You might call the Voice Institute of West Texas a case of “If you build it, they will come”—even if they have to come to Abilene. What else could explain the success of a clinic that treats afflictions like spasmodic dysphonia and mutational falsetto and does it out there in what locals call Big Country but the rest of us call the middle of nowhere? “No question about it, we’re much better known in Europe than we are here in Texas,” says Austin King, an otolaryngologist and a head and neck surgeon who is one of the institute’s founders. “In fact, it’s kind of funny. When I’m at a voice conference in, say, Stockholm to deliver a research paper, the program will say, ‘So-and-so, Berlin. So-and-so, Paris.’ And then, ‘Austin King—Abilene!’”
The institute, the state’s first voice disorder clinic, was founded in 1985 on the campus of Abilene Christian University by King and his two partners, ACU speech-language pathology professor Jon Ashby and classical singer and voice instructor Charles Nelson (who also happens to be the younger brother of golfing legend Byron Nelson and was then the university’s artist-in-residence). On a recent Wednesday afternoon, eight patients are scheduled to be seen in the modest suite of offices. While the sky outside turns greenish with a spring thunderstorm, the three partners try to explain to a middle-aged woman that the reason her voice sounds like a marble rattling around in a garbage disposal is because she has a paralyzed vocal cord.
“What?” she croaks incredulously.
“You have a paralyzed vocal cord,” repeats King, a slender 51-year-old with a soft, reassuring voice. He consults the image of her vocal cords that was transmitted to a TV screen by the tiny fiber-optic cable, or laryngoscope, that he had threaded through one of her nostrils and down the back of her throat. “For some reason, the nerve that powers that cord is not firing.”
The clinic is open only one afternoon a week, and the three partners treat uninsured patients for free (the institute is supported by grants from two West Texas foundations). “You have to understand,” says King. “This wasn’t about money or work. The voice was a real passion.” In a specialty where patients are routinely shuffled from ear-nose-throat (ENT) doctors to allergists to speech pathologists and back again, the clinic offers one-stop shopping: All three partners participate in every diagnosis and treatment plan. There are young singers with nodules, cysts, or polyps on their overworked vocal cords and people whose voices are breathy, squeaky, or choked for causes that are sometimes unknown.
“The voice is probably the most abused and neglected organ in the body,” says King. The vocal cords (also called vocal folds) are part of the larynx, a mass of muscle and cartilage that sits atop the trachea (or windpipe) in the throat and serves both as the vital door between the mouth and the lungs and as the initiating instrument of human speech. Sound is generated by the larynx when air is forced up through the closed vocal cords, causing them to vibrate as the air pushes them open. This vibration is commonly thought to be like that of a plucked guitar string but is actually a more complex movement, a kind of coordinated undulation involving all three layers of tissue that make up the cords: the underlying muscle; the lamina propria, which covers it; and the epithelium, or outer skin. The monotonic hum produced by this wave is then further amplified and articulated by reverberating off the walls of the pharynx (the throat) and then the tongue, the hard and soft palates, the teeth, and finally the walls of the nasal sinuses to produce the actual voice, which is as distinctive in each person as his or her fingerprint.
Most people can live their entire lives and have no vocal problems worse than a case of laryngitis. But about 6 percent of the population suffers from more-chronic and debilitating pathologies of the voice. It was this largely ignored patient population that intrigued King as early as his ENT residency at Houston’s Baylor College of Medicine in the late seventies. An opera buff, he had always been interested in the workings of the trained singing voice—an interest that was further encouraged by the work of a favorite professor, Van Lawrence, a fellow opera lover who treated Houston Grand Opera singers and was a pioneer in the use of fiber-optic technology to provide diagnostic images of the throat. While serving a residency rotation at the Houston VA hospital, King was reminded of just how indispensable the voice is. “Here you had these proud war veterans who didn’t have much left of their manhood but the ability to talk about it,” he remembers. “And they’d come down with cancer of the larynx and we had to take the whole thing out. They just changed overnight when they couldn’t speak. It was like castrating them.”
So when he finished his education and returned to his hometown of Abilene to hang out his shingle, he planned to pursue the study and treatment of the voice. Abilene being something of a small town then, he soon bumped into Nelson and Ashby, who shared his enthusiasm for the subject. The three began getting together informally to exchange research and discuss their pet theories, and soon enough they found themselves opening the voice-disorder clinic.
Though there were plenty of otolaryngologists around the state who treated voice and ear problems, there wasn’t a clinic dedicated solely to the voice, not to mention one staffed by three experts who could cover the gamut of vocal dysfunction. “Oddly, the vocal cords are the last thing a lot of people—including doctors—think of when someone starts speaking abnormally,” says King. “They think allergies or viral infection. And even if a voice disorder is recognized, there’s the widespread feeling that nothing can—or should—be done about it. You’re supposed to live with it. We felt some people were suffering unnecessarily.”
