Pros and Cons of Singing with and without Tonsils

As a vocal coach for over 20 years, I have had a front row seat to the pros and cons of singers and professional speakers having their tonsils removed. For those of you worried about your voice and contemplating a tonsillectomy, let me start by putting your mind at ease and assure you that you will still sound like you! All of the unique qualities that make you identifiable as a vocalist are controlled by your brain and coordination of muscle with only a surprisingly small part of it related to the genetic shape and size of your vocal instrument. However, there are always risks related to any surgery, particularly for singers when it involves intubation. Okay, I may have jumped ahead of myself here… to really understand how tonsils may have an impact on your singing and speaking voice, let’s break it down by first answering the following question:

Tonsils are oddly shaped masses of soft tissue located in the back of the throat, which serve as the immune system’s first line of defense against foreign pathogens (microorganisms that can cause disease) entering the body through the mouth and nose. However, there are actually four sets of tonsils: we have the pharyngeals (commonly known as the adenoids), tubal, palatine and lingual. The ones usually referred to and often removed are the palatine tonsils, which are the two almond-shaped structures located on either side of the tongue that continue upwards to meet with the soft palate, a well known area for many singers. They mature throughout childhood, while they are most active and beneficial to the immune system and stop growing around puberty. The adenoids (pharyngeal tonsils) on the other hand, only grow until the age of five. After that, they shrink and remain relatively small throughout adulthood.

As shown above, the tonsils are located several inches above the larynx, where sound is produced. Therefore, they have little to zero influence on the vibration of the vocal folds and overall vocal range. However, they can conceivably influence a singer’s tone as a result of sound waves bouncing around in the space above the larynx, known as the vocal tract. This includes the throat (pharynx), oral cavity and nasal cavities. Since the tonsils vary in size and are susceptible to swelling, they can sometimes interfere with the quality of sound and comfort of singing due to blockages, sensitivity and pain in the oral region.

If one were to have this space modified by removing the tonsils and adenoids (tonsillectomy), it can potentially alter the sound coming up from the larynx by causing the waves to bounce around in slightly different patterns. As a general rule, the more smooth-surfaced space there is (like a large tiled bathroom), the more overtones will be amplified, creating a fuller and richer sound with less effort. That said, the change in resonance tends to be incredibly subtle and often goes completely unnoticed as discussed in the next section.

A tonsillectomy is a surgical procedure in which the palatine tonsils are removed. Similarly, an adenoidectomy is when the adenoids (pharyngeal tonsils) are removed. If all goes well during surgery, you have nothing to worry about in terms of your voice changing! In fact, many singers, including a few of my own students that have gotten a tonsillectomy, are convinced that their voice sounds even better than it did before. This may be true, but it can be difficult to distinguish a “better sound” from having “better health” to sing with since they no longer need to deal with chronic tonsillitis or tonsil stones! Let’s explore this a bit further:

• Can you listen to someone SING and tell if they have tonsils? No. 
• Can you listen to someone SPEAK and tell if they have tonsils? No. 
• If you’ve never heard a particular person speak or sing before, can you tell if their tonsils have been removed? No. 
• If you know a particular person’s voice very well, can you tell if their tonsils have been removed? Not likely! 

Although there are arguable advantages to having more space above the larynx, it rarely makes an identifiable difference to the listener. Even a study by the Vocal Foundation titled “The Impact of Tonsillectomy on the Adult Singing Voice: Acoustic and Aerodynamic Measures” using electronic measuring devices to compare pre- and post-op vocal samples only suggest that there are consistent and/or identifiable frequency changes. Dr. Satish Babu (ENT Surgeon) goes so far to say that the voice changing as a result of having the tonsils removed is just a major misconception or a myth. 

Whether or not removing tonsils will improve the acoustic quality of the voice, doesn’t change the fact that skill and coordination are still required to sing well! There are no shortcuts to improving your voice. So if you decide to get, or have already had, a tonsillectomy, make sure to take advantage of having a healthy voice to practice often in order to reach your goals.

It’s also important to mention that there will be a NEGATIVE impact on your voice for speaking and singing immediately following surgery, but this is only temporary during the recovery process.

There are several reasons to consider a tonsillectomy, even if singing isn’t a primary concern. First and foremost, be sure to take responsibility in the health of your voice by getting enough sleep, hydrating often and vocalizing before and after long periods of singing or speaking (this includes classroom teachers, dance & performing arts instructors, sports trainers, those who have to speak on the phone all day, and so on). If you feel you are taking care of your instrument and still experiencing one or more of the following symptoms, talk to your doctor to consider all of your options. It’s best to exhaust any home remedies and vocal regimens prior to having a surgical procedure:

• Tonsillitis (inflamed tonsils due to infection) 
• Coughing up white debris, known as tonsil stones (tonsillolith)
• Chronic bad breath due to bacteria
• Disruptive sleep due to partial blockage in the airway
• Uncomfortable to swallow for long periods of time
• Glandular fever (also known as mononucleosis, or “mono”)
• Recurrent strep infections and sore throats
• Swollen neck glands (lymph nodes)

Any one of the symptoms above can result in irritated vocal folds, limited vocal range, inconsistent singing quality and unwanted vocal textures. If it persists, it can even lead to cancellation of performances and job loss, which in turn adds more stress to the body, making symptoms even worse!

