Why I love coughing with SLT Tor Spence

Specialist Speech & Language Therapist Tor Spence joins us for a chat. She's become an expert on coughing - what it is, how we can control it and what it does to your voice.
We break down the physiology of a cough, and describe the technique of mindful coughing.

Tor also talks about the process of vocal diagnosis, both within the ENT structure and "sight unseen" in the 2-week wait clinic.
Find out what the cycle and the seesaw have to do with coughing, and why Jeremy loves filtering in diagnosis (and what that actually means).

Oh and we're talking mucus.
Lots of mucus.

Tor can be found under the VoiceFit banner here
https://www.instagram.com/voicefituk/
https://www.facebook.com/voicefituk/
https://twitter.com/voicefituk
https://voicefit.co.uk
Here's the link to Tor's online modular course for the developing voice therapist
https://voicefitschool.thinkific.com/courses/voicefit-to-practise 

ENT UK - here's a link to the Patients section of ENT UK (the professional membership body representing Ear, Nose and Throat Surgery) https://www.entuk.org/patients/conditions
https://www.entuk.org/patients/conditions/31/hoarseness

And here's some advice from the Physiotherapy for Breathing Pattern Disorders website
https://www.physiotherapyforbpd.org.uk/self-help/

To find out more about voice, vocal health and singing techniques, check out the Vocal Process Learning Lounge - full access to 16 years of voice training resources for less than the price of one singing lesson
https://vocal-process-hub.teachable.com/p/the-vocal-technique-learning-lounge 

Transcript

Jeremy: 0:11

This is a voice podcast with Dr. Gillyanne Kayes and Jeremy Fisher. Hello, and welcome to series five, episode three of this is a voice,

Gillyanne: 0:25

the podcast where we get Vocal about voice.

Jeremy: 0:29

We have a very special episode for you today.

Gillyanne: 0:31

Yes, we have our first guest of 2022 and it is Specialist speech and language therapist, Tor Spence of VoiceFit, and Tor loves coughing.

Tor: 0:45

I do!

Gillyanne: 0:46

What is it that you love about coughing?

Jeremy: 0:49

Hello Tor.

Tor: 0:50

Hello, thank you so much for having me. This is really, really exciting to talk. Yes. About a lot about coughing, which I've found myself working with a lot. And yeah, I just find it fascinating. And it's so linked, closely linked with the larynx and voice as well.

Jeremy: 1:05

And not all coughing is the same. Am I right?

Tor: 1:07

You are absolutely right. Yep. So there's many different causes of cough. And the coughing that I end up working with is patients that have been coughing for more than eight weeks, normally for a chronic cough, a cough that's been refractory to various medical treatments, which means they haven't been successful at helping reduce the cough. And normally where all sort of lung function tests, respiratory, ENT investigations, all of those are normal.

Gillyanne: 1:33

Okay. So it's like coughing for no reason.

Tor: 1:38

It is, well in a way. So I tend to think of it as a help. Dividing coughs between what's helpful and what's unhelpful. So if we think about a helpful cough, being a cough, that expels something from the airway that shouldn't be there, sometimes that's where the lung condition or disease where people need to get rid of mucus. Obviously with an infection, you will be coughing partly to get rid of mucus and sputum as well, and it protects the airway, of course, from anything going down the wrong way, like food or drink and things when we swallow. But unhelpful cough, essentially as a dry, tickly cough, that's laryngeal focused, that's caused or triggered by a sensation where ideally we want to find something else to do to help manage or cope with that sensation rather than coughing. Otherwise people get, tend to get onto a cough cycle that causes more irritation, more coughing. And that's when people come to see me.

Jeremy: 2:33

I just sorry, I just had an image of people climbing onto a cough cycle.

Gillyanne: 2:36

I'm going to check in here because we're very fortunate. We haven't had COVID and I know you've worked with post COVID patients, but I can remember swine flu. Do you remember swine flu?

Jeremy: 2:47

I do.

Gillyanne: 2:47

And I had it. And you coughed every 12 minutes. That was one of the markers. But once it had gone, eight weeks on, I was still blooming well coughing. And it was exactly, as you say that little dry cough, I also was throat clearing. And actually I went to see a laryngeal osteopath, and he said to me, do you know that you throat clear every five minutes? And he did some work on my larynx and then the coughing went away. So I can relate to what you're saying is that suddenly we get this, it's almost a habitual pattern that we fall into. It's is it like. There's an irritant, a sense of irritant in the larynx and it's responding to anything that comes by?

