9UNP0136SD_Seth Dailey_WordPress

- I'm Tom Zinnen. I work here at the Biotech Center. And I'm happy to be partnered with the Wisconsin Alumni Association and the UW-Madison Lifelong Learning Institute to help bring you Wednesday Nite at the Lab. Tonight, we have Seth Daily, from the Department of Surgery here at UW-Madison's School of Medicine and Public Health. Seth got his bachelor's of science in 1991 at Columbia University in New York. In 1996, he received his M.D. at the New York University School of Medicine. From 2002-2004, he was an instructor at the Harvard Medical School in Boston. And since 2004, he's been an assistant professor here at the University of Wisconsin School of Medicine and Public Health. Tonight, he will be talking about "Out of the O.R. and into the Office, the Future of Upper Airway Surgery." 

Please join me in welcoming Seth Dailey to Wednesday Nite at the Lab. 
(applause)
 
- Thank you very much, Tom. It's a real pleasure and honor to be here. Anything that's associated with Public Television and Public Radio, I'm always happy to participate. I feel like one of my earliest childhood memories, for whatever reason seem to be the sound of Morning Edition for me. Anyway, tonight we're going talk about the present and future state of upper airway office-based procedures. This is just to note that the state of upper airway academic research is that there's a recent article published on complications of sword swallowing in the British Journal. Okay, as you might imagine, the number one complications were laceration of the esophagus and stomach. 

So, I'm glad that as we progress technologically, that the quality of academic medicine is also accompanying that. So this is actually a woodcut of early use of ether. But this is what I hope not to do to you by the end of the next hour. So we're going to talk about unsedated office-based procedures in laryngology. And on first pass, it may seem sort of like talking about the tip of left distal finger surgery in the future. It may seem like something that's sort of an unusual niche. But it actually represents sort of an interesting window into the future of many surgical procedures. And there are probably a number of buzz words that will come into play here, minimally invasive, laser, awake, avoidance of general anesthesia, to morbidity, things like that. Things that are in the literature and things that are in kind of public media, public and otherwise, may come to play here. So my preferred format for lecturing is to have it be as interactive and teamwork based as possible. 

So rather than wait till the end for questions, and I'm not sure if this is okay with Public Television here, okay, I'm getting the thumbs up. I would prefer, if there are questions, to just fire away as we go. I'm from New York. I'm not afraid of people interrupting me. It's not a big deal. The goals tonight, I want to try to present to you the logic of some of the unsedated procedures for the upper airway. We're going to talk about what we do both in the larynx and then also in the trachea and the esophagus. More than anything, I'd like to show you what's possible now, things that even I as a fellow, or I should say as a resident, maybe six or seven years ago, would've thought were not only were undoable, but really unwise. I'm going to try to show you quite a few video demonstrations. My mother used to say that I never knew any nursery rhymes now because I could never sit still. 

I could never sit still for a lot of words. So we're going to do a lot of video tape. Then I'm going to review the UW experience, some of the pros and pitfalls of things to take note of, so hopefully this will-- Not everybody is a gigantic lover of the larynx, so I thought it would be useful, even for a moment, just to review some basic anatomy and physiology. The larynx is an organ near and dear to my heart, but not near and dear to the heart. 
(laughter)
 It starts at the base of the tongue, extends up from this bone here, which often is called, in layman's terms, the tongue bone. There is a shield-like part of this called the thyroid cartilage. That is most easily identifiable from afar in men, the prominence there that is a little bit more prominent in men than in women. This cartilage down here called the cricoid cartilage is circumferential. It's more or less like an oval or ring. 

And it's the only circumferential ring of the airway. You'll note that the larynx sits on top of the trachea. It is sort of like the guardian, the sentinel, the protector of the lungs and the trachea. It's supposed to let only air in and out, and nothing else. The esophagus is located immediately behind the trachea, so that the larynx, in many ways, functions like a stop/go valve. Air is supposed to come this way, and food, which also has the same entry point in most cases, goes into the esophagus. So it's really the vocal cords on the interior of this thyroid cartilage that allow it to function well as a stop/go valve. So the larynx, if you look at it, just with all it's cartilaginous or boney parts, and you explode it, here's the cricoid cartilage at the bottom. There are these two small cartilages toward the back that move back and forth. The vocal folds are more or less like a V-shaped valve. 

These cartilages are in back of that V-shaped valve. So if you imagine them as my fingers, those cartilages would be where my finger pads are, so right at the tip. They insert, the vocal folds insert onto the interior of this thyroid cartilage. Then here is this sort of serpent's head shaped epiglottis that folds down every time you swallow to help protect your airway from food and drink, and beer, and all that sort of stuff. So this is the larynx viewed from the back. Again, here is the trachea, the back of the cricoid cartilage, two arytenoids. And the vocal folds would be extending from this one and this one, into the screen, and insert right about there. If you were an anesthesiologist, and you were going to put a breathing tube in someone who's lying down on their back, this, hopefully would be your view. So here are the vocal folds, which are pointing, the sharp point of the V is pointing toward the front. And you can see some tracheal rings. 

That's where the airway goes. So there overall, there are three main functions to the larynx. One is to permit air to go back and forth. The other one is to protect the airway from water. Then one of the other major ones, although developmentally this is a late development, is the generation of voice. The sound source so that we can have a resonant communicative voice. Other functions include cough, so we can clear our lungs and help improve our pulmonary physiology. Then another function is the so-called Valsalva maneuver, which you will hear a lot at airports. When people are carrying heavy bags, that sort of grunting is actually exerting intra-abdominal, intra-thoracic force against a closed set of vocal cords, so that this area can remain stable and you can use your arms and legs independently and in a stable fashion. There are three major criteria for generating voice. 

You need the generator, which is air. The vibrator, something to vibrate. You can use your lips. You can use your vocal cords. Then the resonator. The resonator is everything from your vocal cords up. It is what we call our signature horn. This is why I sound like me and you sound like you. And also why, for example, impersonators can make a living. They can do all kinds of crazy things with their voice. 

It has nothing to do, really, with their vocal cords themselves. It has only to do with your signature horn, starting here and moving up, to the tip of your nose and lips. Question, please. 
(inaudible)
 Right, good question. So ventriloquists use their vocal folds and they use their articulators, their tongue, their lips, but they tend to use them so they don't really have to move their lips a whole lot. So they can make sound and change their articulatory components to make all sorts of sounds. But they tend to have mastered the ability to not use their lips a whole lot. So it appears that they're not talking. But they are. 

