The Art of Treating the Injured Singing Voice

Additional Info

• Audio File:uab/ua163.mp3
• Doctors:Hapner, Edie;Simpson, Blake
• Featured Speaker:Edie Hapner, PhD, SLP | Blake Simpson, MD
• CME Series:Clinical Skill
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4138
• Guest Bio:Edie Hapner, PhD, SLP is the Co-Director of the UAB Voice Center. 
  
  Learn more about Edie Hapner, PhD, SLP 
  
  Blake Simpson, MD is One of the first fellowship-trained laryngologists in the US. Director of the University of Texas Voice Center 1996-2019. Professor, Department of Otolaryngology-Head and Neck Surgery. Director, Division of Laryngology, Co-Director UAB Voice Center 2020-present. 
  
  Learn more about Blake Simpson, MD 
  
  Release Date: August 17, 2020
  Expiration Date: August 17, 2023
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Faculty:
  Charles Blakely Simpson, MD
  Professor in Otolaryngology
  
  Edie R. Hapner, PhD, SLP
  Professor, Speech-Language Pathology
  
  Dr. Hapner has disclosed the following commercial interests:
  Grants/Grants Pending/Research Support – Lakeshore Foundation
  Consulting Fee – Lewis Thomason Law Firm; Dickie McCamey Law Firm
  
  Dr. Simpson has no commercial affiliations to disclose.
  
  There is no commercial support for this activity.
• Transcription:UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
  
  Melanie Cole (Host):  Similar to orthopedic surgeons, working with elite athletes, the laryngologists and speech language pathologists treat the vocal elite athlete, the singer. Welcome to UAB Med Cast. I’m Melanie Cole and today, we’re talking about the art of treating the injured singing voice. Joining me in this panel are Dr. Blake Simpson. He’s a Professor in the Department of Otolaryngology and Division Director of Laryngology and Co-Director of the UAB Voice Center. And Dr. Edie Hapner. She’s a Professor in the Department of Otolaryngology and Director of Speech and Hearing and she is also Co-Director of the UAB Voice Center. Doctors, I’m so glad to have you here today. This is such a great topic. Dr. Simpson, I’d like to start with you. Tell us a little bit about voice medicine. How has it evolved over the years? Is this a new field of medicine? Tell us about it.
  
  Blake Simpson, MD (Guest):  Yeah, it’s interesting. It wasn’t even acknowledged as a subspecialty of otolaryngology really until probably the 90s. So, it’s in that sense, very recent. I think part of why voice medicine has evolved is we didn’t really understand the layered structure of the vocal folds. We hadn’t really seen vocal folds vibrate and when the technology came about in the 1980s, and we began to understand the complex physiology of vocal folds; I think that’s when the appreciation of voice science really started. But training in laryngology, actual fellowship training, didn’t start until the early 90s. So, as a subspecialty, it’s really evolved over the last 30 years or so.
  
  Edie Hapner, PhD, SLP (Guest):  I’d like to add that in speech pathology, it continues to evolve. Speech pathologists have a very broad scope of practice but over the past 17 plus years, we’ve started to move in the direction of laryngologists and trying to specialize in voice. So, I think we’re still evolving.
  
  Host:  Well I certainly agree, and I think that this is what an interesting field of medicine that you’re both in. So, Dr. Hapner, as I said in my intro, and like elite athletes, singers perform at such a high level with increased occupational demands and capabilities, skills that exceed the vocal abilities of most individuals. How does this put pressure on their voices? What are the most common injuries that you see in clinic?
  
  Dr. Hapner:  Like elite athletes, singers have demands on their voice like athletes have demands on their body. And they also have a level of expectation that means that they have to be there with their A game every single time they get on that stage. Knowing that, for example, are singers who also dance at the same time, on Broadway, who maybe do eight shows a week and a couple of days a week they are doing two shows a day, coming with you’re a game to every show demands a very high level of skill and training. So, that also means that there is a need for continuous training and also because of those vocal demands, there is an opportunity for voice overuse and injury with things on stage that you wouldn’t even think about. Like smoke to make a scene look better or heavy costumes and think about the traveling Broadway performer versus the Broadway performer. The traveling performer is in a different hotel every night, in a different city every week and a different venue every week. So, the demands are really high. Dr. Simpson can talk about the most common injuries.
  
  Dr. Simpson:  The most common injuries tend to be swelling at the mid portion of the vocal folds. As we’ve understood, vibration of the vocal folds, we know that the maximal trauma actually occurs at that mid-point of the vocal fold, that’s where the maximal collisional forces are. So, patients tend to get swelling there. That would probably be the most common injury that we would see. And that’s usually reversible, that will get better with rest or get better with voice therapy. I think one of the feared complications or injuries would be a vocal cord hemorrhage. So, you would have bleeding into the vocal cord. This is generally something that we take very seriously, and we put these patients on voice rest usually for at least a week. And they stop performing. So, this is the one injury that we would all agree needs to be treated very seriously.
  
  Sometimes these hemorrhages will over time, expand and form a polyp so not uncommonly, we’ll see these in singers as they are more mature injury once they’ve had a few hemorrhages into their vocal cord.
  