Tor: 3:32

Yes. So it is quite common after an infection or a virus, particularly something like swine flu or we're seeing post COVID that people have been coughing helpfully when they've been unwell. But what they're left with after any infection or illnesses cleared is that the larynx has become quite hypersensitive. So it's very, the larynx is obviously very sensory and it responds to lots of things, but including environmental triggers and the air quality in the world around us. And if the larynx is hypersensitive, think of it as there are too many messages firing up from the larynx to the brain telling us that there's something there that's irritating, or that needs to be got rid of and people end up getting too many messages and a strong urge to cough. And of course people will cough. Cause they don't know at that stage that there's any that they might get onto their cycle or there's something different. They can do that safer.

Gillyanne: 4:26

Yeah. Talk about the effect on the larynx of coughing. Obviously it's something that singers are very conscious of because we're told that it brings the vocal folds together very fast and therefore, there's a potential to cause trauma, but from your perspective and in your experience, what is the impact. On the larynx.

Tor: 4:46

So when you cough, you bring your cords together and then you explode them open quite forcefully. So yeah, there is the can, there is often an impact on the surface layers of the vocal chords and the surrounding area quite often in chronic cough patients. If I examine their larynx, we'll see that the false cause of ventricular bands become quite involved and quite bulky as well. And that creates a tension and can lead to voice problems. So in allowance, where someone's being coughing, you will often see redness inflammation, sometimes a bit of swelling. Now it's quite difficult to prove that's down to the coughing and not something else because there's so many possible abilities and causes for that. Yeah, but some larynx is that where someone's been coughing will look entirely healthy. There's no set pattern and there's actually no set way of us visually assessing a larynx as well. We're looking at a larynx when on with our own experience and what we know of the things that can affect it

Jeremy: 5:45

Well you're looking at the larynx on camera, but you're also questioning the whole person and the whole situation that they're in and what patterns that they've got right then.

Tor: 5:55

Yeah. Yeah, absolutely.

Gillyanne: 5:58

So what do you do? How do you help people in that situation?

Jeremy: 6:02

What do you do Tor?

Tor: 6:04

So I work with people who have been coughing from eight weeks up to 30 years, and it's never too late to look at changing that response, particularly if this is someone who's had all the lung function tests, seen Respiratory, seen the ENT, absolutely nothing to worry about from a medical point of view, but they've got this incredibly frustrating cough which often has a very significant impact on quality of life and affects, like you said, Jeremy, the whole person there's so much to consider when it comes to these symptoms and it might be affecting their voice, it might be affecting their swallow. They've got these constant irritable feelings that might... Maybe made worse every time they talk. So I think of my treatment on a Seesaw. So the patients I see on one side, they'll have heightened laryngeal sensitivity on this side of the Seesaw. And on the other side, they've got an impaired, conscious cough control because the more we cough, the more we want to cough and that, that sort of mechanism of control becomes impaired. So you've got this very off-balance seesaw. Therapeutically by trying to reduce the sensitivity on one side and then improve their conscious understanding and control of what they can do instead, how differently they can respond to that urge by balancing the Seesaw, or you do start to see some improvements to the severity of the cough, and then hopefully the frequency of the cough and the urge people get to cough.

Gillyanne: 7:34

It must affect their quality of life and also social interaction. I know sometimes if I've been on a, a train or something and somebody is coughing, apparently for no reason, and it can be quite loud that kind of cough. And the cough and then a few minutes later to the cough again, and then they cough again. As a, someone hearing that it can impact on you as well. And you know that's not because I'm not, me, I'm not a mean person, but it must impact on them.

Tor: 8:04

And can you imagine if the last couple of years as well with the added component of COVID as well and how, to be honest, all of us do view cough, or have done a little bit differently. And when you hear someone cough, people's sensitivity that have been really heightened haven't they and what people are thinking about it. Yeah, the patients I work with who cough frequently, obviously, you know, home life is disrupted. Work is disrupted and now particularly kind of social interactions are disrupted and they worry when they go out in public it's can be quite lonely.

Jeremy: 8:39

Is there anything specific that we can do to, cause you know, that the cough is triggered? Is there anything that you can do to stop that trigger or replace it with something?

Tor: 8:49

So I tend to focus people on the smaller coughs where there's more warning that the cough is coming first because with chronic cough, not everyone gets a lot of warning the cough is coming. So there are some more explosive coughs that feel involuntary. But if we really tap into what is that feeling you get just before you cough. Cause if there's a feeling before, generally speaking, there is some voluntary control that we can get in there between the feeling that we get and the response, which is the cough. So I spend a lot of time with people focusing on that and keeping diaries and even sitting with me for half an hour, just if they're a frequent cougher, just feeling what they're feeling, tapping into that, being mindful, thinking about the sensations. And then we try and come up with strategies and techniques for what to do instead that's not a cough, that's just a different response because that starts to break the cycle. So you might start with just a gentler cough and then you might introduce techniques, like for example, a sip of water and a swallow sounds really simple, but by swallowing your sort of blocking that cough and you're closing the vocal cords, which can give them people, some relief from the sensation without that force.

