Thursday, May 5, 2011

Lip Swelling, The Embouchure Performance Wrecking Ball

Lip swelling can impair embouchure performance for brass players. Lip swelling can be caused from medications, allergies, certain dietary supplements, foods, mechanical stimulation (vibration/pressure), infections, cosmetics and who-knows-what-else. Lip swelling seriously reduces endurance, range and the ability to make clean attacks.

For some, the embouchure muscles are well conditioned, the players have good mechanics, technique and range, but for various reasons, their lips swell as they play. For these folks, performance is seriously diminished before they begin to feel fatigue in the embouchure muscles.

How can you tell when your lips are swollen? Larry Jellison wrote:
I can tell quickly my swelling condition by putting the mouthpiece on my lips and playing for a couple seconds. If my lips are NOT swollen, then both lips feel like feet being in roomy shoes-- lots of room for the lips to move around which is important for dexterity and overall response with a good buzz. When the lips are swollen, there is less room for the lips to move around in the mouthpiece ... less dexterity, less ability to start notes consistently. 
More recently, Larry added this sage advice.

When the lips are messed up from supplements and meds, my opinion is, go ahead and practice.  Don't get upset about how you may sound.  Practice the best you can.  Many aspects of horn playing are worse-- tone, accuracy, high range, intonation.  But, try really hard to play the best you can.  With super concentration, you can play better.  This kind of practice improves one's overall horn playing then when the lips are in good condition.  Practice when playing is bad does bring overall improvement.   
Sometimes the cause of lip swelling can take a long time to identify and resolve, but sometimes a few simple interventions remedy the problem. The following is a list of various causes and possible remedies I've gathered through personal experience and experiences of others:

1. Those who have swelling due to prescription medications, may talk to their doctors about changing medications. For example, some blood pressure medications work by dilating blood vessels which can lead to swelling. Changing to a medication that treats hypertension with another strategy may ease the swelling. (See #19 below for a specific medication.)

2. One hornist explained that a rushed, strenuous warm up used to cause his lips to swell and stiffen. He now gets better performance because he's using Wendell Rider's gentle warm up. (I also use Wendell's warm up and love it for this and other reasons. http://www.wendellworld.com/html/HornBookSamples.html)
Another horn player doesn't play at all the day of a performance only blowing a few easy notes just prior to the concert for warm up & preparation.

3. Taking aspirin or ibuprophen before a performance helps three horn players I'm acquainted with. One reports that prescription doses of ibuprophen are the most effective.

4. Supplements that have been reported to increase lip swelling are fish oil, arginine, niacin, so one horn player routinely abstains from these products for at least six hours before performing.

5. Two horn players I know find the dietary supplement, Serraflazyme (serrapeptase) very helpful for reducing and preventing swelling. Another finds this same supplement to aggravate swelling. 

6. Two reported that if a salty food touches their lips, they can not play for hours after.

7. A young lady posted on a horn discussion forum about trying a new lipstick that made her lips swell so badly before a concert, she was unable to play the concert.

8. Many report that arnica, an herbal anti-inflammatory, helps reduce swelling. Arnica is available in OTC products such as ChopSaver, creams, gels and tablets. (BTW, every product I've ever used containing arnica makes my lips burn and swell. Go figure.)  At a master class I attended, Gail Williams said she uses oral arnica preparations as well as ChopSaver.

9. Several trumpet players I know put a cold can of beer against their lips during strenuous performances. One said forget soda pop, only beer will do! ;o)

10. Sometimes, if I'm exposed to something I'm allergic to, nothing helps but an antihistamine/decongestant. Yet, one horn player's lips swell more if he takes antihistamines. (Go figure.)  Nuts are a common trigger for lip swelling.  http://www.livestrong.com/article/446613-raw-almonds-and-swollen-lips/

11. Also, certain foods can cause embouchure swelling. I personally have experienced embouchure problems after eating red or green peppers, tomatoes, potatoes, kiwi fruit, pineapple or cashews. I've heard of some who have problems with spicey foods, highly acidic foods or beverages, such as citrus & berries. One horn player reported a disastrous performance after eating spicy chicken verde enchiladas prior to her concert debut as principal. Ouch!

