on the mucosal surface. That's probably
what your doc saw when you were examined. Also, a hazy-white exudate can
cover the vocal folds, and can be visible to an ear-nose-throat physician or
speech pathologist, especially when examined (and photographed) with a
laryngeal videostroboscope.

Nystatin is a common medication for candidiasis. Non-medication measures
include eating plain yogurt and taking probiotics. Probiotics promote the
growth of the "good" bacteria (PRObiotics) and are sold over the counter
(get a reputable product from a reputable pharmacy or health food store). A
common one is Lactobacillus acidophillus. It's also helpful to know that
liquids that we gargle do not make direct contact with the vocal folds at
all, far from it. They stay well up in the throat, in front of the closed
tongue and soft palate. Some of that fluid is likely, however, to become
mixed with mucus and "drain" downward into the laryngopharynx ("laryngeal
vestibule") and onto the folds.

In your case: (background) One of the two most powerful acids on earth,
hydrochloric acid, is produced in the stomach as part of the "breaking down"
of foods for digestion. Cells of the stomach are adapted to its presence,
of course, but none of the other cells of the body are. So, anytime stomach
contents overcome the lower esophageal sphincter and reflux back up the
esophagus, the acid mixes with mucus and some degree of acid "burning" takes
place on any tissue with which it makes contact. [Gastroesophageal reflux
disease (GERD) is the medical term for relatively frequent reflux episodes
that "burn" esophageal tissues. But in a good number of GERD cases, the
reflux also repeatedly overcomes the upper esophageal sphincter (the upper
opening of the esophagus, located just behind the larynx and its vocal
folds) and the strong-acid liquid can make contact with the back end of the
vocal folds and "burn" or irritate them. Then the immune system kicks in to
produce inflammation with its swelling, and so forth. The term for that
medical diagnosis is laryngopharyngeal reflux disease (LPRD).]

Vomiting means that stomach contents have been strongly refluxed past both
sphincters and is expelled up through the throat (laryngo- and oro-pharynx)
and through and out the mouth, so that hydrochloric acid makes contact with
all such tissue surfaces and crevices (e.g., it commonly "invades" the
ventricles that separate the false from the true vocal folds). Some of the
reflux material can be deflected onto the vocal folds. Usually, of course,
people quickly swish and gargle water in the mouth and upper throat and spit
it out to remove most of the refluxed material, and then they swallow water
several times. That clears the reflux material from most of the pharynx,
but when we swallow, the larynx is raised and the tongue retracts the
epiglottis onto the top of the laryngopharynx and thus seals off the
laryngopharyngeal pathway to the vocal folds, trachea, and lungs. So the
hydrochloric acid, diluted to some degree by its mixture with mucus and
other fluids, just sits there and "burns" or irritates the vocal fold
tissues with the resulting inflammation, and sometimes, somewhat severe
swelling. Swelling stiffens the vocal fold surface tissues by "ballooning
them out", and they can become so swollen and stiff that breathflow from the
lungs cannot set them into vibration for voicing (complex ripple-waving
motions). So, you can see how your voice was affected by the circumstances
that you experienced.

After your considerable "vocal down time", your larynx muscles and vocal
fold tissues have become somewhat deconditioned and are likely to still be
swollen to some extent. Both vocal fold swelling and deconditioning
typically result in audible air leakage between the vocal folds, especially
during softer speaking and singing. I, too, suggest a great deal of caution
about the extent and strenuousness of your voice use, as Cindy suggested.
[Are you conducting or singing Carmina?] The deconditioning has weakened
your larynx muscles somewhat (imagine not using your arm-hand muscles very
much from Nov 27 to Jan 4) and has "softened" your vocal fold surface
tissues (reduced their resilience). Impact and shear stresses occur on
those tissues during nearly all speaking and singing. Larynx muscle and
vocal fold tissue conditioning is not fully understood or appreciated in any
of the voice-related professions, in my experience.

Because I don't have a written physician's diagnosis in front of me, no
pictures, and no way to hear your voice, I cannot make specific
recommendations about appropriate ways to use your larynx during its
recovery. I can suggest reducing your voice use during your recovery time,
giving your voice appropriate recovery time each day (silence), and drinking
6 to 8, 8-oz. glasses of water spread through each day. Certainly, easy and
soft-side downward sigh-glides beginning in comfortable falsetto and sliding
through upper ("head") and lower ("chest") registers will be helpful. A
relatively slow buildup of larynx muscle and vocal fold tissue conditioning
(strengthening) would be helpful.

