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BackTable / ENT / Podcast / Transcript #28
Podcast Transcript: Music, Medicine, & Ministry
with Dr. Mark Williams
We talk with Dr. Mark Williams about building his solo ENT practice, taking care of recording artists in Nashville, and aligning his own music, medicine and ministry. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Evaluating Voice Patients: History, Symptoms, & Diagnostic Tools
(2) The Role of Laryngeal Videostroboscopy in Voice Assessment & Diagnosis
(3) Key Physical Exam Findings in Voice Disorder Evaluation
(4) Integrating Physical Therapy into Voice Disorder Treatment
(5) Tailoring Voice Evaluations: Singer vs. Non-Singer Patients
(6) Treating Voice Issues: Managing Allergies & Mucus in Voice Patients
(7) Steroid Injections & B12 Shots in Voice Care for Performers
(8) Key Aspects of Vocal Hygiene: Hydration, Rest, & Healthy Habits
(9) The Role of Surgery & Therapy in Treating Vocal Pathologies
(10) Merging Faith, Music, & Medicine
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[Dr. Ashley Agan]
Hi, everybody. Welcome to the BackTable ENT podcast. If you're a returning listener, you know our goal here is medical education in otolaryngology. We seek to accomplish this through conversations with experts in the field and we hope that you can take this information and apply it to your practice. Quick introductions, I'm Ashley Agan and I'm a general otolaryngologist practicing in an academic setting in Dallas, Texas.
[Dr. Gopi Shah]
My name is Gopi Shah. I'm a pediatric otolaryngologist here in Dallas at UT Southwestern as well. How are you doing, Ash? You doing okay?
[Dr. Ashley Agan]
Gopi, every Saturday I get to do a podcast with you is a good day.
[Dr. Gopi Shah]
I love that you say that every time. [laughter]
[Dr. Ashley Agan]
I mean it every time.
[Dr. Gopi Shah]
I mean it too, likewise. We have a very awesome, awesome guest with us today. We have Dr. Mark Williams, MD, PhD. He's an otolaryngologist in Nashville, Tennessee, who specializes treating and preventing voice problems in singers. Dr. Williams gave me my first job out of residency as a general otolaryngologist in his practice. It was my first "clinical fellowship" as I learned the importance of running a clinic in ENT, working well with the staff, and developing relationships with my patients. Dr. Williams is here today to talk to us about voice care and his passion, music, medicine, and ministry. Welcome to the show, Dr. Williams.
[Dr. Mark Williams]
Thank you for having me on the show. It's good to see you and to you again.
[Dr. Gopi Shah]
I know, it's so good to see you. First of all, thank you for giving me my first job out of residency. That's a big risky move on your part when I think about it now.
[Dr. Mark Williams]
It was no risk at all on my part. In fact, I'm disappointed that you decided to leave. I wish we could get you to come back. We miss you.
[Dr. Gopi Shah]
[laughs] I miss you too. Do you want to first just tell us about yourself and your practice?
[Dr. Mark Williams]
I am a general otolaryngologist trained at the University of Cincinnati. As soon as I finished with residency, I wanted to locate to a city that there was a vibrant musical community. I'm a singer and songwriter myself, and I wanted to be able to treat singers with voice problems. I'm a gospel music recording artist. It became a toss-up for me between Memphis and Nashville. A lot of people don't think about Memphis as a big music city, but the music scene, particularly for the music that I was interested in, is phenomenal in Memphis.
There was a gentleman there, Dr. Neal Beckford in Memphis who would do it, who was doing exactly what I wanted to do. In a general practice, community private-based practice, he was seeing voice patients. I interviewed with him, but the opportunity came available to start my own practice in Nashville, Tennessee. They don't teach us how to run a business in medical school, so that was a challenge in and of itself. Just moving to Nashville, fresh out of residency training, opening a practice myself with no partners, no experience in running a business. Somehow or another, we've flailed along and managed to still be in business here now, 14 years later in Nashville.
[Dr. Gopi Shah]
Exciting.
[Dr. Ashley Agan]
Yes, that's awesome. As a general otolaryngologist, in addition to seeing voice patients, you're seeing all the range of general ENT still as well?
[Dr. Mark Williams]
Anyone who comes through the door, pretty much. I do just about anything that comes through from 8 to 88 days to 80 years old or 90 years old, whatever. We're doing middle ear surgery, middle ear mastoid surgeries. I'm doing thyroidectomies, parotidectomies. Interestingly, as I get older now, I'm starting to really appreciate tonsillectomies and ear tubes.
[Dr. Gopi Shah]
[chuckles] There's some satisfaction and a good tonsil, ear tube day, small, not major problems, but a big quality of life impact [crosstalk] your families.
[Dr. Mark Williams]
Loving it. In fact, I actually thought that I didn't want to do otolaryngology in medical school, at first, I was going to do-- I thought I was more interested in neurosurgery or cardiothoracic surgery. Someone suggested, I was doing my PhD research in the department of surgery and one of the surgery residents came through and she knew I was interested in singing and she said, "You should consider otolaryngology." I said, "I don't want to be an ear tube and tonsillectomy doctor." That's exactly my words.
Now I'm saying, man, I miss those. Over the past couple of years, my pediatric base has declined and I'm anxious at going back in and trying to re-establish that and grow that again, because I miss those patients.
