Philip Weissbrod, MD, Associate Professor of Surgery and Director of the Center for Voice and Swallowing, UC San Diego Health and Erin Walsh, MA, CCC-SLP, IBCLC Speech-Language Pathologist at University of California San Diego Health, Center for Voice & Swallowing, talk about the complicated procedures revolving around vocal cord tumors and how they help patients regain the use of their voice after cancer treatments.
Philip Weissbrod, MD, Associate Professor of Surgery and Director of the Center for Voice and Swallowing, UC San Diego Health.
Can you explain to us why Richard came to see you?
WEISSBROD: Richard was referred to us by one of our community ENTs. He had some longstanding voice issues, the basis of which were not entirely clear.
Upon further inspection, what did you see?
WEISSBROD: He had a lesion on the right vocal cord. It was a lesion that caused some stiffness of the vocal cord, but also had some appearances that were concerning in terms of risk for cancer.
Explain the importance of our vocal cords.
WEISSBROD: The vocal cords are what produce voice. The vocal cords vibrate at a high frequency to produce sound when air flows through them. The sound is manipulated by the throat, mouth, and tongue to produce speech. If you were to take the vocal cords out of the body and just blow air through them, it sounds like a vibratory source. Without them functioning correctly, we cannot produce normal voice and speech.
When you find a mass on the vocal cord, how does that impact it?
WEISSBROD: Any disturbance of the vibration of the vocal cord can create irregularity in the voice. In Richard’s case, he had a mass that was creating some stiffness and disrupting vibration. While one vocal cord vibrates normally, the other doesn’t. That creates changes in the way that the sound is produced. Richard is a professional singer, so obviously that can cause some significant impairment in terms of his ability to perform and use his voice the way that he is accustomed to.
What was your plan of action for him?
WEISSBROD: When we approach someone, who uses their voice for professional purposes beyond sort of day-to-day function and really demands quality, we want to proceed very carefully. In thinking about how to approach him or any patient with a vocal fold lesion for that matter, the first objective is to confirm the diagnosis. So, a biopsy is necessary. But we must be very careful about how aggressive we are with the biopsy, how much tissue we take, and consider all these factors to ensure that we don’t damage the vocal cord unnecessarily. What we try to do is provide a one-stop shop in the operating room if we can for people to minimize the number of times they have to have anesthesia. With Richard, we opted to take him to the operating room for a biopsy, send it to the pathologist to review what was there, and if there was something concerning, to excise the lesion at the same time. The frozen section, or the tissue sampling, in the operating room by the pathologist told us that there was concern for invasive cancer. So, we moved forward with an operation to remove the lesion as carefully as we could.
The surgery is completed and there was no chemo and no radiation. Tell me a little bit about the reasons for that.
WEISSBROD: When people have laryngeal cancer, especially early-stage, we can choose the type of treatment: either surgery or radiation therapy. Both are acceptable choices depending on the clinical situation and outcomes are typically good from a cancer treatment perspective. However, each modality has good and bad associated with it. Surgery can be done very carefully, and we can really focus on preservation of the vocal cord and just touch the bare minimum in order to reduce the inflammation and scarring that can be associated with surgery. Alternatively, radiation therapy, which requires the whole larynx to be radiated, can have side effects that involve fibrosis or stiffening of the vocal cords which can lead to changes in voice in some cases. So, for someone who’s a professional voice user, if it’s appropriate, surgery is a really good option.
What followed surgery for Richard?
WEISSBROD: When we operate on the vocal cords, we have a very calculated post-operative process. People go on complete voice rest for a week after surgery to allow appropriate healing of the vocal cords and reduce the amount of trauma that would happen with normal voice use. We then integrate our speech pathology team into the recovery process to assist in the rehabilitative process over the next 4-6 weeks. So, it’s like an orthopedic surgeon having a physical therapist work with someone after a knee surgery. We’re essentially providing the same service here where we have a speech pathologist, who is skilled in voice production and voice function, work with people during the recovery process.
