Maggie McKay (Host): Your voice. You use it every day, most of the day, but often it's taken for granted until you don't have use of it, like when we experience laryngitis or a sore throat. So how do you keep your voice healthy? Joining us to talk about this is Megan Urbano, Speech Language Pathologist at the USF Health Voice Center and Dr. Yassmeen Abdel-Aty, Assistant Professor of Laryngology, also at USF Health Voice Center. Welcome to MD CAST by Tampa General Hospital, a go-to listening location for specialized physician to physician content, and a valuable learning tool for world-class healthcare. Thank you so much for joining us, Megan and Yassmeen, what a pleasure to have you both here to learn more about keeping our voices healthy.

I couldn't wait to talk to you and learn more about this because it's so crucial for so many professions. So let's just dive right in. Dr. Abdel-Aty, what is USF Health Voice Center and what is a multidisciplinary voice clinic?

Dr. Yassmeen Abdel-Aty (Guest 2): The USF Health Voice Center is the only multidisciplinary academic voice center in the Tampa Bay area. This was founded by my partner, Dr. Yael Bensoussan and our SLP partner, Dr. Stephanie Watson, 2021. So we're a relatively new center. Our mission is to provide state-of-the-art, personalized and evidence-based care to patients with voice, upper airway, and swallowing disorders.

So the multidisciplinary clinic, all patients are assessed jointly by a laryngologist, which is myself and a speech language pathologist to provide optimal diagnosis and management. This way you get both the surgical medical specialist and the behavioral specialist deciding your plan of care at the same time.

This eliminates the extra step of having to go to a doctor and then being referred to a therapist and then being referred back to the doctor, and we're able to discuss not only amongst ourselves, but with the patient to come up with a treatment plan. We also recognize that every patient is unique and everyone has specific needs. Our team of providers customizes a care plan to suit the specific needs of every patient.

Host: And what is a laryngologist?

Guest 2: A laryngologist is a ear, nose and throat specialist that does an extra year in just the T of ENT. So that's any throat issues including voice problems, breathing problems that involve the throat, throat irritation, and also swallowing disorders.

Host: Megan what is a voice specialized speech language pathologist?

Megan Urbano CCC-SLP (Guest 1_: Yeah, so a voice specialized speech language pathologist, everybody kind of thinks of the speech language pathologist as somebody who works with kids or stuttering, speech issues, but when we tack on that voice specialization, we specifically work on things related to the throat. Unlike the laryngologist, who's going to provide that medication, surgery, those options; my job is to provide voice therapy or behavioral therapy.

So we can think of that, kind of like physical therapy, but for the voice, when there's a vocal issue. I work with my patients to find the most efficient, optimal, and dynamic voice possible, helping them use their voice flexibly and for the day-to-day life. I also specialize in performing voice, working with singers, actors, and voice actors.

Host: That must be fun. Do you do accents with them too?

Guest 1: I actually don't do accents, so we're not necessarily looking for the kind of speech, you know, that can shape different accents, but more so looking for the sound quality of the voice. So I can sound like this, or I can sound really rough, right? And I might not want to live my life sounding that way. Or there might actually be something anatomical that's causing that voice change.

And so, I work with a laryngologist to help fix that. Voice specialized speech pathologists also work with other disorders of the throat, including laryngeal hypersensitivity, such as chronic cough or cough that has lasted for over eight weeks. We do cough suppression therapy or certain breathing problems like paradoxical vocal fold motion.

Host: That's a lot. See, I'd never even heard of those, but I know people who suffer from things like, coughing and they're in radio and that's a problem. So good to know you can take care of that. Dr. Abdel-Aty, what exactly is voice health?

Guest 2: So our throats or our voice box is an organ just like any other. And so we have to take good care of it so it functions properly. Just like you would, you know, go to the gym to take care of your muscles on your extremities, there are also things that you can do to keep your throat healthy and give an optimum voice.

Host: Are there certainties, like I've used throat coat before when I had a sore throat and I had to use my voice. Are there certainties that help or is that just more comfort food kind of thing?

Guest 2: It's more comfort because when you swallow, our throats naturally protect our vocal cords. If anything hits the vocal cords, you'll go into a coughing fit. So although those teas sometimes make you feel better, they don't really get on the actual vocal folds.

Guest 1: We've all had that moment of something going down the wrong pipe, and you can actually think of your throat as having two pipes in it. One in front, that's for breathing and one in the back, that's for swallowing.

Host: That's so interesting. Megan, what are factors that do affect voice health?

Guest 1: When it comes to voice health, there are four main categories. We tackle. Hydration, vocal use or load, emotional and physical health, such as stress management, sleep and exercise, as well as management of external and internal irritants like allergies, smoke, reflux, those types of things.