[Dr. Gopi Shah]
I think it was your Fridays that were your pediatric days.
[Dr. Mark Williams]
Yes. You recall, we probably have maybe 55 or 60 patients on the schedule. Now we're lucky if we see 10 pediatric patients on a Friday. We've got to build that back up.
(1) Evaluating Voice Patients: History, Symptoms, & Diagnostic Tools
[Dr. Gopi Shah]
I think the pandemic has also made pediatric ENT in terms of even the bread and butter tubes and tonsils with social distancing and masking. Hopefully, as things open up with schools and daycares and all that stuff, we know what helps that we might, as things open up, see some of that some more. Dr. Williams, how does a voice patient present to you in your clinics?
[Dr. Mark Williams]
Voice patients present a variety of different ways for me, especially being here in Nashville. In Nashville, we have voice patients who aren't presenting for voice problems, even for that matter. They're singers. You can throw a coin into a group of people and that same coin hit about five singers before it hits the ground. They're presenting with every problem that they have.
Many of the patients that I see that specifically have voice issues are coming in for a wide range of problems. They're having difficulty with singing and'or speaking. Then we have even those patients who present with very subtle voice issues, and we're seeing a little bit more of that now that people have been inactive and not singing much over the past year with the pandemic. We see people, their voices have become deconditioned. They're presenting and saying, "Man, after I'm singing a song or two, I'm spent. I'm having early vocal fatigue." These more subtle voice issues, or "I'm losing a little bit of my pitch range" are presenting. These subtle complaints are more prevalent now than they had been in the past.
In the past, it was more like, "Hey, I'm literally hoarse. I'm having a lot of breathiness or this coarse sound to my voice and I can't do my falsetto." They used to be more complex or direct problems. Now they're more subtle and I have to figure out exactly, do you really have a voice problem or is there something anatomical or is it something more functional?
[Dr. Ashley Agan]
When a patient comes in and they are seeing you for hoarseness or something specifically related to voice, what does that evaluation look like? Can you walk us through key questions we need to be asking and what the exam and workup looks like?
[Dr. Mark Williams]
Yes. That's always the challenge for me. It's because when patients describe everything as hoarseness and so they don't know some of the finer descriptions that we have, I'll ask, "What's the problem?" They say, "I'm hoarse. I get hoarse all the time," and trying to get them to be a little bit more explicit about what they mean by hoarseness. Is it breathiness to the voice or is it that you have a more coarse or moist sound to your voice? Have you lost pitch range? You're no longer able to hit the notes that you were hitting or are they just not coming out clear? Are you feeling pain in the throat or have you lost some dynamic control and the agility of your voice?
We have to dig in a little bit more deeply with some of these particularly voice patients because they're just saying, "I'm hoarse." To me, it means almost nothing. As a clinician who specializes in voice, it means almost nothing because people's description of hoarseness is so wide. I know you're familiar when people say, "I've got the sinus." You're like, "What's your complaint? What's my sinuses?" Those are the two areas that challenge [crosstalk] me the most. I'm like, "Describe that a little bit more for me."
We have to help those patients describe what they're talking about. Is it just happening in the mornings when you wake up or is it happening-- Is it worse in the evening or you're fine in the morning then as the day progresses that it gets worse or-- We have to pull that information from our patients because they don't readily offer it and they probably haven't even thought about it until after I've started asking these questions.
[Dr. Ashley Agan]
Then do you ever find that as you go through the history with them, what they're describing to you, is there ever a discrepancy from your perception of what their voice problem is? Have you come on the same understanding of what they think is a problem and what you hear? Is there ever a difference in that?
[Dr. Mark Williams]
There's often a difference in that, and that determines for me exactly how I'm going to proceed with evaluating their larynx. For example, patients may come into the office and complain of hoarseness, and I'm listening to them communicate and speak to me, and their voice sounds just as clear as the clearest of day. I know in that moment that if I look at their vocal cords with a flexible laryngoscope or fiber optic laryngoscope, then I'm probably not going to see a lesion on the vocal folds.
Usually, our ability to perceive a voice disturbance with our ears just from talking with a patient will let me know whether it's worthwhile putting a flexible scope in on this patient. Rarely, do I see someone whose voice sounds normal to me. Rarely, do I see any anatomical pathology or nodules or polyps, or even for that matter, erythema of the vocal folds. It's those more subtle ones.
When I have singers come in, particularly, who seem to have a clear voice, and they're telling me that they're hoarse, I may actually have them sing to demonstrate where they're having the problem. Sometimes they're having problems with their passaggio changing from their full chest voice to their falsetto voice. We'll have them demonstrate where they're having problems. Because I'm not a trained singer myself, I don't try to get too much into that. I'll leave that to my voice therapist who is actually a trained-- she's a pedagogist, but she's also a speech-language pathologist who specializes in voice.
That is one of the things that I'll do to help uncover where the problem is. If everything sounds normal to me, I'm thinking immediately I'm going to proceed to video stroboscopy.
(2) The Role of Laryngeal Videostroboscopy in Voice Assessment & Diagnosis
[Dr. Ashley Agan]
Can you talk about what that is? When we talk about doing a strobe exam for a patient, what does that mean? What kind of information is that giving us that your typical flexible laryngoscopy isn't?
