Transcription:
The Use of FEES and Videostroboscopy For Evaluating and Treating Voice and Swallowing Disorders

Melanie (Host):  Our voice is central to how we communicate with the world and a voice problem can be very stressful.  It can also impact our ability to complete daily activities.  My guest today is David Cravotta.  He’s a Speech and Language Pathologist at Hendricks Regional Health Speech Therapy Department.  Welcome to the show, David.  Tell us a little bit about some of the most common swallowing and voice disorders that you see.

David Cravotta (Guest):  Sure.  Well, thank you, again, very much for having me.  For me, the most common swallowing disorders tend to stem from patients who have suffered from cerebral vascular accidents – that is to say strokes.  Typically, patients have difficulty with the sensory part of the swallow that is the throat noticing that something is in there and then triggering an effective swallow to drive everything through the throat--into the food tube that eventually goes into the esophagus. So, what we do is if a patient has something, we rule in somebody, for instance, having dysphasia or difficulty swallowing.  Then, we try to figure out exactly what is the problem.  Dysphasia itself is not a disease process.  Dysphasia is the symptom of a greater disease process.  So really, my job is to diagnose a part of that impairment and then to evaluate that impairment and treat that impairment as a part of a greater whole.

Melanie:  If somebody notices that they have some of these swallowing issues or they’ve been told that they have Barrett’s Esophagus or things are starting to happen for them and swallowing--it’s very scary to have issues there.  What do you do to test them and see what’s going on?

Mr. Cravotta:  Absolutely. It’s terrifying.  Swallowing is something we typically take for granted.  It’s something we’ve been able to do since we were born practically.  If somebody does notice something that they’re having any difficulties with swallowing – a common complaint may be reflux disease where you feel something may be coming back up into your throat but you’re not quite sure what it is or what’s going on.  Typically, the first step is to go see a physician and after that physician, either an otolaryngologist or a gastroenterologist and explain the symptoms that you’re having.  Gastric reflux is actually the number one cause of dysphasia.  After you see a physician, if that physician indicates that you need further examination, that patient would be sent to somebody like me for one of two tests are typically done.  We might do what’s called a “video fluoroscopic swallow” study which is a radiographic procedure.  We bring the patient into the radiology suite, we give them barium and we basically take an x-ray video of the patient’s swallow to try to figure out what are the problems and what can we do.   We can even do different techniques within the study to see what’s going to be affective, what will affectively treat the patient and what will not.  We are able to tell the patients the results as soon as we’re finished and then recommend a plan of care from there.  The other exam that we do that really has come around a little bit later but has been equally as effective is, we will complete what’s called a “fiber optic endoscopic” evaluation of swallowing.  That involves passing and endoscope through a patient’s nose into the back of the oral cavity and, quite literally, watching food and drink as they’re consumed by the patient and get swallowed into the esophagus.  We can do the same things in the radiographic study.  We can recommend certain postures or certain techniques to see which is most effective for the patient in trying to rehabilitate the swallowing issues.  A lot of times, we can’t cure everything right there during the study so what we do is afterwards we tell the patient, “Here are the results of this study.  Here’s what we’re going to do.  Here’s our treatment plan.”  Then, we might recommend a whole variety of different things to try to assist the patient with the issues with swallowing that they have.

Melanie:  So, this test--is it very uncomfortable or is it very well tolerated?

Mr. Cravotta:  No, it is not uncomfortable.  I would say, for the FEES exam, it is well tolerated.  It does feel strange.  It’s not every day that we have a flexible tube that’s about the width of a coffee stirrer to into our nose and remain in there while we try to eat and drink things.  However, I’ve had this test done.  Our entire department had the test done so that we could experience what the patients will experience when we provide this exam.  Generally, patients tolerate it very well.  Most of the time, afterwards they’ll say, “Oh, that wasn’t too bad at all.  That was a lot better than I thought it would be” which is always good to hear.

Melanie:  That is always good to hear.  Let’s talk about voice disorders because people tend to think that these are only things that are for people in the radio business or opera singers or theater people but a lot of people can suffer from voice disorders and what would you notice?  What are some symptoms that people might start to notice?

Mr. Cravotta:  First, absolutely anybody can have voice disorders – from children all the way to they run the entire age spectrum. The first thing somebody might notice is some hoarseness or a weakness in the voice.  I would recommend to people if you feel hoarse or weakness in your voice--you can’t project-- a lot of people will notice perhaps they can’t sing with their friends or with their church that they like to do.  If you notice those problems persist for two weeks or more, then you should go see a physician.  Go see an otolaryngologist, an ENT.  Then, they will begin the workup to figure out what the problem is.  If they decide that there are some specific problems with the vocal cords themselves, then they will refer that patient to a speech language pathologist who specializes in voice disorders and can perform what’s called “videostroboscopy”.  Video videostroboscopy is done a couple of different ways.  It can be done either transnasally like a FEES exam or transorally which is done with a rigid endoscope.  Most speech language pathologists will prefer the rigid endoscope because it provides a much more clear picture and can definitively tell what the problems might be with the vocal folds as the patient tries to phonate.  An endoscopic one via nasal passages is just as effective as well.  What we do then is, we watch how the folds move while that patient makes a sound or a series of sounds.  Typically, what may happen is there may be some weakness involved so we have some strengthening exercises.  It may be an airflow issue so we may provide some exercises – think of it as physical therapy for your lungs.  We want to make your voice as efficient as possible.  Sometimes, just through aging or bad habits, the lungs don’t quite work and the muscles that are associated with expiration, we get a little lazy with them and as a result our throat, our voice box, our larynx tries to pick up the slack.  That organ isn’t made for that kind of long-term support, so over time the vocal folds start to become impaired and, as a result, we try to rehabilitate that system so that patients can do the things that they love to do whether it’s talk on the phone with their families, if it’s sing in church, have conversations with people.  It’s a significant quality of life issue.  We try to improve the lives of our patients, really, however it is we can, no matter how small people may think it may be.