A couple of years after they started the Wednesday afternoon clinics, a fourteen-year-old Abilene native named Joe Bob Smith showed up. He was chagrined that his voice wasn’t changing the way his friends’ were. In fact, it had remained girlishly high. “It just didn’t sound right,” he recalls today. “It was coming from the wrong place and weak.”
Smith figured he’d outgrow it, but his mother wasn’t so sure and made an appointment at this voice institute in town that she’d heard about. On the laryngoscope, the three specialists could plainly see that Smith had a rare disorder known as mutational falsetto. The medical literature offered many exotic theories about its causes—including the sufferer’s desire to cling to his childhood—but in this case it was clear that Smith’s problem was physiological: The vocal cords and the muscles of his larynx that supported them seemed in a constant state of extreme tension, causing the reedy quality of his voice. But when he laughed—and instinctively relaxed his larynx—the tone of his voice was much closer to normal.
They asked the boy to try to remember what his voice felt like when he laughed and to emulate that when he spoke. After about six weeks of therapy, “I was speaking in a different voice,” says Smith, who is now an aspiring screenwriter in Hollywood. “When I’d answer questions in class at school, the other kids would turn around and stare.”
In 1995 a 55-year-old Jacksboro schoolteacher named Frances Easter came to the clinic with a tale of having suffered most of her adult life from episodes of strangled, tremored speech. King, Ashby, and Nelson quickly diagnosed her problem as spasmodic dysphonia, which is caused when the nerves from the brain that control the vocal cords misfire unpredictably. Most of us have experienced something similar to this when we have to speak in front of a group and notice a drying and tightening in the throat from nervousness. In Easter’s case the problem had become so acute that it had affected her life. “I had become afraid to volunteer to read at Bible study class for fear it would happen,” she recalls. “It was like a panic attack. Until I went to the clinic, I figured nothing could be done about it.”
Given the duration and degree of her suffering, she says, the cure was surprisingly simple. After anesthetizing her, King injected her vocal cords with a drug called Botox, a new nerve-impulse blocker made from the powerful neurotoxin produced by the botulinum bacterium (the same bug that can cause potentially fatal infections of the gastrointestinal tract). Within weeks, the Botox—which is also used to smooth frown lines and other muscle-related facial wrinkles—had worked so well that Easter was able to speak with ease. “There may be some people who are sorry I found the voice institute,” she says with a laugh. “But I’m glad I did.”
So is Joe Sewell, the final patient this Wednesday afternoon. He has dropped by to have his voice prosthesis checked; last year, after being diagnosed with cancer of the larynx, he had undergone a complete laryngectomy. Despite the fact that the worst possible thing had gone wrong with his voice—because, he admits, he had smoked too many cigarettes for too many years—Sewell is a surprisingly sunny 67-year-old, whose leathery complexion and ropy forearms betray his life’s work as a civil engineer.
Perhaps Sewell is cheerful because, unlike a lot of people who have lost their voice to cancer, he can speak without using an often awkward and embarrassing artificial larynx (a handheld vibrating device that, when held to the neck, projects a buzzing sound into the throat, which air from the lungs then propels upward into the mouth, where it is formed into speech) or relying on esophageal speech, in which air is swallowed, then expelled like a belch up through the esophagus and into the mouth, where the sound caused by its reverberations there is then articulated into words.
Sewell is able to speak using a tracheoesophageal prosthesis that King implanted in his throat. The voice it generates is “actually better than his voice when the cancer was still there,” says Sewell’s wife, Susan. The prosthesis, which is appropriate for only certain patients and has been widely available for only a few years, employs new technology to refine esophageal speech: A permanent opening called a stoma is cut at the sternal notch of the neck, and a shunt, or tube, is threaded between the trachea and the esophagus (which sits behind the trachea). Sometimes a small automatic valve is placed into the stoma. In Sewell’s case, however, a filter was installed in the stoma, and he simply inhales, then closes the air passage with a finger. The air in his trachea is forced through the shunt back into his esophagus, where it then rushes upward into his mouth with such force that it causes the walls of the esophagus and the throat to vibrate and create a sound that can then be articulated into speech. “All I had to do was start talking,” Sewell recalls in a hoarse timbre. “The first words I said were, ‘Susan, you’re in trouble because I can talk!’
“When I learned they were going to take my cords out,” he continues, “the first thing I thought of was having to use one of those awful mechanical things. So much of me is a storyteller. How could I do without a voice? I’m just thankful that God put someone like Dr. King here to do what he can do. You can’t take your voice for granted.”