The Voice Committee Speaks about Voice

“I occasionally encounter difficulties with other people accepting my weak voice; sometimes it seems to border on overt discrimination. An example was the attitude I faced when I responded to an invitation to participate in a medical survey, (after repeated skepticism on the part of the survey organization) I completed this interview successfully. On being asked back again to respond to another one (survey), I did the same (completed it), but faced the same initial discrimination as the first time. This experience was an acute reminder that I may always face a harsh reality of potential discrimination based on the quality of my voice.” — Itzhak Brook, MD, MSc Author, My Voice: A Physician’s Personal Experience with Throat Cancer, and the John Conley Medical Ethics Guest Lecturer of the AAO-HNSF 2012 Annual Meeting & OTO EXPOSM Opening Ceremony. No one is more passionate about the power and frailty of the human voice than those who have lost this functionality, such as the amazing AAO-HNSF John Conley, MD, Guest Lecturer, Dr. Itzhak Brook. Each year, aside from working to ensure that quality and appropriate patient care is available to all who need it, the 22 people who make up the Academy Voice Committee champion awareness of the importance of caring for the voice through the World Voice Day campaign on April 16. The theme of this year’s campaign, “Connect with Your Voice,” is explained on previous pages. A full-size poster is bound into the print edition of Bulletin as a member bonus to help you promote this year’s campaign. Mount it in areas where patients can learn that otolaryngologists care for voice conditions and care about patients’ voice health. The poster also offers access to more health information about the voice at www.entnet.org. To assist the individual Academy members in outreach activities prior to the campaign in her/his community, several committee members discuss key points about the otolaryngologist’s role in voice health by responding to some important questions. The seven committee members were asked to respond to several, but not all the questions. Their responses follow. What is the Role of the Otolaryngologist in Treating Voice Conditions? Dr. Altman: The role of the otolaryngologist is the medical diagnosis, medical care, and to perform surgical interventions, if needed. Dr. Akst: Based on history, physical examination, and laryngeal exam, the first role of the otolaryngologist is in accurately diagnosing the nature of the voice problem. Accurate diagnosis then leads to appropriate treatment planning, which might involve some combination of medication, surgery, and voice therapy. The otolaryngologist coordinates this treatment plan, making treatment decisions with the patient that take into account the nature and severity of the voice problem. Dr. Cohen: The otolaryngologist is the physician with skills in examining the larynx, which is essential for accurately diagnosing voice conditions. The otolaryngologist has an essential role in treating voice conditions as treatment depends on diagnosing the cause. Dr. Heman-Ackah: The otolaryngologist is a physician who diagnoses, directs, and coordinates treatment of voice problems. He or she works closely with the patient, voice therapists, and voice teachers to help an individual who is having problems with his or her voice to improve the voice. Dr. Hogikyan: The otolaryngologist is the person who diagnoses and prescribes treatment for patients with voice disorders in order to set them on the path to vocal wellness. Treatment options commonly include medication, voice therapy, or surgery, and multiple approaches are sometimes employed for an individual patient. Dr. Young: Hoarseness that lasts longer than two weeks is not normal, and a laryngeal examination should be performed to rule out more serious causes of persistent hoarseness. This type of examination, a laryngoscopy, is typically performed by otolaryngologists. More specialized care of voice conditions may be performed by fellowship-trained laryngologists (voice specialists). Dr. Smith: The otolaryngologist diagnoses the condition for the voice problem. By discussing the cause of the problem, what is occurring functionally, and treatment options, the patient becomes a student of his or her own voice. The voice “team,” including the patient, physician, and voice therapist, then works to improve the voice problem. What New Resources are Available or on the Horizon for Physicians in the Treatment of Voice Problems? Dr. Altman: We already see greater access to stroboscopy and other high-resolution diagnostic tools, and the advent of clinical practice guidelines defining standards of care (which enhances how we employ a standardized approach to medical and surgical management). Dr. Heman-Ackah: The biggest resource available