I've attached some basic info about candidiasis and about vocal conditioning
that is from an "encyclopedia" of voice information of which I am principal
author and co-editor. Bodymind and Voice is a single, 3-volume book that is
divided into five major sections, called "Books", each with its own title
and body of information, with multiple chapters. The information is based
in the voice, voice medicine, and (believe it or not) the
neuropsychobiological sciences (a term lifted from a prominent
neuropsychobiologist named William Greenough at the University of Illinois).
In case you're interested, some info about B&V is included at the very end.

[SPECIAL NOTES: The National Center for Voice and Speech has built a voice
health website for all educators of all levels and subjects. Highly
recommended: . NCVS is now headquartered in Denver
and is funded by grants from the federal government's
National Institutes of Health. Information about Bodymind and Voice can be
found on the NCVS website.

The VoiceCare Network () is affiliated with NCVS,
and presents very practical summer courses for choral conductors, music
educators, and singing teachers on voice function, health, and lifespan
growth (including effects of conducting gestures on vocal efficiency and
vocal tone qualities).]

I know this is long, but sometimes angels are in the details. I wish
wellness to you and yours.

Sincerely yours,

Leon


Leon Thurman, Ed.D.
Specialist Voice Educator
Fairview Voice Center
Fairview-University Medical Center
2450 Riverside Avenue
Minneapolis MN 55454
612-273-7910

Founder, Development Director
The VoiceCare Network
[www.voicecarenetwork.org]

Principal author and Co-editor [with Graham Welch, Ph.D.]
Bodymind and Voice: Foundations of Voice Education
[info available at www.ncvs.org]

"All the world's a stage...
and most of us are desperately under-rehearsed."
--Sean O'Casey, Irish Playwright


The information below is from:
Bodymind and Voice: Foundations of Voice Education
[edited by Leon Thurman, Ed.D., and Graham Welch, Ph.D., published in 2000]

Book III: Health and Voice Protection

Chapter 2: "How Vocal Abilities Can Be Limited by Immune System Reactions
to 'Invaders'"
by Leon Thurman, Ed.D., Mary C. Tobin, M.D., Carol Klitzke, M.S., CCC/SLP
(Mary Tobin is an Allergist-Immunologist at Loyola University Medical
Center, Chicago; Carol Klitzke is a Voice Specialist Speech Pathologist at
Fairview Voice Center, Fairview-University Medical Center,
Minneapolis--Leon¹s colleague)


Fungal Infections


Fungi are closer in structure to plants than are the other infectious
microorganisms (bacteria and viruses). The most common fungus that can
affect voice directly is Candida albicans. It is a yeast-like fungus and is
part of the normal content of the oropharynx, gastrointestinal tract, skin,
and the vagina in women. Certain bacteria are its natural enemy and
normally keep it in balance. Its infective process is called candidiasis.
Under certain circumstances it can invade and colonize in mucosal tissues of
the pharynx, larynx, and esophagus.

Laryngeal candidiasis is seen most commonly in persons who use steroid
inhalers at high doses and frequencies. Prolonged, broad-spectrum
antibiotic use can lower the number of bacteria that prey on Candida, and
thereby increase the possibility of infection. Typical symptoms and signs
of chronic mucosal candidiasis of the larynx and pharynx are: (1)
hoarseness; (2) a chronic mild-to-moderate sore throat; (3) hazy-white
covering on the vocal folds and/or distinct white spots elsewhere in the
mouth and throat.

[from the For Those Who Want to Know MoreŠ part of that chapter]
Fungi are dependent on carbon sources. Saprophytic fungi sustain themselves
on dead plants or animals, while parasitic ones do so on living plant or
animal hosts, including humans. There are about 100,000 identified fungi.
There are about 100 microscopic fungal parasites that live in humans. Only
10 are pathogenic, among them is the one that most commonly can affect vocal
function--Candida albicans.

AND

Book II: How Voices Are Made and How They Are 'Played' in Skilled Speaking
and Singing

Chapter 15: "Vocal Efficiency and Vocal Conditioning in Expressive Speaking
and Singing"
(by Leon Thurman, Carol Klitzke, Axel Theimer, D.M.A., Graham Welch,
Elizabeth Grefsheim, B.A., Patricia Feit, M.A.)

What happens when reduction or loss of laryngeal conditioning occurs?

