Speaking on the Future of Voice Care

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 excited to be joined by my colleague in the Section of Laryngology in our Voice Center, Dr. Michael Benninger. Quick note for our listeners, Dr. Benninger and I have been working together now for almost 14 years. He hired me to join the Head and Neck Institute in 2010 and played a large role in my career. So Dr. Benninger, welcome to Head and Neck Innovations. It's an honor to have you.

Michael Benninger: Yeah, thanks Paul. It's great to be here and you've had a lot to do with my career too.

Paul Bryson: Well, for our listeners, let's start by having you share some background on yourself, where you're from, where you trained, how you came to Cleveland Clinic, and just there's a lot to share. So yeah, tell us a little bit about yourself.

Michael Benninger: I was born and raised in Cleveland, Ohio. Went to Harvard University as an undergrad and not knowing what I was going to do at that time. I had played football in college and I ended up coaching for a couple of years before deciding to go to medical school. Came back to Cleveland to Case Western Reserve University. Ended up doing my residency at the Cleveland Clinic, so I'm an old timer here. Went up to Henry Ford Hospital and just through a lot of coincidences, about five years after my residency, I became Chair of the Department of Otolaryngology-Head and Neck Surgery and eventually the Chair of the Board of Governors there until I was recruited back here to the Head & Neck Institute as its chair, as the chair in 2007. And after a long time, and given that I'm aging a little bit, I resigned my chairmanship three years ago and great to be just practicing ENT and laryngology.

I've been president of a number of societies, the American Laryngological Association, the Triological Society, the American Rhinologic Society, and I'm currently the president of an organization called the International Association of Phonosurgery, and for anybody that's interested, we're putting on our meeting in Dubai next year, January 16^th-18^th. If somebody wants to go to and wants to present on laryngology, just give me a call.

My interests include most things. I really love vocal fold paralysis. I've been treating and doing medialization laryngoplasty for many, many years. I enjoy seeing patients for microsurgery, see a lot of professional singers and performers and actually the Vice President of Voice Foundation that had its meeting in Philadelphia. And my newer interests are actually in some, not necessarily highly technical, but highly difficult disorders, particularly chronic cough and other hypersensitivity, laryngopharyngeal syndromes.

Paul Bryson: Yeah. I'd also highlight some of the other, you've added a lot of research to the field and a lot of textbooks on this, and with some that I would highlight would be The Performer’s Voice that you have edited and written right for many years. And then the book on Botox injection in the head and neck, and it dovetails pretty nicely into some of the interests that you highlighted sort of in the laryngeal hypersensitivity and sensory functions of the larynx.

Michael Benninger: I enjoy publishing. I enjoy doing research. I think I have nine books. The Performer’s Voice is still going strong and The Singer's Voice is out of print. We sold all the print away and we're going to redo it. I think the Botox is very interesting. Ours was a technical publication of technical book that basically described how to do it for all kinds of things in the head and neck, everything from spasmodic dysphonia to torticollis to cosmetic uses in the head and neck. And then I was editor of the American Academy of Otolaryngology-Head and Neck Surgery Journal from 2000-2006, so I still enjoy reviewing. I'm editor of five different journals at this point, so it's a broad career. It's great to be in our specialty and it's great to be in organized medicine.

Paul Bryson: Well, we recently attended the Combined Otolaryngology Spring Meetings, or COSM, in Chicago just about a month ago or so where our colleagues both at the Cleveland Clinic and across the country shared some of the latest in laryngology research. This was both at the American Laryngological Association and the American Broncho-Esophagological Association. Any topics that stood out to you that you wanted to highlight?

Michael Benninger: Well, I think we were maybe not the first, but innovators in the use of THRIVE, which basically is high flow oxygen anesthesia, and now a large majority of our patients are done under THRIVE anesthetic. We published a number of papers related to this. We use it for microsurgery, we use it for stenosis, and it's really beautiful. The patients are lying there. They, they're basically has this high flow oxygen just resonated in the back of their pharynx and it keeps them well oxygenated. They go off to sleep, they don't move, and then when they're done, they wake up. It's like sleeping beauty. You're just watching them gently wake up after. One of the big concerns with THRIVE has always been, well, is carbon dioxide building up while you're using it under anesthetic? And it does, but it's relatively slowly, particularly in people that are normal body mass index, and we've actually shown in a prior paper that it increases by about 0.8 per minute.

So you think about that, you could operate for a relatively long time without a significant increase in CO2. I've done a patient 54 minutes using THRIVE. The thing we presented at COSM was basically how safe is it? So one of the big concerns with THRIVE has been, you have a high oxygen field, it's a hundred percent oxygen. Can you use things like lasers and coblation and a variety of other things and have a risk of an operating room fire? Other people have shown that they've used laser very successfully with THRIVE. And our study presented was basically looking at a cadaver model where we measured oxygenation throughout the field and tried to determine whether or not where the oxygen was highly concentrated. And then we used the CO2 laser and a KTP laser and we couldn't even start a fire. We tried to start a fire and we couldn't start a fire. And if you use coblation because it's under saline, I think the risks are even lower. So it's very safe if people are cautious and follow normal operating room protocols in relationship to fire prevention.

