The Voice Clinic Who's who: a guide to who does what in a Multidisciplinary Voice Clinic
by Sara Harris (Specialist Speech and Language Therapist and Team member, The Lewisham Voice Clinic, London)
The Multidisciplinary Voice Clinic
The Multidisciplinary Voice Clinic (MVC) is an NHS assessment and treatment clinic for people with voice disorders. The Voice Clinic core team should always include a Voice Specialist Ear Nose and Throat (ENT) Surgeon (a Laryngologist) and a Voice Specialist Speech and Language Therapist (SLT). However, voice problems are complex and often need the expertise of other related professionals to achieve an accurate diagnosis and find the best treatment for each patient. Some MVC’s may have other specialists present in clinic, either as part of the core team or as part of special clinics that cater for selected groups of patients such as singers/actors, children or those with neurological issues. Others MVCs will refer patients on to other specialists as part of their diagnosis and/or treatment.
The Multidisciplinary Voice Clinic Core Team
The Laryngologist: An Ear Nose and Throat Surgeon who has specialised in voice disorders in addition to their general ENT caseload. They are responsible for your medical care. Their role is to:
- Carry out the patient history and document it in the medical notes. Other members of the team will also contribute to the history with questions relating to their own speciality.
- Examine the larynx and vocal folds, and video the examination for the medical records, and to show you and explain the diagnosis.
Usually, it is the laryngologist who carries out the laryngeal examination, although occasionally junior ENT surgeons in training (Registrars) may carry out the laryngeal examination under the guidance of the laryngologist or SLTs who have had special training. The examination may either be done through the mouth, using a small steel rod attached to a light source and camera, or through the nose, using a flexible fibre-optic tube containing a camera and attached to a light source.
- The laryngologist will feel around your neck and throat (palpation) looking for any tight muscles that can contribute to vocal problems or any swellings/swollen glands that might indicate infection or some other systemic diseases.
- If any additional medical investigations or treatments are needed the laryngologist will refer you and explain why. For example, you might need blood tests, X-rays /scans.
- If your vocal problem might be related to a disorder or infection in a different part of your body the laryngologist may refer you to another medical specialist, for example a gastroenterologist or neurologist (see below).
- If you need any medicines to help resolve your voice problem (for example, reflux medication, antibiotics or antihistamines), the laryngologist will prescribe these for you or request your GP does so.
- The laryngologist makes the medical diagnosis and will talk you through what is wrong with your voice and what course of treatment is recommended.
- If surgery is recommended the laryngologist will explain why, and what the surgery will involve. They will explain any risks and what the expected outcome is likely to be. If the patient agrees to surgery, the laryngologist will arrange for their name to be added to the hospital waiting list.
The Voice Specialist Speech and Language Therapist: An experienced speech and language therapist who has undergone further specialist training in vocal anatomy, physiology and a wide range of vocal treatment regimes. The role of the voice specialist SLT in the MVC is to:
- Contribute to patient history gathering.
- Observe the patient’s voice production in clinic, identifying any postural, tension or breathing issues that might contribute to the voice disorder.
- Frequently the SLT is involved in filming the laryngeal examination.
- Analyse the patient’s patterns of vocal behaviour with the laryngologist and trial any treatment techniques to see their effects on the behaviour of the vocal folds.
- Make a functional diagnosis of the mechanical factors involved in the voice problem.
- Explain the functional diagnosis and explain any voice therapy treatment plan.
The Patient: As a patient you are an important member of the core team. You know how your voice usually sounds and can tell the medical team what has changed and what factors/events you think might be involved. Sometimes, details that may seem insignificant to you may give the medical team important clues as to what might be wrong. As a patient your role is to:
- Ask questions about your diagnosis and treatment options if you have any concerns.
- Tell the laryngologist if you feel uncomfortable about any procedures or treatments suggested or if you have had any bad experiences with medication or examinations in the past.
- If you are uncomfortable about having observers present you can ask the SLT or laryngologist if the observers would leave the room before your consultation.
- You can request a chaperone if you wish or bring a family member/friend with you.
- You need to tell the laryngologist if you feel queasy or unwell during your examination.
- You may be asked to complete some questionnaires designed to rate the severity of your vocal or reflux symptoms. The questionnaires are completed at your initial consultation and after any treatment to measure your progress. They are filed confidentially in your medical notes.
The Nurse: A nurse may be present in the clinic or come and go depending on their other commitments. Their role is to:
- Ensure that the laryngoscopes, or any other instruments used during the voice examination, are clean and sterile.
- They may assist the SLT to video the patient’s voice examination or distribute any required questionnaires for completion by the patient before their consultation.
The Extended Team
The Singing Rehabilitation Coach: The singing rehabilitation coach (SRC) is an experienced singing teacher who has received special training in vocal anatomy, physiology, normal vocal function and vocal pathology. They should also have had experience observing in a voice clinic, ideally for a year or more. Unfortunately, there is no recognised qualification to become a SRC, although there are some training programmes springing up to provide training. The role of the SRC is to:
- Contribute to the case history in terms of singing technique and performance issues.
- Observe the patient’s posture, muscle tension and breathing patterns.
- Assist in interpreting the patient’s internal laryngeal behaviour in relation to singing.
- Assist with trialling singing exercises during the laryngeal examination and with explaining the functional diagnosis in relation to singing.
- Advise on vocal technique and aspects of voice care in performance.
- Outline and explain any singing rehabilitation that is recommended.