[Dr. Mark Williams]
Laryngeal-videostroboscopy is a technique where we are able to look at not just the anatomy of the vocal folds, but also how they function as air moves through the vocal folds and sets them into vibration. The vocal folds will vibrate anywhere 80 times to 400 times or more per second. Obviously, that's too fast for the human retina to fix an image on. You can't actually see the vocal folds vibrate. What we'll do is we'll shine a strobe light on the vocal folds while we're looking at their functioning while the patient is phonating or creating voice.
That strobe light makes it appear that the vocal folds are vibrating in slow motion. What it's really doing is it's actually capturing different images of different stages of the vibratory cycle. It gives the illusion that the vocal folds are moving in slow motion. It usually gives us a little bit better resolution of the anatomy, but it also gives us a little bit of insight into the function of the vocal folds. You can find out if the vocal folds are a little too stiff or if there's some deficit of mucosal weight propagation and why the vocal folds aren't as elastic as they should be. That might be contributing to some of their voice issue as well.
It's a little bit more sensitive for picking up on things like nodules or distinguishing between a vocal nodule and a vocal cyst. The resolution, particularly if you do a rigid videostroboscopy, the resolution is a lot better. As you're aware, there are two different ways that we can evaluate the vocal folds. One is with a rigid laryngoscope and then the other one is with a flexible fiber optic one. Fiber optic one goes through the nose. The rigid one will go through the mouth. It's a 70 degree angle, has much better visualization. I prefer to use a rigid scope when I'm doing my videostroboscopies.
Technology has advanced where we can do what's called distal chip, where they put the chip in the distal end of the fiber optic laryngoscope and then you can do a stroboscopy that way. Which is, if you're trying to look at the dynamics of phonation and the voice production, it's much easier to do that with the flexible distal chip video laryngoscope. The reason being is because if we do the rigid one, we have to actually hold the patient's tongue while they phonate and it's a very artificial situation.
Whereas, if you had a flexible scope, you can put it through the nose and you can actually evaluate how they're-- what's going on with the larynx and the supraglottis and even for that matter, the hypopharynx, while they're actually speaking in a more normal manner. In fact, I participated in a graduate student's doctoral thesis research where we were evaluating a vocal technique in gospel music called squall. I don't know if you're all familiar with squall very much, but in gospel music, [squalls] that type of thing. It can be incredibly damaging to the vocal folds if you don't know how to do it properly.
In gospel music, it's a very moving and emotive type singing technique that really moves the audience and the listeners. Singers who have perfected that without causing damage to the vocal folds, we really want to know how to do that. Not many coaches know how to teach that technique. You obviously couldn't do that if you were holding someone's tongue with a rigid laryngoscope. We were fortunate to be able to use a flexible distal chip one to evaluate what structures were actually vibrating whilst singers were using that technique.
We found that different singers use different supraglottic structures and some people actually use their vocal folds and create sort of a fry of the vocal folds when they're singing. Obviously, that can be more dangerous and harmful to the vocal folds as opposed to some who were perhaps using their arytenoids to create the vibratory sound or the distortion in their sound. A flexible distal chip video laryngoscope stroboscope was able to be more effective in that regard. I wish I had the money in my private practice to have one of those things, but we had it for academic purposes and it worked for what it did for it.
In my practice, we use a rigid one, it gives us a better illusion and it's more affordable for people like me.
[Dr. Gopi Shah]
Just to go to some basics, how do you document your strobe? Now, I remember, I think I might've asked you this in practice as well, because laryngology to me, it's something just so foreign still to a certain extent. Because unless you've really had time to shadow or watch a laryngologist and a speech pathologist in clinic in your training or maybe, in whoever's practice, to me, it's a very hard thing to quite understand. I know how I document my basic flexible laryngoscopy for dysphagia or stridor, but I don't know what-- how do you document, what's your note look like, I guess, or what are the things that you definitely always put down in your progress note?
[Dr. Mark Williams]
Videostroboscopy is one of those areas where there's a lot of subjectivity. I think voice, and measuring voice anyway, the GRBAS type assessments, a lot of this is so subjective that there's a lot of variability. If you are going to try to rate someone, the gravelliness, for example, or the roughness of someone's voice, one listener may rate it, zero, one or two, and then another person may do it a different number.
The same thing happens when we're evaluating the video strobe, but there are certain characteristics that we are always looking at. We're looking at the medial surface of the vocal folds, whether it's smooth or whether it's rough. I'm always documenting that. We're looking at glottal closure, whether or not there's complete glottal closure, anterior or posterior chink or gap in the vocal folds. Are there any lesions on the vocal folds? We're also looking at the mobility of the vocal folds, mucosal wave propagation. Does it seem like it's smooth and it's intact, or is it impeded somehow or another?
We're looking also at periodicity, whether or not the vocal folds are vibrating regularly with the videostroboscopy, or are there irregularities to the glottal cycle? Other things that I would document in there are going to be-- it's difficult to not have the template. It really helps to have a template right in front of you because you go through and you click each one of these things, and so I'm trying to remember what the template looks like in my head.
To answer your question, that's how I document it. I fill in the blanks on the template, [laughter] but the level of the vocal folds too, whether or not they're equal or not. We look at what phase predominates, whether the closed phase or the open phase, the glottal phase, glottal appearance or apparatus, whether it spends more time open versus closed. Those are things that we do. Particularly, I'm also wanting to document what the fundamental frequency is. When I have patients always read a passage, it's a standard passage, and I measure--
[Dr. Gopi Shah]
The rainbow.