In general, there are three components for high quality glottic, and glottic refers to the vocal cords, so if you hear me say glottic and vocal cord, those are synonyms. Closure, meaning the vocal cords have to be nearly closed in order for them to oscillate. They need to be soft and pliable. And they need to be one looking like the other. Let me do a demonstration here. By Bernoulli's effect, if you have things that are soft, and you have an air stream that passes by them, they will be sucked together if they are close enough together. So like this. There's an air passage. There's the production of a relatively low flow area. So things that are soft and pliable will be drawn in. 

If I move them apart and blow again... 
(laughter)
 Right? Nothing happens, other than me getting red in the face. They don't get drawn together because they're not close enough. So the vocal folds need that near closure. They need to be soft and pliable so that after they're sucked together, they push themselves apart. So they have to have elastic qualities and viscous qualities to be sucked in in the first place. That's kind of the basics of how that works. This is a section of the vocal cords. 

It is the vocal cord, again, moving back and forth. However, we'll rotate them in this dimension and cut them like this. This is one vocal cord. Can you see that up there if I do that, or do I need to use the pointer? It's okay? So this would be the very surface of the vocal cord, which is thin, really, like Saran Wrap. You can see right through it. If you had enough epithelium of the vocal fold, you could read a newspaper through it. It's only, maybe, 200 microns or a fifth of a millimeter thick. Then there's a crucial area called the lamina propria, which has a tendency of being able to oscillate when air passes by. 

It has both viscous and elastic properties. It has living cells. It has non-living things, like glycoproteins that help it to be a shock absorber. It's really kind of an extraordinary area, where we're trying to, as a group in our division, do quite a lot of work to tissue engineer this so that we can restore voice to a lot of people. Underneath that there is a muscle which allows us to generate tension on the vocal folds and modulate tension. In fact, the superficial most layer of this muscle has a neuro density, which is 50 times that to the hand. So we think that the hand is a very well controlled organ, etc. Well, take for example the vocalis muscle, where the neuro density, the control mechanism is 50 times greater. So the voice, over time, has become something of an important element for our survival. This is a picture of something called a stroboscopy. 

Stroboscopy is a visual technique which we use to image the larynx in the office. And more often than not, we use a rigid telescope through the mouth that looks down at 70 or 90 degrees at vocal cords. You project that image through a camera up onto a video monitor. And apply stroboscopic light, which takes in essence a composite picture of vocal fold oscillation. So if I do this, for example. 
(hums)
 That's about 100 cycles. So we can't see that with our eye. So the stroboscopy slows it down, so according to Talbot's Law, which says that you can hold an image on your retina for about .2 seconds, your brain will turn it into a movie. So it's the same reason why if you have a flip book, and you see different pictures of somebody sequentially doing something and you flip it, your brain will turn it into a movie. 

So moving pictures, same thing. This is a stroboscopy. You see the vocal folds. It looks like they're moving back and forth sort of slowly. But they're not. That's just so we can look at it with our eye in the clinic and make some sort of determination about the pliability, the symmetry, the appearance, the color. Just basic visual examination skills. This is not necessarily new. A German thought this up in 1855. And so, it's taken basically, until the early part of this century to devise some better methods. 

And really until the 1970s to have the imaging technologies, with the rigid scopes and the flexible scopes to be able to use it as a clinical tool. It's really been clinically usable for about the last 30 years. We're still using it. I would say it's the standard of care. So given that we can do a certain number of things in the office, like a stroboscopy, I'm sure just about everybody here has had some sort of office-based procedure. Let's talk about dentistry for a moment, not to make it too uncomfortable. But we can do all sorts of things to people's teeth in the office. Well, why? Principally because of lidocaine, novacaine or any of the "caine" drugs of different varieties that help us to achieve local and topical anesthesia. That is the gateway towards office-based procedures. 

A good dentist will also have a nice, what I like to call anesthesiology voice, so they can come in and... 
(speaking softly)
 Good morning, I'm going to drill out your teeth today. It's good to see you. 
(laughter)
 So there's, you know, verbal anesthesia, if you will. If you are a good verbal anesthesiologist, and you apply your local and topical anesthetics properly, you can really get away with a lot for a short period of time. So we can achieve what we call an anesthetic window. So why should we do things in the office? First of all, compared to general anesthesia, usually there is lower patient morbidity. 

Morbidity is just a different way of saying damage to you. There's often lower pain, because you're not instrumenting the person nearly as much, because you can't, for many reasons. With office-based procedures, there's no sedation. There's no intravenous line. There's no valium. There's no fentanyl. There's no falling asleep. You are awake. You have topical anesthesia and verbal anesthesia working for you. So people, for example, undergo many of the procedures you're about to see, and then drive themselves home from their appointment. 

For all intents and purposes, there is a similar efficacy for the types of procedures that we perform in the office and we perform in the operating room. The caveat to that, of course, is there are certain things that you simply can not do in the office. There are limits. Most patients who have had a procedure done in the operating room and a procedure done in the office will prefer to have it done in the office, even if they have to repeat it. So for example, if they have to have two procedures in the office to achieve the same goal that it would take one in the OR, most people will probably choose the office. Importantly, in the United States, and there's been a lot of talk about this recently, is that we have an aging demographic. This comes up under talk of Social Security, Medicare. The $41 trillion to $135 trillion inheritance for baby boomers over the next 40 years, about which there is a lot of debate. So this is a time when people over 50, people over 60, people over 70, will be having a lot of voice, so to speak, in their own healthcare. This tends to be a generation that knows what it wants. 

It tends not to be shy about saying it as a general rule. And they are overall educated about how the healthcare system has progressed and how to negotiate it a little bit. So the last reason to do it is that it's possible. A lot of these laser procedures, and other things you're going to see, were simply never possible before. So here is, and some of the numbers may be a little small, so I'll just say a little bit. This is numbers in millions, up to 100 million. This is the year 1900. This is the year 2000. So we're right about here, 2008. These are from the US Census Bureau. 

These are projected numbers of folks up to 2040 and 2050, the number over 85. The number of people over 85 in 2050 will be 20 million people. That's a lot, okay, especially given in 1960, it was maybe a million. The number over 65, you can see also where the trajectory is going. This is a reasonably substantial number and proportion of our population that will be involved in healthcare. Here's the other important consideration. ASA stands for American Anesthesiology Association. You can have a risk score. So the risk score goes from one to four. On this axis is the probability of any major complication. 

