Oh No! I’m Sick and I Have to Sing!

by Michael Unger

Since we’re heading into cold/flu season, I’ve been asked to address the question of what to do when you have a performance and have come down with some sort of upper respiratory infection. What can be done? First, let’s separate fact from fantasy.

The first step always is to go see your doctor, so he/she can treat any reversible causes of your upper respiratory symptoms. If you have a runny nose, cough, nasal congestion, sore throat, laryngitis, or any of the other multitude of symptoms that accompany upper respiratory illnesses, it may be something that is curable with antibiotics (bacterial sinusitis, purulent rhinitis, etc).

However, most illnesses of this ilk are simply the Common Cold, caused by a multitude of viruses, for which there is no cure. I’m going to repeat that,

because it’s really important: There is no cure. You may have heard from your great grandmother Hilda that, if you take a teaspoon of honey every two hours and drink lemon tea with every meal, your cold will magically disappear! You may also have heard that 2 drops of Echinacea, 1000mg of Vitamin C, two Cold-Eze and 4 drops of Rosemary oil can cure the common cold! I’m here to promise you that we do not have any cures for the common cold. Nothing will shorten the course of your illness. If there had been any successes in this regard, we doctors would be on it like white on rice! The best you can hope for is to not extend the duration of your cold. Get plenty of rest, eat well, and drink plenty of fluids, so your body can do its best job to fight the off infection.

In the meantime, there are things you can do to get through your symptoms enough to perform. Some of these would be useful to anyone. Others I would only suggest for people who are making their living by performing, and can’t miss the gig or risk performing badly. We’ll take this symptom by symptom.


Coughing in the middle of your show is a no-no… and coughing traumatizes your vocal cords, which can make them swell (laryngitis). This can cause a course sound to your singing, reduce your vocal range, or rob you of your voice altogether. Thus, we want to minimize coughing as much as possible.

The over-the-counter product Delsym is an excellent cough suppressant. It has the advantage of lasting a full 12 hours, which is enough to get you a full night of sleep. Possible side effects include nausea or drowsiness. [Please remember that the word ‘possible’ means that you are unlikely to get these side effects, but they are possible.]

Since the majority of cough symptoms from colds are from post nasal dripping of mucous down the back of your throat, any- thing that reduces the drip will help to reduce your cough. Antihistamines and decongestants help with this quite a bit, at the expense of drying out your nose and throat to some extent, so I strongly recommend drinking plenty of water if you are using these medications.

The best decongestant, by far, is pseudoephedrine. This is the “real” Sudafed, which requires you to show your ID and purchase directly from the pharmacist. The 12-hour, generic form is the one you want. Possible side effects from pseudoephedrine include jitteriness and insomnia, and difficulty urinating in men with an enlarged prostate. The Sudafed version you can buy without an ID is made with phenylephrine. It lasts only about 4 hours and is too weak to be useful.

The better antihistamine is Allegra (generic: fexofenadine), which is the best balance of being effective and non-drowsy. I would avoid Claritin (generic: loratadine) because it is too weak, and I would avoid Zyrtec (generic: cetirizine) because it can make you drowsy. Allegra-D, a combination antihistamine and decongestant, has both fexofenadine and pseudoephedrine in it.

Many of the multi-symptom cold remedies have antihistamines in them, often chlorpheniramine, which can make you very drowsy! I would avoid multi-symptom cold remedies in general. You get medication you may not need, and often in doses which are not effective (so they can call the medicine side-effect free).


Having congestion of the nasal mucosa can change the quality of your voice, though trained singers who have learned proper vocal technique have less trouble with this than us mere mortals. Nasal congestion can be treated easily with the decongestant, pseudoephedrine, as noted above for cough symptoms. However, sometimes this is not enough, or the side effects of the medicine are too severe, especially in terms of drying you out.

If oral decongestants bother you, a little Afrin nasal spray is very potent and can be a godsend. Two sprays in each nostril will keep your nose pristine for up to 12 hours. It is important you not use Afrin for more than a couple of days, however, otherwise when you stop taking it, your symptoms can rebound and be even worse than when you started. However, if you just need to get through a gig, and damn the day after, this can be an excellent option. Antihistamines can also sometimes help nasal congestion, so taking some Allegra can be useful.


