As an elementary school music teacher for nearly two decades, Sam Cruz knows her voice. She also knows that each new school year brings an increased demand for singing and speaking and the hoarseness, fatigue and decreased tone quality that comes along with it. But when these symptoms persisted, she knew she had to do something to fix her voice so she could continue to teach.

“Over the last two school years, I constantly sounded like I had a cold,” Sam said. “I’d have to mimic pitches to my students with my piano because I couldn’t sing them. My voice was always hoarse and fatigued, and I was always tired. At the end of the day, my neck would hurt.”

Seeking Help

Sam visited her primary care physician, who recommended the Froedtert & the Medical College of Wisconsin Vocal Health Program, which is part of the multidisciplinary Froedtert & MCW Ear, Nose and Throat (ENT) care team. The ENT team includes nationally recognized, fellowship-trained physicians who offer the most current and effective options for the full range of ENT-related conditions — from more common problems like snoring, allergies, sinusitis and hearing issues to more complex diseases like throat cancer or skull-base tumors. These specialists include experts devoted to treating voice disorders. Sam’s primary care physician recommended laryngologist Jonathan Bock, MD.

“We see more teachers than any other type of patient in our voice clinic,” Dr. Bock said. “A recent study shows that a teacher’s voice travels three to four times as far as an average person’s voice each day. In this case, traveling refers to the distance vocal cords move back and forth as they vibrate. A music teacher’s voice travels even farther than other teachers — up to six to seven times farther per day than a person who is not a teacher.”

During Sam’s initial visit, Dr. Bock performed a videostroboscopy to view Sam’s vocal cord structure and movement by way of a flexible camera placed through her numbed nose. She was diagnosed with bilateral nodules, which are stiff calluses on the vocal cords that are the result of vocal overuse and abuse. People with nodules have to push their voice harder to make sound, which often results in a loss of voice after little use. To better learn how to use your voice with less strain, the initial treatment option for vocal cord nodules is speech therapy.

“I always tell patients with vocal nodules that the first treatment is therapy, therapy and more therapy,” Dr. Bock said. “The nodules are there for a reason, and it has something to do with how the patient is using their voice. Surgery is sometimes needed to get the patient back to full voice, but we have to address the behavioral issues that caused the nodules in the first place. If speech therapy doesn’t address the initial problem that has caused the nodules, they will come right back.”

Speech Therapy to Help Heal the Voice

In fall 2018, Sam began speech therapy with Caroline Ziegler, MS, CCP-SLP, a speech-language pathologist at the ENT clinic at Froedtert & MCW Froedtert Hospital.

“Sam was certainly hoarse when she came in — across all domains — speaking voice, singing voice and during vocal range exercises,” Ziegler said. “We started with a type of therapy that allows people to realize how their voice is actually produced and how they should use it in certain situations.”

During weekly, hour-long therapy sessions, Sam learned about the fundamentals of voice use, such as breathing support, muscle use and resonance. Ziegler recommended she use a wearable voice amplification system during teaching. It allowed her to speak at a normal volume, and her students could still hear her adequately.

The goal of speech therapy is boosting the efficiency and ease with which participants are able to use their voice, which in turn, helps the vocal cords heal. Occasionally, there are cases where they can’t heal on their own, and in that situation, surgery is required.

Sam’s case was one of those. While her voice improved through speech therapy, she was still experiencing neck pain and having trouble singing the way she used to.

“Everything that Caroline would do with me in speech therapy, I wasn’t able to do as easy as I should’ve been able to,” Sam said. “My nodules weren’t getting that much better, and I couldn’t take as much time off of work as was recommended for the vocal rest I needed. That’s when Dr. Bock and I decided surgery was required so the nodules could completely go away.”

Precision Surgery Normalizes Vocal Cords

Dr. Bock performed surgery to remove Sam’s bilateral vocal cord nodules on March 1, 2019 at Froedtert Hospital. During the procedure, which required general anesthesia, Dr. Bock used tiny scissors under a microscope to remove the nodule tissue and smooth out the edges of Sam’s vocal cords. He also used a KTP laser, a special laser designed to precisely target lesions and preserve normal tissue. With the laser, he eliminated fluid and tissue build up in some of the blood vessels in the vocal cords. Finally, Dr. Bock injected Kenalog-40, a steroid usually used to soften scar tissue in dermatology, into where Sam’s nodules used to be to remodel that vocal cord tissue.

This one-hour outpatient procedure left Sam feeling little to no pain. As part of her recovery, she went on strict voice rest for one week.

“I was excited and ready for surgery,” Sam said. “I had such fatigue and pain leading up to it, that teaching was difficult. I was more concerned with what life would be like afterward and the week of voice rest. I was pleasantly surprised that I had no pain. I enjoyed a milkshake on the way home, and the week of voice rest was maybe my favorite week of the year — probably my husband’s too!”

Back to Teaching and Singing

Thanks to the care and education provided by Dr. Bock and Caroline, Sam is back at school able to talk and sing normally without pain. She is still attending speech therapy to practice healthy speaking habits that will prevent the nodules from returning.

“I had complete faith in Dr. Bock and Caroline,” Sam said. “The way they explained everything that was going on with me was wonderful. I knew my voice would be okay again. I’ve even had some former students visit me, and they told me how much better my voice sounds. That was the coolest thing.”

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