Here is the age in years. This is for folks undergoing procedures under general anesthesia. This, you can see, with every pre-operative ASA score, the risk goes way up. If you have, for example, a number of medical problems, and you're about 80 years old, and you're undergoing a procedure under general anesthesia, the chances of you having a major complication, heart attack, stroke, problem, is about 15%. So that's one in eight people. That's a lot. If you're going to play the lottery and the chances of winning were one in eight, you would play. So this is a very meaningful number. And when you multiply the previous slide times this, you can see that the possibility of a lot of people undergoing major complications, or minor ones, in the future is reasonably substantial. What about playing my own devil's advocate. 

Why would you not do procedures in the office? First of all, the equipment is expensive. So not everyone can do it. I'm an otolaryngologist, head and neck surgeon. But certainly not every practice is going to invest in this sort of thing. We have a specialty practice. There are only, maybe, 50 people nationally who do what I do. It's not a big group. And you need to invest. There are reimbursement problems. 

So for example, even though we can bill for a procedure that would otherwise be done in the operating room, we are not reimbursed in the same fashion, even though the patient is getting the same service. So in fact, currently, there's a disincentive from insurance companies for physicians to learn and do this. So what we're trying to do over time is to demonstrate to insurance companies that this is actually something that would benefit not only them, but the whole population. It takes extra staff and extra training. Again, you know, revenue challenges. There are technical challenges. This is not something that you want, you know, this is not like going out and getting an ipod and using it. Even I can do that. But the technical challenges are considerable in terms of the learning curve, learning how to do it. You know, build some verbal anesthesia, how to coax people through things that are a little unusual, to say the least. 

And anesthetic management both, as I was saying, verbal and the topical. So there are a couple of studies, which have been done preliminarily to try to demonstrate that there are financial incentives to the healthcare system to do these types of procedures. Some of my colleagues have been using a laser, which we have here, called the pulsed dye laser, that we can apply to folks, to their larynx and their trachea in the office. And they're comparative study, from a cost analysis was almost $8,000 versus $2,000. In the operating room, it'll cost $8,000 to the healthcare system to do it, where in the office, about $2,000. So they calculated in the range of somewhere of $5,000 per case. The reimbursement, however, is not all that substantial for the physician. So again, it's disincentivized in the current climate. So we have a little bit of work to do. For other office-based procedures, called vocal cord injections, some of my other colleagues in Pittsburgh did an analysis where they looked at their experience with office-based vocal cord injections versus those in the operating room. 

And they generated a cost analysis where basically, for the number of vocal cord injections that are performed nationally, that it would save the system about $40 million a year. So there can be arguments made about their analysis techniques and that sort of thing, but the general idea you can see. That basically, it's going to save everybody morbidity and money. Question, please. 
(inaudible)
 It's a wonderful idea. What I'm really hoping for is for one of them to become dreadfully hoarse and then need help. 
(laughter)
 Even Bill Clinton needed help, you know? Dreadfully hoarse? 

So, you know, Bill Clinton only needed voice therapy, but man, I would've been so happy if he had needed the vocal cord injection. So distal chip endoscopes are otherwise called chip in a tip. So just to be geeky for a second. Original fiber optic technology was used for flexible scopes starting in about 1968 to 1969 by Olympus in Japan. And what they did was they passed individual fibers through a plastic coating, a sheath. And through a mechanism, you could direct the fibers, the distal end of the scope up and down. Then, through the fibers it would be attached to a camera. The camera is attached to a processor. The processor is attached to a television screen. So you can get direct images, or just look directly through it and see something that you would not be able to see otherwise. 

So this was useful for bronchoscopy, looking in the lungs, and then looking at the larynx and the nasal pharynx and the rest of the throat as well. This was a big breakthrough. The problem is that the images are not that great and the color veracity is not that great. So what people would end up doing is being a little frustrated. So within the last five years, there's something called chip in a tip. You have a tiny, tiny, little camera at the end of this flexible, you know, elephant trunk kind of thing. And so, instead of having the processor back here doing all the image capture, to a certain extent, it's all being done right up close and personal. So also with Moore's Law, I'm probably going to screw this up, but it says that basically every five years, you will half the cost and double the power of your technology, something close to that. These distal chip endoscopes are becoming very popular. You'll see images from them. 

We use them in laryngoscopy, esophagoscopy, and tracheoscopy. So, larynx, esophagus and airway. We can perform photo documentation. So for teaching purposes, for sharing with other physicians, it's extremely useful. For medical legal purposes, in case they're saying you never looked and we did. New injectables. So things that go into the vocal cord, this is going to be a big, big topic here at the UW within the next three to five years, because we will be in the process of developing something called hydrogels. Hydrogels are going to be biologically active. And they are, in fact, instead of just being a filler that just kind of sits there like a little gel, they're actually going to initiate biological changes to the lamina propria, to help people with scar, to help people with certain variants of scars, maybe people with irreparable changes from smoking, a whole host of things. So these injectables are definitely on the horizon for us. 

Lasers are something that came into use, we first reported this, I think in 2004, when I was a fellow back in Boston. My boss was developing the use of this laser for people with papilloma of the larynx. A papilloma is a benign lesion, generally speaking, and has a propensity to go under the vocal cords. So it makes people very, very hoarse. And we don't have a cure. So the idea is to try to help people while hurting them as little as possible, both in terms of anesthetic and then in terms of thermal damage to the vocal cords and that sort of thing. So with all that said, here are some of the things we can do with these injections: Biopsies of the vocal cord, laser procedures, esophagoscopy and airway examination. So how the heck do we get into the larynx? The difference in many ways between hoarseness and dermatology, just as an example, is that with dermatology, you roll up your sleeve and you say, you know, I was in the shower and I noticed something funny, doc, what do you think? I can take a look. 

But if you have a hoarse voice, really all you can do is say, you know, there's something wrong with my voice. Then you know, you can try and look through there with a larynx scanner, or whatever, but it's not going to work. You need to have imaging. So after you have imaging and you want to do something about it, you then need to gain access to the larynx. So how do you do that? I'm going to show you a couple different methods here. You can go through the mouth. And the first trans-oral procedure was done in about 1855 by a guy named Horace Green, an American. He looked inside someone's mouth and saw this very large cyst sitting on top of the epiglottis and was able to retract it and pull it out. So it wasn't particularly pretty, probably, but it was historic. 