Gillyanne: 10:06

I love that you used the word mindful and I'd actually already written down mindful coughing. Yes.

Jeremy: 10:13

Yeah. Yes. And you're raising awareness in a particular area, which is that moment between feeling that you need to actually coughing.

Gillyanne: 10:22

The firing, and it also helps put that person in control because otherwise you've got the sense that the cough is in control of you.

Tor: 10:31

Yeah. Oh, I talked so much about that with people.

Gillyanne: 10:34

Yeah. Yeah. So what would be a gentle cough? Yeah.

Tor: 10:39

So just pulling right back on the force, maybe turning it into a throat clear. So I might try it. Our huffy cough, hopefully the sound picks that up. Or just a very gentle throat clear because yes, we don't want people to throat clear regularly and replace coughing with throat clearing, but it is less forceful than a cough. And we're just trying to work down those steps and finding less forceful responses and different responses.

Jeremy: 11:05

It's really interesting listening to you doing your gentle cough because you are basically doing a gentle glottal stop. And then this slightly it's a slower speed of air and a slightly more air. So it's slightly less voiced in that makes it both softer and more diffused.

Gillyanne: 11:24

It's something that's, cause singers often talk about I've got guck, I've got guck on my vocal folds and Jeremy, you have a technique don't you where you just say. And I'm doing it with nasal breathing. And I know we're going to talk about that later, but there must be something where, forgive me if I'm preempting where you want to go, but you're triggered by the cough. Course, then you take a breath in, so you can do that forceful, closing, and opening. Whereas if we do it with nasal breathing, I think that might make a difference. And I know we hope to go there later, but Ooh, I'm really geeking out here.

Jeremy: 12:02

That's so interesting. And you're breaking it, breaking down all the components of the cough and the sequence that you go through.

Tor: 12:09

So if you imagine when you've got a sensation of a tickle, what normally people will do is take a big breath in through the mouth. And then lock the vocal chords and then explode them open. So it's, yeah, it's breaking down that that cycle, that process, and just, people have caught, people aren't going to realize what they're doing. It feels like a natural response to getting rid of something in the airway. Well, there isn't a person on the planet who hasn't coughed at some point in response to an irritant of some kind or a feeling in the throat. But these people with cough hypersensitivity are people where that threshold of response has really lowered. So I walk into a room where someone's just sprayed deodorant and yes, I might smell it I'll or perhaps feel it in my throat a bit, but it's not a bother, know, these people with cough hypersensitivity, one tiny spray of perfume or an aerosol or cleaning product and it sets them off immediately.

Gillyanne: 13:02

Deodorants used to do for me, didn't they? That's that's really interesting. It sounds like when you're talking about the vocal fold behavior, that it's the explosion open that is more problematic than cause I got in my mind, I'd got oh, we're bringing the vocal folds together. The speed of closure is quite high which we know can cause shearing of the, the outer layers, but it's the exp the force is greater outwards. Is that what you're saying? Interesting.

Tor: 13:32

Yeah. People's coughs will vary hugely. And it's very interesting when you've got a clinic full of chronic cough patients. And it's on a Monday morning, I see lots of cough patients coming through from the respiratory team and they've done a they've had all their tests done. And the medics feel that no, this is a chronic refractory cough. This is something that can therapeutically be worked at. And the differences in cough, there's lots of similarities, but there's also lots of different types of coughing. And people get into patterns of coughing as well. I don't know whether you've ever noticed particular people will cough in and very much a habitual pattern. It might be two or three or four coughs in the same pattern each time. So that's quite an interesting task of tapping into individual people's patterns and why that is and how we can break the patterns. But yes, it's the forceful nature of the explosion open when you cough. Causes the most problems.

Gillyanne: 14:23

That is so interesting. You mentioned the word huffing. Yes. I happen to know what huffing is. What are the benefits of huffing, maybe in this situation?

Jeremy: 14:32

Well first of all we should say what is huffing?

Gillyanne: 14:35

Yes, true.

