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5th BVA Voice Clinic Forum Day

6th March 2008, London

A Speech and Language Therapist's perspective

British Voice Association event report – Philippa Moll

The meeting was opened by Ruth Epstein SLT, the BVA Voice Clinic Forum organiser, who introduced the first speaker, Lesley Mathieson. It was Lesley who organised the first National Voice Clinic Meeting at Northwick Park Hospital with her colleague, ENT Consultant Ram Dhillon, in 1993. As Lesley explained, these meetings have given ENT, SLT and other colleagues an equal opportunity to express their views and thereby promote interdisciplinary understanding and respect. Since voice clinics have the potential to offer best practice in the care of individuals with voice disorders, she suggested that future forum topics might include 'standards for voice clinics' and 'unifying terminology.'

We then moved on to the main topic of the day — 'To Rest or Not to Rest: Protocols and issues related to post-operative management of voice disorders.' The speakers included ENT surgeons and SLTs, all of whom mentioned factors which should be considered when advising on the type and duration of voice rest. These included the site and extent of the surgery and whether the free edges of the vocal folds are involved. They agreed that there was a need to balance allowing time to heal with too much voice rest potentially causing muscle atrophy. There were references to skin wound healing and sports injury surgery/rehabilitation and how research in this area had influenced decisions about voice rest. Vocal demand and vocal load were also considered. Advice is mainly based on received wisdom and clinical experience due to paucity of evidence.

Declan Costello, ENT Surgeon, kicked off by reminding us about the principles of phonosurgery: careful patient selection and meticulous surgical technique. He discussed some research and considered the impact of laser versus steel, reflux and whispering on the healing process. He presented voice rest advice from several eminent laryngologists but there was no consensus.

Gary Wood, SLT said the patient should be advised to avoid activities that can be injurious to the healing process and that advice and therapeutic techniques need to be clinically sound and specifically targeted.
The Voice Clinic team from Derby, Sharat Mohan (Consultant ENT surgeon) and Kate Young SLT, continued with the voice rest theme. Kate talked about the different aspects of voice rest: complete, relative, voice conservation and the role of voice care advice. She outlined some therapy intervention, pre and post surgery and touched on the issue of patient compliance. Sharat discussed the rationale for voice rest following phonosurgery for different vocal pathologies. They concluded their talk by saying, 'As representatives of voice health we need to prioritise research looking at these issues.' Later on there was discussion about research and the practical and ethical challenges.

Simon Eccles, Consultant Plastic and Craniofacial Surgeon, gave a talk entitled 'Microbiology of Wound Healing'. He considered the surgical wound in terms of type, position, pre-existing conditions, systemic illness, effects of topical agents and scarring reaction. He outlined the four stages of wound healing, acknowledging it is a complex process and mentioned potential complications.

The morning session concluded with a round-table session with the speakers, chaired by Guri Sandhu, Consultant ENT Surgeon. It was suggested that the meeting could agree on some basic standards on voice rest based on our current level of knowledge. There was some heated debate as to whether guidelines could be formulated which are not evidence based. It was agreed that a 'Voice Rest' working party would be convened and their findings reported.

After lunch Sara Harris gave a comprehensive talk on the role of the SLT and post-operative voice therapy. It linked in well with the previous talks and she also addressed the issues of SLT staffing levels, and the timing and number of treatment sessions.

Ruth Epstein introduced Ambulatory Phonation Monitoring. This comprises a portable device which can monitor key phonatory behaviour and assess vocal load. Pilot studies have already demonstrated that the individual's perception of vocal behaviours and what they are actually doing (measured by the device) are very different! Further research is needed to assess if it has the potential to be a beneficial and cost-effective clinical tool.
The day concluded with an update on administration and management issues related to voice clinics. David Rees, Operations Manager at RNTNE, talked us through a range of issues. The final discussion session was chaired by John Rubin, ENT Consultant, who pursued the theme of government regulations and the potential threat to NHS voice clinics.