Getting a tonsillectomy can be scary for anyone, especially for those who rely on their voice for singing or speaking for a living. However, the removal of tonsils and adenoids have been practiced for nearly 3,000 years and there is no evidence showing that tonsillectomies weaken or impair the lymphatic system in adulthood. Of course, there are always risks involved with any kind of surgery and should be taken seriously when considering a tonsillectomy. Though uncommon, the two greatest risks tend to be bleeding and intubation.

• BLEEDING: Shortly after surgery, the tonsil bed is at risk of bleeding while the scabs heal. A small amount of blood won’t have any direct long-term effects on the voice and typically goes away after just 10 days. If persistent bleeding occurs, notify your doctor. 
• INTUBATION: Intubation is when a flexible tube is used to allow a patient to breathe without obstruction of the airways. Since the tube has to travel between the vocal folds in order to provide air to the lungs, it often causes a temporary swelling of the folds and makes singing and speaking difficult for several weeks. In rare cases, the tube is forced improperly or scrapes against the folds in a violent manner causing them to bruise or agitate the edge of the folds creating more complications in the healing process. Typically, general anesthesia is used due to the invasive and uncomfortable nature of the tube entering the larynx and trachea, so this won’t be something you will remember or be awake during

Don’t be shy to share your love of singing and concerns for post-op vocal use with your doctor AND anesthesiologist (the one that does the intubation). Since your voice is particularly important to you (why else would you be reading this?!), you want to make sure that they both have many years of experience in this type of surgery. Make it known that you want to learn about the procedure and all the steps that follow to gain a quick and healthy recovery. The more genuine interest and respect you show in their work, the more inspired they will be to do their best! 

Additionally, you can discuss the possibility of using the smallest diameter tube possible for the intubation with your anesthesiologist to help minimize any risks to your vocal folds. There are also wonderful new technologies surfacing that allow the surgeon to use low-heat lasers to cauterize the area from which the tonsils were removed to reduce scarring.

Assuming all goes well in surgery, the tonsillectomy should only take about 30 minutes and patients typically go home the same day. After which, there should be at least two days of minimal physical activity and little to no speaking. Gradually introduce speaking normally and vocalizing (exercises not singing) over the next two weeks to prevent bleeding. Recovery will be a unique experience for everyone, but most are back to their normal singing routine within 4-6 weeks. 

During this recovery process, you will likely notice several temporary challenges with your voice. It will take time for the muscles in your throat to stretch and flex pain-free and for the inflammation of the vocal folds to reduce from the intubation. Some silver lining here is that you can take advantage of the extra sensitivity in your throat to make sure you’re not using any unnecessary muscles or efforts during specialized vocal exercises. However, you should wait at least a few days after surgery to do so. For more information, see a vocal therapist or experienced vocal coach to assist.

Here are a few additional tips to help you through the recovery period: 

• Oral hygiene is essential, so brush your teeth several times per day
• Drink water often and occasionally gargle with salt water
• Chew gum to help the healing process by creating more saliva
• Cold liquids, ice chips and ice cream will help numb pain
• Start with soft foods and gradually work your way to hard foods
• Avoid hot and acidic foods and juices for the first two weeks 
• Use a humidifier in the bedroom to help prevent dryness
• Avoid aspirin and similar products as this may increase the risk of bleeding
• Get a travel (handheld) steamer to use several times a day if you are in a dry climate (or indoor environment that uses a lot of air conditioning or space heaters)

Stay patient and take care of your instrument. It won’t be long before your throat feels better, breathing becomes easier, you get quality sleep and most importantly, sing again! If you notice an audible difference in your speaking or singing voice after several weeks of recover, it is either due to an unlikely injury from the surgery, or most likely; a communication issue where the brain attempts to play old “programs” during phonation with a new, slightly-modified, vocal-instrument. This behavioral imbalance can cause a singer to over compensate with muscle tension, leading to friction and fatigue of the vocal folds. This can be addressed by simply practicing fundamental breathing, intonation and tone based exercises to re-balance the instrument and reprogram the mind over a few months time.

In case you’re still wondering, YES, you can absolutely sing without tonsils. In fact, if your tonsils were interfering with the health of your voice, you can now spend more time singing than ever before! Keep in mind that the risks related to having surgery, although minimal, are not justified solely in hopes of getting a better sounding voice. After all, a great sounding resonator does not equal great singing. Think of it this way, a $100,000 9-foot Steinway grand piano, perfectly tuned and maintained, will sound incredible when a trained pianist performs in it. Just as it will sound terrible when an untrained person bangs on the keys without proper skills. Vocal practice and experience are required to sound great, with or without tonsils. No exceptions!

Finally, let me remind you that I am a seasoned vocal coach and not a doctor or surgeon, as such, always be sure to consult with a medical professional before making any final decisions. Best of luck and keep singing!

AUTHOR: RICHARD FINK IV