Melanie:  Can you have an acute injury to the vocal cords from yelling, screaming, something along those lines?

Mr. Cravotta:  Yes and those tend to get quite a bit more serious because then we may be talking more about polyps or hemorrhages or cysts or things like that.  It would be unusual for one event to cause some kind of injury like that but a series of those kinds of events absolutely so.  If you use your voice in a way that you feel hurts your throat, then you are probably doing something that you shouldn’t be doing to your voice.  A significant cough for a while can do that.  Consistent yelling or screaming at sporting events or things like that, loud or even what we call abusive kinds of singing can cause problems with your voice.  Sometimes it’s just bad luck.  Sometimes people will have kind of a series of events that they don’t realize any one of those things may have contributed to a problem and then, when you have a whole cumulative effect then a more significant problem can arise.

Melanie:  So, if someone has vocal cord nodules or they have some of these things you’ve discussed, are there exercises, is there rehab, as you said, physical therapy for your voice?  Give us an example.

Mr. Cravotta:  Sure.  One of the most well-researched treatment modalities we use are called “vocal function exercises”.  They are a series of exercises that are very simple to complete and they involve sustaining your voice for a period of time, gliding up the pitch range kind of like a siren, if you will, sliding down a pitch range with your voice and then actually pitch matching with say a piano to try to hit specific notes in certain ways.  Typically, those work well with patients who have weaker voices.  So, we’re trying to kind of strengthen the vocal folds and strengthen the respiratory system to try to make that airflow as efficient as possible.  If the problem is a little bit more significant, say, a patient has Parkinson’s disease and as a result has significant hypophonia, then there are a number of treatment programs that we can use that involve using usually loud, effortful voices.  So, that can really assist in boosting the patient’s voice, vocal quality and quality of life.

Melanie:  In just the last few minutes, David, and it’s such great information. It’s so interesting.  Give the listeners your best advice about how voice and swallowing disorders and why you want them to come to Hendricks’s Regional Health for their care.

Mr. Cravotta:  Well, to start with voice, I think the best thing you can do, really, is to listen to your body, stay well hydrated and get plenty of rest.  I interact with lots of friends throughout the year and they’ll say, “I’m hoarse now and I have a vocal performance coming up what do I do?”  I’ll say, “You need to be quiet and drink your water.” That’s pretty much it.  You hear a lot of things about lemon and honey and those kinds of things.  They make our throats feel good but they don’t really help solve the problem which usually is more some kind of laryngitis or a swelling so I tell them, “Get your rest, drink your water.” Those are the best two things you can do.  It helps to avoid caffeinated beverages, unfortunately, although I think there’s some literature that’s questioning that. There are other things that pull water out of the body such as alcohol and tobacco.  There a number of reasons not to have plenty of those kinds of things but one of them is they do tend to hurt your voice as well.  So, good, long-term vocal cord health would involve decreasing things like alcohol, tobacco and caffeine and increasing things like rest and water and good fuel for your body, good foods as well.  As far as swallowing is concerned, it’s usually more about how we eat than what we eat.  It’s kind of the opposite with voice.  So, with swallowing you don’t want to eat too much, especially if you feel you have the potential for reflux disease which, again, is the number one cause of dysphasia.  You don’t want to have too much.  If you feel  like you are prone to symptoms such as heartburn,  you’re going to want to avoid higher fat foods such as pizza and spicy foods, foods that have a lot of acidity to them – tomatoes, tomato sauce.  It doesn’t mean you can’t have those things but it’s good to be aware of that and try to limit those foods that may exacerbate those kinds of problems.  Again, if anything persists for, I would say, two weeks, definitely, see a physician and see if you need a further test from a speech language pathologist as well.

Melanie:  Tell us about Hendricks and your team there.

Mr. Cravotta:  Sure.  At Hendricks, we are a county hospital just west of Indianapolis and we’re certainly unique in our programs because we are able to offer these kinds of things on an easy to get into sort of basis.  If a patient were to contact our office and say, “I’m having a problem with swallowing” or “I’m having a problem with voice” our first question is, “Well, have you seen your physician?”  Then, if the answer to that question is “yes”, then we say, “Alright.” We get an order from that physician and we’ll be able to see that patient within the next day or two perhaps, certainly within the week.  Our staff here is well trained in those kinds of things and, typically, the way our department works is that each speech language pathologist in the department tends to focus on just a few things and do those things really well.  It’s actually my job specifically to do videostroboscopies and to do FEES exams.  So, when you call, you talk to me and I’m the one who says, “Okay, let me talk you through this process and tell you what these exams are” and when you schedule the appointment that is, again, with me.  We have already developed a rapport even before you’ve set foot in the office.  The same thing goes with our physicians. So, if you come to our physicians they say, “You’re going to go see Dave in the speech therapy department.  He’s the one who does the FEES exams and the stroboscopies”.  We kind of help support each other in that manner as well.  So, if a patient contacts me and they haven’t seen a doctor, I’ll say, “Well, go see this physician in Hendricks practice.”  I can give them the head’s up and we have that kind of relationship.  It’s just a smaller kind of community relationship sort of like the small town of which we are a part as opposed to much bigger network.  Things just move much more seamlessly and fluidly, I think, here at Hendricks than they do at the much larger corporations.

Melanie:  Thank you so much for being with us today, David.  It’s really great information.  You’re listening to Health Talks with HRH.  For more information, you can go to hendricks.org.  That’s hendricks.org.  This is Melanie Cole.  Thanks so much for listening.