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VISUAL FEEDBACK

Lindsay Doidge and Daphne Carpenter were initially reluctant to extend their role by offering nasendoscopy to clients with voice problems. But pioneering speech and language therapists and their forward-thinking ENT department encouraged them to go for it with very positive results.

READ THIS IF YOU ARE WARY OF INVASIVE PROCEDURES WANT CLIENTS TO SEE THE DIFFERENCE NEED AN EXTRA PUSH TO GO FOR IT

Increasing th
an effort to address perceived shortcomings in the provision of ENT services. Amongst other initiatives, it recommended extended training for professions like speech and language therapy to fulfil NHS waiting list targets.

n 2001 we were inspired and challenged by Helen Rattenburys presentation at the 5th Newcastle Voice Conference describing the use of nasendoscopy in her practice. At that time only 7 per cent of ENT speech and language therapists were trained to do this. At the 9th Newcastle Voice Conference we attended the excellent presentation by Sue Jones describing how she uses nasendoscopy to assess patients in her clinics. This motivated us to share our experience of setting up a nasendoscopy voice treatment clinic. Nasendoscopy can be used to examine a client from the nasal cavity to the larynx. The procedure involves inserting a small flexible tube called an endoscope through the nose. Real-time images are transmitted to a TV monitor. While it was developed as an assessment instrument for use by ENT surgeons, its potential value as a visual feedback tool in therapy sessions for voice, velopharyngeal dysfunction and dysphagia is gradually being recognised. Our ENT colleagues had wanted us to develop nasendoscopy skills for a long time, saying that as professionals working with voice we should have as ready access to laryngeal images as they do. We knew this would also enable us and our patients to benefit from the objectivity the procedure would provide. However, like many speech and language therapists, we were reluctant due to its perceived invasiveness. But, encouraged by Helen Rattenbury that this could only enhance the service we offer our patients, we realised we really needed to go for it! The publication of Action on ENT(2002) gave us another push. This NHS Modernisation Agency document was

Competencies
We therefore enrolled on an excellent day run by the speech and language therapy team at the Royal National Throat, Nose and Ear Hospital, Grays Inn Road. We subsequently built up our competencies with additional training and supervision from our own ENT team. Action On ENT encouraged speech and language

We have been pleased to find that patients are able to tolerate the procedure for as long as the therapists arm can hold out!
therapy-led parallel clinics, which are specialist voice clinics run concurrently with general ENT clinics. Patients are triaged and selected for such parallel clinics, and almost always have a non-organic diagnosis such as muscular tension dysphonia. However, we felt nasendoscopy was of most benefit to us and our patients in a treatment / therapy environment, so we set up our existing clinic once our competencies were completed in December 2002.

We run our clinic on a fortnightly basis in the ENT OutPatients Department with nursing support. Immediate medical support must be available should any emergency or other unforeseen event arise (epistaxis, vasovagal episode, laryngospasm or tissue trauma). We see three to four patients per session, allowing 45-60 minutes with each. Voicecraft is our main therapeutic intervention with adult patients who have organic voice disorders. The techniques encourage the patient to understand the importance of releasing laryngeal constriction prior to working on sustained voicing and improved voice quality. Voicecraft lends itself well to the visual feedback that nasendoscopy can provide. We use the ENT departments Laryngograph software with recording facility, TV monitor and nasendoscope. Two of us run the clinic; one therapist scopes the patient which frees the other (treating) therapist to show the relevant area on the screen and aid understanding with demonstration. We introduce new treatment techniques and encourage patients to use the treatment techniques we have already taught them. We focus on both successes and problems. If a patient has found a particular technique difficult to master and has stopped making progress, they are often able to move forward following the procedure. The patients have the benefit of immediate visual feedback, which helps them to correct mistakes they may not have been aware they were making. We have high numbers of occupational voice users such as professional singers in this area. All are particularly interested in seeing how their voices work. We also see other professional voice users such as teachers and call centre operators.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007

VISUAL FEEDBACK

he scope
Focus shifts
Initially patients can be apprehensive when the procedure is outlined to them. However, once they can view their own larynx on the screen, we find the focus shifts; we have a high degree of compliance and they report very positively. We have been pleased to find that patients are able to tolerate the procedure for as long as the therapists arm can hold out! We have had two patients decline nasendoscopy in the three years the clinic has been running, and have never received any negative reactions from those undergoing it. Indeed, patients report that the Voice Treatment Clinic has been an invaluable part of the therapeutic process. A brief case example is in figure 1.

Figure 1 Case example Jim - a teacher and amateur singer - presented with a fixed left arytenoid following neck injury. His voice was weak and breathy due to the inability to adduct his vocal folds on phonation. He had a good mucosal wave on the vocal folds, but these did not adduct. We used Voicecraft techniques to improve Jims adduction, including Sob and Twang. When visualising his larynx he was able to improve the quality of his voice, having seen the changes the techniques made. His response was Can I do more of this? Its so useful to see whats happening as Im talking and also to know when Im pushing it and actually making it worse.

Other feedback has included: its fascinating to have it confirmed that I was doing what I thought I was doing; I never thought it looked like that!; it helped link the feeling with the seeing; .. that makes sense of the model you showed me; I wish the doctor had let me see that. We are in the process of compiling a formal feedback form and a patient self-rating scale to audit our effectiveness. Depending on funding, a potential development of this clinic is to use it to discharge patients with non-organic conditions from the speech and language therapy and ENT caseload, thereby reducing clinic time and cutting waiting lists for ENT clinics. Once treatment has been completed, ENT are happy for us to do this. As this is not a diagnostic clinic, we routinely obtain consent from the patient to show the recording of the procedure to their doctor for his or her information. We have on several occasions needed to show recordings to our medical colleagues when we have observed a worrying laryngeal change. Not only has the use of nasendoscopy as part of our therapy enhanced our patient care, it has also improved our standing as members of the ENT team. In addition we have helped two of our ENT doctors to organise and run an in-house training package in nasendoscopy, to enable more speech and language therapists to develop these skills. Some therapists have used this training as part of objective assessment of swallowing (FEES Fibreoptic Endoscopic Evaluation of Swallowing), so this development is very exciting. If anyone is planning to set up a similar clinic in their area we would be pleased to hear from them.

REFLECTIONS DO I LISTEN WHEN PEOPLE ENCOURAGE ME TO UNDERTAKE AN EXTENDED ROLE? DO I SEE THE WIDER BENEFITS OF WORKING MORE CLOSELY WITH PROFESSIONAL COLLEAGUES? DO I LOOK FOR WAYS TO REDUCE WAITING LISTS AND STREAMLINE PATIENT JOURNEYS?
Lindsay Doidge and Daphne Carpenter are specialist speech and language therapists with South Devon Healthcare Trust, Crow Thorne Unit, Torbay Hospital, Torquay, Devon TQ2 7AA, tel.01803 654931.

References
Jones, S. (2006) SLT endoscopy applications, 9th Newcastle Voice Therapy Conference. Newcastle, UK, June. NHS Modernisation Agency (2002) Action on ENT. Crown copyright. Available at: www.institute.nhs.uk/Products/ActiononENTGoodPracticeGuide.htm (Accessed 8 January 2007). Rattenbury, H. (2001) Can SLTs afford not to be doing their own fibreoptic nasendoscopy?5th Newcastle Voice Conference. Newcastle, UK, June.

Resource
Voicecraft see www.voicecraft.com.au
SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2007 SLTP