12. Another cause for my lips to swell is dehydration making them feel hot and burned, then swell and I end up "clamming" all over the place. [Since clams are aquatic creatures, it stands to reason that they'll stay calm & quiet if given plenty of water. ;o) ]

13. Aside from dietary interventions & antihistamines, something else that has helped me is to get allergy tested, start allergy shots and remove as many allergens from my home possible. In testing I was found to be highly sensitive to insect proteins & molds. I don't live in an area where insects are a problem, but I did have a lot of silk in my bedroom. (Silk is an insect protein.) Removing the silk bedding, drapery and throw pillows made a significant improvement in my embouchure function and overall well being. My husband and I also had the 30 year old moldy insulation in our attic replaced and that has really helped, too. (It was surprisingly affordable.) I only occasionally need antihistamines anymore, whereas previous to the interventions in this paragraph, I used them twice daily for many years.

14. (5/6/11) I just heard from a horn player who took hydrocodone before and after surgery. He wrote,
"It worked for the pain, but made my face swell enough that playing the Horn was very inconsistent. For a while I used one of my Neill Sanders wide rim mouthpieces, because it was easier to move around in. After the surgery it took about 3 months for things to get back to normal. Now I am back on either my trusty Schilke #30 or a mid 70's Giardinelli F-16. (Giardinelli's version of the original Farkas mouthpiece)"

"It took me several days to realize it was the Hydocodone, that was the cause of the problems with my Horn playing. My first reaction was: Oh damn, along with everything else, I have the first stages of embouchure dystonia! It was only after my brain kicked in and said: A doctor's first question would be: What have you eaten, taken or done differently recently? With that thought in mind I looked up the side effects of hydrocodone in the internet. "
15. One horn player with embouchure dystonia reports that symptoms are more manageable if he reduces lip swelling with ibuprophen before a performance.

Of course, what works for me and others mentioned in this post, may not work for all. I'm sharing ideas hoping that something here will help any who may be struggling with performance problems related to lip swelling. If any have additional related experience, please share so I can add it to this list. Feel free to leave a comment or email me directly ValerieW78 "at" Gmail "dot" com. Thanks to all who have contributed.

16. This just in (5/10/11) from one of a BE correspondents in Europe :
About lip swelling, it was an issue for a couple of years ago. It was mainly due to bad lip functionning and the overuse of mpc pressure for extensive periods of practice. I had to play a really big mpc so I could get low notes. Since BE helped me improve my lip functioning, I do not have that problem any longer. I can play for hours without any swelling, neither on the moment nor the next day. I now play a Holton Farkas MDC, which is a fairly small mpc diameter wise (it is already quite a deep cup) and my low register has never been better.
17. This from Larry:
BE DOES help with the lip swelling, the RO-RI helps to adjust the lips the minimize the worst of it.  You touch on a key concept-- an inefficient embouchure will make swelling worse, and this because the lips are getting "beaten up", thus aggravating the swelling. Swelling may at least be partly a symptom of an embouchure problem.
18. Reading this jogged my memory of my first few months back to horn. The center of my upper lip was always swollen, sometimes bruised and a few times it tore leaving a tiny thread of loose skin attached to the underside of the lip. This particular problem completely resolved after I began BE.

19. A specific hypertension medicine may adversely affect horn playing. This came today (8/15/11) from one of my readers:
There are many Internet sites that describe the side effects of Norvasc. Here is one: http://www.drugs.com/sfx/norvasc-side-effects.html . Side effects include flushing and swelling. Supposedly, these side effects apply to a small percentage of users, less than 5%. In my case, I experienced both flushing and swelling. Swelling was noticeable in my ankles. The flushing is gone and the swelling is reducing since quitting the medication.

I am one data point that indicates that these the side effects happen. The swelling affected my lips and my horn playing. Playing was difficult, and most aspects of my horn playing were affected. I suspect that flushing and swelling occur together, so if one experiences flushing, the swelling is likely occurring.

