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How best to care for patients with voice problems

October 25, 2017
What’s more intimate, iconic and identifying than the sound of someone’s voice? Just think of those on the radio, to start. And yet singers and radio personalities aren’t the only professional voice users. Teachers, lawyers, salespeople, receptionists — anyone whose job entails speaking to communicate, connect or cajole relies on voice as a primary tool.

If someone’s voice changes, then, it can affect a person’s entire life, including their sense of self. That’s where laryngologists and speech pathologists — like those at the Johns Hopkins Voice Center, part of the Milton J. Dance Head and Neck Centers at Greater Baltimore Medical Center — come in. In this highly collaborative and specialized practice, restoring someone’s voice is the priority.

“We are focused on functional outcomes,” explains Lee Akst, M.D., medical director of the Voice Center and director of laryngology at Johns Hopkins School of Medicine. “We are focused on preserving voice.”

A typical day at the Voice Center

On any given day, Jessica Silinonte, a speech-language pathologist at the Voice Center, may be administering therapies for someone recuperating from vocal cord paralysis, or examining someone suffering from a hoarse voice.

For each diagnostic visit, Silinonte performs a general health history and intake. Then she takes special measurements using acoustic analysis software and gets a baseline recording of the patient’s voice. She may view the larynx (voicebox) internally with a flexible endoscope. And then the laryngologist comes in to discuss treatment options, hand in hand with the speech pathologist.

Only a small percentage of patients go to the operating room, Silinonte explains. “For the vast majority, we get them in the therapy frame of mind and see where we get.”

A lot of what Silinonte then does is simple education. “The first thing we do is bring awareness to what your voice demands are, professionally and personally,” says Silinonte. Then she uses proven therapies to optimize the voice and limit vocal abuse.

“Voice is a little abstract,” Silinonte explains. “If you see someone who loves to run, limping, you’d say ‘Oh no, what happened?’ If you hear someone with a raspy voice, you don’t think of it in the same way.” Her goal is to help people to think of their voice as something they can rehabilitate, the same way one might rehabilitate from a sports injury.

More than just hoarse

“A number of patients find us with a symptom, rather than a diagnosis,” explains Dr. Akst.

Indeed, patients come in with a wide variety of issues, most indicated by hoarseness or loss of voice. It could be vocal cord paralysis. It could be nodules or growths. It could be spasmodic dysphonia — involuntary spasms in the larynx. It could be chronic cough.

“In one room is a patient, a singer with new voice problems,” explains Kenneth C. Fletcher, M.D., director of laryngology at GBMC. “In the next, someone with lesions waiting to be treated. In the next room, Botox.” (Botox injections are used to relax the larynx.)

Another common issue is respiratory papilloma, a typically benign precancerous condition where a patient might need to come to the Voice Center as often as every six to eight weeks to deal with new growths on the vocal cords. This is where the benefits of in-office procedures, which are relatively quick and minimally invasive, really play out.

Beyond your typical ENT

Indeed, a primary benefit of the Voice Center is its access to technology, including lasers, that make possible in-office procedures, as opposed to general anesthesia surgery.

This is particularly important to those with respiratory papilloma.

Patients who in the past had to have surgery can now have growths lasered away in about 30 minutes, explains Dr. Fletcher.

“Everything old is new again,” he adds. “Decades ago, prior to general anesthesia being as easy and safe as it is now, laryngeal procedures were done in the office.”

Another primary benefit of the Voice Center is the speech pathologist who works closely with the laryngologist. The Voice Center’s six pathologists bring their unique training and personal experience to their practice.

“We have the luxury of specializing within a specialty,” explains Marisa Sanders, senior speech pathologist, who, in a previous lifetime, was an actress. “The transition to the voice world was fairly fluid as I’d been working on my own professional voice in theater for years,” she says.

Sanders’ area of interest is breathing dysfunction — she’s currently pursuing certification in a breathing treatment called Buteyko Method. “Many of these individuals have nodules on their vocal folds. These are phonotraumatic lesions caused by overuse or misuse of their voices.” Meanwhile, two other colleagues, singers themselves, tend to the many singers who visit the Voice Center.

The specialization, and the collaboration between laryngologists and speech pathologists makes for a dedicated team for each patient and voice problem.

“It’s a team approach, explains Dr. Akst. “And it’s on purpose, not by accident.”

— Laura Lambert for Greater Baltimore Medical Center
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