  Host:  Well then Dr. Simpson, how do these injuries present themselves? Tell us a little bit about the clinical presentation and what you see.
  
  Dr. Simpson:  Yeah, so most of the singers we see, and I think Dr. Hapner would probably agree with me, come in not with speaking voice problems, but specifically with problems in their singing voice and it could be something very specific like my transitional register is giving me trouble or I’ve lost the top three notes in my range. It’s generally a fairly specific singing voice complaint. If it’s a more severe injury, obviously, they’ll come in also with speaking voice issues but not uncommonly it’s just the singing voice issue. And it could be loss of tone, it could be fatigue, it could be any number of problems that are interfering with their performance.
  
  Dr. Hapner:  Can I just add here too. You would expect to hear us say that they come in with complaints of hoarseness but that’s generally not it. That’s why it’s such a nuanced area. They come in and they say I can’t get the crispness in that top note or I’m just so exhausted that I don’t feel like I have the stamina. But rarely in these people, do we hear oh my voice is hoarse.
  
  Host:  That’s so interesting. And Dr. Hapner, before we talk about treatment modalities, tell us about what types of care are involved. Does it require the management of several aspects, a multidisciplinary comprehensive care model? Tell us how that works.
  
  Dr. Hapner:  Well I always say it takes a village. So, as a speech pathologist, I don’t practice without a laryngologist like Dr. Simpson who can look at the vocal folds, understands them, because he surgically gets to operate on them and to feel them and to be part of understanding how they are made up. But laryngologists to make a good diagnosis and then the speech pathologist generally comes in and – our goal often, with these patients is to get them back to healthy vocal folds. Whether they need surgery, or they don’t, to get them to use vocal behaviors that enhance healing. Kind of like an athlete on the disabled list. Our job is to get them healthy and then to help their transition to getting back to their elite level of singing with their voice teachers. So, already I’ve said there’s the laryngologist, the speech pathologist, and the singing teacher who are part of that core team in addition to the patient. But of course, there could be others. A pulmonologist if there’s respiratory issues, a gastroenterologist if there’s GI issues and sometimes a psychologist.
  
  Host:  Dr. Simpson, speak about some of the current issues in medical or surgical management. Tell us what treatments you might try, your first line of defense if someone comes to you with one of the injuries that we’ve mentioned.
  
  Dr. Simpson:  Probably the most common thing we would do for a singer would be voice rest. This is not as a cure. It’s only a Band Aid to let the swelling go down so we can provide further treatment in many other different ways we’ll talk about. But the most common thing we would do is first put a patient on voice rest. For swelling, we frequently use corticosteroids like prednisone, like a prednisone taper. These again, are sort of Band Aids when we see an injured performer. But ultimately, these people need behavioral treatment. They need to work with a speech pathologist on the way they are using their voice to use their voice more effectively and not infrequently, work with their singing voice coach in tandem with the speech language pathologist. As Dr. Hapner said, it really does take a village. I would love to think I could take care of patients by myself, but if you don’t have those – the core group of the speech language pathologist, singing voice teacher and the laryngologist, you are really not providing adequate care.
  
  And interestingly it rarely comes to surgery. One of the talks I give is on treating the injured singer and one of the things I say is conservatism works. And that’s really true. You always start with the most conservative thing, voice rest, corticosteroids, working with the speech language pathologist, and only after other things have been tried, do we finally escalate up to a surgical procedure. In fact, I would say the majority of singers don’t need surgery. I think most of them can be treated with behavioral management and nonsurgical methods.
  
  Host:  Well then Dr. Hapner, tell us about those. What’s involved in the singer’s vocal rehab plan? What does that look like for the patient?
  
  Dr. Hapner:  You know it’s interesting Dr. Simpson talked about voice rest and just to put that in perspective. Voice rest doesn’t look like voice rest used to years ago. It’s much shorter and well-defined. As he said, maybe to add that extra layer of healing and getting reduced swelling. But the goal of the speech pathologist in rehabilitating anyone, especially singers with voice problems; first and foremost, is to allow for healing but we have to let people talk. The vocal folds are muscles. If you don’t use them, you lose them. So, we want to keep them moving and active and vibrating, but we teach people to be attuned to the level of vocal effort that they are using to make voice and effort translates to muscle strain, extra respiratory strain. And so, we teach people to be intuitive about using their voice and optimizing the way they produce their voice to allow for continued healing.
  
  Once we have gotten the vocal folds to a pretty good medical state, then we’ll start to rehabilitate them back up to normal speaking and back to singing. I’ll just add this, it’s silly to think that somebody wouldn’t raise their voice ever in their life. You have to call to your neighbor. You have to call to your kids. But all of these vocal behaviors can be done in healthy vocal postures that don’t cause vocal injury down the road. Because our goal always is that the patient never needs to come back to us.
  
  Host:  Well that’s certainly true and Dr. Hapner, sticking with you for a minute, as we work with athletes, and we know that there’s this whole psychosocial and psychological aspect, mental fitness we call it, right, for athletes. But for singers, they have different emotional needs but just along the same lines. Speak about working with that psychological impact of voice problems when that is in a sense, their instrument, that is their livelihood. Tell us how you work with them.
  