Within one week of quitting Norvasc, my horn playing improved and my lips were more comfortable while playing horn. Norvasc (amlodipine) is a calcium channel blocker used to treat high blood pressure and angina. Similar reactions as described above can be expected from other calcium channel blockers.
20.  This just in (9/9/11) from a reader:
My embouchure hasn't functioned well in the morning for years. I just thought it was my "normal" not to play well until about 2 or 3 PM.  I stopped taking krill oil with breakfast three or four days ago and have been frankly surprised at how much better I'm playing in the morning now.  If my doctor insists I keep taking krill oil, I'll try taking it at bedtime or I'll ask him to suggest a substitute. 

21.  Bizarre thing happened to me this past weekend.  On Friday, the insides of my mouth suddenly became so sensitive, eating my normal lunch left the insides feeling burned.  After about a hour, I looked in the mirror and saw that much of the mucous membranes had turned white and were actually peeling.  It looked like burns, as if I'd taken a big bite of hot cheesy pizza, except it was in a perfectly symmetrical pattern.  I hoped it was only a temporary thing, but the tenderness continued.  By the end rehearsal that evening, my lips were significantly swollen and I clammed quite a bit.  I discussed it with a dentist who plays in the orchestra.  We agreed that it wasn't a chemical burn and could possibly be the first signs of an impending viral infection, possibly a herpes virus similar to those that cause fever blisters.  The dentist suggested I try lysine. Before I got home, I stopped at my local grocery store's health food department and purchased some L-lysine.  When I got home I looked in the mirror and saw there were swollen ridges and a few blisters inside my lips and mouth.  (PANIC!  I was preparing for a concert in two days!  Herpes infections typically last a week or more.)

I reasoned that if this was the beginning of a viral infection, I might as well do all the anti-viral things I could think of.  So that evening, in addition to large doses of L-lysine, I began taking large doses of vitamin C w/ bioflavanoids, oregano oil & olive leaf extract, echinacea, and zinc lozenges.  The next morning, Saturday, I continued with the supplements taking them every 2 to 3 hours.  As the dentist and I suspected, I developed a low grade fever with chills.  I spent the day in bed feeling just awful, mostly sleeping.  I was scheduled to attend the fiinal rehearsal that evening and wasn't sure I was going to make it.  By 4 PM, the chills & fever "broke."  By 5 PM I had energy again.  By 6 PM, there were no more blisters inside my mouth and no sign of lip swelling, just a little remaining white peeling tissue.  I attended rehearsal and played pretty well.  I continued the supplements the next day and performed in the concert with well functioning chops.  Nailed my solo with the high sustained G.  Whoo hoo!

22.  A similar incident recently occurred involving a friend of mine.  About 6 PM and two days prior to a critical concert, one of my horn friends found his lower lip swollen up two or three times its normal size & he couldn't play a note.  There was no pain, there had been no injury or trauma, he had no allergies that he was aware of.  He called his friend who is a nurse.  She suggested he alternate ice packs with warm packs, take a vitamin C tablet every hour or two (to tolerance) and follow recommended doses of an over-the-counter antihistamine.  He reported to me that within an hour the swelling began to resolve and he was back to normal within 24 hours.

23.  Larry contributed the following December 19, 2011:

I have knowingly been struggling with lip swelling for a year that adversely affects my horn playing. The struggle may have occurred much longer; I just didn't know that it was going on until Dave Stoller recognized the symptoms I was having after he read my comments about my playing that I posted on a hornlist. David e-mailed me and told me my problem could be lip swelling,and he suggested some solutions.