This rarely interferes with vocal performance, but it can make it hard to stay hydrated, or to eat properly, if it hurts to swallow. Consider using any of the following for sore throat. Ibuprofen (generic Advil) or Naproxyn (generic Aleve) both do a passable job taking care of pain of any kind, including sore throat. They can both cause stomach upset, so be sure to take them with food. Chloraseptic Spray is awesome for a sore throat. It only lasts about an hour, but can be used as often and as much as required, with no real side effects. It just numbs the throat. Sucrets lozenges do the same thing but are much more expensive. The only advantage is that they last longer, so if you need it to last the length of a 2 hour show, they might be a better option. Gargling with plain salt water also works pretty well, but only lasts about 30 minutes.


Uh oh! This is the big baddy. Clearly, this is what can spoil your performance entirely. Vocal rest (i.e. no speaking, no singing) can sometimes reduce the inflammation of the vocal cords, but if you are barely able to produce reasonably pretty sound, and it’s 4 or 5 days (or less) before your show, you need to take some drastic measures. Otherwise, there is a good chance you will not have enough voice to perform come show day… or to rehearse enough to properly prepare. We physicians have a magical elixir which can perform miracles in these singer-emergency situations.

Steroids. No, no, no… not those steroids! We aren’t going to bulk you up. Those are anabolic steroids. The type of steroids we use for this problem are the most powerful anti-inflammatory medications available. Prednisone is the most common of these, but there are a myriad of others that work equally as well. Steroids act directly upon the inflammation present in the vocal cords, reduce the swelling, and lead to normal vocal architecture and sound delivery. Steroids can work pretty quickly, even showing some noticeable effects in as little as 12 hours for some people. We can get marked improvement in most people in 48 hours and, if given at least 96-120 hours, usually we can return your voice to near-normal, even in the worst of cases.

There are considerable downsides to steroids, though, so we prefer not to use them except when absolutely necessary. Steroids suppress your immune system, so it’s possible, even likely, that your illness will actually be prolonged. Steroids often cause mood elevation (not a bad thing for most people), but when coming off the steroids, there can be some mood depression. Steroids often cause significant insomnia, so I often recommend patients take a sleep aid while they are on them (like plain Benadryl, 50mg, 30 minutes before bedtime). Even when used short-term and in reasonable doses, steroids can worsen osteoporosis (thinning of the bones) and can, rarely, cause serious side effects including osteonecrosis of the hip (dying bone) or steroid psychosis (as shown on the TV show, Smash… poor Megan Hilty!).

Because of these risks, the benefits of being vocally ready for a performance have to be significant enough to justify the use of steroids. Steroids can only be prescribed by a physician and, given the possible side effects, the physician will need to see you before (and maybe after) their use. Doctors who have little experience with singers may be reticent to prescribe them in the high doses required to get a vocal cord response.


Please understand that, while these may help your voice, or your symptoms, none of these things will shorten the duration of your cold.

  • Steam – Moist heat has a beneficial effect on your voice, vocal cord swelling, and nasal Hot liquids have a similar effect (hot tea, etc.), but using a steam vaporizer can help much more than just drinking hot liquids.
  • Rest – I cannot over-emphasize Healing occurs primarily during sleep, so to maximize your potential for healing, you need to give your body plenty of rest; else you risk prolonging your illness. 8 hours of sleep, kids!
  • Fluids – Remaining well hydrated also allows your body to heal maximally, ensuring you don’t prolong your
  • Nutrition – Your body needs nutrition in order to fight off infection, especially protein, which your body uses to create all of the antibodies and other inflammatory molecules to fight Eat well, and eat healthy.
  • Avoiding other sick people – It should go without saying that your body is in a weakened state when it is fighting off an infection and being around someone who could give you a second infection is just begging for double
  • Wash your hands and face frequently – The passage of infections is largely through contact with them. Plague Person #1 touches doorknob. You touch doorknob. You touch your face. You are now Plague Person #2! Washing your hands and face several times daily really helps to prevent the passage of You need not use antibacterial soap. In fact, there is good evidence that this may cause more harm than good. Plain soap and water is just spiffy!

I hope this brief treatise was helpful. If you feel you must look online for medical information, I recommend www.webmd.com as a web site with reputable medical information. You may also check my medical blog at SeussMD.wordpress.com.

Dr. Michael Unger is a board certified Internist, in solo practice, and has become the Cabaret Doctor to many CCP members.
You are welcome to visit his office in Northbrook, Illinois at 1500 Shermer Road, suite 212. Phone 847-498-9090. Website www.ahadoctor.com.
His practice takes most insurance plans, and he offers payment plans and discounts for people without insurance.

−Michael J. Unger, MD

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