[Dr. Mark Williams]
What's that? The rainbow, yes.
[Dr. Gopi Shah]
The rainbow passage.
[Dr. Mark Williams]
[crosstalk] division of white light divided to many colors. Yes, exactly. That rainbow passage. We look to see what their speech frequency is. Then you ask them to sing. Then all of a sudden they're speaking right here, but then you have them say "E" or "Aa," they "Eee." You're like, "Wait a minute. In your normal speaking voice." "Okay. Eee." Okay, we're fine. "Okay. Aaa." We'll measure those as well because you can see some differences where people are normally speaking out at a higher pitch or lower pitch than they really should.
That's something that's helpful for my voice therapist. How exactly she used it, unfortunately, I don't know, but I do know that if you're speaking at a much lower pitch than you normally should, then that needs to be corrected. They will help to coach our patients back to that range.
(3) Key Physical Exam Findings in Voice Disorder Evaluation
[Dr. Gopi Shah]
Are there any other physical exam findings that are really key, that you're looking at when you're evaluating these patients?
[Dr. Mark Williams]
Yes. There are a variety of different things that can cause voice problems in patients. Of course, I'm also evaluating even-- especially if I have a patient singing, I'm looking at their posture when they're singing. Because that often can give you some clues into why they may be having a voice disturbance. One of the more easy things that I'm screening for early on is dissipation at post nasal drainage. Are they having signs and symptoms of esophageal or laryngopharyngeal reflux? As those will contribute to some voice dysfunction as well.
As you're aware, the voice requires three functioning systems, the respirator or the lungs, the phonator, the vibrator, the vocal folds. Then the resonator, everything above the vocal folds, so the throat, the teeth, the nose, the mouth, all of those things shape the voice, the sound that's created by air moving through the vocal folds. They shape that into an intelligible sound that we call voice. If there's a disturbance in any one of those three systems, then you're going to have a voice disturbance.
As part of our evaluation, we really do have to evaluate the entire person. If they have nasal congestion or turbulent hypertrophy, I'm even looking to see the size of people's tonsils because those things will actually impact the resonating chamber as well.
Most of my exam is directed toward looking for, or at least it's guided by the history. If you give me a history of post nasal drainage, I'm going to be looking in the oral pharynx to see if I see any evidence of that. If you give me history of esophageal reflux or heartburn symptoms or frequent throat clearing, globus sensation, cough with that, when I do my laryngoscopic examination, I'm going to look in the posterior glottis to find out if I see any pachydermia in that region.
Subtle findings sometimes can help to identify where the voice issue comes from for these patients. Often, we find that it's just muscle tension. We have a lot of patients who are having voice problems that started from something physiologic and then they compensated for it with a behavior. Because they've been talking through and singing through this for so long and they developed some compensatory behaviors that now the compensatory behaviors are causing more problems than the original pathology did after the original pathology healed. We have to get them working with a good voice therapist to break those compensatory behaviors, get voicing back to normal.
[Dr. Ashley Agan]
Is there anything on your laryngeal palpation exam? When you mentioned muscle tension, like when you palpate, are there certain parts of the laryngeal framework or the cartilaginous framework, I guess, that you palpate or check for? Do they have pain often? Is there stuff like that on your physical exam?
[Dr. Mark Williams]
As a matter of fact, I do. Patients who relay a history of pain, particularly after singing or after voice use, I'm specifically palpating their strap muscles and seeing if they're tender along the strap muscles, along the thyrohyoid membrane as well. Those things are key indicators that patients may have some muscle tension dysphonia. If you have that tenderness in those areas, I'm really thinking that muscle tension is at least contributing to some of your voice problems.
(4) Integrating Physical Therapy into Voice Disorder Treatment
[Dr. Gopi Shah]
For your mentioned patients, in addition to voice therapy, do you ever send them to physical therapy or for a massage or anything like that?
[Dr. Mark Williams]
Occasionally, we do have some patients who have horrible muscle tension. It's not just in the extrinsic muscles of the larynx, but the entire cervical group of musculature and their shoulders there really need some additional physical therapy. I've even had several patients who've had problems with dysphagia because they've had so much tension in the neck. Usually, most of-- I send them to my voice therapist first and my voice therapist is usually the one who will request that they see the physical therapist afterwards. Then I'll just make the referral after that. Unless, of course, they're presenting with complaints of cervicalgia.
[Dr. Gopi Shah]
That's similar to what we see in our practice too.
(5) Tailoring Voice Evaluations: Singer vs. Non-Singer Patients
[Dr. Ashley Agan]
Is there a difference in how you evaluate hoarseness in a singer versus a non-singer or is it pretty standard, or do you not even think of the groups that way?
[Dr. Mark Williams]
Oh no, I think of them that way. [laughter] I really do. With our singer patients, I do actually get a much more detailed history about what their training is, what their usual singing routine is, what are their upcoming and pending engagements, how is this impacting your income? Because for a lot of people who depend on their voice for their living, that added stress really can contribute to worsening voice problems with anxiety and other issues that come as a result of that. Yes, I do have to expand my interrogatories, I guess, and my history for my singer patients.
