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Unable to say hello from the other side

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February 20, 2017
by Adam D. Rubin, MD

April 16 is World Voice Day. As otolaryngologists, we are responsible to celebrate this day with the community. The day was created to raise awareness of laryngeal cancer. Early recognition of vocal fold cancer can yield a better prognosis for cure and voice preservation. However, early recognition of any voice problem yields the best chance for voice recovery. The day's meaning has expanded, and the main message is to not take your voice for granted.

You may not realize how important your voice is to you until it is gone. I say “you,” because I think it is important that we as physicians consider what voice loss would mean for each of us. Last year, I experienced this firsthand and hope my story will inspire you to not take your voice for granted.

Every year that I have been in practice, I have hosted a concert in honor of World Voice Day. As a former professional actor and singer, I admit I enjoy being on stage again. However, I get more satisfaction watching my patients who have lost and regained their voices share their stories with an appreciative audience through beautiful performances and testimonials. These are not all Adeles or Frank Sinatras or Plácido Domingos. They are people who love, or have grown to love, their instruments and realize through voice loss and recovery, how important their voices are to them.

There have been some inspiring performances. One came from a young pharmaceutical representative (former professional singer) who presented to me after losing her voice following surgery for an aggressive thyroid cancer. The cancer had invaded the recurrent laryngeal nerve, and after dissection the nerve was not functional. The contralateral nerve was uninvolved with the cancer but was transected during the surgery.

This patient was left with bilateral vocal fold paralysis and a wide-open glottis. Her voice was barely a whisper. She went through multiple surgeries and radiation to battle the cancer, which recurred multiple times before ultimately being defeated. The intact vocal fold would intermittently regain function but then would become temporarily paralyzed with each additional treatment. During this trying time, the patient often seemed more distressed about her voice than the cancer. Without her voice, she lost part of herself.

The young pharmaceutical representative performed at many of our concerts through the different stages of her battle-at times with unilateral, and other times with bilateral, vocal fold paralysis. Through hard work with our voice team, she was able to regain a beautiful singing voice and move audiences to tears every April.

Another memorable performance was a testimonial from a prosecuting attorney who had been required to postpone a trial for a horrendous murder case after injuring his voice. He had a large hemorrhagic polyp requiring surgical intervention. He had never recognized how important his voice was until he found himself powerless in the courtroom and unable to read to his children at bedtime. Fortunately, we were able to help him restore his vocal power so he could put away the perpetrator for life and entertain his children.

Then there was the young band teacher who had developed meningitis and sepsis years ago and suffered severe injuries to the vocal folds from a prolonged intubation. He had significant scarring of the vocal folds, impairing their ability to vibrate and close. Through hard work and treatment, he continues to wow people and do what he loves best.

Last, but certainly not least, there was the reverend who could not preach to his congregants because of vocal injury. After recovery, he blessed us all with a moving rendition of Martin Luther King's “I have been to the mountaintop” oration.

In 2016, I celebrated World Voice Day in a somewhat different fashion. After talking over loud noise at a party in late February, I found myself hoarse the next morning. I performed self-stroboscopy (advantage of being a laryngologist) and discovered a small, localized hemorrhage in my left vocal fold. I then became ill and coughed for 2 weeks straight. My hemorrhage developed into a polyp. Although, I initially was most concerned about having to cancel the concert, I soon recognized much more was at risk.

I struggled as a physician. It was difficult to talk to patients, let alone demonstrate vocal tasks that I routinely ask them to perform during examination. It was difficult to be myself and demonstrate the empathy that routinely accompanies patient care. I came to the stressful realization that my polyp required surgical management. How was I going to manage this? Taking significant amount of time off work is not practical for a physician. I wondered, “What if I do not have a good result and cannot regain my voice?” I had just transformed from physician to patient-a difficult transition as we are often too busy taking care of others and forget to take care of ourselves.

I took 10 days off work after surgery and drove to the East Coast with my wife and two kids. I was on complete voice rest. Imagine spending a week with your family without speaking. To top it off, we were visiting Grandma! I improved my texting, writing, and self-made sign language skills. I might have even improved my listening skills. There were moments of comedy, and many moments of frustration. I subsequently returned to work, but I did everything I could not to overdo it with my voice. I scheduled fewer patients, wrote a lot, created more pre-prepared instruction, and used my support staff to explain things I normally would. I had the front desk forewarn patients of my predicament and was moved by how understanding most patients were.

I continued to be a good patient, did my voice therapy, and am singing and doctoring again at full strength. I attribute this to recognizing and facing my problem expediently, despite the inconvenience, anxiety, and other challenges involved. Had I delayed treatment, my polyp might have caused additional injury. Perhaps I would have formed a type III contact sulcus on the contralateral fold, and my voice would have continued to worsen. Perhaps my recovery would not have been as successful, and I would continue to struggle as my dysphonia affected my work and quality of life.

Being a physician is a vocally demanding job. I wonder how many of us recognize this. What kind of physician would you be without a voice?

When Adele, Sam Smith, or John Mayer must cancel a concert or tour, the whole world hears about it and mourns. This is because these are incredible voices that we all cherish. But I would argue that the voice each of us should cherish most is our own. This is the message of World Voice Day.

There was no World Voice Day concert for us in 2016. In 2017, I will have an even greater appreciation for the day. There is no better way to develop more empathy and understanding as a physician then to go through what your patients experience. I will be ready to rock this April 16-of course, with good vocal technique. Happy World Voice Day!

If you would like to see some testimonials and performances, please visit: www.youtube.com/user/lakeshoreprofvoice/.

Director, Lakeshore Professional Voice Center, Lakeshore Ear, Nose and Throat Center, St. Clair Shores, Michigan, Associate Professor, Oakland University William Beaumont School of Medicine, Rochester, Michigan, Associate Clinical Professor, Michigan State University, Lansing, Michigan
Ear Nose Throat J. 2017 February;96(2):50-51