Let’s go back to why Richard was referred to you and the value of him coming here.
WEISSBROD: Richard was referred to us by a practitioner in the community because we specialize in dedicated care of the larynx. We treat people with voice disorders, swallowing disorders and airway disorders at a very high level and in a multi-disciplinary way. So, when they come here, they meet with a physician and a speech pathologist. You get both the medical side and the rehabilitative side all in one visit, which is sort of unique to the community here in San Diego.
Can you tell me a little bit about your team and what some of their specialties are?
WEISSBROD: The voice center is comprised of several practitioners. We have two full-time laryngologists who are ear, nose and throat doctors and specialize in care of the voice and treat airway and swallowing disorders. Then, we have four very experienced speech pathologists who each are sub-specialized. For example, Erin Walsh, who worked with Richard, cares for professional voice users and has classic singing training. We have others who focus on issues in the dysphagia, head and neck cancer, transgender, neuro, and dysphonia populations.
Specifically, what’s the benefit of Richard working with Erin?
WEISSBROD: Speech pathologists come in all shapes, sizes, and specialties, just like physicians. The analogy that I often use is that even though I’m a medical doctor, you wouldn’t want me doing your knee surgery because I don’t really know anything about knees. Similarly, having someone who is highly specialized in a specific aspect of speech pathology is important. For Richard, it’s important to have someone who can appreciate his context of being a professional singer and incorporate that into his treatment plan. So, understanding how the voice works and specifically how the singing voice works and helping people work through some of the difficulties that come after surgery, really can be essential in enhancing our outcomes. Erin’s a unique person in the San Diego community in the sense that she has a classical singing background, she’s worked extensively with singers and performers, and she’s had experience working with me in the early stage laryngeal cancer population. She really can provide the type of care that they’re in need of.
Erin Walsh, MA, CCC-SLP, IBCLC Speech-Language Pathologist at University of California San Diego Health, Center for Voice & Swallowing.
Tell me where Richard was when he first got here and where he is now.
WALSH: When I met Richard, he described very subtle progressive singing difficulty in aspects of his range. As we examined his larynx, we found he was functioning extraordinarily well with one vocal cord vibrating instead of two. There was very little detection of that in his speaking. We determined that the signs were a bit ominous that this has recurred despite watching it and taking steroids. He continued to struggle in specific aspects of his range. So, he underwent surgery knowing that he would have a vocal deficit afterwards. We prepared him that it could range from no voice whatsoever to a functional voice. We knew that with his day job that it involved extensive talking. We set him up in advance with a microphone and an amplifier that he wore. For that first week we had him not talk at all. We examined him and the healing was going as anticipated. As he continued to come in each week, we started him humming a little bit. He then went back to work and was using his microphone. He was communicating functionally, and we were surprised he sounded good. He continued to expand his range. On the second week when he came in, he had developed this very unusual adaptation of speaking. His speaking was very high and strained. It was somewhat incongruent with the way his laryngeal exam was. This is not uncommon when someone has a vocal injury of some sort. They can develop muscular tension which makes their voice sound very distorted when they have adequate vibration and function. We worked on lowering his pitch and keeping it relaxed while having continuity with the words. By the next week, his speaking voice was very good, and he didn’t need his microphone anymore. He’s now working full-time during the day talking. and then on. By week four, we started singing. He started in his lower register and I would follow his lead. He’d say it feels comfortable. We’d check him on endoscopy and make certain we’re not creating any sort of inflammation. Then, we continued to push the envelope and do more and more. Now, he’s several months out and really singing the repertoire that he did before he ever had cancer.
What kinds of exercises do you do to get somebody back to that kind of ability or to develop a new ability?