I usually do my videostroboscopies because they can take quite a bit of time and be pretty disruptive to the flow of patients. I usually schedule those in a specific appointment just for videostroboscopy. I typically do those on a Friday. If I have a singer patient who presents to me and I'm listening to them and their voice sounds normal, I automatically know that I'm going to videostroboscopy as opposed to even putting a flexible scope in their nose while they're in the office. Non-singer patients, I may start off with just using a flexible scope, but if you are a singer, I'm pretty much resolved to the idea that I'm going to do a videostroboscopy on you fairly early on.
(6) Treating Voice Issues: Managing Allergies & Mucus in Voice Patients
[Dr. Gopi Shah]
Just moving on to maybe treatment options, we talked about some different things that you see, postnasal drainage and laryngopharyngeal reflux. Can you talk about different treatment options that you're using in your practice? Particularly, I would be interested to hear how you counsel your mucus patients. [laughter]
[Dr. Mark Williams]
Interesting, because we get a lot of patients in who will come in with allergies. Being here in Nashville, allergies are a huge problem for us down here. Number one is any patient who's having voice issues, I want to get their allergies under good control. Even if it's not directly contributing to their voice issue, I think that if you're not taking care of all this resonator, you're not going to get the best voice that you can possibly get anyhow. If you didn't present to me with that complaint, I'm screening for it as well and make sure that I initially start off with just a nasal steroid spray.
I'm a big fan of the nasal steroid sprays. I prefer that they use that over an oral antihistamine any day. In fact, before I put you on an oral antihistamine, I'll put you on a nasal antihistamine if the nasal steroid is not sufficient alone. By the time I have you on a nasal steroid and antihistamine sprays, if you're still having problems, we need to be allergy tested. I need to get you tested. We'll perform the allergy testing and look at getting people started on immunotherapy if appropriate.
The goal is I like to avoid as many antihistamines as possible, whether they're nasal or especially oral. Of course, the first generation antihistamines, I really try to keep all of my patients away from the diphenhydramines, chlorpheniramines and the over-the-counter cold and sinus medications like Tylenol or Advil. I try to keep them away from that one at all costs.
Now, some of the second or third generation antihistamines, the Allegra's, the Claritins and Xyzals, all of those have a less drying effect, but often they're less effective in controlling the allergies for our patients. Unfortunately, we sometimes have to get patients on some of those more drying and sedating courses, but we have to control the allergies however we can.
My goal is to have a long-term perspective with treating that. I counsel the patients to say, listen, we don't want to keep you on these drugs all the time because they will impact your voice. Our goal is, gradually, to get you desensitized to those allergens. That's how I approach it with allergies, first starting with the nasal steroid sprays and then adding in an antihistamine spray. I may allergy test you even before I add the antihistamine spray into it. My last resort is going to be something like Zyrtec or/and then Benadryl even beyond that.
If I had to put you on an antihistamine, I'm usually starting with a Singulair, especially a singer, I'd much rather add Singulair. I know it probably won't do very much good, but if you are a singer who's already having voice problems, before I even put you on an Allegra, I'd really rather put, as a third line, something like Singulair and see if we can get some results with it. Because if we can't, then we just, of course, have to move over to an oral antihistamines. Yes, I discriminate against our oral antihistamines.
[Dr. Gopi Shah]
[chuckles] I say the same thing. I'm glad to hear someone else who's so anti-antihistamines, because I'm always like, "We need to get you off of these, it's too drying."
[Dr. Mark Williams]
Exactly. I had a singer friend who flew in from Texas actually to see me and he was like, "Man, I just can't sing." He and his wife are dynamic singers, phenomenal singers. They sing background for a variety of different artists or whatever, and has just released his own project. He's like, "Man, I just can't sing. I'm losing my voice right off the bat." I'm wondering, what do you sound like? Get all this breathiness.
I listened to him and he's taking antihistamines left and right, Benadryl four times a day. I said, first of all, we have to get you off of all of these. Once we get you off of all of these, then we perhaps notice a big improvement. I'm excited when we can do a simple intervention that provides a very dramatic response for these patients.
(7) Steroid Injections & B12 Shots in Voice Care for Performers
[Dr. Gopi Shah]
Tell us about the singer that's got a performance. At what point are you like, you can't sing in this performance? Do you ever have to recommend canceling a performance? How does that go?
[Dr. Mark Williams]
That is a tough one. I try not to get into that too much. I try to present to patients the options. One of the ways that I presented to them is to say, what's the cost of a bad performance? Will it cost you more to have a bad performance than it would be to cancel?
I had another singer patient who was just on their way to travel across seas to do a concert. They had a reunion tour. This patient presented with a horrible polyp. I'm saying, yes, I don't know that you're actually listening to you now. I don't know that you're actually going to be able to perform during this. Are there other ways? As much as I hate to suggest it, can you lip sync? Can you lower the key? These are some options that we have. Is there someone else in your group who could perhaps sing a certain part of this that it can relieve some of the burden of singing for you?
We start looking at different alternatives before we flat outright say you can't sing. If it comes down to the point where you can't sing, I usually put that into the hand of the patient to say, what's the cost of a bad performance for you? Because you really never get a second chance to make that first impression. If it means sometimes you just have to pass up on this one and deal with the consequence of that than having a bad performance.
[Dr. Gopi Shah]
The oral steroid burst and the B12 shot, does that work or not work?
