Art and Science of Voice
We often take the ability to talk for granted, unless it is diminished or even taken away. When that happens – such as vocal tremor or because of damage from laryngopharyngeal reflux – the experience can be both frightening and frustrating. Speaking, after all, is part of our identity and how we interact with the world.
Every day, nearly 30 people are seen by Dr. Lerner (a laryngologist, with fellowship training, specialized ENT for voice, swallowing, and airway disorders) and Andrew Keltz (a voice-specialized speech language pathologist) at The Voice Center at Greenwich Hospital. Michael Lerner, MD, is an Associate Professor of Surgery (Otolaryngology); Director of The Voice Center at Greenwich Hospital; Chief of Otolaryngology, Surgery, Greenwich Hospital. Andrew Keltz, MS, CCC-SLP, collaborates with Dr. Lerner in providing multidisciplinary care in the evaluation and treatment of voice (including singing voice) and upper airway disorders.
Specific, Yet for Many
“When you say, ‘ENT’ [ears, nose and throat], our patients, essentially, have problems in the ‘T’ part: the throat, or the larynx,” begins Dr. Lerner. “When people hear ‘Voice Center,’ they think it’s for singers and other voice professionals. We absolutely do that, and we enjoy doing that a lot, but we also work with patients who have other conditions, including neurologic disorders, such as Parkinson’s disease, and vocal cord paralysis from cancer or surgeries, such as spine surgery. We give them their voices back.”
They also treat R-CPD (Retrograde Cricopharyngeal Dysfunction), a medical condition known as “no-burp syndrome,” in which the cricopharyngeus muscle (located at the top of the esophagus) is unable to relax. The condition leads to bloating and discomfort. “We are a destination practice for this. Our program pioneered this treatment with Botox here on the East Coast, and people travel from very far to have to have this done with us,” says Dr. Lerner. “In addition to Botox, Andrew and I developed a complementary behavioral protocol to enhance our patients’ outcomes.” (See their article recently published in The Laryngoscope.)
Before becoming a speech pathologist, Keltz was a singer and an actor. “What drew me to the realm of voice, of course, was that I used my voice, he says, “but also the collaborative nature of this specialty. At the Voice Center, you see the doctor and the behavior specialist, who can help fine tune the treatment. There’s often a role for trying to identify behaviors that may be causing and/or perpetuating a problem.”
Looking at Sound
Losing one’s voice can be related to overall voice use — singers, actors and politicians — but age can also play a part. Presbyphonia is the age-related change in voice characterized by a weak, breathy and hoarse voice with reduced volume and stamina. This deterioration is caused by natural atrophy and thinning of vocal muscles, leading to reduced vocal fold closure. “There are a lot of things we can do about it,” says Dr. Lerner, referencing speech and voice therapy as well as vocal cord injections. Of course, high-end medical equipment also helps.
Laryngeal stroboscopy employs stroboscopic light to examine the vibrations of the vocal folds during speech by generating a slow-motion effect. This way, healthcare professionals can analyze the vocal folds edges, closure, and vibration patterns, which are essential for diagnosing voice disorders. For the procedure, a flexible endoscope is inserted through the nose and uses a synchronized flashing light with vocal fold vibrations for video. “Vocal folds vibrate hundreds of cycles per second. Only with this type of equipment can you play it back and really examine the vocal folds’ vibratory properties,” says Dr. Lerner. Patients also see biofeedback on a monitor. “They find it fascinating.” As voice imaging technology continues to advance, continued investment in stroboscopic lighting and computer processing plays an important role in maintaining the highest standards of vocal healthcare right here in Greenwich.
Other equipment analyzes acoustic recordings, and, thanks to a donation from a generous patient, phonatory aerodynamic system helps to objectively measure features like the velocity of air while a person is voicing as well as aerodynamic resistance.
They recently added a second voice therapist, Sari Koppel, MS, CCC-SLP, and are designing a second voice therapy room equipped with advanced acoustic and aerodynamic tools. “This will expand both clinical capacity and research opportunities,” Dr. Lerner says.
On the Horizon
“We can now see, measure, and treat voice conditions in ways that weren’t possible before,” Dr. Lerner says. “Using an advanced array of tools, we are able to analyze the voice acoustically and closely evaluate the structure and movement of the larynx.” He notes that EMG (electromyography) helps him precisely guide Botox injections into the small vocal muscles. Additionally, the program’s KTP green light laser allows many vocal polyps to be treated in the office under local anesthesia, avoiding the need for general anesthesia and a trip to the operating room.
“I grew up in Connecticut,” Dr. Lerner says. “Andrew and I care deeply about building an exceptional voice program for our community.”
Andrew adds: “The voice is how you convey who you are. The voice is an intrinsic part of our sense of self and our identity. Making space for that is very meaningful for us.”