Voicing their relief

Although these patients - (from left) Mr Tee Poh Huat, 62, Mr Jeffrey Soh, 63 and Mr Goh Hwa Luck, 80 - lost their voices due to various reasons, surgeon David Lau (extreme right) has managed to help them, through various procedures, to speak again.
PHOTO: Voicing their relief

SINGAPORE - Mr Tee Poh Huat, 62, lived life in silence for years.

Not because he could not hear, but because he could not speak. He is among hundreds here who suffer from voice disorders every year for various reasons.

In Mr Tee's case, he had laryngeal or voice box cancer in 2005 which necessitated the removal of his voice box. This left a hole in his neck, called a stoma, that he breathed through.

He could no longer force air from his lungs through his mouth, which meant he lost his ability to speak.

Two procedures - to try and give him an artificial valve which acts like a voice box - failed, because the valve could not be placed accurately in the correct position.

Mr Tee tried to communicate with others by writing in Chinese, but it was slow and clumsy.

The former carpenter, who lives alone, steadily became more withdrawn from society and depressed. He could not even answer the phone when it rings.

In 2010, Dr David Lau, an ear, nose and throat surgeon now practising at the David Lau ENT Centre at Gleneagles Medical Centre, offered him the same procedure again.

This time, he used a new technique to insert the valve in a much more accurate place.

Dr Lau invented the technique, while still working at the Singapore General Hospital (SGH), together with his colleagues.

He uses a special telescope passed through the nose into the food passage which shows surgeons all the structures in the area clearly, so they can place the puncture precisely where it is needed.

This takes the guesswork out of the conventional procedure.

The valve is then inserted several days later, when the puncture tract has healed.

This can be easily done in the clinic in about 15 minutes. No general anaesthesia or sedation is needed.

This is a big advantage over the conventional technique, which requires general anaesthesia and one day of hospitalisation, said Dr Lau.

The "speaking valve" is the most common way that surgeons use to restore speech by creating a connection between the wind pipe and food pipe through a small puncture at the stoma site.

The voice box is involved in three important functions - breathing, swallowing and speaking, said Dr Lau.

These are complex and highly coordinated actions. For example, the voice box must open to breathe but close during swallowing and speaking.

The small, one-way valve placed into this puncture replicates this action by restoring the patient's ability to force air from his lungs into his mouth.

LEARNING TO SPEAK AGAIN

After his operation, Mr Tee could cover his stoma with a finger to force air out of his mouth so he could produce sustained speech.

It took much practice for him to get the hang of it, with the help from Ms Elizabeth Roche, a senior principal speech therapist at SGH. "There is much coordination involved," said Ms Roche.

The patient has to take a deep breath and then cover the stoma so that when he breathes out, the air that would normally come out of the stoma is shunted through the valve.

The air goes through the one-way valve and up in the food pipe, where muscle vibrations help to produce vocal sounds, she said.

Since 2010, all such surgery at SGH has used Dr Lau's technique. He published two papers on this in international journals on ear, nose and throat surgery in the same year.

So far, SGH is the main public hospital which uses this new technique.

Changi General Hospital (CGH) has done a couple of cases with Dr Lau's help last year. Dr Peter Lu, a senior consultant ear, nose and throat surgeon at CGH, said that the technique is "an excellent innovation" to help patients who need to have the puncture done at a later date after surgery to remove their voice boxes.

The special telescope warranted by this procedure is available at the National University Hospital (NUH) but has not been used for this purpose on any patient there yet.

Dr Lim Chwee Ming, a consultant at the department of otolaryngology - head & neck surgery at NUH said that the new technique would benefit those who need the puncture done after their cancer surgery. When there is an appropriate patient, he will be offered this new technique, said Dr Lim.

Dr Paul Mok, a senior consultant ear, nose and throat surgeon at Khoo Teck Puat Hospital, said he still uses the conventional method. The majority of his patients have the puncture put in during the cancer surgery, he said.

And if a patient needs the puncture to be put in at a later date after the cancer surgery, he still prefers to do it in the operating theatre under general anaesthesia, where the patient is asleep and not moving, giving him more control, said Dr Mok, who also runs voice clinics at Tan Tock Seng Hospital and Alexandra Hospital.

Dr Lau is now working closely with an engineering team in the National University of Singapore and his colleagues from SGH, where he is still a visiting consultant, to improve on the technique with a new device that will enable the puncture and the valve insertion to be done in a single step.

This will allow the patient to have his voice back immediately.

Patient trials will start in the next couple of months, said Dr Lau.

Mr Tee is among about 60 people here a year who get voice box cancer but there are far more who suffer from other voice box problems.

In the public sector, doctors estimate that they see close to 1,000 such patients a year at voice clinics.

"Our voice is often a reflection of our emotions and ourselves. To lose it can be very devastating," said Dr Lau.

