It’s hard to imagine a voiceless Armando Vidal.

An orthopedic surgeon specializing in sports medicine at UCHealth University of Colorado Hospital on the Anschutz Medical Campus, Vidal warmly greets a visitor to his office near the hospital and speaks easily and clearly during an extended early-morning conversation.

“I’m a pretty gregarious guy,” Vidal said. “I like to chat. I like to have conversation.”

Vidal uses his voice for more than telling stories. He has a thriving practice, seeing as many as 40 patients in a single clinic day. During the busy Colorado ski season, roughly November to April, he typically performs 10 to 15 surgeries a week, communicating with his team as he repairs anterior cruciate ligaments and other casualties people sustain on the slopes and in other active pursuits. He regularly speaks with colleagues, both informally and professionally, teaches, and lectures. On top of all of this, he serves as head team physician for the Denver Nuggets and team physician for the University of Colorado Buffaloes and the Denver Pioneers (the sports teams of the University of Denver).

Vanishing voice

Around Thanksgiving 2016, Vidal’s voice began to desert him. It started with a cold that made him hoarse. He didn’t think much of it at first. He seemed to get ill once a year and had a tendency to lose his voice briefly when he did. The problem had always resolved.

“I thought it was a non-issue,” Vidal said.

But this time it persisted and worsened. He struggled through clinic visits, apologizing to patients for his strained voice. He rationed his words in the operating room. He cancelled scheduled professional talks, knowing he couldn’t get through an hour of speaking.

His weakened voice also changed his life outside of work. Calling out for his two kids, now ages 12 and 13, to come to dinner became a thing of the past. On nights out with his wife and friends, he struggled to make himself heard. That further taxed his voice, making communicating at work more and more difficult.

“I found myself turning down more and more social events,” he said.

Vidal’s vanishing voice changed his world. “It affected every aspect of my life,” he said.

Tiny disrupter

The source of the havoc was a tiny cyst, just one 1 or 2 millimeters in diameter, on one of Vidal’s vocal cords. The lesion was benign, but UCHealth laryngologist Dr. Matthew Clary recognized the profound effect it had on Vidal’s professional life. Clary is one of the experts at UCHealth’s Comprehensive Lung and Breathing Program.

“He couldn’t communicate,” Clary said. “If you can’t talk to patients and you can’t teach, that’s a showstopper.”

The show wasn’t stopped for good. The cyst is a thing of the past, thanks to surgery Clary performed in May 2017.

During the outpatient lesion-removal surgery, Clary inserts a tapered metal tube called a laryngoscope into the patient’s airway. The instrument holds open tissue of the larynx, or voice box, allowing Clary to see magnified surfaces of the vocal cords. This allows him to find the cyst and painstakingly dissect and remove it with a scissor-like tool without damaging the delicate layer of tissue that vibrates during speech.

After three days of complete voice rest, Vidal slowly but steadily returned to his normal workload. “I came back 100 percent,” he said. “It was like it never happened.”

Valuing the voice

With help from speech-language pathologist (SLP) Juliana Litts, who is fellowship-trained in treating voice disorders, Vidal also is aware of the importance of preserving the essential resource that is his voice.

Clary and Litts are members of the only interdisciplinary voice, airway and swallowing disorders team in Colorado. Patients with problems like Vidal’s or a host of others caused by vocal cord paralysis, spasms in the voice box, atrophy of the vocal cords, polyps, nodules and many more, see a surgeon and SLP together. The team jointly develops a treatment plan tailored to each patient’s specific needs. Clary handles a variety of surgeries and in-office procedures, such as bronchoscopies and injections to build up weakened vocal cords, but about 80 percent of the patients referred to the team can repair their voice disorders with therapy alone, he said.

“Ideally, we keep patients out of the operating room as much as possible,” Litts said. “We try to determine if there is an opportunity for patients to heal themselves.” Litts and Clary co-authored a 2015 paper detailing a study that showed that patients who received a medical speech evaluation from an SLP at their initial appointment had better therapy session attendance and outcomes than those who did not get an initial evaluation.

Real-world solutions

At UCH, the path to a treatment decision lies in laryngologists and SLPs collaborating with patients to figure out the best path to making their voices functional again.

“We interview patients based on their symptoms: when did they start and how do they limit them,” Clary said. “A lot of what we discuss is how much does the voice disorder impact them on a daily basis.”

Professional singers, announcers and voice-over artists are among their clientele – “the popularized version of our care,” Clary noted. But the majority – teachers, salespeople, and call-center staff, for example – hold everyday occupations, he emphasized.

Litts calls her work as a voice disorder specialist “feeling therapy”: literally teaching patients to feel their voice and where it is coming from: through the mouth as the end result of air pushed from the lungs, up the airway, and to the vocal cords, which vibrate to produce sound.

“We want the driving force of the voice to be the lungs,” Litts said.

In many cases, however, people with voice disorders use the neck muscles to drive their voices, for a variety of reasons, including pain and stress. This strains the vocal cords and generates less than ideal sounds, which Litts easily demonstrates with guttural growling, squeaks, breathy whispers, rasps, and so on. With therapy, patients learn to recognize the physical sensations that produce those sounds and alter the way they speak.

“We change the way people feel their voice as a sort of feedback loop,” Litts said. “This teaches them to relax the muscles in their neck so they can produce a functional voice.”

Voice lessons

Vidal’s vocal cord cyst meant he couldn’t avoid surgery. But he had sessions with Litts before and after the surgery that continue to serve him well.

“I haven’t changed how much I talk, but I’m a little more mindful of making sure that when I talk, it comes from my lips and mouth, not from my neck,” he said.

That recognition is important, Litts said. “Exercises are great after surgery to prevent scar tissue from building up, and they breed flexibility,” she said. “Practicing using the voice in a more efficient way helps to prevent a cyst from re-forming. If you’re going to the OR, we only want you to go once.”

Patients don’t get high-tech tools in their work with Litts. Asked to demonstrate a voice-therapy exercise, she pulls out a plastic cup with water, puts in a straw and forces air through it to blow bubbles – an effective technique for strengthening the vocal cords. For another, she rattles air through her lips – the kid-favorite “raspberry” – which helps to loosen the muscles around the mouth and the lips.

The self-help approach is essential. “Typically we get to see patients four times for 45 minutes,” Litts said. “Practicing behavior change happens when patients are having conversations at work and with their families. They do most of their work when they are not here [in the clinic].”

Speaking out

Whatever the source of the voice disorder and the therapy used to treat it, Litts and Clary each stressed that the benefits extend well beyond restoring clear tones.

“Voice is one of those things that doesn’t just affect your professional life,” Litts said. “We are social creatures. We need interaction with people and when you take that away, it can cause a significant emotional burden. People’s identities are closely linked with their voice and when you have a voice that doesn’t sound confident, others automatically judge you. Many patients tell us, ‘I don’t do social things anymore.’”

Vidal is back to speaking comfortably, and he has a new appreciation for being able to do so. The uninvited sounds of silence changed the way he views himself and others.

“There are very few things that are so critical to your life,” he said. “I think in terms of mobility, motion and function because I’m an orthopedic surgeon, but I didn’t realize how much you take for granted something as simple as being able to talk. It was surprising to me how fundamental it was to my daily functioning and my relationships, both personal and professional. It’s made me more sympathetic to my patients because I think holistically about how an injury impacts their lives.”