  Dr. Hapner:  So, of course, I spoke to a group of singers today and they always talk about how they get in their head if there’s any little change, any vocal variability during a day. So, first and foremost, I, voice therapist, empower the singer to understand their vocal mechanism. It’s a black box. You can’t see it. so, we have to teach them how to understand how these mild, minimal vocal variabilities from day to day can be remediated or turned around with just some simple changes in a routine. And we all have vocal variability. Our voice is a mirror to our soul so depending on how we feel and how our day goes; our voice is going to represent that but if you stay out of your head, you don’t go down the rabbit hole of it getting worse and worse.
  
  If a singer has a very big injury, that is going to sideline them from singing or performing or canceling a concert; that’s a much bigger deal. And sometimes, I actually encourage some professional help to help people understand that they may be temporarily broken as they think about it but let’s understand where we can be with some help, with some time and with some good care. How long is it going to take to get better and what is their role in getting better.
  
  Host:  Well that’s true. They certainly do. We have to work for ourselves and again, patients have to be their own health advocate and really do what you’re telling patients to do. Now Dr. Simpson, for other providers, how have been your outcomes. Tell us about the clinic and really what you’ve seen as why it’s so important for other referring physicians to look at the Voice Center at UAB Medicine.
  
  Dr. Simpson:  I think what we believe makes us stand apart from the other voice centers is that both Dr. Hapner and I over our careers have started a number of voice centers from the ground up and Dr. Hapner actually created the one in Emory and as well sort of resurrecting the one at University of Southern California and then I’d spent my career in San Antonio with the voice center there and we saw – I don’t want to say we’re all, but at the tail end of our careers, we saw an opportunity to collaborate and sort of design the [00:14:08] voice center that would sort of do what we couldn’t do in the past because now we’re working together. There is some synergy here. And we really wanted to make the [00:14:17] interprofessional clinic where we see the patient together, we design a collaborative plan of care. I think the patients get the best outcomes when you are really working together, seeing the patient together, coming up with your decisions as a group. And I think that’s what’s really is going to distinguish us as a voice center from all the others.
  
  Host:  Well then Dr. Simpson, tell us some of the most innovative technologies that support your work. What’s exciting in your field?
  
  Dr. Simpson:  Office-based procedures have become one of the most exciting things. we spent most of our careers taking patients to the operating room, putting them under a general anesthetic and working in that capacity. But as time has gone by, the technologies improved. We have better scopes to look at the patient, the optics are better. We have flexible laser fibers that can go through these scopes. So, now, under local anesthesia, with the patient sitting right in the clinic chair; we can take care of like small polyps on the vocal cord with the laser, with the patient completely awake. We’ve had a series we published a year ago on singers with vocal fold polyps that were treated just under local in clinic and successful outcomes that have been associated with that. So, that’s probably the technology I think that has been most exciting for surgeons. That ability to take care of the patient without having to go to the operating room.
  
  Host:  And Dr. Hapner, last word to you. Wrap it up. Let other providers know what’s so exciting about what you do for a living and the UAB Voice Center. Give us your best summary and what you’d like them to know about the art of treating the injured singing voice.
  
  Dr. Hapner:  I think what’s so exciting about the UAB Voice Center is that we have a three fold mission. We have the mission to state of the art clinical care and the University of Alabama Birmingham Department of Otolaryngology has supported us to set up a voice center where we have state of the art equipment. We have a flow that allows for the best patient care and so, that support cannot be matched in a lot of places.
  
  So, we have state of the art clinical care. And the way we get to state of the art clinical care, is that we also have a mission towards research. And so, it’s not uncommon if you sit with us in any given clinical day, that we are furiously writing research ideas that have literally come from the person we just saw together in the clinic. And both Dr. Simpson and I are clinical researchers. So, we want to help find solutions and answers to questions that clinicians have. And we will as long as we are working together continue to do that.
  
  And our last mission is teaching and mentoring. So, we both feel that it is our responsibility to develop the next generation of interprofessional voice care providers from the laryngology side, from the speech pathology side, and our involvement with the School of Music and other places and soon to be UAB, because we are so new here. I think will just reinforce the model of collaborative care. There’s a lot of studies that talk about collaborative care is what provides the best outcomes for patients with voice disorders. So, I’d like referring physicians to know that they are always welcome to call us, to ask us questions, to send us patients for second opinions and more than anything, we’re always willing to work with them and excited to work with them. And so, we hope that everyone will start engaging with us and give us a chance.
  
  Host:  Thank you doctors so much. As I said at the intro, what a fascinating topic. Thank you again for coming on and telling us about it. A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That concludes this episode of UAB Med Cast. To refer your patient or for more information on resources available at UAB Medicine, please visit our website at www.uabmedicine.org/physician. Please also remember to subscribe, rate and review this podcast and all the other UAB Medicine podcasts. I’m Melanie Cole.
• Hosts:Melanie Cole, MS