Caring for the Professional Voice

Podcast Transcript

Paul Bryson: Welcome to Head and Neck Innovations, a Cleveland Clinic podcast for medical professionals exploring the latest innovations, discoveries, and surgical advances in otolaryngology - head and neck surgery.

Thanks for joining us for another episode of Head and Neck Innovations. I'm your host, Paul Bryson, Director of the Cleveland Clinic Voice Center. You can follow me on X, formerly Twitter, @PaulCBryson, and you can get the latest updates from Cleveland Clinic Otolaryngology-Head and Neck Surgery by following @CleClinicHNI on X. That's @CleClinicHNI. You can also find us on LinkedIn at Cleveland Clinic Otolaryngology - Head and Neck Surgery, and Instagram at Cleveland Clinic Otolaryngology.

Today I'm joined by a returning guest, my colleague and also Director of the Voice Center, Dr. Claudio Milstein. Dr. Milstein is a speech language pathologist and my partner now for almost 14 years. So welcome back to Head and Neck Innovations.

Claudio Milstein: Thank you, Paul. It's good to be here. Thank you for the invitation again and it's fun and interesting topic, so I'm ready to roll with it.

Paul Bryson: Before we dig in, I encourage everyone to go back and listen to Dr. Milstein’s previous Head and Neck Innovations episode. In that one we covered exercise-induced laryngeal obstruction, but for our new listeners who might be tuning in, let's start by having you share some background on yourself, where you're from, where you trained, and how you came to Cleveland Clinic.

Claudio Milstein: Alright, well, the accent that you hear is from my native country Argentina. I was born and raised there and I went to med school and then speech pathology school in Buenos Aires, my native city. Then moved to the United States to get a doctorate in speech science, and that's what kind of started my career here in the States. My interest in voice comes from theater because I was a professional theater director for 10 years. I started really young when I was 16. We had a theater group in Buenos Aires and I got really, really interested in actors and singers voices and what somebody can do with a voice to really reach and move people sometimes to tears just by some twitch in your voice quality. I found that really interesting and wanting to know more about how we produce voice, how we teach it, how we learn, and how to do those things. And then started getting into the world of what can go wrong with the voice and pathology. So that is what got me started in this line of work.

Paul Bryson: I had forgotten about your theater work. So yeah, forgive me. I forgot about that piece. That had to be pretty fun and interesting.

Claudio Milstein: It was great. I did that when I was very young. I don't think I'll do it again, but yeah, it was fascinating.

Paul Bryson: Well, part of what makes our Voice Center so special is how we're able to help people really from across the city, across the state, really internationally for people that use their voice professionally. As you and I have seen in our careers, the goal is to perform better, have longer careers and help them preserve their vocal health. Can you share just your experience here over the years? Talk about some of the issues that we see in our professional voice patients when they come to the center. I guess specifically maybe speak a little bit to the real cross section of what we call voice professional. That definition is very broad.

Claudio Milstein: So when we say professional voice user, most people think about a singer, but in reality, anybody that uses their voice in a professional manner, meaning making a living out of talking, can be a professional voice user. And that includes actually most of us, like 90% of the workforce in the United States is communications based. That means that if you don't have a voice, you cannot do your job. So it's a wide range of patients that we see that come to see us, like you said, from close to very, very far away. And they do that because we have a real center of excellence for voice care. We have a really phenomenal team. Our team is comprised of laryngologists like you, and voice expert speech-language pathologists like me. We have three others and right now we have four laryngologists and we are actually looking to expand our team because we see patients not just in the main campus of the Cleveland Clinic, but at several regional hospitals.

And what makes our work so interesting is that we see such a wide variety of patients and disorders. We have from the more simple patients, like a teacher that after talking for 20 years in loud classrooms develops a vocal fold nodule, to patients that it is more of a mystery what they have. These are patients that come to see us because they have been to many, many specialists before and they are getting no answers. They are getting no good treatment. And that forces us to put on our detective hats and as a team, we have a multidisciplinary assessment of these patients. Try to figure out what is the underlying problem, why these people are having voice problems. And those problems can come from issues with their digestive system, can come from how they use their voice, sometimes a neurological problem. We really reach out to other specialties in the clinic to collaborate with us to end up with the best diagnosis and the best treatment option for each and every one of our patients. So that makes our practice never boring and very interesting and challenging.