for physicians in the treatment of voice problems is laryngeal videostroboscopy. Videostroboscopy provides a magnified view of the vocal folds and allows the otolaryngologist to observe the motion of the vocal folds while they are vibrating. This is an invaluable tool in helping to delineate the cause of an individual’s voice problems and is the key to directing treatment. Dr. Hogikyan: We will more and more be able to translate knowledge acquired through research into active treatments for voice patients. This includes research related to tissue scarring, laryngeal paralysis, and new types of lasers. We also are training an increasing number of laryngologists, and this will make subspecialty voice care more broadly available to patients. Dr. Akst: One relatively new technology, which helps otolaryngologists care for patients with voice problems, is digital imaging. This technology provides for high quality laryngeal exams. Laryngologists may use videostroboscopy to supplement laryngoscopy, allowing insight into vocal fold function and structure. A variety of new technologies and techniques have allowed for many beneficial procedures to be performed in the office rather than the operating room, including office-based laser therapy, vocal fold injection, transnasal esophagoscopy, and pH probe testing. Taken together, these resources are allowing for ever-greater quality of care to be provided to patients with voice complaints. Dr. Young: The field of voice-related disorders is ever expanding. We are able to perform more surgical procedures in the office setting, thus avoiding general anesthesia and intubation. This is a significant benefit to patients, in terms of both time- and cost-savings. We are able to treat and improve more complex voice problems, and there are more laryngologists (voice-specialists) available to treat people with complex voice issues. Dr. Smith: Real-time imaging of vocal fold physiology is an area of constant improvement. With better visualization, and therefore improved characterization of what is occurring, the otolaryngologist becomes a better diagnostician. What Would You Like the Healthcare Consumer With a Voice Problem to Know? Dr. Altman: I would like to tell those with concerns not to delay proper evaluation, and to be aware of risk factors such as tobacco smoking, reflux, and HPV. Dr. Cohen: Voice problems are common and may be caused by a variety of conditions from benign to neurologic to malignant. They can have a significant impact on patients’ ability to communicate, work, function socially, and are treatable. Patients should seek evaluation if symptoms persist more than three weeks. Dr. Heman-Ackah: As industry and technology require a greater use of the voice on a daily basis for working and communicating, more individuals are experiencing difficulties with their voices. Devices as commonplace as a Bluetooth headset present a unique demand on the vocal folds that most people never had to accommodate before, and many individuals are experiencing vocal problems in numbers that did not previously exist. Voice problems today are the 21st century version of carpel tunnel syndrome from the 1980s and 1990s. Many voice problems are the direct result of repetitive use of the vocal folds and occur from repetitive vocal fold injury. Dr. Hogikyan: I feel that there are two key items here: 1. Hoarseness or voice change can be a sign of a serious problem and should be evaluated by an otolaryngologist if it is persistent (longer than about two weeks can be considered persistent), and 2. Most voice problems can be helped so don’t just accept hoarseness without pursuing treatment by a specialist. Dr. Akst: Voice quality is an important part of how we present ourselves to others and how we are perceived by others. Voice problems are a very common source of work-related difficulties, especially as more jobs depend on verbal communication. Voice disorders need not be “accepted as normal”—very often, there are things that can be done to diagnose and treat voice problems.Diagnosis and treatment for voice disorders should involve an otolaryngologist with experience in working with voice patients. Dr. Young: Many voice disorders can be improved with proper treatment. Evaluation by an otolaryngologist (or laryngologist) is invaluable. Hoarseness does not need to be simply “tolerated.” The most important message is that persistent hoarseness is not normal, and laryngeal examination should be performed to rule out more serious underlying causes, such as cancer. Dr. Smith: There are dedicated otolaryngologists/laryngologists and voice therapists who want to help. We realize that voice is often a reflection of self, especially for the professional voice user (singer, preacher, teacher, etc). But, the quality of life related to voice is just as important for non-professional voice