[Dr. Mark Williams]
They work sometimes. I do have a big problem with people, with otolaryngologists who-- had a voice coach texting me just yesterday, said, "What do you think about steroids and doctors who give shots for steroids for singers?" This guy is a very scientific voice science oriented coach. I love this about him. He wanted to ask me about my thoughts on that first. I said, my policy is that no singer should get a steroid shot for voice issues until their vocal folds have been examined. It just creates a sense of false security.
My biggest concern is what happens if you have an ectasia, a prominent blood vessel on the vocal folds and you give someone a steroid shot that reduces some of the inflammation around the vocal folds. They go at it and they have a vocal fold hemorrhage and/or some other complications as a result of it. I just don't believe that steroids should be given without first carefully evaluating the vocal folds to find out what's going on. Now, I do think that they do have a place in their treatment, especially in people with pending engagements and so. I have given the steroid shots as well to help get people through that. It's always after I've had a chance to evaluate their vocal folds first.
(8) Key Aspects of Vocal Hygiene: Hydration, Rest, & Healthy Habits
[Dr. Gopi Shah]
I think that makes a lot of sense. Talk to us about what is meant by vocal hygiene. Is that drink a lot of water?
[Dr. Mark Williams]
Drink a lot of water.
[Dr. Gopi Shah]
Oh, and don't talk? What does that mean?
[Dr. Mark Williams]
That's usually what it means for me. I try to keep it simple. [laughs] Just drink a lot of water and do your exercises. Exercise the voice. It's a wide range of things. It's drinking plenty of water. Obviously, that's the number one place is make sure that you stay well hydrated. I'm amazed at how many singers every time I go to speak at a conference or something with singers, they always want to grab a bottle of water right before they sing. I'd say, this is not the time to drink it. You can drink it now if your mouth is dry. Your goal is to have this homeostasis, a steady state of hydration. Just drinking this water right before you sing is not very helpful for you. Drinking the water--
[Dr. Ashley Agan]
Speaking of water, what about bubbly water? Does that count, or are we talking about just straight up water?
[Dr. Gopi Shah]
Can we get a Topo Chico going or is it just still flat, doesn't matter?
[Dr. Mark Williams]
There are three categories. There are things that are definite no's. There are things that are definite yes, like water. Then there are things that I say, it may help, may not help and it may not harm. As long as it doesn't harm, I don't know that the bubbly water that there's any scientific evidence that I'm aware of, at least that carbonated water will impact the vocal folds. I prefer it just be regular water instead of even, for that matter, the water sweeteners or flavors that you put in. If it's not going to cause any harm, if that's the only way you're going to get the water in, I'd rather you get it that way.
Then the caffeines. Then there's a whole discourse of whether or not caffeine really has an effect on the vocal folds. The academicians are debating this now, whether or not. If you're used to drinking caffeine all the time, then drinking caffeine is probably not going to be harmful to your voice. If you're not a regular caffeine drinker, then obviously you take a big caffeine load, it dries the vocal folds out. These are things that my response is, it's better to just avoid the caffeine. If you can, just avoid the caffeine. That would be part of vocal hygiene.
Watch what you eat and when you eat and how much you eat. For my patients, I'm telling them, try to avoid lying down within three hours of eating. If you have to sleep, sleep with the head of your bed elevated, let gravity help prevent some of the reflux. Avoid the spicy, greasy, acidicy foods. They hate it when I tell them to avoid the alcohol, all those things that can contribute to reflux.
For me, for a really great Friday night, a happy hour. I usually say take all things in reason. Take all things in moderation. It doesn't mean that you can never have these things. I would never go that far, but understand where your voice is and understand the impact of some of the things, your behaviors, some of your diet and lifestyle, how those things impact your voice. You have to make the determination whether or not it's worth being very extreme about it or if you can get by with a couple of cheats here or there.
There was another thing that I was going to say about voice hygiene that we often don't think about as it relates to voice hygiene, but I think it is just mental health and staying in good physical shape. Staying in just good physical shape, obviously, if you can't breathe, you can't sing. Keeping good physical and mental health, those are things that I think do contribute to helping to maintain good voice production and good voice performance for those of us who depend on those.
[Dr. Ashley Agan]
When do you have to tell somebody to do voice rest and how long do you tell them to do that for? Does that mean you can't talk at all? Does that mean a couple of days, a week? How does that play or how do you tell them to do that?
[Dr. Mark Williams]
That's an evolving area of voice science as well, and you've got different voice specialists who practice differently. There's a general consensus that nobody should be on voice rest for longer than one week. Certainly after surgery, I usually do put my patients on voice rest for one week. There's evolving thought to say, two days is probably long enough, and some people say, maybe you shouldn't put them on voice rest at all. You should just immediately get them back to using their voice.
I haven't gotten that courageous yet, so I still like to see that my patients are on voice rest. Complete voice rest, no whispering for a full week. I find that it works best after their surgeries, just maybe more anecdotally. Now, do all of my patients comply with that? Of course not. You get people who are still speaking right after the surgery, and they heal just fine as well.
Although, I will say that I have noticed some cultural differences in the way that people who speak different languages, how they talk. Certain languages require a very guttural and forceful phonation that I see if they start talking after the surgery, just because of the way that they normally talk in their language, it can start causing poor healing.