Paul Bryson: Yeah, I mean it has really been a change in our practices. When I started and you've seen all sorts of things, we do intermittent apnea where we put the breathing tube in or take it out. Jet ventilation, which requires some comfort and some technical expertise from anesthesia, and now this, I think the science is still pretty technical, but the ease of use is pretty significant and the safety seems to be really quite good. I probably use it most commonly now for those types of procedures.

Michael Benninger: Yeah, I bet well over 50% of my procedures are done with THRIVE. The one limitation would be somebody that's obese, their CO2 tends to rise fairly quickly and their oxygenation tends to drop fairly quickly, so you have to pick your people carefully. You also can't do it in very large bulky tumors where you're going to have a lot of bleeding because there's nothing really protecting the airway below. So we would typically use an endotracheal tube under those circumstances, but I've seen it used now internationally. I can't tell you how many papers I've reviewed related to adaptation adoption of THRIVE for a number of different laryngology procedures.

Paul Bryson: What else stood out to you? You had mentioned sort of your interest in chronic cough and hyper hypersensitivity disorders in the larynx. Any things on those topics that you wanted to highlight?

Michael Benninger: Well, the interesting thing is we thought for a long time there would be these new P2X3 inhibitor drugs that would come out and would give us an option in patients with chronic hypersensitivity disorders such as chronic cough, unexplained chronic cough, and they've basically kind of fallen by the wayside as far as we can tell. There's still one that I know of that's still in development, but the FDA hasn't approved, it hasn't been approved in other countries. So we see this really complex group of patients with, we'll talk about cough primarily, that basically have had everything done for their chronic cough. They've had a thorough pulmonary evaluation, allergy evaluation, a trial of nasal treatment, reflux treatment, even aggressive reflux treatment and fundoplications, they're still coughing. Well, our next modality tended to be neuromodulator medications such as gabapentin and amitriptyline or nortriptyline and a number of others, and only a certain number of patients respond to those, so we were kind of stuck with a high percentage of patients that had no relief for their chronic cough.

I saw a lady in the office about a year ago who was coughing every 15 seconds, maybe even less every 10 seconds, and apparently throughout the night. Over the past five years, we've been doing superior laryngeal nerve blocks, Blake Simpson initially introduced this and it was fantastic, and we adopted it fairly quickly. Now, we've done hundreds of injections in our group for people with chronic cough with remarkably good success with about 75 to 80% of people having some response, about 50% of people having a 90%+ response.

We do a series of three injections with one cc of Kenalog of 40 milligrams and one cc of 1% lidocaine of those people that respond to three injections, about a third are fixed, and then there's another third, another group that aren't, and we come back and we can do repeat injections. Well, the interesting thing is we started to think, well, maybe there's a lot of hypersensitivity that cough is just one manifestation, but patients with chronic throat pain, particularly if they have isolated trigger zones, patient with a lump in their throat or globus sensation or chronic throat clearing or just generalized throat discomfort, and this is probably part of a bigger vagal sensory neuropathy that is all tied up together, and we found in those groups, maybe not quite as well as the chronic cough patients, we've had a pretty remarkable response with a number of those orders, probably about 50% of those patients.

And then as a last resort, well, maybe not as a last resort, maybe it's sooner we try Botox injections, and there was a recent paper that showed that Botox injections can be effective, and now we do a bunch of patients, that isolated group of patients that either don't respond or respond and it comes back, with Botox and we probably get about a 50% response with Botox. And it keeps them off those neuromodulators, I mean the neuromodulators have terrible side effects in many patients to the point that our pulmonologists now send us, you and me and our other two laryngologists, some of their more senior patients before they even try a neuromodulator because they don't want to risk falling and they don't want to risk the fatigue associated with it. And if we get a success, then they don't have to worry about it. So it's really been remarkable what's been going on in relationship to this vagal neuropathic disorders and sensory neuropathy.

Paul Bryson: Yeah, I mean this is another one of those things that really, over probably, what do you think the last 10 years or so has really the paradigms in the approach have changed a bit. There was definitely sort of that arrow where a lot of complaints were attributed to laryngopharyangeal reflux or things like that, and yeah, it's been a really nice thing to be able to offer patients. We have sort of an arsenal of things to try for people, and it is nice to spare people like oral medications if you can.

Michael Benninger: We published a paper, Andrea Campagnolo, who's a laryngologist, who treats the stars in Rio de Janeiro, and I published a paper, we submitted it in 2015, published in 2016, just discussing this whole idea, is this all part of a big vagal neuropathy? And you actually think about it. If it is, then maybe reflux is related to it. Also, decreased esophageal motility, decreased lower esophageal sphincter tone, decreased gastric emptying. The gallbladder is not necessarily releasing the bile acids that it's needed to or at the wrong time, so it's kind of exciting. I think the other exciting thing with reflux is increasing use of the alginates and kind of moving away from the proton pump inhibitors. The alginates are very different the way they work.

