Dear Doctors: I started taking voice lessons from an instructor in her 30s who works with younger singers. I’m 72 and have COPD and asthma, and I am recovering from bronchitis. I can’t always reach the notes she thinks I should, and she says I give up too easily. Can I ask her to focus on the vocal range I already have, or is that copping out?

Dear Reader: First, we want to congratulate you on such an interesting enterprise. You are choosing to expand your world at a time of life when circumstances often dictate a contraction. For anyone at any age, taking the time to learn a new skill is both brave and admirable.

When it comes to the mixed results of your singing, it’s not that you aren’t trying hard enough. At age 72, you are undergoing physical changes that begin to affect the voice. Add in the underlying health conditions you described, which affect breathing and breath control, and the challenges you face as a singer are even greater.

Based on your instructor’s response, she may not be fully aware of how aging can affect the voice. As we grow older, the mechanisms that produce vocal sound are aging right along with us. The tissues of the larynx and vocal folds, including the muscles, mucous membranes and connective tissues, often stiffen, grow thin or lose bulk. This can lead to higher voices in men; lower voices in women; a hoarse, weak or shaky quality; reduced breath control; and decreased volume and endurance. One treatment for age-related changes in the voice is exactly what you’re already doing: exercising them. However, because of these physical changes, vocal work in older adults can require special expertise.

When you reach for and miss a note, whether high or low in the register, it’s not due to a lack of effort. It is a misfire within the complex apparatus that creates vocal sound. Concentrating on those missed notes can actually lead to vocal strain in an aging voice. Instead, vocal coaches who work with older adults take a more global approach. They concentrate on strengthening breath support, improving resonance and developing the parts of the voice that remain reliable and expressive. That is, they do exactly what you are asking, which is focus on the vocal range you already have.

This doesn’t mean you have to give up on growing as a singer. But doing it safely can require working with someone who understands the older voice. That means appropriate warm-ups, targeted exercises and realistic goals. The instructor should also be able to recognize each student’s specific limits. For adults like you, living with COPD or asthma, breath management can fluctuate from day to day. It’s important that vocal goals are both individualized and flexible.

Sharing this information with your teacher would be helpful. And to be sure you are on the right track, you might also consider working with a vocal therapist who specializes in older adults. If you are interested, your health care provider can help you with references.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

Kansas City, MO 64106; 816-581-7500

Hello, dear readers! Welcome to our monthly letters column. Cold weather is here, and the annual flu season is ramping up. The dominant virus this year, H3N2, is a nasty bug that can cause severe symptoms. If you haven't had your flu shot yet, we urge you to book an appointment. The vaccine lowers the risk of severe illness and being hospitalized. And now, on to your letters.

-- A column about misophonia, a condition in which people find everyday sounds to be distressing or even unbearable, caught the attention of a reader in Los Angeles. "One of the girls in our sorority has that with chewing, which she can't stand the sound of," she wrote. "We play music during dinner so it's easier for her. But isn't there some kind of therapy she can do that would help?" Estimates suggest up to 20% of people have misophonia. Despite how common it is, research into the disorder remains limited. There is some evidence that cognitive behavioral therapy or exposure therapy can be helpful. Pharmacological treatments are also being explored. An audiologist with a specialty in sound sensitivity disorders would be a good guide in her search for treatment.

-- We often write about the gut microbiome. It plays a crucial role in physical, mental and emotional health. We heard from a reader regarding the effects on the gut microbiome of treatment with antibiotics. "In 2018, I had two bouts of sepsis, four weeks apart, that required broad-spectrum antibiotics," he wrote. "How long should gut health be affected? I’m still having gut problems to this day." Research on broad-spectrum antibiotics and their effect on gut microbiome finds that microbial colonies begin to rebound a few weeks after treatment. They are fully restored within three to 12 months. However, multiple courses of powerful antibiotics can cause longer disruption. Sepsis itself can affect the permeability of the gut. This in turn influences the microbial recovery. So the window for complete healing can become significantly longer. That said, with seven years elapsed, it is time to consider the symptoms you are experiencing are not solely due to a gut disruption. We think it would help to consult a gastroenterologist. They can review your history and evaluate your symptoms to determine whether something else might be going on.

-- Readers are still interested in a study we discussed in which people were exposed to a rotating roster of scents during the night. It improved their scores on a simple cognitive test. We received this letter from a reader in Massachusetts: "Ever since reading that column I've been taking care to pay attention to the scents all around me," he wrote. "I can't say if it's helping my memory; it is enriching my life."

Thank you, as always, for taking the time to write to us. We love hearing from you. A quick reminder to newer readers that we can't make a diagnosis, offer a second opinion, comment on medication or review any medical records.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)

Dear Doctors: I slipped and slammed my shin on the metal ledge of a moving van. I could still move my toes, turn my foot, stand on it and walk, so I figured it wasn’t a break. A few days later, a big lump showed up, with lots of swelling and bruising. Could it be it actually was broken?

Dear Reader: The bone you injured is known as the tibia. It is the second-longest bone in the body -- and one of the strongest. Its unique triangular shape provides the structural support needed to bear the weight of the body while standing and in motion. The three distinct borders of the bone, along with their adjacent surfaces, serve as attachment points for muscles and connective tissue.

Due to its size and heft, the tibia requires a high-energy force to cause a break. This might be a car accident, a fall from a height or a blunt force or twisting injury in a contact sport. Osteoporosis can also play a role. But in a healthy adult, the mishap you described is not likely to have resulted in a fracture. However, and this is important, bones are susceptible to other types of impact injuries. These include bone bruises. Based on your symptoms, it’s possible that this is what happened.

A bone bruise occurs when force strikes the bone hard enough to cause damage to its surface structure. Rather than a break in the bone, as happens in a fracture, a bone bruise is a localized area of microfractures. Depending on the severity of the injury, these can reach into multiple layers of bone tissue. Symptoms of a bone bruise include the pain, bruising and localized swelling that you described. But unlike a fracture, a bone bruise does not impair the integrity of the bone. That means it does not need to be stabilized.

The word “bruise” in this type of injury can be misleading. Even though you are able to stand and walk, the damage to the bone can be substantial. The swelling and bruising and tenderness of a bone bruise can take weeks to subside. During that time, you need to dial down your activity level, regularly elevate the affected limb and avoid percussive movement. You can also use anti-inflammatory medications to manage pain. The structure of the bone itself needs to heal as well. This can take a surprisingly long time -- up to three to six months, or even longer.

It would also be wise to check in with your health care provider to rule out other possible injuries. These include a deep bruise that may benefit from a guided healing process; a cortical fracture, which is a break in the outer layer of the bone; or a hematoma, which is a collection of blood outside of a vessel. Your doctor will ask for details of how the injury happened and assess swelling, pain and mobility. If they suspect a more serious injury, they may recommend imaging tests. The goal is an accurate diagnosis and appropriate treatment to head off any long-term problems.

(Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o UCLA Health Sciences Media Relations, 10960 Wilshire Blvd., Suite 1955, Los Angeles, CA, 90024. Owing to the volume of mail, personal replies cannot be provided.)