I started studying my condition and studied how food, supplements, and medications affected my horn playing. Hypertension medications were the worst, and I went through different hypertension meds to find some that worked the best for my horn playing. I finally got down to taking only beta blockers (atenolol, propranolol) and a diuretic (water pill- hydrochlorothiazide (HCTZ)). I had always taken the HCTZ once a day away from my horn playing time, as I assumed that it would be a problem. My doctor then doubled my HCTZ dosage to 25 mg. twice a day. I could no longer keep this med away from my horn playing. When I doubled the dosage of HCTZ, I noticed a remarkable improvement to my horn playing. I then tested this further by dropping off the med for a few days, played horn, then resumed taking the med, followed by playing horn. The beneficial effect could be noticed a within a few hours of resuming the med. All aspects of my horn playing improved, most notably tone, accuracy, dexterity, high range, and endurance. I noticed that my lips felt roomier in the mouthpiece, and the increased room actually created a minor temporary problem of needing to strengthen my lip support structure within the mouthpiece. I will check later to whether I can downsize to a smaller mouthpiece rim; for now I will stay on the Laskey 85G. The amount of improvement is significant, and I am able to play more confidently. 

24.   I personally experienced troubling episodes of swelling, tooth sensitivity & break outs of rashes in the mouth for a couple months before discovering that it was all caused by a bad tooth. Once the dental problem was resolved, the symptoms went away.

 25. From Larry:  I want to make another update to your blog on the lip swelling issue, to reflect my latest findings.  My current strategy involves recognizing that we can tolerate some minimum level of lip swelling.  It is a continuum, and the more swelling, the worse the playing.  My new finding is that (after all my criticism of Norvasc) these troublesome medications can be taken, as I have been back on them for about three weeks now.  They can be taken IF one reduces the other supplements that cause swelling.  Now I realize I got into trouble with lip swelling because i was taking both troublesome medications and troublesome supplements.  I have had to greatly cut back on supplements, especially on important horn playing days, starting with the day before.  

26. From Doug:  

Started on my aunt's cornet.  Lovely little Reynolds.  Never had any range on that and remember hating the mouthpieces.  An absolutely wonderful 7th grade band teacher (Eric Sorenson, who I believe died last year, great educator) told me I had French Horn lips.  He was a horn player.  HAH!! Imagine that.  Put on a horrible compensating horn with a Bach 11 (I Think).

All throughout jr high I had problems getting through a performance without tiring.  My horn teacher (8-11th grades) switched me to a giardinelli mouthpiece, much better made he said, and found a very used, very good custom H-181 that I still have as my second horn.  

I played Giardinelli's all through college (just orchestra with required lessons, though my studies were in composition) switching from very deep cups to very shallow, C1 through s15!  Finally settled on an s15.  After college I mostly stopped except for a brief stint playing in the Kensington Symphony Orchestra (community).  Then almost 2 years ago (after I think a decade) I picked up the horn again.  Here's the lowdown:

  • Bach 11 bad compensator - rough time through concerts
  • Giardinelli C4 (I think don't own anymore) with silver plate screw rim and Holton - Got through the Mozart stuff and had problems with high-end.  Told that I had some embouchure issues that teacher and school instructor didn't know how to work out
  • College - Conn 8D with (Briefly) Holton tuckwell goldplated - Embouchure issue persists, switch to old Giardinelli S15 with old C Rim.  High end improves, embouchure problems continue, college instructor thinks I need to build strength puts me on lots of long notes.  No improvement.
  • After college - S15 and Holton 181, notice that high end is fine at beginning of playing but flexibility and range degrade quickly.
  • Various community orchestras
  • Return after long time away - for first time going through exercises identify that lips are tingly and actually get puffy (look in mirror and see ring that persists for 30-50 minutes after playing).  Suspect something is wrong.  Switch from Holton 181 to Paxman 25.  Decide to buy lots of New Old Stock off ebay to figure out mouthpiece issue (as I'm calling it).  After trying about 6 or 7 find that I have much worse problems with the unplated/bad plated mouthpieces, and last longer on the silver plate.  Try the Kelly Lexan mouthpieces and have no tingle, no puffiness, and no red ring.  Try out the Laskey MP's in San Francisco and find I love them so decide to try one and switch to it for working out pieces, while the Kelly is the warm up.  Find I have almost no reaction to the Laskey, allows for much longer practices and don't feel tingle or puffiness to nearing my practice duration anyway (about 1.25-1.75 hours).  Correspond with Mr. Laskey, very kind in taking his time and says that his brass blanks are nickel free and he plates in extremely pure, as nickel free as possible, silver.  Suggests I have an allergy test done to narrow down the metal.  Have not tested yet but suspect zinc, cadmium, or rhodium may be to blame.   
27.  From Ann:  I recently found that I can get relief from lip swelling without the usual stomach irritation that comes from other anti-inflammatories by taking Pepto Bismol instead.  It contains the anti-inflammatory, aspirin, plus bismuth to protect the stomach.  Works great.  