WALSH: This is his new normal and there’s really no recipe for what we do. With my singers, and even the non-singers, I do warm them up on the piano. I can be very objective, and I listen the whole time. So, every week when Richard would come in, I would warm him up and figure out, ok, there’s this pocket where it sounds really good. So, I’d give him humming and buzzing exercises. We’d try to glide from that area of his voice where it’s very comfortable to up 2 where it’s a bit higher or a bit lower where he was struggling and try to keep everything in alignment. We knew that there was a physiologic deficit. His one vocal cord, for quite some time after the surgery, didn’t move. But he was beginning to function very, very well despite this. As we continue to progress throughout his range, and the pieces he began performing, we found that there was some restoration of vibration. He did not have that prior to the surgery. This has really allowed us to tap into pieces that he’s avoided for years.
What were you looking at today?
WALSH: Every time Richard comes in, something is different. I last saw him a month ago and he was struggling to find this pure clear resonant tone on a specific vowel. Now, we’re finding that that’s sort of migrated into another place. He’s working with a singing coach locally. I’m the vocal mechanic in the picture and his teacher puts the artistic flair to this. We work together to find what will give him the purest sound with the least amount of effort. Rich has given us feedback that not only does his voice feel unrestricted in the way that it was when the cancer was very likely slowly growing over many years, but he’s finding that he’s able to open up his voice in ways that he wasn’t many years ago and really address technique that had always been maybe a possible hindrance.
What is your role here at the Center for Voice and Swallowing?
WALSH: Well, it’s somewhat unusual to have a speech pathologist in an ENT department. So, we are specialized in voice and swallowing and laryngology. We have two laryngologists that work here, and three speech pathologists. In this division, we all have different, but focused, specialties. I have a background in performing and music, and that is the population I see. We work in collaboration with the physicians. I’ll go in first, and take some measures of their voice and assess, from a behavioral and a functional standpoint, how is this person using their voice? And, even I also try to predict what we are going to see when we scope them.? We perform the endoscopy together and come up with a plan. And from that point, someone might go through the surgical door or the therapy door. They might even also go through both doors. We are constantly working in a collaborative way that is very professionally stimulating for me. And, patients benefit dramatically from this sort of collaborative approach.
What is unique about UC San Diego to what might be offered somewhere else?
WALSH: I’ve worked in a voice center at another institution. It allowed for interaction with the type of patients I see here. However, it lacked having physician involvement and. So, it was fragmented care. Someone would be referred from an ENT and consult with us. We would often perform the endoscopy independently and talk about what is the function, how does it relate to what we see in their larynx, and where should we go from there? Is this something that should be surgical? Is it something that should be therapy? In the absence of having a physician at my side whom I’m very familiar with, sometimes it was hard to make those decisions. Sometimes there would be disagreement with those decisions. What I find is unique about our center, and in any center where you have this collaborative speech pathology / laryngology role, is that the patients aren’t getting different information. They feel very confident with the treatment that’s recommended and know that at any point they can check in with either provider.
What is your goal with your patients?
WALSH: I work with all levels of singers. My goal with Richard was to find: what is the most functional status? Where can we get you? We had set goals and he surpassed them. We set new goals and now he’s singing music that he didn’t 20 years ago. With other individuals, my role is to find out how did you function before, and I want to get you back to that status. So, if it was, I could sing alto in my church choir without my voice getting hoarse or without coughing, then that’s where we get them him back.
Is there anything else you would like to add?
WALSH: The big thing that you’ll want to touch on is the collaboration. That is unique. from our center that others don’t have. What’s very unusual about our center that is not only professionally stimulating, but extraordinarily beneficial for patients, is this collaboration of the physician the laryngologist and speech pathologist. s that are specialized in voice and swallowing and airway care. I think Richard would’ve found his cancer much later earlier if he wasn’t a singer. It was sort of hidden because he spoke so well. There were no signs of this in his speaking voice. The signs in his singing voice were subtle and possibly attributable to a cold, or an allergy. It just never went away. It wasn’t until it was eliminating specific aspects of his singing range that he felt the need to address this. Steroids were not giving him any long-term benefit. When we examined him, sure enough, he had no vibration of one vocal cord. It was extremely inflamed, yet he sounded normal.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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