It's always a little ugly at the beginning, I would say. So trans-nasal injections are done by putting one of these distal chip endoscopes through the nose. Then they have these, if you picture a cylinder, and you core a small tunnel in the cylinder, that would be what we call a working channel. So in this hose, you can have a have a working channel through which you can pass the laser fibers, and do suction, and pass these cute, little needles, so you can also inject the vocal cord that way. And then you can also go through the skin. This is a plastic model of a throat and head, cut right down the middle, more or less. Here's the voice box. Here's a needle, which you can see going through the mouth, so that would be trans-oral. Here's a needle going through the skin, right into what we call the endolarynx, so the interior of the vocal cords. And I'll show you some pictures. 

This is our basic set-up. Question, please. 
(inaudible)
 
(laughter)
 It is a wonderful time to ask. And in about three slides I will show you how we begin to work with that. So here, this is our general set-up with a whole lot of equipment. So this is probably a quarter-million dollars of stuff just sitting here. There's a power chair. 

There's a processor. There's the video monitor. There's one laser. There's another laser. There's a bunch of fibers, and protective eyewear, etc. Here's an attachment to the computer system at the hospital. So when we record these images, they go right into the radiology system. So that way, if other physicians or other people want to look at them, they can. It's really, really good for patient care. These are some of my assistants, who work with me and make the procedure clinic run. 

Here's a video, okay, getting to your question, of how do you apply topical anesthesia to the larynx. This is just one way. This is me. And here is the patient. In my left hand is a rigid endoscope, which looks down at the vocal cords. In my right hand is a curved canula, a curved metal tube, which is attached to a syringe. You deliver lidocaine while the patient is phonating, while they are saying "e". 
(inaudible)
 You can see it kind of bouncing around here. He's going to breath it into the trachea and cough. 

This is a little uncomfortable. Okay? This is what it looks like if you have a telescope and you're looking down at the vocal cords. There's no sound on this video. Here's the drip. You can see drip, drip, drip. You really don't need a lot, somewhere between a half a cc to a cc two or three times. And by the time that bounces around, it basically does all the work for you, it's great. So it bounces around and it anesthetizes all the mucosa of the interior of the larynx. You have to remember that there are three major things that we're fighting here. 

One, is people's psyche. Two, is the jaw and tongue, which is a very powerful complex of muscle and bone. Three, is the larynx itself. The larynx, if you were to ask the larynx during a job interview, larynx, you know, what really makes you tick? "I like to protect." So the larynx is a protective organ. When it gets nervous, it shuts. It's a protective organ. So we're having to work with all those things to try to make it happen. And it can. 

But it has to have the right type of situation. And it has to have lidocaine. So vocal cord injection is one of the things we do a fair amount of. And I'm going to say, well, who cares. So basically people with vocal cord paralysis is one reason. When you have vocal cord paralysis, there's one side that moves and the other side that doesn't. So when you think about the vocal cords like a valve, vocal cords work better, again, like the paper example, when they're close together. So I'll now do a voice of someone who has vocal cord paralysis. A very breathy voice, and he's air wasting. The vocal cords don't come together. 

You have air leakage. And when you have air leakage, people get very tired. They get very frustrated. And then, even because they can't close well, they can't protect their airway well, so they have trouble with swallowing. They also have trouble with coughing. They can't expel things from the lungs. So it's problematic. This is something, again, which we can easily address in the office with vocal cord injections. The most common reason, probably, in our practice and in the community as a whole, is surgery that challenges the nerve that goes to one side of the larynx. So there are basically two nerves from the top and two nerves from the bottom for each half of the larynx. 

It's usually the bottom nerve, called the recurrent laryngeal nerve, which is the one that gets challenged the most by these types of surgeries. We can inject a lot of other things, including Botox. So Botox gets a lot of press for being used in plastic surgery. It's a wrinkle reducer and it's really a fabulous and amazing drug. It has uses for chronic pain in certain instances. It can reduce saliva in people who are chronic aspirators. We do that. And it can also be used, and this is our primary use, is using it for people with neurological disorders of the larynx. So something called spasmodic dysphonia, where people end up having strained voices. Speaking of Public Radio, etc., 

Diane Rehm is someone who as spasmodic dysphonia, but is able to function as a radio announcer because of Botox. Steroids can be injected, sometimes for vocal cord nodules, for other inflammatory conditions. So there's a whole host of things which we can get in there. Here's another video. Here is a video of a very small, this is a 25 gauge needle, going into the very superficial part of the vocal cord and injecting steroids. This is for mid-vocal cord nodules. We find that this can be helpful to initiate voice therapy in people with nodules, which a lot of singers get, a lot of moms with three kids and a dog, people who use their voices a lot, or in loud places, and people who really drive their vocal cords with a lot of force. 
(inaudible)
 I'm injecting some steroids. So a glucocorticoid steroid, not anabolic steroids. 

Glucocorticoids will shrink swelling, and exert only a local effect. That's kind of the desire there. Remember I talked about the transcutaneous, so through the skin approach to the larynx. Here is a video of a young lady with spasmodic dysphonia. And the needle is going right here, below the vocal cords, in a place called the cricothyroid membrane, which is where we do our emergency airways in the emergency room. We do it as infrequently as we can. The needle goes through the superficial part of the vocal cord called the lamina propria and into the muscle. That's the Botox is exerting its effect, on the muscle. It's a so-called chemodenervator. It denervates muscle. 

It weakens muscle, partially through a chemical effect. It does that both here and here. You can literally be done with the doing part of the procedure within a minute. But the preparation, all that, can take 10-15 minutes. If you think about it like some gigantic airplane taking off or something, it's taxiing and taxiing, taking up speed, and then finally it lifts off. But it's all in the picking up speed that's important. Question, please. 
(inaudible)
 So the Botox treatment lasts somewhere between three to 12 months, depending on the severity of symptoms of the patient. If we're talking about neurologic disease of the larynx, somewhere between three and 12 months. 

Usually around three or four. It's more unusual to have it last 12 months. It's usually about every three to four months. It's not a cure, but it's a pretty effective, pretty minimally invasive treatment. So we don't have a cure for many of these diseases, which are actually centrally based. So in other words, they have to do with your central nervous system, and they're simply manifesting in your larynx. Question, please. 
- It's so intricate, how are some birds able to imitate the human voice? 
- Well, sure, I'll repeat the question. Our anatomy is very intricate in terms of the larynx, how is that birds are able to imitate a human voice. 