28.  Following my injury in December, I had a lot of swelling issues.  I found the best way for me to use ice during the healing phase was to gently rub an ice cube on the center of my lips (the part that's inside the mouthpiece) for about 10 seconds every 10 or 15 minutes during the first 30 minutes of playing.   I was careful not to use ice for too long while playing.  I only wanted to cool them down, not dampen response.  

29.  I'm a retired registered nurse with a history of thyroid illness so I can't believe I failed to mention before now. DUH!  Swollen lips can be a sign of a poorly functioning thyroid.  See this: http://medical-dictionary.thefreedictionary.com/myxedema   And... one of the main causes of thyroid disease is iodine deficiency.  From The Silent Epidemic of Iodine Deficiency we read:   
In 2008, researchers concerned about the growing threat of iodine deficiency analyzed 88 samples of iodized table salt—the main supply of this critical micronutrient for most people. Less than half of those tested contained amounts of iodine sufficient for optimal health. Coupled with the trend of reduced salt consumption, rates of iodine deficiency are now reaching epidemic levels.  In the developed world, iodine deficiency has increased more than fourfold over the past 40 years. Nearly 74% of normal, “healthy” adults may no longer consume enough iodine....  You will discover iodine’s vital role in thyroid function. 
I believe adequate iodine intake could reduce some of the chronic lip swelling that is so common among brass players.  For up-to-date information on thyroid health see this site.

30.  Just received this from Eric.
Valerie, I read your most recent comments about embouchure swelling. I made and interesting discovery this summer. Myself, and several colleagues have been trying Laskey mouthpieces for a music store in the Omaha / Council Bluffs area. They are trying to get players to use them, as they are relatively unknown in this area.   
I usually play on an older Schilke #30. (because, it was made by hand, before computer driven equipment, it has a flat rim) While I still prefer it for most of my playing I did find that a Laskey G70 works quite well when my embouchure has swelled a little bit. The G70 is basically a 21 Century version of the Schilke #30 Farkas model. The rounded rim of the computer designed G70 seems to give that needed space inside the cup. Everything else feels and plays the the same as the Schilke #30. Tone, intonation, note placement etc.
Have a great rest of the summer!
Eric in Iowa
31. This is the latest from Larry.  (July 2014)  He kindly shared this with a horn player who is struggling with swelling issues and taking blood pressure medications.

I am my only "subject", so a scientific study of one person isn't much science at all.  Read  Valerie's blog on the topic of lip swelling. What might negatively affect one person may not affect another.  I suggest as much as you can, simplify your intake to simple whole foods and only the necessary meds that you need.  Then, one by one, add something else in and see how it affects your horn playing in the following 24 hrs.

Things that cause lip swelling for me are: calcium channel blockers (are the worst), omega oils, Co-Q10, vitamin D3 (in larger than 1000 unit doses),   Beta blockers and diuretics will reduce endurance, but don't cause lip swelling. These are the things that affect me. I take the mentioned supplements, since they are important to health, but not within 48 hours of important horn playing.  With my home practice, I will "suffer" with self-inflected lip swelling-- you can actually make progress in playing and also try to learn how to play with swollen lips.  BE helps with learning to play with swollen lips. Some horns and mpcs are easier with swollen lips (I found my 8D to be the most challenging).   If I can help further, feel free to e-mail.