users, as it allows us to communicate with friends and family, conduct our jobs, and sing. How Does the Observation of World Voice Day Benefit the Public? Dr. Altman: It raises awareness for the working public, but also helps expand the limits of care we provide for voice professionals. Dr. Cohen: By promoting awareness of how vital the voice is to our everyday life, awareness of resources if problems do arise, and discussing prevention in order to keep the voice healthy. The voice is often taken for granted until its function becomes compromised. Dr. Heman-Ackah: Observation of World Voice Day helps to bring awareness of the fact that hoarseness and vocal fatigue are medical problems that can be treated medically and successfully. It helps the general public understand that there is something that can be done to help when one is experiencing difficulties with the voice, and it brings awareness to the fact that voice problems are occupational health issues that contribute to significant disability and absences from work. Dr. Young: So many people use their voices extensively in their day-to-day life (work, home, etc.) and yet most people don’t think about their voice or how to care for their voice properly. World Voice Day is a wonderful opportunity to bring awareness to this supremely important, but often overlooked, ability. Many people with voice problems or difficulties think that hoarseness should just be tolerated or that it will go away on its own. World Voice Day is a great time to remind people that persistent hoarseness is not normal and should be investigated further! Dr. Smith: By placing a spotlight on the importance of voice in all realms of society, we hope that people with hoarseness will seek help. Whether hoarseness is caused by cancer or a noncancerous process, voice does matter. Dr. Akst: By increasing awareness that vocal difficulty is a medical condition that can be evaluated and treated, we help the public understand that they can be helped. Dr. Hogikyan: It reminds us of the importance, power, and beauty of the human voice. Educational outreach efforts related to World Voice Day help educate the public about how to maintain good vocal health and when to seek an otolaryngology evaluation. Can You Give an Example of How Use of Your Voice has Helped You to Connect With Others? Dr. Altman: The voice is a window to the soul, and conveys emotion on top of the words that are communicated. Dr. Cohen: I feel most connected when speaking with my patients, reading to my children. Dr. Heman-Ackah: I use my voice on a daily basis to teach both patients and students. My voice is the essence of my ability to impart information to others. Dr. Hogikyan: I think about this every day when I interact with patients. Particularly when people come to see me about a serious health problem, the voice I use in the clinic is vital to letting the patient know I care and that I will take care of them; the voice establishes our doctor-patient connection. Dr. Young: As a physician, I spend all day talking to my patients. I am able to connect with them, communicate with them, and educate them. Every day, I describe to my patients the findings of their laryngeal exam, what it means, and what we will do next to address their voice problem. I absolutely could not do my job if I didn’t have my voice. And I know that there are many other jobs for which this is also true. Some of these are obvious (teachers, call center workers, lawyers, radio and television personnel) and some are less evident (cashiers, secretaries, nurses, flight attendants). For most people, if they stop to ask themselves if they could still do their job if they didn’t have a voice, the answer would be “no.” Dr. Smith: As a laryngologist, I speak with patients all day. They know I care about their voice, much like they do. Through the connection of talking and singing with patients, their knowledge about voice improves. This allows them to “own” their voice. Together with the voice “team,” their voices are heard. Lee M. Akst, MD Director, Voice Center Assistant Professor of Otolaryngology-Head and Neck Surgery Johns Hopkins Medicine Kenneth W. Altman, MD, PhD Director, Eugen Grabscheid, MD, Voice Center Associate Professor of Otolaryngology Mount Sinai School of Medicine Seth M. Cohen, MD, MPH Associate Professor of Surgery, Division of Otolaryngology-Head and Neck Surgery Duke University Medical Center Yolanda D. Heman-Ackah, MD Associate Professor of Otolaryngology Drexel University College of Medicine Philadelphia Voice Center Norman D. Hogikyan, MD Professor and Director of Vocal Health Center Department of Otolaryngology-Head and Neck Surgery University of Michigan Libby J. Smith, DO Assistant Professor UPMC Voice Center University of Pittsburgh VyVy N. Young, MD Assistant Professor UPMC Voice Center University of Pittsburgh