Paul Bryson: I'm always amazed at the number of other services that we can collaborate with to take care of patients. The neurologists, sometimes we'll look after patients that have had early laryngeal or advanced stage larynx cancer and have undergone treatment. We collaborate with our gastroenterologists or rheumatologists or pulmonologists. We even have developed a pediatric voice center in the last few years to maybe work with our younger patients.

Claudio Milstein: I forgot to mention pulmonology and allergy specialists because those two things really can affect how we sound. So a way to look at the patient from different areas of expertise is really important.

Paul Bryson: Just to highlight, we have a complimentary approach to patient care. I like to think that we kind of personalize care, and not everybody needs surgery. Not everybody gets a voice therapeutic approach. We try to meet the patients where they are, and a lot of times there's a combination of approaches at times. Do you want to speak a little bit to how we might approach a patient getting a surgery, what they might expect afterwards? Or even if a patient is trying to avoid surgery, there's often opportunities to avoid that.

Claudio Milstein: And these are patients where the collaboration between all of us is really, really important. So for example, the preoperative care, suppose a patient will need surgery and we've come to the conclusion that they have a lesion or something that requires a surgical procedure. So what's really important is to do a very good preoperative assessment. And I have the luxury of having a longer time with each patient so I can go in depth with each patient what to expect from surgery. And most important then to do a plan for postoperative care. Why is that super important? Well, everybody knows that. For example, if you have knee surgery, you are not going to go running two days after the procedure with voice. We're not so aware of those things. And the thing is that the vocal chords after surgery, they don't really hurt. So it's very easy to do too much too soon – to talk too loud, to go back to singing with a lot of power too early. And that can lead to traumatizing the vocal chords again or to a longer recovery period. So it's really important to work with each patient, have a very good idea of what their vocal load is, that means how much and in what manner. They use their voice on a daily basis and have a very individualized plan for each patient on how to navigate their voice, use for the week, two week, three weeks post-surgery. And that is one area where we really individualize the care for each one.

Paul Bryson: I'd also highlight that as part of this approach and then part of this personalized care, we really are fortunate to have some very nice technology to show patients their larynx, which is often a novel experience for patients. It allows us to look at the outcomes after surgery or other therapeutic approaches. Can you kind of speak to how the technology has integrated into this multidisciplinary approach and maybe how it's been useful for our patients?

Claudio Milstein: Yeah. We are fortunate to have really, really state-of-the-art equipment in our voice center that includes digital imaging. We have the latest generation scopes and towers that can allow us to look at the very finest detail of the anatomy and the function of the vocal cords, both when they are rested and when you have the patient talk sing or do what they usually do with their voices and look at the vibration of the vocal chords in slow motion. Like you said, a lot of people never saw their instrument. We call the larynx or the voice box their instrument because that's where they're using to sing, for example. And being able to see in fine detail what the problem is, being able to understand what are the reasons why they may be hoarse, and being able to provide the patient the ability to record the exam with their own phone so they have their own record and if they go to their singing teacher or to see other specialists, they can show them, which is very powerful. When we were talking about the care team, particularly for performers, we also have to keep in mind that there are several other professionals that are involved in that singing teachers or acting coaches. So all those can come into play and oftentimes we reach out to them and we can work together to try to get the patient into their best vocal health that we can.

Paul Bryson: And I wanted to also follow up and say the cool thing about people can be nervous about having a scope exam in the office while they're awake. I would say that the vast majority of the time it's doable. And depending on the patient's voice issue, they can at least demonstrate to us in real time what the issue is. And it's a place where I think that patients will feel listened to not just listening to the story, but if they have a problem with their voice, we can often hear it too. And so part of the technology is great, but it's also I would say almost a fun exam I think for the patient in some instances because they can at least demonstrate what the issue is when I think about our vocalists in particular.

Claudio Milstein: Yeah, that's very true. And a lot of patients come with a little bit of anxiety because of the exam that they are going to go through. And we have such great expertise and we've done this so many times over many, many years. So I think that everybody in our team has the ability to put the patients at ease and make them feel comfortable with the procedure. It is not a painful procedure or in the majority of times it's not uncomfortable. And when the patient is able to just be very relaxed during the procedure, we get the best results. Like you said, for a performer to be able to sing and show us where the voice is faulting sometimes is in one particular note and we need to figure out how to fix that. And we have audio booths where we can put the patient in and they can actually sing to the top of their range and volume without really disrupting the normal day-to-day run of the Voice Center.

