Introduction of the Workshop
The session is led by James Smithson, a Senior Voice Specialist pertaining to Speech and Language Therapy (SLT) at Prifysgol Wrecsam, which translates to Wrexham University.
Workshop Structure
The one-day voice workshop follows a structured plan outlined as follows:
Introduction: Overview of the goals for the workshop and introductions.
Overview of the Voice Clinic: A detailed explanation of the operational framework and function of a voice clinic in providing assessments and therapies.
Voice Production Review: Examination of the mechanisms involved in voice production, including anatomical and physiological aspects.
Voice Disorders and Classification: Discussion on various voice disorders, their classifications, characteristics, and implications on voice health.
Assessment: Procedures and tools used for assessing voice disorders.
Management: Strategies on how to manage voice disorders, including therapeutic interventions and recommendations.
Housekeeping Matters
Prior to commencing, some housekeeping points were discussed to ensure a smooth flow for the day:
Teaching Duration: Noted as a long day of teaching.
Breaks: Scheduled 2 x 10-minute breaks and a 30-minute lunch break. Additional comfort, toilet, and water breaks are encouraged as needed.
Engagement: Participants are encouraged to ask for clarification, repetition, or to interrupt if the speaker diverges from the main topic. Highlighted is the notion that there are no stupid questions. Participants should not hesitate to guess, even if they might get it wrong—learning is a process.
Presenter Background
Personal Dossier
James shares his journey and qualifications to establish credibility in the field:
Background in Performing Arts: Initial training at a drama school, followed by working as an actor and voice-over artist.
Transition to SLT: Shifted focus towards the field of Speech and Language Therapy by acquiring an MSc degree from City, University of London.
Clinical Experience: Experience includes rotations in acute care, stroke, head and neck (H&N), and voice specialization practices in Norwich.
Professional Roles: Served as a voice specialist at Wythenshawe and currently holds the position of senior voice specialist at the Manchester Foundation Trust. In addition, involved in private practice.
Passion for Voice
Three Dimensions of Voice Work
James emphasizes his love for working with voice through three main perspectives:
Therapeutic (The Caring Bit): The emotional and healing aspects involved in helping patients regain their voice.
Scientific/Medical (The Thinking Bit): The application of scientific and medical knowledge in understanding voice disorders.
Creative (The Fun Bit): The artistic elements in voice work, showcasing its expressive capabilities.
Overview of the Voice Clinic
Functionality and Services
The voice clinic aims to provide comprehensive evaluations and treatments for various voice issues impacting individuals.
Common Voice Complaints
James outlines typical complaints encountered in the voice clinic, which include:
Hoarseness: Described as a raspy, gravelly, or rough quality to the voice.
Breathiness: An airy or light voice due to insufficient closure of vocal cords.
Weakness: A noticeable lack of vocal strength.
Reduced Volume: The voice lacks projection and is quieter than normal.
Strain: The voice requires excessive effort to produce sound.
Inability to Project: Difficulty in projecting the voice over distances.
Tiring with Use: Loss of voice endurance and increased fatigue while speaking.
Reduced Singing Range: Limits to vocal range affecting singing capabilities.
Pain/Discomfort: Physical sensations such as ache or a feeling of presence in the throat (globus sensation).
Voice Cutting Out: Instances when the voice unexpectedly fails.
Aphonia: Complete loss of voice.
Referrals for Voice Therapy
Protocol for Referrals
James emphasizes the necessity of referrals for voice therapy, citing the standards from RCSLT, 2005:
"Each individual must have an examination by an Ear, Nose and Throat (ENT) Surgeon prior to or simultaneously with speech and language intervention in order to identify disease, assess structure, and contribute to the assessment of function."
Case Example
A specific case discussion was highlighted:
Patient Profile: A 34-year-old female presenting with intermittent hoarseness and laryngeal discomfort. Examination showed no palpable lymph nodes. A Fiber Nasal Endoscopy (FNE) revealed a normal larynx with no obvious lesions but evidence of muscle tension, leading to the conclusion that she requires voice therapy.
Access to the Voice Clinic
Patient Referral Pathway
To access the voice clinic:
Patient presents to their General Practitioner (GP).
The GP initiates a 2-Week Wait (2WW) referral to ENT.
ENT assesses to exclude potential Cancer (Ca).
If necessary, ENT will refer to Speech and Language Therapy (SLT).
SLT assessment services vary depending on the clinic; therapy may be provided or surgery may be indicated.
Voice Clinics Overview
Categories of Clinics
Voice clinics can be categorized into SLT-led clinics and Joint Voice Clinics (JVC):
SLT-led Clinics:
Comprise senior voice specialist SLT and assistant SLTs along with potentially other specialist SLTs.
Include processes such as Patient-Reported Outcome Measures (PROMs), case history collection, and perceptual and observational assessments.
May involve endoscopic examinations with stroboscopy for visual assessment of vocal cords.
Joint Voice Clinics (JVC):
Involves collaboration between ENT consultants ( from oto/laryngology), ENT registrar/fellow, senior voice specialist SLTs, assistant SLTs, and potentially other specialists.
Incorporates similar evaluative processes as the SLT-led clinics, with a stronger focus on multi-disciplinary team (MDT) discussions and tailored planning based on collective findings.
The Multi-Disciplinary Team (MDT)
Composition
The MDT collaborating in voice clinics typically includes:
Speech and Language Therapists (SLTs): Play a central role in voice assessment and therapy.
Consultant ENT Surgeons: Oversee medical evaluations and surgery if indicated.
Highly/Senior Specialist SLT: Offer expertise in clinical voice disorders.
Specialist SLTs (typically Band 6): Provide focused therapy on performance-related voice issues, upper airways issues, and chronic coughs.
Respiratory Team: May assist in cases related to voice and breathing.
Gastroenterology Experts: Help manage voice issues linked to acid reflux or esophageal problems.
Clinical Psychologists: Address any mental health concerns affecting voice issues.
Musculoskeletal (MSK) Physiotherapists: Provide rehabilitative support if required.
Vocal Coaches/Singing Teachers: May also collaborate to address artistic aspects of voice use.