Some MVCs provide one or two sessions of singing rehabilitation coaching on the NHS. However, in many cases, the SRC will need to see patients for short courses of coaching on a private basis at the patient’s request.
The Manual Therapist (MT): The MT is a qualified and experienced Osteopath or Physiotherapist who has taken specialist post graduate training in laryngeal anatomy, physiology, vocal function and the application of soft tissue techniques appropriate for manipulation of the laryngeal musculature. The MT will need to have spent a year or more observing and assessing in an MVC as part of their specialist training and ideally should receive mentoring from a more experienced laryngeal manual therapist. As with the SRC, there is no current recognised training or qualification to specialise as a laryngeal manual therapist.
The MT may be part of the MVC core team or may attend clinics on a less regular basis. Their role is to:
- Assist case history gathering from their perspective.
- Assess general musculoskeletal posture and laryngeal muscle tension.
- Apply laryngeal manipulation/soft tissue techniques as appropriate.
Some MTs are employed by the NHS to provide short courses of 1-3 sessions of laryngeal manipulation for MVC patients. Where this is unavailable patients may need to seek manual therapy privately.
The Psychologist/Psychotherapist/Counselling: Many voice problems have an emotional component either in response to the voice problem or as the trigger for its onset. The Psychologist/Psychotherapist is unlikely to have any specific training in voice disorders. However, their experience working with emotional difficulties and psychosomatic conditions of a similar nature means that often the counselling techniques they use prove valuable to patients with voice disorders.
Sometimes, one of the MVC team may be dually qualified as a counsellor as well, and can provide psychological help and support for patients. Often this is the SLT but it could also be the MT or the SRC as these professionals work with clients who have psychological difficulties arising from or contributing to their physical symptoms or loss of the singing voice.
In counselling the focus is on the patient and their story. It helps them to identify any difficult relationships or situations that exacerbate their vocal symptoms and provides a safe, confidential space for the patients to explore their feelings and talk about difficult experiences.
The Psychologist/Psychotherapist/Counsellor may take NHS referrals but often patients need to access help privately. The Laryngologist can often refer patients directly for counselling or alternatively, referrals can be arranged by the GP.
The Junior Doctor: NHS voice clinics have a responsibility to teach the next generation of doctors, so a Junior Doctor (a Specialist Registrar) may be present observing or assisting the laryngologist in clinic. For example, they may carry out laryngeal examinations under the guidance of the laryngologist.
Trainees/Other Observers: As part of the MVC’s teaching commitment sometimes other professionals are allowed to observe the work of the clinic. They may be singing teachers or manual therapists interested in vocal rehabilitation. Medical and SLT students, or school leavers interested in medicine may also occasionally be observing. Most MVCs try to keep observers to a minimum as it can be intrusive for patients.
The Volunteer: As part of auditing the effectiveness of treatment, many MVCs use questionnaires rating the severity of symptoms before and after therapy. These are usually given to the patient to complete in the waiting room. In some clinics distributing and collating the questionnaires is carried out by the SLT or nurse, but sometimes a hospital volunteer will take on this role. The volunteer will have received special training from the hospital in order to work with patients. They usually have an interest in voice if they are working in the MVC and are likely to be student SLTs or singing teachers keen to learn about vocal rehabilitation.
Some voice disorders are symptoms of disease or malfunctions in other parts of the body. When this is suspected the laryngologist will refer the patient for assessment and/or treatment by another specialist doctor. Commonly referred to specialists include:
The Gastroenterologist: Specialises in diseases or malfunctions in the digestive system. Problems such as acid reflux can affect the voice, either directly by causing irritation and swelling in and around the larynx, or indirectly by causing increased laryngeal muscle tension in order to guard the airway against acid over spill.
Acute or chronic abdominal pain from problems such as irritable bowel problems or food allergies can sometimes alter breathing patterns. Poor breath control can also impact negatively on voice production. The gastroenterologist can provide accurate diagnosis and treatment for these problems, helping the voice problem resolve.
The Chest Physician: The breathing mechanism is a vital part of voice production. Poor airflow or poor control of breathing can have a negative impact on the voice. Chest complaints such as asthma, emphysema or damage to the lungs from smoking and pollution are likely to affect breathing and respond best to specialist assessment and treatment from the chest physician.
The Neurologist: Some voice disorders may be related to malfunction in the brain or nervous system; for example in Parkinson’s disease following on from a stroke. The Neurologist can help identify the problem and refer for any appropriate therapy or treatment.
The Allergist: Approximately 25% of the population suffer with allergies which can impact on the voice. When patients are believed to be allergic to irritants such as to pollen, grasses, dust mite, mould, animal fur or chemical sprays, they may benefit from a referral to an allergist. The allergist will run appropriate tests to find out which irritants are affecting the patient and provide treatment and advice to manage these conditions.
A Nutritionist: A nutritionist is a specialist who can advise on dietary/nutritional issues. They can be helpful in the management of voice disorders that are exacerbated by food allergies or reflux.
It can feel daunting to be faced with a group of people when you attend the Multidisciplinary Voice Clinic, but remember; whoever is present is there for you. They genuinely want to help find an answer to your vocal problem. Once the ice is broken, most people adjust to their presence quickly and find the experience well worthwhile.
This information is intended for guidance purposes only and is in no way intended to replace professional clinical advice by a qualified practitioner.
With grateful thanks to Kristine Carroll-Porczynski, Jackie Ellis and John Rubin.