What is an Otolaryngologist? What does an ENT surgeon do? Part 3: Laryngology

The finesse of the ear surgeon and the precision of the nose surgeon is matched by the throat surgeon’s light-handedness. Tremor can be hidden in most other surgeries, but not in laryngology. This one needs a real steady hand. A good laryngologist has a set of steady hands, a calm demeanor, an approach matching that of a psychologist, and an artistic, cultured manner. Why? Because they deal with voice, and professional voice users, including performers, singers, teachers and politicians. Prominent VIPs with expensive voices see the laryngologists, hence the need to be impeccably presentable.

Laryngology is about voice, and it is probably the fastest growing subspecialty within ENT. This is because of the progress of technology and the accumulation of evidence and experience in treating voice disorders. We’ve talked about hearing, smell and taste. Now think about voice. Voice is who you are. You may loose hearing, smell and taste, but still be an active person. Once you lose your voice, you are crippled in communication. Vocal frequencies, intonations and projections add colour to who you are. Voice expresses your character and emotions as much as the face. If you had a different voice, would you still be you?

We ENT’s are privileged to be dancing on this immaculately delicate organ called the vocal cords. I attended a conference once by a laryngologist who is the chief surgeon to some famous broadway productions in New York. He would sit and listen during rehearsals and be able to pick out which one of these professional singing and dancing troupe members not using their voice carefully. He is charged with a mission to get a vocal cord better as soon as possible. Those professional singing vocal cords are insured and are worth millions. Imagine if an ENT says strict voice rest to a lead Broadway Musical performer. How much does that decision cost the production company?

In the past 2 months I had danced about 7 times over vocal cords. Each time it was for a different procedure. One I was really anxious about was when I did vocal cord surgery on a fellow hospital colleague and dear friend who is a professional voice user. This gorgeous young girl spends her day educating, liasing, organising and communicating with so many people around the hospital. Everyone knows her voice. She was a little hoarse, and it was due to a small cyst on her vocal cord. This small cyst has changed the mucosal waves and vibrations of the cords, changing the airflow physiology of her voice production. Operating on her meant everyone in the hospital will hear and know of my results. A few milimetres too shy would result in a potential recurrence of her cyst and keeping her still hoarse. A few milimetres too aggressive could potentially cause her permanent voice damage.

She laid on the operating bed. I wrapped her head with a towel like she has just washed her blonde hair. I stood on the head of the bed. Using a few medieval contraptions I inserted a device that would keep her mouth and throat open in a straight line to her voice box. This device suspended her throat as I mounted it on a chest support over her body. Placed wrongly, I could twist her neck, break a few teeth, bruise her gums, tear her tongue, or damage her larynx. I had to get the perfect position so I could bring a multi-thousand-dollar operating microscope over her throat and work through a small opening onto her larynx.

Once her larynx is well suspended and her vocal cords are in full view I inserted various microscopic instruments through the scope. I used a combination of microscopic knives, forceps, scissors, needles and laser equipment. They are about an arm’s length and the tip is only visible through the microscope. This is why you absolutely need steady hands. The tip of your knife is held about 25cm away through a tiny hole under a microscope over thin vocal cords. Every little movement and tremor is like an earthquake on the microscope view. Removing the cyst and putting the vocal cord back together again so my dear friend could return to work was nothing less than stressful. I was mindful that I was using laser and microscopic instruments on her instrument of living, her voice.

In phonomicrosurgery (vocal cord procedures) I needed to be like a trapeze artist dancing on a tightrope. I did not drink any coffee or tea and made sure I was not in any way rushed or flustered. I had to be in a zen moment.

That’s why I love it! Just like when I tiptoe over the facial nerve and taste nerve in the ear under a microscope, or hanging off the skulbase a little off the eyeballs in the nose, vocal cord surgery gives me that adrenaline rush mixed with zen-like peace. Micromilimetres spell success or disasters. A man I highly respect once said “Faith is walking amongst miracles always at the edge of disaster”. I think ENT is like that too. We can approach the larynx from inside, and outside, whether the patient is asleep or awake. There is one particular procedure we do where we make a cut on the neck next to the Adam’s apple and we fiddle with the voice until we get it just right, all while the patient is awake and we have a knife in their throat. We can put a camera through the nose into the throat, and while we hover over the larynx, we can stab the larynx from the outside with a needle containing steroids to bulk up the cords. In fact, some performers do that regularly before their seasons. Cords on steroids as a performance enhancing drug.

Laryngologists fix vocal cords in all shapes and forms. Those with growths on it, both benign and malignant, those that are fixed, crippled or paralysed in any way, those that are just not working, and those that are the main source of extravagant income in professional users.

But we ENTs do not do it alone. We do it with the help of our friends the Speech and Language Pathologists or Therapists. ENTs work closely with allied health: audiologists, vestibular physiotherapists, and ‘speechies’. We love them, and in particular, the ‘speechies’. Why? (And here’s another reason why ENT is such a blessed specialty.) Because the speechies by far are the best looking of the allied health lot. Seriously. I don’t know why, but it is universal knowledge that speechies tend to attract really good looking people. Most of the speechies I know are pleasant to the eyes. One of the recent Miss America winner was (or going to be) a speechie. And I too have had the blessed privilege of examining a patient with a speechie who is a professional fashion model. You can imagine how hard it was for me to concentrate on her examining the physiology of swallowing on a patient while my mind was on the picture of that revealing dress or swimwear she wore in one of the magazines.

Speechies look good. And speechies make ENTs look good. They train the vocal cords, rehabilitate voice and speech, assess and re-train swallowing, helps children to speak and articulate, looks after tracheostomy and PEG-tube dependent patients, etc. Their clientele include paediatric, trauma, stroke, neurological patients, and many others. They are really good in what they do. And they look good. Have I said that already?

I do take my hat off to the Speechies, Audiologists, Physiotherapists, Dieticians, Psychologists, and many other allied health teams we ENTs work with.

Have you had enough of ENT fun? I’m only halfway through. There’s more to talk about. We’ve now done Ear, Noses, Throats, and next stop: Paediatric ENT! Where fun is really what the patient needs.