Correspondence Address:
Prakash Boominathan
Department of Speech Language and Hearing Sciences, Sri Ramachandra University, Porur, Chennai 600 116, Tamil Nadu
India

Full Text

'Vocal health and Care' is evolving as a subspeciality in speech language pathology (SLP) and ENT practice. Globally, the orientation to assessment and management of voice disorders has undergone a paradigm shift from a physical impairment/disability perspective to a more holistic 'well-being' perspective. Nowadays, several psycho-social attributes like emotional, environmental, and occupational aspects of the individual have also been added to the typical structural and psycho-acoustic dimensions of describing a voice disorder/pathology. This change has warranted a dynamic and a more inclusive evaluation process that addresses the patient's need, feelings and attitudes while managing voice disorders. Further, the technological advances in capturing and analysing voice and related data (such as imaging of larynx, analysis of voice, etc.) have necessitated 'transdisciplinary binding' than ever before.

SLP training provided in India is primarily rehabilitation focussed, barring a few programs attached to medical colleges and hospitals. On the other hand, the ENT postgraduate training is relatively less orientated to rehab needs. Considering the differences in the nature of professional training in ENT and SLP, developing team synergy toward a comprehensive patient care is not easy or smooth. Despite different orientations in training, synergistic functioning of the team is possible when the members of the team are aware of their distinctive and collaborative roles.

In the team, the ENT surgeon provides the medical diagnosis (cord pathology) based on clinical examination and visualization of structures of the larynx. The SLP provides the functional diagnosis (hyper/hypofunctional) based on perceptual analysis, acoustic analysis and visualization of the movements of vocal folds. Yet another aspect is self-assessment of the patient, which provides scope to understand the impact of voice disorder in his/her day to day activities. These inputs help to arrive at clinical diagnosis and management decisions for voice disorder through discussions and consensus.

The idea of providing 'voice care as a team' is still developing in India. One such example demonstrating team work is presented below. [1] It showcases the collaborative roles of the team in being as 'engaged partners'. The guidelines from European Laryngological Society [2] were adapted to meet Indian conditions without compromising on 'universal accepted standards of practice'. The developed protocol included case history, physical examination, stroboscopic visualization of larynx, perceptual voice analysis (GRBAS scale), acoustic voice recording and multiparametric analysis (Dysphonia Severity Index), simple aerodynamic measures, and a culturally modified self-percept scale. [3]

The feasibility of using the comprehensive protocol in an interdisciplinary voice clinic was tested on 200 patients with voice concerns/problems. [1] The study revealed that other than in primary organic pathologies such as vocal cord palsy, cancer, etc., the patient's self-assessment of voice and lab based measurements by the clinician did not correlate. This highlights the complementary nature of information obtained from these tests. Thus, emphasizing the need to consider the patient's 'feelings and judgments' while making clinical decisions for effective patient care. This is especially necessary in the Indian context, where these are not yet mandatory by law, and our societies are considered 'more tolerant and inclusive'.

The synergistic work environment of the team is best realized when the ENT surgeon and SLP share compatible views regarding management approaches to facilitate vocal health, and a voice that is acceptable to the patient suffering from voice disorder. A joint review following the assessment process provides several advantages to the professional team and the patient with voice disorder. Some of them are enumerated below:



Making management decisions: Working as a team offers an increased scope to discuss relevant physiological parameters contributing to the disordered voice. For instance, in a patient with vocal cord palsy, measurement of parameters such as glottic gap, vertical level of vocal cords, amplitude and mucosal wave, helps in making decisions such as duration of trial therapy versus immediate need for surgery or a decision to wait for spontaneous recovery with minimal therapeutic intervention/assistance.Documenting progress: In the team, the SLP can routinely review and document improvements or changes in voice and discuss with the surgeon. This allows for a possibility to change certain management strategies for e.g., from therapy to surgery in case of slow or poor improvement. Sometimes the patients' requirements (especially in case of professional voice users) and other medical conditions also influence the process of making decisions in management. These needs are best addressed as a team.Providing feedback: The visual imaging procedures such as stroboscopy, high speed imaging are excellent feedback tools that help SLP to plan therapy. Further, explaining the video to the patient with voice disorder augments his/her understanding of vocal physiology and thus facilitate learning of new healthy vocal behaviour during therapy. These instruments are easy to access and use in a facility where both ENT surgeon and SLP work jointly.Improved postoperative care and treatment: Traditionally in voice pathology, the need for a team approach is emphasized while handling laryngectomees. However, such an approach is required while treating any patient with voice disorder. Preoperative assessment and therapy helps to document and undo several unwanted faulty compensatory vocal behaviours, and aids in reducing post operative treatment period. Further, the joint clinics have slowly but surely impacted advice given by the surgeon with regard to voice rest. The current emphasis is on prescribing short periods of voice rest (48-72 hrs) postoperatively as against a complete prolonged postoperative voice rest. Today, surgery is followed by modified voice rest and early initiation of voice use under the guidance of the SLP.

In summary, a voice care team working in synergy will improve face validity of the clinic, facilitate better documentation and audit, and help evolve a philosophy for assessment and management, thus promoting best practices in patient care.

References