I've got particularly one patient who I find that I'm going to have to take back to the operating room because she talks the exact same way now that she talked before we removed the cysts. Guess what? She's got a cyst again. I'm saying, how do you change this cultural or language problem that's contributing to the voice disturbance? I just don't have a good answer for that one.
(9) The Role of Surgery & Therapy in Treating Vocal Pathologies
[Dr. Gopi Shah]
That's a good segue into when do you know, or what are the indications for microlaryngeal surgery? How do you know which singer needs to go?
[Dr. Mark Williams]
It's all dictated by the pathology, I think. Vocal nodules rarely require surgical intervention. Usually, those can be addressed with voice therapy. The other end of the spectrum is vocal polyp, it's almost always going to require surgery. That voice therapy is not going to be helpful for it. Vocal polyps and cysts, those are definitely going to require surgery. Then occasionally, we'll have vocal nodules. We have to do something for vocal nodule.
Truth of the matter is sometimes even with a rigid laryngoscope, video laryngoscope, it's difficult to distinguish a cyst from a nodule sometimes. If I look at a patient and I think they may have a cyst, I'll send them to voice therapy first and see if they get better. If they don't, then I'm taking them to the operating room and say, oh, yes, that's why, because it was a cyst with some reaction on the other side to make it look like a nodule.
[Dr. Gopi Shah]
In regards to voice therapy, what's your spiel when you're talking to patients about sending them for voice therapy? Because I feel like sometimes I'm like, "Oh, we're going to send you to our speech therapist, voice therapy, it's going to help. You're going to get better. It's going to be great." Then they're just looking at me like, what are you talking about? What does that even mean? [laughs]
[Dr. Mark Williams]
I slip up often and say speech therapy. When I say speech therapy, my patients immediately go to stuttering. "I don't have a stuttering problem. I'm articulate." They're thinking about articulation disorders as opposed to a voice issue. I try to remember to use the word voice therapy in that regard. I also forewarn them that they will have to do some-- they'll probably require that the patient do some exercises that seem silly. They probably seem like it can't possibly do anything.
I encourage them just still to remain compliant, no matter how silly the instructions seem to you. Because if you really want to get better, you have to be compliant with their recommendations. They really do know what they're doing and really can help nurse you back to good voice health.
(10) Merging Faith, Music, & Medicine
[Dr. Ashley Agan]
Now that we've gotten you to talk to us for a good time about how your voice practice is. I know, because your passion is music and ministry, tell us how you've merged your otolaryngology practice and your passions with music and ministry?
[Dr. Mark Williams]
I am a gospel recording artist. For me, it's probably the primary reason why I went into otolaryngology, was because it gave me an opportunity to be able to teach other singers how to properly use and care for this instrument. I call it God's Stradivarius. The reason why is because as a Christian, I believe that there's a lot of things that we speak into existence.
I often tell crowds when I'm speaking to them that the voice is the way that God has created us and allowed us to be able to use our natural bodies to create a spiritual force to impact the atmosphere around us. Because voice is energy, voice is sound, sound is energy, and energy displaces anatomic particles in the atmosphere around us. I think that when we open our mouths and we begin to speak positive and we begin to speak life into people, life happens. This is where my faith comes into it.
I get excited about talking about being careful about the things that we say, because it really does change the world around us, not just on a theoretical perspective. If you start looking at the energy that we release into the atmosphere in the form of a sound, we start seeing how that impacts it. I love talking to churches and singers and groups about how to use that voice in worship and how to use it for spiritual purposes as well. Being a voice expert and connected with the gospel music community here in Nashville and across the country really helps me be able to do that.
[Dr. Ashley Agan]
I love sound as an energy and voice as an energy.
[Dr. Mark Williams]
I believe it works. I give the example that when I was in medical school, it just felt like a lot of things was coming. I was the president of the Student National Medical Association at my medical college, and I think some people weren't terribly happy about my appointment to that position. They never said anything to me about it, but you know how you can feel energy or something, like something's not quite right? I asked my wife, I said, "Listen, I need you to pray for me." "That's fine." "I also want you to just speak some positive things about me into the atmosphere. I don't have to hear it. Just speak some positive things about me in the atmosphere."
My hope is you guys know how a sine wave is, you got the peak up here. If you got the peak going out of phase, they cancel each other out. I said, "Just speak some positive about me to cancel out the negative that maybe some other people are speaking in." I don't know if she did it or not. I have to ask her now 20 years later if she ever did it, but I felt the difference-
[Dr. Ashley Agan]
That's all that matters.
[Dr. Mark Williams]
-so I believe it.
[Dr. Ashley Agan]
My mom says the same thing, that there's vibrations that we create around us and that the more positive vibrations that we create around us, the better we'll feel.
[Dr. Gopi Shah]
The better you make other people feel.
[Dr. Mark Williams]
Exactly.
[Dr. Gopi Shah]
All of us have met people that you just enjoy being around and you're not really sure, you can't put your finger on it. They have a good vibe.
[Dr. Mark Williams]
Part of it is the voice. It's what's coming out of their mouths. What comes out of our mouths really does have the ability, I think, to produce life in people. It has the ability to produce death in people as well. I think we just ought to be much more careful and mindful about the power that we have resident in our voices.
[Dr. Gopi Shah]
Do you find that there's certain qualities in ministry that you use on your day-to-day at the bedside with doctoring?
