Diagnosing and Treating Voice Disorders Webcast May 3, 2012 Katherine C. Yung, M.D. Please remember the opinions expressed on Patient Power are not necessarily the views of UCSF Medical Center, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion with your own doctor, that s how you ll get care that s most appropriate for you. Introduction Your voice is your unique calling card, and when it's damaged it can negatively affect your communication skills and maybe even your livelihood. Coming up, we'll hear from an expert from UCSF Medical Center who treats patients with voice problems and voice disorders. It's all next on Patient Power. Hello and welcome to Patient Power sponsored by UCSF Medical Center. I'm Andrew Schorr. Think about what makes you you. One of the things is your voice, and it is so important in so many interactions. But think about your job. What if you're a teacher, or you're in sales, you talk on the phone all the time? What if you're that news anchor person? Your voice and the quality of it is vital. You don't have to be an opera singer for it to be important. And so there are issues that come up. Now, sometimes it may be you just had a cold and you lose your voice, and that's happened to me, and then I couldn't do any broadcasting of course for a couple days, but it comes back with rest, and the virus that caused it, my body beats it. Also I know I've yelled at my kids, I've regretted it, but sometimes that's strained my voice. Or you're a San Francisco Giants fan and you yell at a game, hopefully they won, and you strained your voice. But there are other things that can happen too. Maybe it's the way you use your voice and that is inefficient and can cause voice problems. Or maybe you can develop what the doctors call a lesion on your vocal cords. They talk of vocal folds. Maybe it's a polyp, some kind of benign growth. What do you do about that? Well to help us understand is Dr. Katherine Yung. She is an assistant professor of laryngology at UCSF, and she works at the UCSF voice and swallowing center. Doctor, thanks for being with us. Thank you for inviting me, Andrew. Understanding Voice Disorders 1
So we'll put aside yelling at the game and yelling at the kids and getting over a cold. There are people who after a while maybe are not using their voice efficiently, and so that can cause problems. Am I right? Yeah, that's right. People don't really think about how they're using their voice, how they're using their own voices, but voice is a combination of breath support and vocal fold tension, and so when that balance becomes disrupted voice problems or vocal fold lesions can result. All right. So vocal fold lesions are on your vocal cords, and you have two, right, a left and a right? Correct. It's like channels of stereo, left and right. Okay. So what does that look like? What is that? Because it changes the quality of your voice. I don't know if you necessarily become hoarse or it changes it. What do they look like? So the vocal folds are in a V formation, and they move in and out with your breath. So when you take a breath the vocal folds pop out into a symmetric V, and air can go down into your lungs. And when you talk or when you swallow your vocal cords come together and touch so that the vocal folds can vibrate to create voice. And when you develop a lesion, so a nodule or a polyp, is it just like a little bump? Yeah. So nodules can be small, little bumps or calluses on both vocal folds, or a polyp can be a growth on one vocal cord. And what happens is it disrupts the closure of the vocal cords so they can't touch properly and air leaks in and around the lesion. All right. So then your voice sounds different. Right. So the difference in the closure disrupts the vibration and creates the rough quality or the raspiness that you hear. So it's kind of like violin strings that are wearing, I guess, or have little bumps on the violin strings, violin wouldn't sound as good. 2
Right. Yeah. So if you didn't have correct contact from the bow on the string you wouldn't get a smooth sound. And so we don't have the same contact with the air that passes through. Yeah. So if the vocal cords don't touch completely and there's a big gap where air leaks out when you try to talk, then that alters the sound that you hear in people's voice. All right. And just so I understand, when somebody sounds hoarse, is that inflammation? Hoarse of kind of a vague description, but we just take it to mean a difference in the voice quality. So it's hard to pinpoint exactly what's going on from just the descriptor hoarse. I guess a trained voice professional just listening to a voice could maybe ascertain what's going on, but it really has to be diagnosed with a laryngoscopy or a stroboscopy, so actually looking at the vocal cords and their vibration. Diagnosing Voice Disorders So if somebody comes to your clinic and their voice is not right, whether it's for professional reasons or just it's bugging them, what do you do? So we always start by doing our perceptual voice evaluations. So when I'm chitchatting with you or asking your history I'm also listening to the voice quality or how you're supporting your voice with breath, where the resonance comes from. So I'm evaluating how the voice sounds the whole time we're talking. And then I also do a head and neck exam, examine your throat structures, lymph nodes, the cartilage structure of the neck. And then we look at the vocal cords and how they vibrate. Now you mentioned a scope or something a minute ago. Do you put something in the mouth or the throat to watch the vocal cords? Yes. So we actually put a laryngoscope, so either a flexible laryngoscope that we place through the nose and suspend over the vocal folds, or a rigid laryngoscope that we place through the mouth to look at the vocal fold vibration. 3
