Working with Professional Voice – the value of ENT & SLT collaboration

Ahead of the RSM Laryngology & Rhinology division‘s webinar on The Professional Voice, on 5 th February, I’m mindful once again of how valuable close ENT & SLT working is to caring for our patients and clients. In this particular webinar, I’ll be taking part in the professional panel, as a voice specialist SLT, responding to any questions that may come my way.  

For me, the definition of a professional voice user is broad, including a diverse range of occupations including teachers, lawyers, religious ministers, telesales workers to name just a few, and extending to broadcasters, professional performers and singers. 

A standard and well known aspect of our work tends to be around vocal hygeine and voice care advice; by far the most straightforward area of our work and one that poses the least challenge . However, voice care advice alone is rarely sufficient to rehabilitate damaged vocal folds and / or remediate voice dysfunction – an hour glass vocal fold closure pattern for example is unlikely to be improved solely by increasing water intake, steam inhalation and longer periods of vocal rest. 

The areas of greater work for SLT voice clinicians tend to centre instead around selecting the right exercises to restore function and in gaining the client’s trust first to trial different techniques. and then to generalise them – a process which generally requires a period of time, confidence building and a structured therapy process.

The triple focussed early starting points for voice therapy clinicians are:
⁃ the ENT diagnosis 
⁃ the perceptual presentation of the client’s voice 
⁃ the voice history.  

In this article, I will feature vocal fold swellings, one of the most common injuries experienced by professional voice users. Vocal folds closing with too much force or constriction within the larynx are just two reasons why they may form. Over time, the size of the swelling(s) can increase, usually resulting in correspondingly increased levels of dysphonia, voice variability and vocal fatigue. For vocal folds to vibrate in the spectacularly fast way that they do during phonation, they need to travel light and any increased mass impedes the efficiency of their vibration. The increased effort required for voicing leads to one of the most common complaints from clients of vocal fatigue e.g. “It gets harder to speak as the day goes on” or “After singing, my voice is taking longer to recover”.

In most cases, the laryngeal exam carried out by ENT will reveal any vocal fold pathology . A very small swelling, depending on its position and the general status of the larynx at the time of the assessment can sometimes be hard to detect. Clients who struggle to tolerate endoscopy can compound the difficulty as adequate visualisation of the larynx is sometimes not achieved.  

If swelling(s) is/are detected, distinction between the type of growth(s), as early as possible is important. Therein lies an area of Voice SLT work where experience level of clinicians and their collaboration with ENT becomes highly important. To illustrate this, I will draw upon two fairly recent cases, each involving a female singer. 

Case example 1: ‘Ellie’

Ellie self referred to my private practice due to difficulty with her singing voice. She worked as a performer in musical theatre, mostly overseas in her European homeland. Ellie came to the U.K and began work as a singing teacher at a theatre school. Her voice difficulties had increased to a level where had asked her agent to not put her forward for any musical theatre roles. 

In her native country, Ellie had seen an ENT twice and had been diagnosed with vocal fold nodules. She was recommended to have speech therapy which she was unable to start before leaving for the U.K. Working with the initial ENT diagnosis of vocal nodules, I began a treatment programme which the heavily compliant Ellie initially appeared to respond to. However, by session 3, there were signs of particular blocks in her voice. This, together with a lack of general progress and the admission in her initial voice history that “looking back, my voice has been effortful for a very long time” influenced my decision to ask Ellie to have a second ENT assessment with a specialist laryngologist prior to continuing with additional voice therapy.  

Ellie describing her voice at her initial assessment

Once clinical instinct and reasoning bring the SLT to this point, practical obstacles need to be overcome to progress things forward. Ellie had referred herself to private voice therapy but she did not have private health insurance which posed a challenge regarding accessing a private ENT assessment. After discussion with Ellie regarding NHS and private options, I wrote to the client’s G.P requesting an NHS referral to a tertiary Joint Voice Clinic service. In the interim, a request to a private ENT colleague regarding the possibility of a reduced self-pay fee was successful and Ellie was seen promptly.

Rigid endoscopy revealed a polyp which would require surgical management followed by voice therapy. The initial voice sessions were helpful to reduce the level of Ellie’s dysphonia and to help her maximise her voice’s ability but carrying on with voice therapy in light of the lack of adequate progress and subsequent diagnosis of vocal polyp would not have been the appropriate management for Ellie.  

Case example 2: Rose

A professional cruise ship singer named Rose self referred for private voice therapy following her struggle with ‘voice deterioration’ and an ENT diagnosis of ‘a vocal fold nodule’. Even prior to the impact of Covid-19 on the entertainment industry, Rose had ceased working on the cruise ships due to loss of vocal ability, including restricted vocal range and stamina. She had reverted to her previous profession of hairdressing.  

Immediately when I come across the description of ‘a vocal fold nodule’ , the words set off the need to find out the type of swelling and where on the vocal fold it was located. 

Although Rose’s voice quality showed minor signs of improvement with the techniques trialled in my initial assessment, I suspected a likely vocal fold cyst due to the type of vocal restrictions she presented with. I recommended an ENT review so that her management could be optimised. Rose was found to have a large intracordal cyst requiring surgical incision and a surgical date was booked.

In the above cases, the experience of the voice clinician including recognition of the dysphonic presentations of the clients’ voice played a central role which was grounded in a background of allied medical knowledge of working within both NHS and private practice systems. Close liaison with ENT helped to advance the clients’ journey towards gaining a more specific / recent diagnosis which in both cases led to surgical interventions by ENT as the primary form of management prior to further SLT treatment. Successful ENT and SLT liaison and collaboration yields the best chance of restoring the professional voice user back to sustained healthy voicing. In many cases, it can return them to performance careers that many fear they have lost.