1. Decreased demand on mucosal tissues, compared to a previous higher
level of demand, produces adaptive micro-level changes in the vocal fold
cover tissues that decrease tissue resilience and "toughening", along with a
decrease of tissue elasticity. Lower tolerance for extensive and vigorous
voice use results. When vocal demand is highly reduced over a longer time
period, then mucosal tissues take on a degree of "softness" that reacts more
chaotically when higher vocal volumes are attempted.

2. Laryngeal muscles decrease in:

strength [higher vocal volume will be less available and voice quality is
likely to be less clear or sound "fuzzy" at softer volumes];

endurance [laryngeal muscles will fatigue more quickly];

neuromuscular speed, precision, and smoothness in vocal coordinations
[pitch accuracy will be more "off-tune", timing will be more sluggish,
stability of sustained tones and crescendi and diminuendi will decline, and
vibrato pitch excursions may widen;

bulk [loss of bulk in the thyrovocalis muscles (shorteners) results in
vocal fold cover tissues receding away from the front-to-back laryngeal
midline, and can result in bowed vocal folds if vocal underuse is
considerable (see Book III, Chapter 1)].

3. Recovery from vocal fold tissue and larynx muscle fatigue is slower when
the muscles and tissues are underconditioned.

What happens when optimal laryngeal conditioning increases?

1. During all voicing, numerous complex ripple-waves (vibrations) occur
in the vocal fold cover tissues, especially the mucosal tissues (epithelium
and superficial layer of the lamina propria; see Chapter 6). As a result,
these tissues undergo impact (collision) and shearing forces. Increased
demand is placed on mucosal tissues when: (1) speaking and/or singing are
relatively extensive over a day, week, month, or year, and (2) higher
pitches, louder volumes, lowest pitches, and faster muscle adjustments occur
during speaking-singing. Increased demand on mucosal tissues produces the
adaptive micro-level changes that increase tissue resilience and
"toughening". When the degree of increased demand is appropriate to the
current conditioning state of the tissues, then increased tissue tolerance
for extensive and vigorous use occurs and optimal elasticity and compliance
are achieved. When the degree of increased demand exceeds the current
conditioning state of the tissues, then the tissues begin to "fatigue" and
inflammation may occur in the mucosal tissues, with swelling-stiffening of
the folds and reduction of elasticity and compliance. Vocal capabilities
are then diminished (see Book III, Chapter 1).

2. Laryngeal muscles increase in:

strength, the capability to contract muscles with greater and greater
intensity;

endurance, the capability to sustain more intense contractions over
longer and longer periods of time before fatigue begins;

speed, precision, and "smoothness" of neuromuscular coordinations;

bulk, that is, protein is added to the fibers of the thyrovocalis muscles
so that they increase in size (hypertrophy), thus moving the cover tissues
of the vocal folds slightly closer to the front-to-back laryngeal midline.

3. Recovery from vocal fold tissue and larynx muscle fatigue is faster when
the muscles and tissues are well conditioned.

Conditioning an out-of-shape larynx for extensive and vigorous use?

With appropriate conditioning of laryngeal muscles and vocal fold tissues,
athletic speakers and singers can avoid laryngeal fatigue or voice fatigue
syndrome. Voice conditioning would follow the basic principles of all
neuromuscular conditioning, that is:

1. a progression from less voice use time toward gradual increases in same;

2. a progression from less strenuous voice use toward gradual increases in
same (higher-intensity vocal volumes, higher and lower pitches, faster
speeds of movement);

3. use of physically and acoustically efficient vocal coordinations to
optimize conditioning effects and help prevent vocal fold tissue and larynx
muscle disorders;

4. adequate hydration;

5. a nutritional base that provides support for energy expenditure and
tissue regeneration;

6. whole body movement that stimulates stronger blood vessels and greater
production and wider distribution of beneficial transmitter molecules.

A sample of pitch pattern sequences for conditioning are presented in Book
V, Chapter 5 (see also Brown, 1996). Such skills as efficient body
alignment-balance and breathing are extremely important skills. So, when
your voice use is going to be vigorous and/or extensive, the following three
processes will help you perform all of your vocal and musical skills at
optimum and will provide added voice protection.


The Bodymind and Voice section titles are:

Book I: Bodyminds, Learning, and Self-expression
Book II: How Voice Are Made and How They Are 'Played' in Skilled Speaking
and Singing
Book III: Health and Voice Protection
Book IV: Lifespan Voice Development
Book V: A Brief Menu of Voice Education Methods

The chapters in Book III are written by three quite prominent
ear-nose-throat physicians, an allergist-immunologist, an endocrinologist,
an audiologist, my speech-language pathologist colleague at Fairview Voice
Center, and me.



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