Voice Therapy So now you see someone who maybe they have some nodules or maybe they've just been using their voice inefficiently. Does that mean the next step is surgery, or what is the next step? We never jump right to surgery. If someone is using their voice inefficiently, and we say, Let's go to surgery tomorrow, and cut off that polyp, and they go back to using their voice the same way, then the polyp grows right back. So the first-line treatment for most voice disorders or vocal fold lesions, if they're benign, is voice therapy. Voice therapy. So you have that at your clinic, like people, that's what they do? Yes. So we like to say it's like physical therapy for the voice. Our voice clinicians, our speech pathologists, that sub specialize in voice. So I get it with physical therapy like they're helping me, you know, get better range of motion with my shoulder or back, so what are they doing with my voice? They're trying to help me regain quality with my voice and train me how to keep doing it right? Yeah, it's the same sort of idea as physical therapy because you have muscles in your larynx that are taking part in voice formations, and so the voice therapists work with you in trying to optimize how you're using those muscles. Where Does Surgery Come In? So [say that we] go through voice therapy or physical therapy for my vocal cords, but still there's a problem. So now you're a surgeon too, so what could happen next? So if there is a lesion such as a vocal fold polyp or a cyst that hasn't responded adequately to therapy, then we talk about surgery. And the surgery is typically an outpatient procedure. We call it a micro-direct laryngoscopy with micro-flap excision of the lesion So something is put down my throat, I imagine, but I'm not asleep. I'm probably-- 4
You are. Oh, you're totally asleep? Yeah. If we are doing an excision then we do it under general anesthesia. Okay. But still outpatient. I'm going to go home the same day. Correct. And then will I have to rest my voice for a little while? Yes. So the voice rest that is recommended is kind of voodoo. We don't really know the optimal time frame for how long a patient should be on voice rest or whether voice rest is necessary at all, but it just makes sense that patients' vocal folds will be able to heal better if they weren't being constantly used after surgery. So we like to recommend one week of complete voice rest after micro-flap excision with then modified voice rest. So after that first week you don't go back to your normal voice use. We start slowly and under the supervision of our voice therapist. Now, if I had another kind of surgery, let's say orthopedic surgery, I would go to the physical therapist then. What about the voice therapist after surgery? Yes. So it's the same idea. The voice therapists are critical in the rehabilitation after voice surgery as well. So after surgery, like I said, they would take the patient off of voice rest and start working with the patient on how to use their voice after surgery. So let's say I'm that big anchor person in San Francisco--I wish I were--and I had this problem and you found out maybe I wouldn't using my voice quite right but I developed maybe a nodule and I had the surgery and the voice therapy. If I'm back on track and doing efficiently, could I just go on and hope that's it, that it's not going to happen again? That is the goal, that after successful surgery and therapy after surgery that you as an anchor would know how to use your voice efficiently now and would not have 5
problems in the future. That would be neat. Hey, I have to ask you something everybody wonders about. My mom taught me that when my voice was hoarse she would give me tea with lemon and honey to soothe my voice. So does any of that work? Is that proven? Or lozenges or--where does that come in before we have to go to the clinic? Patients ask that all the time. Is it hot water that helps, cold water, tea with honey, and there really isn't any scientific evidence behind any of that. We just tell patients hydration is good and whatever feels the best for you, go with it. So if it's tea with honey, that's fine. If it's warm water, that's fine too. Gargling with saltwater is a good habit as well. The main things I disagree with are when patients insist on excessive drinking of wine or other alcohol after surgery or smoking after surgery. And I was going to say smoking is probably not good for your vocal cords. No. So any sort of irritant to your vocal folds like smoking, inhaling fumes or any sort of chemical irritant is bad for the vocal fold health. Preserving the Voice So we've got an aging population. So as we get older what strategies would you suggest so that we could have a voice that makes us sound like we're 30 when we're 70? How do we preserve the quality of our voice? Well, there's not much we can do to counteract aging. Just like the skin on the outside of your body changes can with age, so does the skin of your vocal cords. So similar to how you preserve your skin health, you keep well hydrated, avoid abusing it. Like you would want to stay out of the sun for your skin, you would avoid smoking and heavy alcohol use, and exercise, you know. So keep doing what you're doing. If you like singing, keep singing and practicing so that your vocal cords don't get out of practice for what you enjoy doing. Closing Thoughts I think it's good to know that you have your clinic at UCSF, so if someone has a concern they can come and you're going to listening to them, you're going to scope them to see how things vibrate, and then between you and your whole team there you can both give voice therapy and if you needed I'm sure you have very modern surgical techniques so you can get at what needs to be fixed and send us on our 6
way. Yeah. Laryngology is an exciting field at the moment. There are new technologies and new techniques that are coming or being developed all the time, so it's an exciting area to work in. And I really enjoy being able to help my patients improve their voice and interaction with the world. Well, Dr. Katherine Yung, we're going to have you back another time, but we're going to give you an assignment. You're going to have to sing for us so you show us how you're keeping your vocal cords in shape, okay? Well, that you may not want. I used to sing in college, but I haven't sung since then, and it's been quite a while. Well, you've got to keep that training up. You're right. Thank you for all you do at the UCSF voice and swallowing center, and thank you for helping us understand what can be done to help us get our voice back in shape. It's very helpful. Thank you for being with us. Oh, thank you, Andrew, for having me on Patient Power. Well, this is what we do on Patient Power is connect our audience with experts like Dr. Katherine Yung and help us understand something that may be very significant in our lives and help how to keep it healthy, and our voice is certainly way up there on the list. I'm Andrew Schorr. Thanks for joining us. Remember, knowledge can be the best medicine of all. Please remember the opinions expressed on Patient Power are not necessarily the views of UCSF Medical Center, their staff, or Patient Power sponsors, Patient Power partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion with your own doctor, that s how you ll get care that s most appropriate for you. 7