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


South Med J. 2002;95(7) 

In This Article

The Brass Section: Trumpet, French Horn, Trombone, and Tuba

Like flute players, trumpet players with nickel allergies have had hypersensitivity reactions to their instruments. Eczema in the lip area has been described in trumpet players with positive patch tests to nickel sulfate. These nickel-related conditions have resolved after the musicians switched to gold or plastic mouthpieces.[48,49]

Players of brass instruments must form an embouchure (the positioning of the mouth, facial muscles, tongue, and jaw such that the lips will vibrate when blown through). The lips of brass players are subject to high pressures; it takes strength and agility of the lip musculature to maintain the proper embouchure. Both higher and louder notes require greater pressures, translating to greater stresses on the lip musculature.[50] The high stress from the combination of prolonged playing, high notes, and fortissimo intensity predisposes brass players to lip muscle injury.[51]

An example of such an injury is rupture of the orbicularis oris, also known as "Satchmo's syndrome." Trumpet players are most vulnerable because of the high pressures required to play the trumpet, but players of other brass instruments such as the French horn or trombone are also affected. This injury results in a decline in the strength and agility of the lip musculature with weakness during pouting and an inability to maintain high notes. Some trumpet players with Satchmo's syndrome have been treated surgically with success, though prolonged rest is another treatment alternative.[50] In fact, this syndrome is named for Louis Armstrong because it matched the symptoms he experienced in his lips in 1935 that forced him to stop playing the trumpet for 1 year.[50,52]

Because brass instruments place great demands on the muscles of the face and tongue, dystonias of these muscles can severely impair a brass player's ability to play. Cases of "embouchure dystonia" have been reported in French horn players whose lips would involuntarily separate, producing a gap in the air seal.[53] These players improved somewhat with muscle retraining and technique alteration.

Like most other instrumentalists, brass players are subject to entrapment neuropathies and dystonias, but they also have more serious neurologic risks resulting from the elevated intrapharyngeal, intrathoracic, and intra-abdominal pressures. A 17-year-old trumpet player had transient ischemic attacks during intensive trumpet playing.[54] He was found to have a patent foramen ovale, and Doppler ultrasonography showed increased rates of microembolic signals in the middle cerebral arteries during trumpet playing and Valsalva maneuver. An increase in positive end-expiratory pressure may occur in brass players and would increase the cardiac right-to-left shunt fraction, thus causing embolization.[54,55] After the patient had the foramen ovale operatively closed, the symptoms disappeared and no microembolic signals could be detected, even during Valsalva maneuver.[54] A second example involves a 23-year-old trumpet player who had a spontaneous cervicothoracic epidural hematoma after a professional trumpet performance.[56]

As in wind instruments, the intraoral pressures generated during playing of brass instruments can be extremely high, and otolaryngologic disorders such as stress velopharyngeal incompetence and laryngoceles can be manifested. A 17-year-old trumpet player had velopharyngeal incompetence while attending band camp, where he practiced 8 to 10 hours per day, approximately four times his usual practice duration.[45] Nasal air escape developed during instrument play, as well as nasal regurgitation of liquids and hypernasal speech. Rest and palatal exercises were prescribed, and his condition improved.

A 16-year-old trumpet player was found to have bilateral laryngoceles after his band leader noticed a left neck mass that developed during playing.[57] Physical examination showed a 6 cm air-filled mass in the left side of the neck with forced expiration against a closed mouth and nasopharynx. Surgery was deferred while the laryngocele remained reducible and asymptomatic, and the boy was allowed to continue playing.

Several studies have examined the relationship between French horn playing and cardiovascular conditions. In one study, 37 (49%) of 75 French horn players had a wandering atrial pacemaker while playing, and one had second-degree AV block of the Wenckebach type, suggesting that "musical athletes" may possess unusually sensitive vagal reflexes.[58] A second study described a 47-year-old French horn player with essential hypertension who had immediate increases in diastolic pressure when playing, especially when playing higher notes.[59] Fortunately, other studies have found no correlation between horn playing and hypertension.[60,61]