[Dr. Mark Williams]
I play my music. [laughs]
[Dr. Gopi Shah]
That's awesome.
[Dr. Mark Williams]
I know, shameless plugs. You call my office and you get put on hold, you have to listen to Dr. Mark Williams. I was a little worried about that at first because I was playing gospel music and I didn't know how people would respond to being on a hold on gospel music. People, now, they're much more pleasant when they get on the other end with my front office staff. Maybe it calms them down. Some people are like, "Put me back on hold. I want to finish listening to that." [laughter] I think in 14 years that I've been doing that, I've had one complaint.
I see patients with all different types of faiths or no faith at all and I've had one complaint and they just thought that you shouldn't be playing Christian music. Maybe it's because I'm here in Tennessee at the Belt Buckle, The Buckle of the Bible Belt. I don't know. We see a lot of Muslim patients and people of other faiths as well. No one has ever really complained about that, so I'm glad for that. Plus it opens the door and allows patients to know that, if they want to talk on a spiritual level, that I'm here and available to speak with them on that level. If they want me to pray, I'm happy to engage in that regard. I don't take the step to engage or push that on anyone, but they know that I'm available if they choose.
[Dr. Gopi Shah]
I'm a Hindu and I enjoy gospel music and religion, spirituality. To me, it's pretty much there's different faiths, but with lots of the same messages and values. I think it's okay.
[Dr. Mark Williams]
Thank you. I'm glad to know that that's not the reason why you left us. [laughter]
[Dr. Gopi Shah]
I don't know if my boss is listening. Dr. Mitchell, if you are, I didn't think about not coming.
[Dr. Mark Williams]
Full circle here.
[Dr. Gopi Shah]
Exactly. Completely. Dr. Williams, if our listeners want to check out your music, other than calling your office and being put on hold, how else can they find and listen to you?
[Dr. Mark Williams]
I hadn't thought about recommending that way, but call the office and be put on hold. They can find anything they would like to know about me at drmarkwill.com. On that page, we're merging music, medicine, and ministry. You can learn more about my music. You can learn more about the ministry that I offer, including the book that I just wrote.
[Dr. Gopi Shah]
Congratulations.
[Dr. Mark Williams]
Thank you. During [crosstalk] pandemic.
[Dr. Gopi Shah]
Tell us about the book.
[Dr. Mark Williams]
The book was based off of a CD. My most recent CD I recorded was called When A Man Worships. After I recorded, I called it dude worship. A lot of times dudes like to be real tough and macho and everything. We don't like to get involved in worship or anything. Seems too soft, but I called it dude worship. After I recorded the CD, a friend of mine said, you should write a book and each chapter in the book should be a song. Each song on the CD should represent a chapter in the book. I thought that was a phenomenal idea, but I just never really found the time to do it. Along came Rona. You know Rona? Corona, we're on first name basis like that. I call her Rona now.
[Dr. Gopi Shah]
That nickname.
[Dr. Mark Williams]
Yes. We had a dramatic slowdown in our practice last summer around April, May, June. It was pretty slow. I had already had many of these lessons and a lot of the writing already in my head and some of it actually in writing from courses that I've taught on worship. It was pretty easy within a matter of about three weeks to be able to put everything on paper and get the book published. I was really glad to be able to do that. When A Man Worships is also available on Amazon. You can also find that on drmarkwill.com.
All of my social media is the same, @drmarkwill, whether it's Facebook, Twitter, or Instagram. Be aware-- Wait a minute, I think-- Yes, I was about to say, don't go on my Facebook page because you might find a whole bunch of other stuff, political thought. [laughter] You might find a lot of political thought. If you go on drmarkwill's Facebook page, you won't find that. Don't find my personal Facebook page, otherwise, you might not like what I say politically.
[Dr. Ashley Agan]
Congratulations on the book. That's awesome.
[Dr. Mark Williams]
Thank you.
[Dr. Gopi Shah]
Thank you for taking the time to come onto the show today, Dr. Williams. It was so nice to reconnect and just see that you're doing so well and doing so many exciting things. I love how you've been able to personalize and self-express parts of your practice into other passions in your life. That's very unique and that's something awesome.
[Dr. Mark Williams]
I think it really does make up for the lack of compensation that I get from being a solo practitioner. Sometimes I really wish I had partners, was an employee position. I said, soon I'm going to retire, but I need to probably work a little bit longer as a solo practitioner, but I wouldn't trade it for the world.
I totally enjoy what I'm doing. I love the freedom that being in solo practice offers for me to be able to be open and expressionate about my faith, open and expressionate about my political views or whatever it may come about. Patients have the right then to choose whether or not they still want the excellent care that I would provide for them, or if they would allow their political or religious biases to prevent them from doing that. That's their prerogative. In any case, I can still be an open book called When A Man Worships.
[Dr. Ashley Agan]
You have your voice. That's the best part about it.
[Dr. Mark Williams]
Definitely.
[Dr. Gopi Shah]
Awesome. Thank you. Thank you again to our guests and to our listeners.
Podcast Contributors
Dr. Mark Williams
Dr. Mark Williams is a practicing Otolaryngologist at his solo practice, Ear, Nose & Throat: Specialists of Nashville.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, August 3). Ep. 28 – Music, Medicine, & Ministry [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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