Paul Bryson: Yeah, they're almost nutraceutical, right? They're not traditional medicines, and so they help form this little barrier raft in the stomach when you take them. Yeah, that's a great point.

Michael Benninger:

And they're relatively inexpensive and you buy them over the counter. I think there's one limitation that people don't really pay much attention to is that they may not be very effective at bedtime because the lower esophageal sphincter, if you're lying flat, is lower than the acid level in your stomach, so you either have to elevate or you have to turn on the side to try to keep that acid level actually below the lower esophageal sphincter.

Paul Bryson: Yep. No, that's a great point. Well, I wanted to switch gears a little bit and discuss our Voice Center and in the work that you do and have been doing for people really across the world who use their voice professionally. Care of the professional voice has been a passion of yours for really throughout your career. Can you speak a little bit, what are some of the issues that these types of patients may have and when the complaints that you've heard when they come to our center and the work that you and our team do when we treat these patients?

Michael Benninger: Well, we have a remarkable Voice Center. I mean, we have four experienced laryngologists. We have four outstanding voice pathologists that focus only on voice, one of whom is a PhD, and we've been very fortunate. We actually have a recording studio in our clinic. We don't use it so much anymore for recording because everybody can record with their cell phone now, but we use it to have a soundproof room to let people warm up and it's comforting…

Paul Bryson: We have a piano there and it's a great place for treatment and therapy…

Michael Benninger: But professional voice and performing voice has been part of my career since I was a resident working with Richard Miller at Oberlin University, doing my research project and becoming an officer of the Voice Foundation very early, probably in about 1993 or ‘94. It's great to be at the Cleveland Clinic if you're interested in professional voice or performing voice in part because a lot of the performers get their executive health at the Cleveland Clinic, so they come in periodically just to get their heart checked or they get their general physical examination or executive or wellness evaluations, and they kind of float up into our clinic and we can check on them and make sure things are fine. The things that we see primarily in performers are acute illness for the most part, so a lot of the big performers, whether they're based in Cleveland or coming from out of town, they come in because they have an acute problem.

Locally, we see a lot of people with more chronic problems. We see students at our fine universities and we have Oberlin University and Classical Music and Baldwin Wallace and musical theater and Kent State University and the Cleveland Institute of Music, even Cleveland State has built a fine voice program. They send us a lot of their students either because they want to know if they're going to hurt themselves or if there's anything wrong, or if they do have a chronic disorder like nodules or strain or stress disorders or reflux, then we can evaluate and treat them and then they can kind of advance their career within these institutions. Many of us actually have appointments at Oberlin University as part of their faculty, so it's a beautiful symbiosis. I think it's the wonder of treating voice patients and being part of a voice team is that combination of laryngologists, speech, language, voice pathologists, teachers of singing, and if you look at the Voice Foundation, really some of the best science that we've seen and voice scientists anywhere in the world, combining all of those is more multidisciplinary than many other of the medical specialties, and it's fun.

Paul Bryson: We have a good time, and I think for a lot of the patients to be able to come and get treated and to be heard, I think we have a good time delivering the care that we do.

Michael Benninger: Absolutely.

Paul Bryson: Well, as we wrap up, any final take home messages for our listeners? Anything you're excited about on the horizon from a research standpoint?

Michael Benninger: Well, I just heard a presentation at the Voice Foundation by Susan Thibeault who is at Madison University, and she really was speaking about the genetics and the ultra-structure of vocal folds and how genetically it develops and lamina propria and all these really interesting things that we're just starting to understand after all these years.

And I'll finish with the one last thing is that we've worked very, very closely with the Cleveland Museum of Natural History that has this phenomenal skeletal collection, maybe the finest skeletal collection anywhere in the world of hominids, from Homo sapiens to apes, to chimps to antiquity, hominids, Homo Erectus and you name it. And we've really done some work with them looking at skull base angles and the descent of the larynx, and maybe this made a big difference. Our ability to develop connected speech, which may have separated, for example, Homo sapiens from Neanderthals Homo Erectus that were about the same time, Homo Erectus a little bit earlier, very smart species. The Homo Erectus domesticated, the dog, Neanderthals had bigger brains than humans did and had cave drawings and fire and were hairy and could survive the ice age, and yet they're all gone now. There are other theories, but it's an interesting theory and we've been able to publish on this, and perhaps we'll find out more that how we developed our larynx is really what separates humans from other antiquity species.

Paul Bryson: Well, it's very fascinating and I really appreciate you coming on the podcast today. It's great to have you.

Michael Benninger: It's great to be here. Thanks, Paul.

Paul Bryson:

For more information on our laryngology and 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. Benninger, thanks again for joining Head and Neck Innovations.

Michael Benninger: Great to see you, Paul. Thank you.

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.