You mean like a parrot, something like that? Got it. Well, I must say I haven't looked into that a whole lot. But I would say that birds actually have pretty intricate larynges. I think they even have something where they can have two different sets of vibratory elements. So I'm not so sure that it's any less intricate than ours. But it does obey all the same rules of physics, as far as having a generator for air, a vibratory source or something to vibrate, and then an articulatory source. So the fact that, for example, a parrot can mimic a human voice is based in part on their own auditory ability to process what they hear and then repeat it. But from a physical standpoint, it's also that they have a tongue, that they have lips, a beak. They have a throat which they can alter to shift the shape of the sound and all its frequencies, etc., 

so that it can sound like something else. It's really all basic physics. And the anatomy is conserved enough that in certain birds, they can do that. So if you're going through that cricothyroid membrane you can't, as the surgeon, hold the scope through the nose and then inject. You know, with two hands, it's not going to work. Here, you have to have an assistant. This is one of the residents who is helping me by holding the scope while I place the needle through the front of the neck there. So another way, you saw at the beginning, some of those pictures of the larynx, that thyroid cartilage, that's like a shield. And it kind of protects the vocal cords. So you can go through that, directly through the shield and into the vocal cord. 

So if you watch here carefully, the lights up here, I don't know if those can be doused. If they can't, it's not a disaster. But if you look in this area, you'll see that there's sort of a poking. Thank you, very much. That's great. You're going to note there's sort of a poking right there. That's the needle that's gone through the cartilage, through the muscle, through the lamina propria, and is identifying itself under the epithelium. Then I can draw it back just a touch to be able to put the medicine, the Botox in this case, in the right place. We can have the lights back up please, thank you. Great. 

So what else is possible? Question, please, yes. 
- When you go down the throat with a scope, why wouldn't you do your injections through that instead of subcutaneously? 
- I'm being instructed to repeat the question. The question is if you can look through the nose with a scope, why wouldn't you use the working channel of that scope as a pathway to inject. The answer is that you can. The answer is that you can, and that's a reasonably new technology, for which the largest series has only just been reported within the last year. And we, actually just got the catheters to be able to do that within the last two weeks, to be able to try that out. Can you? Absolutely. 

One of the advantages of that is that you can do it yourself in sort of a one-person show. You need less personnel. That's nice. One of the disadvantages is that the needles thus far, are a little large. And differences in gauge can mean a reasonably considerable amount of risk in bleeding, potentially. Because everybody now, if they're over 65, is on 81mg of aspirin, or plavix, or coumadin, or some combination therein. So there's a lot of people on blood thinners. And so for me, I'm going to feel more comfortable once-- You okay? Okay, sorry. All this talk of anesthesia, you know, I should've brought my lidocaine. 

Okay, all right. So the answer is that it's possible. I don't have great data for you yet, about how much better or worse it is than anything else. But it is, at some point or another, becomes a question of preference and use. So there's science and then there's art. So it's somewhere in there. So who benefits from these biopsies? There are a certain number of people who are bad anesthetic risks. Let's say for example that there's someone who comes in, they're a smoker. They have something in their vocal cord, it doesn't look favorable. 

They just had two heart attacks. They're going to need treatment for their vocal cord cancer, and possibly a form of radiation. Okay, because they couldn't get surgery because they have a bad heart. Fine. How are you going to get a sample of their vocal cord to prove that they have cancer? Well, you can do it in the office. These you can also do using a trans-nasal scope, because there's a little biting forceps you can use. Or you can go through the mouth. I think we have an example of this. So here's someone on whom I have done a cancer procedure for vocal cord cancer. 

They had a little bit of growth there. After six to eight weeks in the healing phase, I wanted to make sure from a screening perspective that it wasn't recurring cancer or persistent cancer. So here's is a biopsy forceps going through the mouth, after an anesthetic has been applied, to sample that area. It's reasonably straightforward and well-tolerated. You can see that there's really minimal bleeding. Very good. Let me ask the audience. If we keep the lights up, can you see most of these videos? Yes? Okay. 

Then probably unless I ask specifically, just go ahead and keep the lights up. Thank you. So what else is possible? We can do some things with the larynx using lasers. There's a gentleman at Mass General Hospital, Harvard Medical School, who as a medical student dreamed up this thing called the 585 nanometer pulse dye laser. Basically, all lasers have targets. What that means is that there are different types of tissue that absorb the laser energy differentially. So for example, using a CO2 laser, probably in human tissue, the thing that uptakes that the most is water. Okay, so it superheats water, explodes it. And it's pretty good, for example, at destroying tissue. 

Or, if you make the spot size very small, at cutting tissue. The dye laser targets oxyhemoglobin. Oxyhemoglobin is one of the components of red blood cells. So when you apply this energy to red blood cells within microvasculature, so tiny little blood vessels, the oxyhemoglobin in the red blood cells becomes denatured. It changes shape. And so if you picture small blood vessels almost like small rivers, then those rivers become clogged. They stop. They freeze up. That's what's called photoangiolysis. Photoangiolysis is possible due to the application of this laser. 

There are similar lasers, like the pulsed KTP. It stands for potassium titanyl phosphate. It's basically using the same principles, though. And the most recent one that we've been using is a holmium based laser. That has been used in urology and neurosurgery in all sorts of stuff. The advantage of this is it acts like a CO2, but it can put through a flexible fiber. So again, a lot of this is sort of technical advances. We've been dreaming about a flexible fiber for the carbon dioxide laser for the last 37 years. Finally, basically it's here, so it's very, very exciting. Previously, the CO2 laser can work in the straight line. 

Or, if you want it to bend, you have to produce this really complicated series of mirrors. So that really wasn't working out too well. So finally, after 37 years, it's been figured out and you can have a CO2 laser equivalent. So who benefits from this? RRP on the slide here stands for recurrent respiratory papillomatosis. Papilloma of the vocal cords, again, it's a benign lesion. In pediatric form, it's really devastating. And kids who are six years old can often have 60 procedures. It's principally for airway management. Kids are not as concerned about their voices. 

Their parents might be. But the kids just want to have a clean airway. In adults, it tends to be a little less aggressive. And adults, especially in the work force, now that we have largely a communication based society versus, you know, industrial or agrarian, everybody has their cell phone and that sort of thing, you need to communicate. So voice in adults with papilloma is really important. Leukoplakia. Leukoplakia is basically white keratin on the vocal cords. Vocal cords, as you saw the pictures before, are very thin and smooth, and they don't have flaking keratin. Keratin is house dust, and it comes from your skin. Your skin is keratinizing epithelium. 