Paul Bryson: The sound booth is a really cool resource that we have. We have an amplifier, we have a keyboard. It is definitely a place where patients can be treated, but also a place where patients can show us some of the specifics of maybe a difficulty that they're having with their voice.

Claudio Milstein: And just the environment of being in that booth is very similar to a recording booth. So for a performer, they don't feel that they are in a medical setting. They feel much more comfortable because we have the instrumentation, the microphones that they are familiar with and that allows them to reproduce to the best of their ability what the issue is. And that helps us understand the problem better.

Paul Bryson: And I think I would emphasize we see not just the most professional of singers, we see people that have day jobs and maybe sing in a band or sing in a community choir or sing in a high-level choir. We have students from the universities that see us around here. We have teachers like you mentioned earlier, very eloquently. Most people rely on their voice. I would say we can provide them with a personalized approach centered on inquiry and compassion here. And it's nice to see that we can also design sort of an individual treatment plan for people that tries to respect what their obligations are, what the demands of their work are, and maybe what their aspirations are.

Claudio Milstein: And one thing to mention is that we speak their language. Paul, a singer, you have a lot of experience with singing before. I have experience with theater and actors and pretty much everybody in our voice center has some kind of singing background. So that allows us to, first of all, to understand the problem better. And when patients come, they realize, oh, they're not just talking to a doctor, but they're talking to somebody who really understands and speaks the lingo of singing. And that allows also to have a better rapport with the patient. One fun thing is that we also, in our voice center, we have our walls of fame. So we have pictures, we have pictures of a lot of well recognized singers and actors that have come through our center. So when patients come for the first time and they see all the famous people on our walls, they say, oh wow, I think I'm in really good hands. And I think that they are.

Paul Bryson: It's a very nice sort of pictorial history of the center too. Some of the patients have been through and they're doing pretty well a lot of times, people, we can help them navigate that and get them on their way. So yeah, it's been good. Well, any final take home messages for our listeners?

Claudio Milstein: I do. I want to bring the attention to a lot of our performers to an article that we just went in for publication. And this is a joint statement that we did with all the organizations in the country that take care of voice professionals. So that is the American Speech Language and Hearing Association that kind of forms all these speech pathologies. Like myself, I'm a member of this organization. The other participating was the National Association of Teachers of Singing, or NATS. The Pan-American Vocology Association, called PAVA and the Voice and Speech Trainers Association, VASTA. So this was a joint statement characterizing the roles of each of the different voice professionals highlighting how we all can collaborate with each other and kind of defining the roles of each one so we don't step on each other's toes. So actually that's going to be available probably in the near future. I think we're hoping to be able to publish it in April, which is actually World Voice Day, and is going to be available in the websites of ASHA, NATS, PAVA, and VASTA. So for all the performers and professionals that are listening to this, look forward to reading that joint statement.

Paul Bryson: Thank you for sharing that. That is going to be a really nice contribution, I think, not just for practitioners, but for patients as well. And once we know when it's out, we'll have to highlight that our social platforms too, just to try to increase awareness. So thank you for that.

Claudio Milstein: Absolutely. And also a reminder that every year on April 16th, that is World Voice Day and it's a day that is dedicated to dissemination of information, both for health professionals around the world, but for professional voice users on voice care, voice health.

Paul Bryson: Well, for more information on our caring for the Professional Voice services at Cleveland Clinic, please visit ClevelandClinic.org/Voice. That's ClevelandClinic.org/Voice. And to connect directly with a specialist or to submit a referral, call 216.444.8500. That's 216.444.8500. Dr. Milstein, thanks for joining Head and Neck Innovations.

Claudio Milstein: As I told you before, it's a lot of fun and thank you for having me again.

Paul Bryson: Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website clevelandclinic.org/podcasts. Or you can subscribe to the podcast on iTunes, Google Play, Spotify, BuzzSprout, or wherever you listen to podcasts. Don't forget, you can access realtime updates from Cleveland Clinic experts in otolaryngology – head and neck surgery on our Consult QD website at consultqd.clevelandclinic.org/headandneck. Thank you for listening and join us again next time.