A stimulating day which emphasised the importance of good practice, teamwork and sharing of knowledge and skills.

Thank you to the exhibitors: Kay Pentax, Laryngograph, Medtronic and Plural Publishing and thank you to the organisers Ruth Epstein and Guri Sandhu for an excellent day.



A personal view of the day

A Speech and Language Therapist's perspective Joan Viskant


It was surprising to find no voice teachers at the March Voice Clinic Forum. I have noted inconsistencies between various teachers' physiological/mechanical knowledge of the voice, and often very little medical knowledge.

There is indeed a wide variety of skills listed for teachers on the BVA website. So I could see the enormous benefit of the day as an opportunity to learn, provide another point of view and contribute to developing a benchmark for healing time that could be used as a rubric for medical professionals, teachers and professional voice users.

The Forum topic was VOICE REST (Protocols and issues related to post operative management of voice disorders). Every performer looks for someone to answer the question 'When not to sing, and for how long in case of voice injury?' So I came looking for answers.

Dr. Ruth Epstein (Consultant Speech & Language Therapist RNTNE Hospital London) introduced the programme, announcing that it has been 15 yrs. since their inception. Technology, experience and practice have changed since then, and the Forum has allowed experts to share their expertise and discuss many issues.


Topics included the following:

'Pros and cons of voice rest' – Problems of too much voice rest can include muscle atrophy and inflexible scar tissue. Too little rest could lead to scarring, inflammation or bleeding.

'Principles of surgery and wound healing' – the location of the wound could determine how it heals and how long it takes.

'Voice hygiene' (e.g. avoiding coughing, throat clearing, smoke or chemical irritants).

'Conservation' (different techniques, including the 'confidential voice'). I was very pleased to see that both Mr. Nohan and Dr. Epstein expressed the importance of nutrition in healing.

'What is adequate care?' (including standards that define competent voice clinics).

The floor then opened up to discussion with the morning speakers, chaired by Mr. Guri Sandhu. I asked if the surgeons discuss with their patient anything that might help determine the time of wound healing. After a VERY long pause I received my answer: No. I was told that the patient can be in a very vulnerable state at the time the surgeon actually gets to speak to them. However, one surgeon did say that he asks to see other wounds/scars to determine how their body has healed in the past. It was my impression that not all surgeons do this, so this was very useful information to pass on.

As the surgeon has a very specific job to do, perhaps someone other than he should be available to assemble specific patient information which may influence the wound healing. The SLTs who spoke at the conference impressed me by their willingness to do their utmost for the patients. They insisted that the best recovery is one which includes a meeting with the therapist BEFORE the operation (although this often does not happen, according to some). This makes perfect sense to me after listening to the stages of wound healing. They are a vital link. I know that my recovery time would have been a fraction of what it was had I been able to see an SLT sooner after my operation (and ideally before as well). Some also complained of inadequate case notes, or having to see the patient with no notes at all.

The Forum agreed that there was no standard pathway for healing. Dr. Epstein has organised a committee to put down guidelines for the members based on the expertise available and the consensus of the Forum.

Until the specialists have a general accord in this matter (allowing for differentiating factors of each specific case) how does this trickle down to the voice teacher and the patient? Ultimately the result of treatment should be both the improved health of the patient and hopefully the successful continuation of their career.

I would like to see the committee follow five difficult patients, from pre-injury health/behaviour through surgery to the resumption of their voice career, and see what gaps exist in their treatment (and what questions might have provided clues to better treatment). Voice teachers/users could add some useful insight.


Joan Viskant is a professional singer from Chicago with experience in voice-overs and performance for film, T.V, radio and theatre (mainly in jazz music) in the U.K. and overseas. She has trained in the U.S., Great Britain and France. She has taught voice privately and is currently completing a course in Naturopathic Nutrition at CNM London. Having had invasive surgery which affected her voice, she is looking to use her experience and training to provide auxiliary support to professional voice users.



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