So when you see it flaking off, that's the covering that's keratin. Vocal cords don't normally produce that. When they're irritated, when they have genetic changes, when people smoke for a long time, they change. They start to produce this white patches. Or if you like Greek, white plaque, leukoplakia. The laser has been shown to clear some of that plaque. We don't know if it's actually reversing some of the genetic changes. It's unclear what's happening. There's still science to do. So far, it has a favorable effect. 

Because a lot of this mucosa, including vocal cord epithelium, was thought to be condemned because of years of smoking and irreversible changes, this is actually a very favorable thing. One thing that gets to me, speaking of media, is poor media coverage of people with vocal cord cancer and people with leukoplakia. The reason that it irritates me is because years ago, 40 or 50 years ago, for many of the World War II vets, for example, cigarettes were always handed out to the GIs, no problem. Everyone started smoking. It wasn't for many years the results of this were understood. Even if people stopped smoking, 40 or 50 years later, they can start to get leukoplakia, and they can get vocal cord cancer. That's because there are irreversible genetic changes that happen with smoking. It's the gift that keeps on giving, if you will. So even for people who quit, they can still get these problems later. And a lot of folks in the media do not like to cover these stories because many people don't have any sympathy for folks who have smoked. 

And personally, I don't think that that's very nice. So that's just my little axe to grind. So Reinke's edema is another change in vocal cords. This is typically seen in middle aged female smokers. So if you're a fan of watching the Simpsons, you will recognize Marge's sisters. Who all talk like this, "Hey, Bart, come here." So they have very low, rough voices. And those are the voices of people with Reinke's edema, which kind of flop back and forth, and they're very large vocal cords. And then granulomas are the last one. I'll show you some examples here. 

So this is the pulse dye laser in action. It's pulsed. You can see the flashes. Flash, flash, flash, flash, flash. It does pulse. It makes a little noise in the clinic because of the pulsing. So you can see that this is not sort of a Star Wars blow up, you know, thermally based laser. It's just something that's been termed a smart laser because it targets certain things to block up the blood supply to these growths. For example, there are a lot of chemo therapeutic approaches which target blood vessels to tumors. Same thing. 

Same idea. If you can choke off the blood supply, presumably you can help reduce the bulk and burden of the tumor. Okay, this is a patient with Reinke's edema. If you've ever wondered what Marge's sisters vocal cords might look like, this is what they would look like. They're big and floppy. You can still see the flashing of the laser. And again, you can see the patient moving. This patient is sitting in a chair, awake. And you have to, again, kind of talk them through it. Sometimes with breathing, distraction. 

We try, actually, rhythmic things, where we'll get them to either count out loud or I will count to them, give them a break here and there, a lot of expectation management. We're going to do this for 30 seconds and then stop. There's a little bit of work for everyone to do. But we feel that that's probably beneficial in avoiding the general anesthetic. This is another example of a laser. This is the pulsed KTP. And here you see a lot more flashing. Flash, flash, flash, flash, flash. You can increase the pulse rate on this laser, which means you can probably get the work done more quickly. So if I go out to my car and find $65,000 in the glove compartment, I'm going to go out and I'm going to buy one of these. 

This is, remember I was talking about kind of the holy grail is getting a CO2 type laser through a flexible fiber. Well, it turns out that the holy grail has arrived. This is the Holmium laser called the Revolix Junior. And when you-- This is not a laser that kids around too much. It's pretty hot. So you want to definitely avoid the part of the vocal cord that vibrates, the sacred lamina propria. You want to keep that intact. So here, we're going to stay back toward the back of the vocal cords for these things called granulomas. These happen to people-- They used to be described in people with vocal hyperfunction. So, so-called type A personalities, in part, and in people with reflux disease, which may perpetuate bad healing and you get these lumps at the back of your vocal cord. 

This is a post-op, or post-procedure video, and so, after application of the energy. I'll play that again and see if I can freeze it appropriately. 
(inaudible)
 Hmm, sorry, it's a little bit difficult to get an idea. The left granuloma is probably about 30% to 40% of its original size. This is after six to eight weeks. So bronchoscopy. Has anyone in this room had a bronchoscopy. Okay, so bronchoscopy, where more often than not, you'll receive sedation. You get an IV and you get some lidocaine in your airway. 

But we prefer to do is to use only lidocaine, and then verbal anesthesia. We don't have to go down as far into the lungs as the segmental bronchi, blah, blah, blah. All we really need to do from a laryngological perspective is view the larynx and the trachea, all the way down to the split off of the trachea into right and left main stem bronchi, that's called the carina. So we want to go down to the carina. Here's the typical airway exam. There's no sound on this video. So the vocal cords, here and here, are moving nicely in this patient. We're going to do a little bit 10,000 Leagues Under the Sea. Actually, maybe if you could douse the lights, please. So this is a patient who had symptoms of airway restriction. 

That's better. Then the trachea is supposed to be round. But here we see this slit-like opening. And this is a patient who had undergone a previous tracheotomy. Perhaps I'll just play it again. Had undergone a tracheotomy. And when you take out the tracheal canula, which we put in for airway support and ventilatory support, in an acute situation to save somebody's life if they have upper airway obstruction, when you take that out, sometimes this area here in the trachea, the front wall, kind of collapses. So you get what we call an A-frame deformity of the trachea. And so this is a patient, as you might expect, with some airway restriction. So office laryngotracheoscopy is basically a fancy way of looking at the larynx, looking at the trachea. 

People with stridor. Stridor is the name that we use for noisy breathing. That's in the most general sense. It has three flavors: inspiratory, expiratory, and biphasic, which is both. This is not a sound we like too much. So stridor is something that we're going to want to investigate. And office laryngotracheoscopy is one of the ways that we can do that. This is the remainder of the airway exam. So you're probably saying to yourself, well, how do you know that the rest of the airway past that is okay? Well, let's look. 

If there's enough airway, and sometimes the airway is narrow enough that you have to ask people to hold their breath or they get kind of uncomfortable, because the scope is going through their main small airway. Then you take a peek all the way down to the carina, which is where the trachea splits into left and main stem bronchi. Then you come back and you pull out. So this is another video. We'll keep the lights low for a minute. This is TNE. It stands for trans-nasal esophagoscopy. I'm sure, probably more people in this room have had esophagoscopies, or upper GIs, more than they've had bronchoscopies. This is a pretty common procedure. Lots and lots of people have had this. 