MANY WAYS TO LOSE ONE'S VOICE

There are a myriad of ways to lose one's voice. Muscle tension voice disorders, acid reflux-related voice box injury and voice misuse and overuse are the most common reasons, he said.

Then there are benign growths such as vocal nodules, polyps and cysts, which also compromise the voice box's ability to function.

Another group of patients with voice issues suffer from paralysis of the vocal fold nerve, said Dr Lau.

This nerve runs from the brain, through the neck, into the chest, does a U-turn and then goes back to the voice box.

It can be injured anywhere along this pathway, he said, for instance through tumours of the lung, thyroid gland, the area at the upper part of the throat behind the nose and the base of the brain.

Other reasons include nerve conditions such as stroke and, sometimes, surgery in the areas where the nerve lies, he said. On rare occasions, physical injury can also do the same damage.

If the person cannot close his vocal folds due to paralysis, he will not only have a weak voice but may also have difficulty swallowing and be at risk of getting chest infections if food particles enter his lungs.

Helping the vocal folds to close effectively in this situation can improve both the voice and swallowing functions, said Dr Lau.

Because of the complexity of the swallowing mechanism, there is sometimes a need to strengthen a weak muscle on the one hand, and weaken an overly tight muscle on the other.

This may require a combination of fillers and Botox injections, techniques which require the doctor to study different methods and materials to best improve the patient's voice, said Dr Lau.

Less common are conditions that affect the voice box muscles and nerves such as spasmodic dysphonia, where the muscles go into spasms and the patient speaks as though he is being strangled, said Dr Lau.

There are also psychological conditions that can affect the sound of the voice or, sometimes, the ability to speak, he said.

Mr Tee, for one, is very grateful for Dr Lau's interest in this area.

"You never realise how important your voice is until you lose it. I felt like a dead person without a voice," he said in Mandarin.

Finding his voice again has led to big changes in his life.

Instead of staying at home all the time, he is now actively engaged in many activities, including dragon boating and helping others who have lost their voice.

"I feel alive again," he said.

Tennis mishap paralysed his vocal cords

Mr Jeffrey Soh, 63, a father of four, played tennis for 30 years without incident.

In January 2012, while he was running for a ball and looking upwards, he tripped and fell.

His head crashed into a concrete wall and he blacked out.

The base of his skull was fractured.

He was diagnosed with pneumocephalus, which is the presence of air or gas within the cranial cavity, as well as vocal cord paralysis.

He stayed in hospital for three weeks and when he was discharged, he could not swallow.

When he spoke, he had barely 20 per cent of his original volume and speaking strength.

He had to be fed via a feeding tube inserted directly into his stomach.

He consulted many ear, nose and throat specialists and saw three speech therapists.

After 30 sessions of electrical therapy to help him swallow did not help, he started losing hope.

"I thought I had to depend on the feeding tube for the rest of my life and also go through life whispering to everyone," said Mr Soh.

Life came to a standstill. He stopped his work as a consultant engineer. He also stopped playing tennis.

His weight plummeted from 66kg to 41kg.

Then, a speech therapist referred him to Dr David Lau, a specialist ear, nose and throat surgeon at Gleneagles Medical Centre.

"Vocal cord paralysis can cause an inability to speak and swallow, but the voice can be restored by a procedure to bulk up the vocal cord to help it to close," said Dr Lau.

"It is a deceptively simple procedure with life-changing effects," he added.

Various techniques and materials can be used, though the resulting success would depend on the surgeon's experience, he reasoned.

Dr Lau carried out the procedure on Mr Soh last year, 14 months after his tennis accident.

It turned things around quickly.

Two weeks after the surgery, Mr Soh could eat. He regained some weight and is now 55kg.

"I became more confident in swallowing my food knowing that I could protect my airway better," he said.

His voice also improved and is almost back to normal now.

"I can go back to work now and eat anything I want. It's a huge relief," he said in a clear and steady voice.

LASER SURGERY FOR VOICE BOX CANCER

Another patient, Mr Goh Hwa Luck, 80, found out he had voice box cancer when he was 76.

Before the diagnosis was made, his voice had been gradually getting weaker and weaker.

"When I spoke, I had no strength and I had to rest often when speaking," he said.

He also had difficulty swallowing.

Even then, he suffered the symptoms for two years before he went to a doctor, because he kept thinking his symptoms would improve with time.

Fortunately, it was still early enough for him to undergo minimally invasive laser surgery through his mouth to remove the cancer.

His voice box could also be preserved.

He bounced back with a much stronger voice and has been able to travel regularly with his wife and family since.

"This type of surgery can be used in selected patients and allows them to keep their voice without leaving a scar and without radiotherapy," said Dr Lau.

"It is another example of the many ways available to help patients regain their voice," he added.

wanching@sph.com.sg

This article was published on April 24 in Mind Your Body, The Straits Times.Get a copy of Mind Your Body, The Straits Times or go to straitstimes.com for more stories.