Let's Talk About Larynx Disorders

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 looking forward to speaking with my colleague, Dr. Rebecca Nelson, a laryngologist and colleague of mine here in our Section of Laryngology. Dr. Nelson, welcome to Head and Neck Innovations.

Rebecca Nelson: Thanks for having me.

Paul Bryson: Well, let's start by having you share some background on yourself for our listeners, where you're from, where you trained, how you came to Cleveland Clinic, how you got interested in laryngology.

Rebecca Nelson: Yeah, so I grew up not too far from here in a suburb outside of Detroit, and I first came to Cleveland for medical school, so I went to Case Western and it's funny, so as a part of our med school curriculum, we had a research block and opportunity and I kind of randomly fell into a research position here in this department and it just took off and went really well. And that's kind of when I solidified my interest in otolaryngology and specifically laryngology. And I ended up staying here for residency. So, I did my training here and then I took a year away for a fellowship in Oregon just to kind of get some different experiences but knew pretty early on that I wanted to come back. And so, I've been here for about two years now.

Paul Bryson: It's been great to have your back. It's been great to see your career start and develop and continue on here. Just as a colleague, it's been really gratifying to see all of the good work that you've done and now here for a few years, starting your practice. It's been really awesome to see larynx disorders and things that affect the larynx can make everyday life really challenging for our patients. It can really affect quality of life. Do you want to give the listener just some background on some of the things that you regularly see? And what are some of the treatments and things that you do when you see these issues that make life better for our patients?

Rebecca Nelson: So, we generally see disorders. The larynx will encompass problems with voice, airway or breathing and swallowing. So, it's things that we do every day, things that we really take for granted, and if you're missing one piece of it, it really can affect your quality of life. A lot of these things impact patients in very different ways, which makes my job very interesting. And there's lots of different things that we can do for people. So, from a voice perspective, we see all sorts of different people, people who are just hoarse for a period of time. We see many different professional voice users, and this can be anywhere from high-end singers to teachers or people who talk on the phone a lot for their job. Those are really professional voice users, and if obviously they have an issue with their voice that can impact their livelihood and also have a pretty significant social aspect as well.

From an airway standpoint, I mean, people who can't breathe are very limited in their activities, and we do see some patients who have tracheostomies. And so being able to manage those and sometimes get them out of patients so they can kind of go back to their old life is very gratifying. And then in terms of swallowing, obviously eating is one of the simplest pleasures in life, and so having difficulty with that can be a big thing for patients. And so, for each of these, sometimes we do medical things where we manage them medically. Sometimes we have in-office procedures, which we can do and sometimes we do things surgically. If that answers your question.

Paul Bryson: I wanted to highlight a little bit, and during your time training here in our residency program and the time in Oregon, you've had the opportunity to see a number of complicated and complex airway reconstructive strategies. Is that a part of your practice now and how has that been going?

Rebecca Nelson: Yeah, definitely. Yeah. One of the most gratifying things that we do is I think airway. So people, usually what we see most is airway stenosis that affects the upper airways near the voice box and trachea. And so there are a lot of different things that we can do. And there's a range of treatments that are within my practice and anything ranges from doing. Sometimes we do an office procedure or steroid injections to try to keep this open. Sometimes we take people to the OR and doing an endoscopic procedure through the mouth, do a dilation, and sometimes we do much bigger surgeries such as open airway resections or tracheal resections. And so these procedures sometimes helps patients get a trach out or just restore their exercise capacity that they didn't have. And so it's a really cool breadth of different procedures that we can do.

Paul Bryson: And having you back and being part of the team, it's really expanded our ability to see patients with those problems. So, I really commend you on the care that you provide in the domain of voice. We had the opportunity to be co-authors on a paper called "Hoarseness, when to Observe and When to Refer," and that was published in our Cleveland Clinic Journal of Medicine. Do you want to share with the listener just a little bit about the paper and maybe make some points?

Rebecca Nelson: Sure. Yeah. So, this is kind of a highlight of the recently updated guidelines from our academy of when to refer when observe. So really the take home points are if a patient comes in with hoarseness and they've had it for four weeks or longer, you really need to suspect something. It's not always something serious, but sometimes there can be a serious condition that's underlying, and they recommend actually expediting a laryngoscopy, so get them referred over to an otolaryngologist or a laryngologist so we can scope them in clinic just to see what's going on. And to also highlight, there are a few different symptoms that can really suggest that there might be something going on. So, things like if the patient is an active smoker or has a significant tobacco history, if they have a neck mass at the same time, that might indicate malignancy. But other things such as if they've been intubated recently, we're seeing some patients who have what's called a posterior glottic stenosis or an acute laryngeal injury from intubation, and they can have some pretty serious issues with their airway, sometimes voice related to that.

And so, getting them in sooner rather than later can make a difference in terms of outcome. And then also things such as having recent head and neck surgery, or chest surgery might indicate that they have a vocal cord paralysis that we can address. It's something that a patient doesn't need to suffer with for a long time. A lot of times we can get them in for a quick office procedure of vocal cord injection to get them to restore their voice sooner rather than later. They also recommend avoiding just kind of treating it empirically with reflux medications, steroids or antibiotics. It's just really hard to know if it is an infection or something else just based on listening to their voice. And so, they're trying to avoid a kind of blind treatment of hoarseness. And if you can get a patient into our clinic, it's really easy for us just to take a look and we can usually solidify a diagnosis right then and there, and that way we can really treat them with directed therapy that's going to help them rather than wasting time with the empiric treatment.