And for all these procedures, you're sedated. You get an IV. You get valium. And from a general anesthetic risk standpoint, receiving valium or any type of sedation, from a risk perspective is almost as dangerous as receiving general anesthesia. So it's almost the same risk profile. So by eliminating the sedation, and keeping things only limited to topical anesthetic, you can significantly improve the risk profile. So for example, one of my colleagues published a series of 700 esophagoscopies. And the most serious complications were a couple episodes of nosebleed from the scope going in, which were self limited with a little pressure, or people feeling a little faint. That's it. So, so far, pretty favorable. 

So far, there has not been a single reported case of perforating the esophagus. So here, by using air insufflation, puffing air in, you blow up the mucosa so that it separates. The esophagus is sort of a floppy tube, so you need to kind of convince it to have the walls separate. You do that by blowing air in. And after you blow the air in, there's kind of a muscular contraction that's set into motion. You kind of follow it down, follow the peristalsis all the way down. We go all the way down in this video. You can go all the way into the stomach. And because it has this retro flexed ability, the scope does, you can look back up at yourself at the gastroesophageal junction. And so there's quite a bit of flexibility with this. 

People tend to do a lot of burping during and after the procedure, because of the air that we insufflate. So we have to manage that a little bit. You have to make sure you suck all the air out of the stomach before pulling the scope out, because otherwise, people feel a little funny. So who benefits from this? People with refractory GERD, where you're suspecting ulcers. People with a chronic cough, where you want to make sure the esophagus is not causing the cough, because that's a cause of cough. If there's a stricture that you want to examine. If there's potentially a pouch in the esophagus that you want to examine. And for people with refractory what we call globus. Globus is short for globus pharyngeus. 

It's a sensation in the throat that something is there, a lump in the throat sensation. A fair number of people have this. It has a number of different causes. It's difficult to identify from a diagnostic standpoint. One thing we want to make sure is that there's nothing going on in the esophagus. These are in people who don't respond to standard medications. So it's not for everyone, but it does have some use. So in the UW experience, since the time I've been out here, we've done about 450 procedures in about three years. I'm sorry this slide is wrong. It's about 450 in three years, in the larynx, the trachea and the esophagus. 

We've only had two admissions. And one was for a laser procedure to the airway. The other one was from a reaction to one of the injectables. One of these injectables caused a reaction, sort of like an allergic reaction. So that person had to be admitted, put on steroids. They did fine and went home. But of all those procedures, only two people had to be admitted for any reason. So given that everyone-- There were lots and lots of people on blood thinners. Given that there were a lot of people with multiple medical co-morbidities, there are certain people who simply cannot be intubated. They cannot be put to sleep without a tracheotomy. 

And any type of procedure for them would be impossible with this sort of things. In Wisconsin, we have a fair number of people who are over 200 pounds. And sometimes, for them, it's difficult to have a breathing tube put in. They're a bad anesthetic risk. And so, offering things in the office can allow better and more efficient treatment for things which otherwise put them at significant cardiovascular risk. There are two people in two years for vocal cord injections who have needed to go to the operating room. And for anyone who's been to the hospital, there's something called the FACES scale, which shows six faces. One is sort of a smiley face. One is a very neutral smiley face. And they go from a smiley face that doesn't look very happy to one that looks extremely unhappy. 

And so it's used for kids and adults. It's a validated scale to try to assess what your level of pain was at any given time. So we've gotten into the habit of asking people what their pain experience was. And for most people, especially for vocal cord injections, it will be either a zero or one. For some of the laser procedures, because it's a little weirder, and a little bit more uncomfortable and anxiety provoking, especially at first, that's from a one or a two to a three. Some people don't like these esophagoscopies because of the burping, either for social reasons or because it's just a little uncomfortable. So this is really an amazing shift from the last 50 years of the 20th century, when we've had the advent of general anesthetics, respirator machines, endotracheal tubes, paralytic agents, you know, real control in the operating room. But we realized, and we've been forced to realize with the demographic changes that maybe not everything should be done in the operating room. And that there's a fair number of things that we can do now on an out patient office-based unsedated manner. So reimbursement with insurance companies. 

This is something that we're working on, to try to incentivize all of our colleagues on a national basis. Time and familiarity with it. We have a course this summer, a surgery symposium, where we're going to trying to teach colleagues locally and nationally how to do some of these things. It's really a lot of fun for the patients, for the staff. It's extremely gratifying because you know that they're getting great care, and that you're not exposing them to the same level of risk. This is just a little mini plug for the University of Wisconsin Voice and Swallowing Clinics. We have a pretty special set-up here. And you know, people from the Midwest tend to be a little more reserved, but I'm from New York City, so I'm not as shy about tooting our horn. It's a very effective, professional and caring group of physicians, speech pathologists, and scientists. And we are really trying to advance the field. 

We have a very, very busy clinic. And we try to pride ourselves on providing world class care. Interestingly, for voice funding from the NIH, the National Institutes for Health, there's the most extramural funding of any place in the whole country. So this is really a place where voice research has been popular for many years, and many important things are happening, including, as I mentioned before, tissue engineering with a vocal fold, the lamina propria and eventually maybe even other elements of the larynx. Questions, please. You first. 
- How do you know, how can you tell whether a person has had adequate training to, like if it would be somebody you'd go to? 
- That's a really good question. I don't know that there's any one perfect answer for that. I'm sorry, I keep forgetting the repeat the question rule. 

So the question is, how do you know where to go to seek care from an otolaryngologist for something like this. The answer is that there aren't that many people who do it, even on a national basis. So as a general rule, except for trans-nasal esophagoscopy, it would probably be university centers and places with kind of an established line of care for upper airway disorders. So more often than not, it's going to be university centers, places where they can generally afford a little more input for staff and training and equipment, and that sort of thing. Because it's hard for folks in private practice to support this level of primary investment. 
- Is there a certification? 
- No, there's not. There's no certification for these procedures. There's nothing formal like that at this point. I think you had a question? 

- Yes, I was going to ask if any of the procedures you discussed would be appropriate for sleep apnea. 
- The question was would any of these procedures be appropriate for something like sleep apnea. The only one that I can really think of is an examination of the throat with a scope. Sometimes, that's probably part and parcel of an evaluation that we perform to understand how severe an obstruction might be in the level of the throat. But in terms of the interventional procedures, probably not. Question. 
- When people develop what we think of as an old person's voice, a kind of rattly. Is there any of your injections that could remedy this situation? 
- Great question. So the question is when many people age, develop a gravely or altered voice. 

