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Clinical Voice Disorders: A Practical Approach
British Voice Association event report – Gill Jolly, Speech and Language Therapist, Huddersfield
Anyone worried about moving the BVA clinical voice days to Manchester would surely have been reassured as the packed programme on day one began with a great presentation by Jane Shaw (SLT) and Mark Watson (ENT Consultant) from Doncaster. They described how they use nebulised lignocaine to provide local anaesthetic to patients who attend for cord medialisation/ augmentation in the outpatient clinic. The procedure works well for patients who need some 'fine-tuning' after thyroplasty, or a quick fix (for whatever reason), those who can't tolerate GA and those who need something temporary so they can 'test drive' the effects of cord medialisation.
Jenny Ellis then shared her inspiring but gloomy story of navigating a small SLT canoe over some serious NHS rapids as she attempted set up a speech therapy-led endoscopy clinic in a rural cottage hospital in Northumberland. Sadly, having finally got everything in place, the cottage hospital was closed! She shared the podium with Professor Janet Wilson who highlighted the effect of patients being redirected from voice clinics into the cancer waiting time clinics (despite only 7% of people with hoarseness having cancer). She then led a discussion on how we solve the problem of getting patients into the most appropriate clinic.
Phil Jones followed this with his thoughts on the value of a specialised ENT/Speech therapy service for voice and swallowing disorders, laryngeal procedures and non- specific throat symptoms. He encouraged us all not to give up, but to pull together, and produce evidence to support our cause.
After coffee we had to choose between 'neurolaryngology' or 'laryngeal mechanics and voice therapy'. I thought a bit of revision wouldn't go amiss and opted for the latter. It is reassuring to find that, finally, concepts that were once perplexing have become familiar and not so threatening. Thanks to Tom and Sara Harris!
After lunch, we had to select 3 workshops from a choice of 10. I had opted first for 'acoustic voice analysis'. This was fascinating, but a lot of it went over my head. As a therapist with no proper therapy room to work in for goodness sake, I can only dream of having access to objective acoustic measures!
I spent the next 45 minutes with Tom and Sara Harris as they demonstrated a high definition digital stroboscope with laryngograph. The rep, Xing Huihu, was an experienced and tolerant 'patient' and therefore easy to scope. The pictures were fantastic and the accompanying objective measures clearly useful. I'll keep dreaming…
My final session of the afternoon was an invigorating voice workshop with Lynne Wayman. After a day of mostly sitting it was great to do something more physical and make some noise! Lynne had lots of useful, practical ideas about working with singers and I left feeling inspired and re-energised.
Day 2 began with a very helpful presentation on vocal cord dysfunction with Sue Jones (SLT) and Dr Robert Niven (chest physician). Dr Niven talked about the different patterns of dysfunctional breathing (most of which I'd never even heard of) and how asthma patients may have more than one. He personally believes that VCD is the least common pattern for asthmatics, (but other centres think it's more common.) He then described the patho-physiology, presentation, aetiology, diagnostics etc and Sue Jones then went on to discuss the role of the SLT in managing these complex patients, emphasising the importance of working as part of a MDT. As she talked about therapy techniques (release of constriction, accent, sniff and/or pursed lips techniques, relaxation, counselling etc) I was both reassured by the familiarity and disappointed that she hasn't discovered the one therapy technique that always works for everyone!
Dane Chalfin then gave us an excellent session on rehabilitation of the singing voice. He managed to get us all (even the men in suits!) out of our seats and making some noise and altering our posture. He talked about effort levels and the importance of developing the kinaesthetic awareness that enables the singer to "work on releasing superfluous tension while maintaining desired work".
After coffee we again had a choice.' The diagnosis and treatment of benign vocal fold lesions' was tempting (lots of excellent pictures!) but I opted for the session on 'measuring outcomes'. We divided into 3 groups, each to discuss the best way to measure outcomes for a particular patient. I'm afraid our group didn't completely stay on task, but there was some lively debate about what exactly we should be measuring. (e.g. Is the appearance of the vocal cords post therapy as important an outcome measure as patient satisfaction? Should we be doing a GRBAS every session?) We raised more questions than we answered. Finding effective but simple outcome measures will remain an important challenge to our professions for some time to come.
After lunch (when I mistook a meatball for an onion bhagi – bad moment) Sue Jones and Dane Chalfin bravely stepped up to lead a session on the effects of 'distortion singing' on the voice. (Julian McGlashan was unable to do this presentation as planned – although you can see him on Youtube!). We watched some videos they had made of Dane speaking and singing with various vocal sets, and Dane did a live demonstration of distortion in a number of vocal sets. This was great stuff -thanks to Sue and Dane. Tom and Sara Harris also helped out, showing videos of a variety of singers.
Finally, and by this time I have to confess to feeling a bit 'saturated' and not sure I could take in much more – the sign of a good course I think – we had some case discussions led by Drs Perouse and Colombeau. (The delicious French accents adding a 'je ne sais quoi' to their fascinating films of organic lesions.) The Harrises and the Joneses then presented a case each and we were all sent on our way, grateful to the Wythenshawe team and the BVA for an excellent 2 days.
Other speakers: Jacob Lieberman DO MA Osteopath and Psychotherapist, Moira Little specialist in voice disorders, Dr Andrew Marshall Consultant Clinical Neurophysiologist, Dr Robert Niven set up multi-disciplinary, severe asthma clinic at South Manchester Trust/ University, Dr Mark Roberts Consultant Neurologist, Dr Jon Sussman Consultant Neurologist.
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