Larry Jellison 
Oceanside, CA 

Richard Prankerd  commented the following on FaceBook:  Valerie, if you want to re-post on the BE site, please do. With reference to Larry's last post: "I am my only "subject", so a scientific study of one person isn't much science at all. " On the contrary, there is a very well established science based on the concept of the "n = 1 clinical trial". This recognizes that in many things, we humans display a great deal of individuality. What works for one person does not and never will work for another. So, how do we make this "n = 1" concept work? By applying a sufficient number of positive and negative controls, with a statistically significant number of repetitions to the problem under study. By applying (a) the treatment under test, (b) a known treatment that works, and (c) a placebo treatment to the one subject can be made into a meaningful test of the treatment. It's best if the subject does not know which treatment is being applied at any time, that there is an objective way of measuring the response, and that the number of repetitions is significant. This last criterion can be hard to gauge, and depends on the magnitude of the response. A big response requires fewer repetitions of the test, but 4-6 is usually OK.

[Thanks, Richard!]

32.  There was a recent discussion on FaceBook about lip swelling.  Most of what was discussed is mentioned above except for one item posted by Christina Marioneaux.  She knew of a brass player who used Preparation H (yes, the hemorrhoid medication) to shrink swollen lips. 

The Vibrass Lip Massage Trainer has been suggested on FaceBook.  

Lip Medex, Carmex, Bag Balm have also been suggested. 

Witch hazel, the natural astringent and active ingredient in some hemorrhoid medications was also suggested.  


33.  Donald D Krause wrote on FaceBook: "I have been using apple juice for the past 15 years-- really lick my lips with it -- brother and I used it when deer hunting in Wyoming many years ago-- not apple drink as it has a bit of alchohol in it.. works for me... On solo ensemble day for the past dozen or so day -- the thurs and friday before that when I have all my students come to the house for a last run through-- I give them a 12 oz can of Apple Juice and the morning of solo ensemble some of my students come again with another can of Apple juice -- I have had Doctor parents say I'm crazy but, I know for me it works especially in winter -- had a student a couple years ago always came to youth symphony rehearsal with a jar or can of apple juice-- so I know quite a few of my students think it works and even if they think it does -- nothing wrong with that..


34.  Audrey Destito wrote on FaceBook: Using tea bags (let them cool off first) like a hot compress helps swelling. I struggled with swelling a lot before figuring out that I have a metal allergy. Tea bags were the only thing that reduced the swelling enough for me to keep playing.  

6 comments:

  1. That is an excellent presentation on lip swelling. I was one of the contributors of information to Valerie. Lip swelling can be a major problem, but the good news is that it can be largely controlled.

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  2. Playing with swollen lips can make playing in tune more difficult. I have wondered why this would be. Tone can be deteriorated by lip swelling, but what I also just became aware of is that lip swelling, by keeping the buzz zone from working properly, reduces one's ability to buzz a core pitch-- the buzz is more unfocused. By not being able to buzz a good core pitch, then the horn doesn't lock into a solid core pitch on each note; the sound is unfocused and the pitch easily wanders (especially on a wide slotting horn like my old 8D). In this condition, I need to mentally concentrate much more on intonation to keep each tone in tune.

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  3. Update, Summer 2012. Lip swelling is no longer a significant problem for me. I avoid lip swelling for important horn playing events by reducing supplements to only a multiple vitamin/mineral during the 24 hours prior. Taking a half-dose of ibuprofen or aspirin 8-12 hrs. prior helps; not a good idea to be on these during the performance, as lip endurance is compromised.

    Practicing during periods of lip swelling, especially when used with knowledge of the Balanced Embouchure techniques, helps for increasing playing proficiency under swollen lip conditions. Just take it easy and take frequent rests. Frequent rests reduce lip swelling.

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  4. Thanks, Larry! Nice to hear you're finding solutions.

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  5. I can personally vouch for the use of ice. It's not only very effective(possibly even the most effective), but importantly it's also *free*, and completely safe. So it can be used as regularly both in the short, and the long term...unlike NSAID's for e.g., which are not recommended to be taken regularly for more than a few weeks.

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  6. This is great "real world" information Valerie. Thank you!

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