Is there anything that we can provide to help that. And the answer is a resounding yes. The answer is a resounding yes. What we often, let me just explain in part why people, let's say, over 60, begin to have changes. There are, I would say, two or three major changes. One is that the overall muscular activity, the vim factor, if you will, can begin to decline slightly over time. And our voices, you notice, for example that people always have a louder or better voice when they're standing versus when they're sitting. You'll note, sometimes, an athletic pose when people sing. Well, why is that? That's because, in part, it's exercise. 

You have to use your lungs and your belly, blah, blah, blah. So that's part of it. Part of it is also that the vocal folds have a slight recession of three-dimensional volume of the lamina propria and muscle as we age. So instead of having vocal folds that line up nicely, they begin to slowly recede, and then there's more air loss. Remember, we're talking about the vocal folds as kind of a valve. So there's more air loss. Then people end up becoming a little bit frustrated because they can't project as much. It's a little bit effortful, a little bit fatiguing. And then, especially in men, the voice tends to rise. Okay, I have to do my over 60 man voice now. 

So you end up getting a little bit of you know, a voice like this. Where'd I put my hearing aids, okay, I don't know. Okay? So it's a little bit like that. And in women, often the pitch tends to drop a little bit, but many of the symptoms are the same. Vocal instability, trouble making yourself heard, feeling fatigued. It can lead to social isolation, especially because there's also accompanying hearing loss in that demographic. So one person has trouble making themselves loud, and the other person has trouble hearing them. So it's kind of a double whammy. It's kind of a frustrating situation. 

So, in answer to your question, what do we do? Usually, we offer some combination of voice therapy, okay, to enhance voice support, air support, projection and resonance. And then we often offer a vocal cord injection to both sides to close down the valve a little bit to allow for enhanced efficiency. Some of the newer generation injectables last quite a while now, maybe up to a year, maybe more. It can be re-injected. There are also more durable things we can do to help enhance the efficiency of the valve, injecting your own fat, for example. There's a funny story I have to tell about that. One of our previous chairmen in the department reported on this, I think back in 1991, injecting fat into the vocal cords. The next day, the switchboards at the U lit up because everybody wanted to donate their fat. 
(laughter)

 But the unfortunate part is you have to donate it to yourself and you can't really give it to somebody else, so there was a little misconception there. But you get the idea. So there are more durable things like fat. I think there are other options, something called a thyroidplasty, where they place implants and can move the vocal cords closer together. So there's a whole host of things. And it's for people over 60 who have that concern, it's often relieving to know that at least something can be done, and that it also doesn't involve a gigantic rigmarole like getting, you know, a heart surgery. It's not a big deal. So that can be very relieving for folks with that problem. There are also some other techniques in addition to the hydrogels, some other operations that we're trying to devise to help people with this situation. I don't know who's first. 

I'll migrate back. Yes? 
- With papilloma treatment, is that a cure or do the papillomas come back? 
- So the question is for the papilloma treatment, is it a cure or do the papillomas come back. The papillomas come back. We don't have a cure for papilloma. I wish that we did, but we don't. So we try to limit the damage to the vocal cords with the laser procedure or any other procedure, while trying to expose the patient to as little general anesthetic risk as possible, while still maximizing the function of keeping their airway open. 
- Is the tumor a virus? 
- A papilloma is a benign growth. 

I feel like you guys are plants. This is terrific. You're asking all the right questions. So papilloma is a benign growth of the vocal folds in the airway, which is usually induced by human papilloma virus. The human papilloma virus probably initiates and perpetuates the growth of these papillomata. The disease is probably in some way an immune defect in that eventually the disease burns out. So in kids, for example, they don't have it their whole life. And even in adults who contract it in their 30s and 40s, they usually don't have it by the time they have Social Security. So there are changes over time, which we don't yet have a good handle on. But basically, there's something about the immune system that either becomes more competent or manages to defeat the virus, etc. 

Yes, sir? 
- There have been research challenges in this whole area. And relating to that are there any really exciting technologies or clinical trials that you see? 
- The question is what are some of the research challenges, and what are some things that may be coming over the horizon with new technologies. Is that pretty close? So new technologies include some of these newer lasers, okay, which I think will become more popular in general otolaryngology use. Right now, it's still sort of peppered amongst some university places. I would say that there are research challenges in the homeostatic mechanisms of the lamina propria. The lamina propria is a very interesting little compartment in the vocal fold. And it maintains itself through certain mechanisms and changes. 

And in order to provide gels to it, and cells, and scaffolds, and growth factors in a way that makes sense, we're, as a field, doing a lot of work in trying to understand how those mechanisms work, and then what types of things that we implant in there will work the best. Another major challenge. I would say overall there are two major holy grails in laryngology. One, is regenerating the lamina propria. And the other is making a paralyzed vocal cord move again. So nerve tissue engineering and muscle tissue engineering will play into the reanimation of the paralyzed hemi-larynx. That will be extraordinary once we can do that. That's not quite on the horizon yet. That's on the horizon, but on a really big planet, okay. That's kind of farther off. 

But I would say that trying to restore the lamina propria is going to be huge. And we'll be able to fix tens and hundreds of thousands of voices. It's very, very exciting. Other questions. Yes, ma'am? 
- There are rumors that voice therapy or music therapy can help people maintain their larynx and supporting musculature. 
- The question is there any truth to the fact that music therapy or voice therapy can help maintain larynges as they age. Anecdotally, I would probably say that that's true. I don't think we have hard data to support that. I don't know that there are articles comparing voicing individuals, say over 60, to you know, reasonably quiet individuals, and what exactly would be maintained. 

You know, do their vocal cords look better? Would their voice parameters be better on objective testing? I would say, from an intuitive stand point, and an experience stand point, yes. But there's no hard data that I know of that I can look it up for you. 
(inaudible)
 Yes, so she was saying that it may be helpful in people with swallowing difficulties, and that we tend to adhere to the general rule that the more you swallow the better you swallow, because it's a whole coordinated neural cycle. And so voicing in many ways is no different. The more you can get into good habits with voicing, which is one of the bases of voice therapy for improving your voice, is recognition and maintenance of good neural cycles. So with swallowing, it's analogous. Okay, I'm really, really glad to be able to come tonight. 

I appreciate your time. It's about 8:25, so thanks very much. 
(applause)