Steven Liu, MD, and Gregory F. Hayden, MD


South Med J. 2002;95(7) 

In This Article

The Wind Instruments: Flute, Piccolo, Clarinet, Oboe, Bassoon, and Saxophone

Several cases of "clarinetist's cheilitis" have been described.[33,34] One case involved a 15-year-old girl who had recently changed from a polystyrene reed to a cane reed (Arrundo donax) because she preferred the tonal quality of the wood reed.[33] She subsequently had redness and scaling of the median portion of the lower lip, corresponding to the distribution of the cane reed. Patch testing showed no evidence of cutaneous hypersensitivity, and the cheilitis was thought to have been caused by irritant contact factors. The patient was advised to switch back to the polystyrene reed.

Much like clarinetist's cheilitis, saxophonists have also been described as having cheilitis from their reed. One saxophonist had slight eczema on his central lower lip, not spreading beyond the vermilion border, exactly where his lip would contact his cane reed. He showed a positive scratch test with fine saxophone reed scrapings and was treated with 1% hydrocortisone acetate cream with good results.[35]

"Flautist's chin" has been described and is similar to fiddler's neck. A 32-year-old amateur flautist presented with an eruption of acneiform lesions and hyperpigmentation confined to the central midportion of her chin, where she was in contact with her flute.[36] Wetting of the chin with saliva or breath condensate was suspected as a predisposing factor, as this slipperiness could cause the player to increase the pressure of the flute against the skin.[36,37] Flutes are often made of alloys containing multiple metals including nickel, so the reaction could also have resulted from a sensitivity to nickel.[37] In one report, an amateur flautist with flautist's chin had a positive patch test to nickel, so it appears that flautist's chin can be caused by mechanical irritation, metal allergy, or a combination of the two.[38]

Overuse syndromes in wind players usually present differently from those in string players. In flute players, the right shoulder is the most common problem area because of its abducted, externally rotated position when the flute is played. In clarinet, oboe, and English horn players, the static loading of the web-space muscles between the thumb and index finger used to support the instrument predisposes them to overuse problems.[39]

Changes in the construction of wind instruments during the 19th century affected the prevalence of overuse syndrome in wind players.[40] In the early 1800s, the clarinet was usually made of a light boxwood, weighed about 300 g, and was held with both hands. Overuse syndrome in clarinetists was not reported during this time. However, after the boxwood was replaced with grenadilla (a heavy hardwood) and heavy keywork was added, the 20th century clarinet weighed about 830 g. Because of this increased weight, the clarinet could not be held comfortably by the two hands and was loaded onto the right thumb with a thumb rest. Overuse syndromes in clarinetists appear to have arisen as a result of these changes. Conversely, changes in the construction of flutes have probably lowered the prevalence of overuse syndrome in flute players. The 19th century flute was made of wood and was heavier than the modern flute made of metal. For this reason, overuse syndrome in flute players is likely to be less common now than in the 19th century.

In addition to peripheral mononeuropathies, cranial mononeuropathies have also been reported in wind players.[28] An oboist had numbness of the upper lip after intensive practicing and was found to have sensory loss in the distribution of labial branches of the trigeminal nerve. Similarly, a clarinetist had trigeminal neuralgia in a maxillary distribution that was almost exclusively triggered by playing the clarinet.[28]

Clarinetists playing scale passages have manifested focal dystonias with involuntary third finger extension and fourth and fifth finger flexion, predominantly of the right hand.[41] This incoordination made trills more difficult for the clarinetists.

The high intraoral pressures required to play wind instruments may cause a variety of otolaryngologic disorders. A 23-year-old oboe player was found to have velopharyngeal incompetence after complaining of a 6-year history of "nasal snorting" that would begin after 10 minutes of continued playing. The incompetence would only manifest itself while she played the oboe.[42] This type of disorder could potentially ruin careers in music, because oboists are often required to play long phrases without taking a breath. With air leakage associated with an incompetent palate, the musician loses air reserves more quickly and is forced to break the musical phrase more often to take another breath.[43] Velopharyngeal insufficiency has also been reported in a concert bassoonist who failed orchestra auditions because of a clearly audible "noise coming from her head" while playing the bassoon.[44] Rest and palatal exercises have been used to treat stress velopharyngeal insufficiency, though surgical options can include endoscopic posterior pharyngeal augmentation with Teflon injection or a surgically created pharyngeal flap.[45]

Another otolaryngologic disorder associated with increased intraoral pressures from wind instruments is laryngocele, an abnormal enlargement of the saccule of a laryngeal ventricle. Laryngoceles are generally filled with air, and are termed internal when limited to the interior of the larynx or external when they protrude laterally into the neck. Wind and brass players are at increased risk for laryngoceles; one report showed laryngoceles in 52 (56%) of 93 of band members studied.[46] Since none of the laryngoceles in these musicians caused symptoms, no treatment was advocated.

The playing of high-resistance wind and brass instruments such as the oboe, bassoon, French horn, and trumpet has been associated with increases in intraocular pressure and greater incidence of visual field loss. The Valsalva maneuver associated with high-resistance instrument playing is thought to be responsible, because it causes a rise in intrathoracic pressure and compression of the intrathoracic venous system. This leads to vascular engorgement, increased choroidal volume, and a rise in intraocular pressure. The cumulative effects of long-term intermittent intraocular pressure may result in glaucomatous damage.[47]