And then finally, they also, we recommended based on their recommendations that you should really send patients to otolaryngology or laryngology for a scope before they get sent to speech therapy for kind of the same reason. And there's different things that speech therapists will do to treat hoarseness and we want to make sure we're treating what the patient has. You don't want to be treating like a tumor or something on the vocal cords with voice therapy when it's something we could give a different treatment for, then we're usually able to get patients in pretty quickly in our office. So, a referral, usually patients don't have to wait too long.

Paul Bryson: Yeah, I mean great points. I mean, seeing the larynx, visualizing it, is really key. And as you said, empiric treatments or blind treatments, they only would seem to delay care. So, it's a good opportunity for our referring providers to try to get them into our team and have us take a look. As we look ahead. Is there anything you're working on now or that's on the horizon as far as additional research into how we treat larynx disorders?

Rebecca Nelson: Yeah, there's always lots of stuff happening in our department, and lots of research projects are always ongoing. Something that I'm working with a colleague is we want to look at, take a review of our pregnant patients who have issues with airway stenosis. So, one disorder that we see a lot is fairly rare, but we see it a lot. It comes to us as what's called idiopathic subglottic stenosis, and it's called idiopathic, but it really seems to be a distinct clinical entity. It affects almost exclusively women of kind of reproductive or perimenopausal age. And there's definitely some thought of there being a hormonal component, though we don't fully understand the mechanism yet. But something that we do notice is that when patients become pregnant, their disease becomes accelerated. I mean, that always makes it a little bit more challenging to manage. And so, we want to do a review of how we've managed it here.

We've actually published a recent systemic review on what it looks like in the literature, but we have actually a decent sized population of this that we want to describe just so we can treat them better. A lot of factors to consider. Another exciting thing that's relatively new in the last year or so, we've also had this multidisciplinary airway conference, and so we're really lucky here at the Cleveland Clinic to have just excellent colleagues in different departments, and we work together with them frequently. Sometimes we'll get very complex patients that require lots of different kinds of minds working on the same thing. And so, we meet with our interventional pulmonary colleagues and our thoracic surgery colleagues and anyone else who wants to join, sometimes pulmonologists will join as well about every other month where we kind of talk about difficult and challenging patients just so we have that nice multidisciplinary approach.

Paul Bryson: Yeah, that's great. Those are very exciting things. And as you said earlier, we really are a busy center for airway problems, specifically for idiopathic subglottic stenosis, and I think we're learning a lot, and we have a lot to offer.

Rebecca Nelson: Definitely.

Paul Bryson: So, if a listener wants to refer a patient to our laryngologist, or maybe we have someone listening who's having issues eating, speaking, or even breathing, what can they expect when they come to your office for evaluation?

Rebecca Nelson: Yeah, so we'll see you in our office, and one of the nice things is we can do a laryngoscopy or usually specifically a video stroboscopy the same day of your visit. And usually that helps us get a diagnosis on the same visit. It doesn't add much time to the appointment. Usually, we'll see you get your history and do a head and neck exam, and then the procedure is generally very well tolerated. We put a little bit of numbing medicine in your nose. I think the worst part, which I warn my patients, is the numbing medicine tastes kind of bitter. And then we perform a laryngoscopy with a scope through the nose and we look down at the voice box. We have high-definition video stroboscopy towers, and so we get a great image that's very magnified of your voice box. Then we'll play it back for you so you can see what's going on. And for some of our patients, we're often able to go a little deeper into the trachea to really see what's going on. So, it's a very powerful tool that we can get a lot of really good answers on the same day we see you.

Paul Bryson: Yeah, and I'd say it's important for the listener to know too that we record the exam, so it's an opportunity for them to see the organ and to also track any changes after treatment or surgery. So, we're fortunate in our center to have high-definition cameras and recording ability.

Rebecca Nelson: Yeah, no, it's great. Our established patients who come back have repeat scopes and we're able to pull those and compare them. And so, it's a really powerful tool too, I'm not just relying on my memory for what your larynx looks like. I can pull it next to each other and play them back. So, it's neat.

Paul Bryson: Well, as we wrap up today, I just want to thank you for coming in, and we're excited for the practice that you're building and the expertise that you're bringing to our center and division. And I would say to our providers or patients that are, please reach out if you're having a problem with your voice, with your swallowing, with your breathing, we have the tools and the team to try to better understand and design a customized treatment plan for you here at the Cleveland Clinic.

For more information on larynx disorder treatment at Cleveland Clinic, please visit ClevelandClinic.org/Larynx. That's ClevelandClinic.org/Larynx. And to connect directly with a specialist or to submit a referral, call 216.444.8500, that's 216.444.8500. Dr. Nelson, thanks for joining Head and Neck Innovations.

Thanks for listening to Head and Neck Innovations. You can find additional podcast episodes on our website at clevelandclinic.org\podcasts, or you can subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. Don't forget, you can access real-time 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.