ENT problems
- a) Hearing loss and tinnitus.
Musicians have a much higher incidence of noise-induced hearing loss and tinnitus due to their profession, with the hearing loss tending to be in the higher frequencies of 3000-6000 Hz. In a recent study (Distadio et al, 2018) 22, hearing loss was found in 38.6 % of professional musicians overall, with rates of 63.5% in pop and rock musicians, and 32.8% in classical musicians. This hearing loss was symmetrical in 68% of pop and rock musicians, and in 44.5% of classical musicians. It is thought that the lower rate of symmetrical hearing loss in classical musicians is due to those musicians whose instruments are played in an asymmetrical manner. Tinnitus was found to be equally distributed in both classical, pop and rock musicians. 
Earplugs and an increasing awareness of the risk to musicians’ hearing both have an important role to play, and orchestras have become far more aware in recent years of the noise levels to which their members are exposed. Orchestral managers now have an obligation to provide a safe working environment for their players, both employed and freelance. For example, noise levels at the back desks of second violin and viola players in large orchestras situated just in front of the brass, woodwind and percussion sections can be extremely high.
BAPAM have a useful factsheet on hearing loss on their website, ‘Don’t lose the Music!’ 23. Other sources of help include RNID, previously known as Action on Hearing Loss (www.rnid.org.uk), the British Tinnitus Association (www.tinnitus.org.uk), and Musicians Hearing Services, a private audiology service with a good understanding of the specific needs of musicians (www.musicianshearingservices.co.uk).
Help Musicians UK run a Musicians’ Hearing Health Scheme which gives all professional musicians in the UK access to specialist hearing assessments and protection (www.helpmusicians.org.uk).
- b) Hyperacusis/diplocusis
Hyperacusis, which is the heightened sensitivity to certain sounds, has been found to again be more common in musicians. A study in 1999 found that of 100 patients with hyperacusis, 25% were in a music-related profession, and 31% felt that exposure to loud music (either professionally or at loud pop or rock concerts) had caused their problem. Cumulative exposure to loud noise seems to be the major risk factor, and drummers appear to be at particular risk.
Diplocusis, ie the same musical tone being perceived as being of a different pitch when heard in the right and left ear of the same listener, is commoner in those with hearing loss, particularly asymmetrical loss. This can be a devastating problem for professional musicians, especially those who play instruments where they have to pitch each note that they play.
- c) Vocal nodules and other vocal cord disorders.
Vocal cord disorders can be particularly problematic for singers, and include injuries, nodules, polyps, sores, infections, and virus-induced growths. Other problems include vocal cord paralysis, and gastric reflux.
Singers with voice disorders are most likely to have Muscle Tension Imbalance (MTI) rather than organic pathology or structural abnormality, and this diagnosis is often missed in ENT clinics. MTI in singers is assessed by means of nasendoscopy in a small number of specialist voice clinics.
Symptoms include a hoarse or raspy voice, losing the ability to hit high notes when singing, a deepening of the voice, sore throat, and an increased effort needed for talking. Vocal cord disorders are often caused by vocal abuse or misuse. Excessive use of the voice, smoking and inhaling irritants are all causative factors.
Early diagnosis is needed for successful treatment. This may include stopping the behaviour causing the problem, resting the voice, medication, referral to SALT, or even surgery to remove any growths.
Important ways of protecting the voice include hydration, adequate warming up, good posture and technique, resting in the event of an upper respiratory tract infection, and avoiding alcohol, cigarette smoke and caffeine. Good upper body posture is also important.
As with any patient with hoarseness lasting more than 2 weeks, new onset hoarseness should be referred under the 2 week wait, and specialist voice clinics may also be helpful.
The British Voice Association can also be a source of help. BAPAM have also produced a couple of useful factsheets: 'BAPAM recommendations to GPs regarding voice clinic referral’ 4 and 'Vocal Health problems in performing artists' 5 and have a Vocal Health Working Group to advise on best practice in vocal health. This comprises of ENT specialists, SALT therapists, physiotherapists and vocal rehabilitation coaches.
- d) Pharyngeal pouches.
Wind and brass players, in particular trumpeters and clarinettists, have been found to have an increased incidence of pharyngeal pouches. Indeed a study 26 showed that in a sample of 21 wind and brass players, all had some degree of lateral laryngopharyngeal diverticulae, and the authors considered that this must be considered an ‘overuse injury’ in these players.