So the first category, hydration. Just a quick note on the vocal folds, since no one can see us, I want them to imagine what it looks like if you put your two fingers out in front of you using your middle and your pointer finger and make a V.

That's essentially what the vocal folds look like. And you can think V for vocal folds. And this V like structure sits at the top of your windpipe. You can even think of them as the doors to the lungs. The basic motion of the vocal folds is this opening movement when we're breathing to let the air in and out of the lungs, and a rapid opening closing movement when we talk.

So another visualization is hands coming together when you clap. In that moment, a sound wave is created. So now imagine the vocal folds are doing this. They're opening and closing, creating sound waves each time they come together hundreds of times per second. So that's around 120 times for deeper voices and 200 times a second for higher voices. So now that we know very basically how we're creating sound at the level of the vocal folds, let me talk a little bit more about hydration.

Since the vocal folds hit each other a lot, we really need to make sure that they're protected, Unlike your hands that are relatively dry and would probably hurt a lot if you clap them hundreds of times; the vocal folds are actually gliding off of each other when they come together.

They're basically a muscle that's covered in these two jelly-like layers. So the hydration that we have in our bodies, acts as a lubrication, allowing the vocal folds to glide against each other easily. So when they're actually more dry, you know you, again, you can imagine your hands clapping a whole bunch of times; they can get really irritated and you can harm the tissues of your vocal folds, which changes the sound quality. There are two types of hydration. There are systemic and direct hydration. Systemic hydration relates to the water we have in our diet that takes time to be digested and hydrate our entire bodies.

We suggest drinking eight glasses of water a day. Something a lot of people ask us is, is coffee hydrating or dehydrating? Well, yes and no. So research has debunked the diuretic effects of coffee, especially for people who drink, you know, one or two cup of coffee regularly. But we notice that people will also slowly sip one cup of coffee all morning.

So if you're one of those people, then you're probably not hydrating. You're probably forgetting to drink water when you should. And the other thing that can be really great for adding hydration is direct hydration. So this includes breathing in steam from humidification, from a steamer, like a facial steamer, or even boiling a pot of water and breathing in the steam that way, because in that case, you're actually allowing some of those droplets to touch the vocal folds, to touch the tissues that might be irritated and help provide them with direct hydration.

The second factor that could affect voice health is vocal use or vocal load. And this relates to how much you use your voice and how you use it. So thinking about duration, do you talk all day for your job? And then the load, do you talk loudly all day for your job? Right? I might be able to talk for three hours consistently, but I might not be able to yell for three hours. So thinking the length and in what manner. And so a good rule is kinda like this 50/50 rule, essentially, meaning you try to talk half as loud throughout your day and maybe half as much on days where you might need to save your voice.

Also, vocal budgeting, taking little, what we call voice naps, 10 minutes every hour. Let's say if you're a teacher and you have to talk consistently, really trying to save your voice. Or if you're a singer, maybe not staying up all night the night before a gig. And Dr. Abdel-Aty will talk about the other two factors related to voice health that are more from the medical side.

Guest 2: So one of the things that people don't really think about when they think about your voice is your overall health does affect your voice, so emotional and physical health globally does contribute to your voice and whether it's healthy or not. So things like stress management, sleep and exercise are very important.

To go through each one of those things, stress management. People actually get tightening of muscles in their throat. If you can remember a time that you've been really stressed out and you hold it in your neck and you actually get neck pain or shoulder pain or back pain, that same tension is in the muscles in your throat, which are the ones that help you speak.

So people can actually get a condition called muscle tension dysphonia, which is abnormal speaking, rough gravelly speaking just because of muscle tension. And it's not only caused by stress, but there's definitely a component. Exercise is really helpful because the fuel to our voice is our breathing and our airflow.

So the air comes from the lungs and goes up through the vocal folds, and that's the fuel and allows the vocal folds to vibrate. So if you are, don't have a lot of breathing, you kind of don't really project your voice that much. That's why holding your breath is not the best for speaking. But when you're taking big, deep breaths, like when you exercise, you're actually increasing your lung capacity, which gives you overall more endurance for voice.

And then there's a lot of research on sleep as well that there's increased stiffness of the vocal chords related to decreased sleep. Low sleep duration is also associated with inadequate hydration. So taking care of your whole body actually helps you take care of your voice. And then other factors that can irritate the throat include things like allergies, reflux, drying medications. For example, if you take an antihistamine because you have allergies, well that's a drying medicine, so it might dry your throat out more. And these are kind of things that you would talk to your laryngologist about to optimize. The other thing people don't think about is irritants. So smoking, inhaling different particles. Even medicines like inhalers have particles in them and these go straight on the vocal cords on their way to the lungs and can cause damage that way as well.

Host: Are there any foods that are good for your vocal cords? I know that sounds weird, but like I used to know people who ate an apple before they went on the air, cause they said the acid in that helped their voice. Is that true or is that a myth?

Guest 2: So that's mostly a myth. I think some foods that are very hydrating and help you retain water are good for your voice, but at the same time, like Megan was talking about, it has to go into your system. So if you eat the apple right before you go on the air, you haven't really had a chance to digest and process it. And actually increasing acid in your diet might cause reflux, which is bad for your voice. And so I would err towards the side of not having a heavy meal before you go onto the air and staying hydrated.

Guest 1: Something that's kind of funny about that, that might have been helpful for that person is actually the sourness of the apples. So we don't recommend things like cough drops that have menthol in them, because menthol can have long-lasting dryness effects and can make you more prone to coughing, things like that. So we recommend lozenges that do not have menthol in them, things that are more glycerin based, like Grether's Pastilles, for example, or Halls Breezers, or even things like Jolly Ranchers. So that's where that sour comes in. Maybe like the apple that's going to make you produce more saliva, and that can help you feel more hydrated orally. So for someone who is in radio or voice acting, that can be a good trick for that reason.

Host: So Megan, when should patients come to see you? Do they know that it's time to come and see you for some help.

Guest 1: Yeah. So somebody should come see us when they've had voice changes or hoarseness for two weeks or more. That's kind of our general timeline. If it's lasted two weeks or more, then we think that there could be a problem. If their voices are easily fatiguing. So, you know, you talk for a little bit and you're, you feel tired, you feel like it's really effortful to get your voice out, if you're regularly losing your voice, if you're a singer and you've had a loss of range, right? Suddenly you can't hit high notes or low notes, or feeling the need to push, like suddenly it's constantly effortful to get your voice out and sounding clear. And another thing could be dry cough lasting eight weeks. So two months or more.

Host: That is fascinating. I am taking notes. I can't tell you both how much I've learned already today. Dr. Abdel-Aty, did you want to add something to that?

Guest 2: Yes. Any throat irritation. So if you find yourself throat clearing a lot or just feeling this tickle sensation in your throat. The throat is for us, something really easy for us to look inside and see if it's healthy. If we can optimize you. You don't have to suffer with those symptoms.

And I think, especially since COVID, people with throat irritation that are coughing or clearing, it's very terrible to be doing that in public. And so we actually have a lot of patients come see us sooner than they would.

Host: I love the idea of voice naps and using your voice less on days you don't need it as much and your overall health had so much to do with voice health. When I was younger, I used to get laryngitis when I was really stressed out, like before a job interview, which did not work out well. But is that possible that stress can bring on laryngitis?

Guest 2: So the term laryngitis is actually a very broad term for inflammation of the vocal cords. So if we have a rough voice, we call it laryngitis, but that can be because of a virus or an infection, or that kind of thing. But it can also be due to all these other factors. So for example, if you scream at a concert and the next day you don't have a voice, well, you have laryngitis, but it's not because you got sick, it's because your vocal chords are inflamed from all the trauma you induced at the concert. So with your stress prior to an interview, your throat muscles might be really, really tight. So you might be putting so much more effort to speak than you need to, causing inflammation and giving you a laryngitis, that's not necessarily infection related.

Host: Oh, it's interesting. Dr. Abdel-Aty, in closing, is there anything else you'd like to share?

Guest 2: Yes. So the one thing I would like to share is that our doors are open to all patients. A normal person who works at Publix, can have a voice disorder. You don't have to be a professional singer, voice actor. Actually, a professional voice user, in our opinion, is someone who uses their voice for their job. So you could be a telemarketer, you could be a lawyer, you could be a teacher or a fitness instructor. Those are some of our most common patients. And I think, having the term voice center kind of scares people away thinking, oh, this is for, you know, the famous people. But that's not true. Anyone can have a problem with their voice and everyone deserves to have optimal voice care.

Host: Megan?

Guest 1: Nope. Just, uh, I think that's a good place to end.

Host: Okay. Thank you both so much for being here. It was a pleasure, and I cannot tell you how much I learned today. I feel like I just went to like a masterclass.

Guest 1: Thank you so much for having us.

Guest 2: Thank you so, so much for having us, and don't be a stranger. You know where our clinic is. We'd be happy to see you.

Host: Again, that's Megan Urbano, speech language pathologist at USF Health Voice Center. And Dr. Yassmeen Abdel-Aty, assistant professor of Laryngology, also at USF Health Voice Center. Thank you for listening to MD CAST by Tampa General Hospital, which is available on all major streaming services for free. To collect your CME, please click on the link in the description. For other CME opportunities, including live webinars, on demand videos, and local events offered to you by Tampa General Hospital, please visit cme.tgh.org. Thank you. And if you found this podcast helpful, please share it on your social channels and check out the full podcast library for topics of interest to you.