Tor: 14:36

Yeah. And so half a Huff cough is letting the air out without too much... without full closure of the vocal cords, essentially. So you're not getting the forceful adduction and explosion open of the vocal cords. So you're protecting the layers of tissue on the vocal cords and the surrounding area. The air movement through the glottis can then help expel a little bit of sticky mucus that might be there. So in my experience, people do often say to me, there's something there that needs clearing. However, if you were to look and examine the larynx with all those people at that given moment, yes. Some would have a little bit of a stringing mucus perhaps across the glottis when they're breathing or a little bit of sticky patches of mucus, but not, by no means would everyone have anything visual to actually look at? So sometimes that feeling of that, being something there can be a sensation perhaps of dryness or of, a bit of muscular tension that's caused that feeling of Globus, for example. And a huff, the breath moving through the larynx can sometimes be enough just to give a person that feeling of relief.

Jeremy: 15:48

I'm glad you talked about this because we've been talking quite a lot about and the dispelling of the mucus, but actually it isn't always mucus is it? You can have really dry vocal folds.

Tor: 15:59

Yeah. Yeah, absolutely. mean, People sometimes are absolutely convinced there's something there or the must be mucus to clear. And when a chronic refractory cough is dry in nature, because there's nothing to clear it's unproductive, but some people will say to me, but it is productive. I can feel something moving or loosening. If any of us cough enough, we're going to produce a little bit of mucus because of the forceful nature of it. Again, there is mucus in the linings of the airways below and a strong cough is going to displace that. So yes, what comes first really? There's with chronic dry cough, there is rarely anything significant to clear, but if we cough enough, we will produce a bit of mucus.

Gillyanne: 16:43

Yeah. Because, aren't there mucus glands in the ventricular folds? Obviously, if the the system detects that the vocal folds are getting very dry, what are they going to do? They're going to create mucus. So I imagine you get this sort of cycle going on. Very interesting.

Jeremy: 16:59

I'm really curious. Just thinking about the physiology. Uh, And we talk about sipping water, but the water actually doesn't get down to the vocal folds. It's the action of the vocal folds closing fairly gently in a swallow that is going to do something, am I right?

Tor: 17:16

If we think about the upper airway as a whole, and the fact that yes, the cough is happening in the larynx. And a lot of people will feel that trigger in the larynx, but actually, the pharynx above can also be dry and irritable and cause an urge to cough or clear something from it. So the water in a sense, washes down the back of the pharynx before it goes down behind the larynx, into the esophagus. And, equally the back of the mouth, the palate, if that's all dry that can contribute to an urge to cough. So sipping water will help in that sense, but yes, it's it's the swallow part of that process where the cords close and it gives you something different to do. Often a swallow, when we use a swallow for cough control, often it's about distraction. It's about choosing to do something different for the purpose of moving away from a typical response, which often is a cough.

Gillyanne: 18:08

It sort of sounds like cause I know this can happen with pain, can't it that, maybe you break a bone or something and obviously you get pain and you can get pain for quite a long time. And I remember being told by my physiotherapist, when I broke my wrist, she said, you must take the pain killers because I'm all right. I can manage without! No, she said, take them now because otherwise what can happen is a pain response will be set up and your body will continue that pain response after it's in fact no longer needed. And I was shocked actually. And in a way you're seeing that this is what happens with coughing.

Tor: 18:48

Yes, in a way. Yeah, coughing becomes chronic because of that that, that idea of that cycle. So if you cough, you cause potentially cause irritation or the muscles to tighten up that be tension there. And that brings about more urge and feeling to cough. So it's about breaking that cycle. And like I said, over many years that cycle might've developed, it doesn't necessarily mean that it's harder after 30 years versus one year to work to break that in fact.

Gillyanne: 19:16

Oh, that's wonderful. That's fantastic. Tor, I think we should talk about your other love, which is probably your first love as a speech and language therapist, which is voice. So as a speech and language therapist, what does voice mean to you? Being a specialist in voice.

Tor: 19:35

So I quite quickly, when I graduated, I went into a very generalist adult role, but thankfully that did include some voice work in an acute hospital. I worked in a voice clinic and got to see patients who have experienced change or problems with the voice plus other throat symptoms as well. Of course, we can't really isolate a voice change without thinking about the upper airway and other symptoms at the same time. But I have always loved the medical side of voice. But also the fact that you can weave that in with, the art and performance voice, and all the amazing things that go along with that. And the how fascinating the larynx is that it helps us with these hugely important life altering functions like communications, swallow, breathing. It's also interlinked. So I've always been fascinated by the larynx. And as a voice therapist, I'll see people with a huge range of different voice problems or voice disorders, problems linked directly with the larynx, but also sometimes problems linked with breathing patterns, for example or problems in the nose or elsewhere in the upper airway. But yeah, so there's, huge range of voice disorders from structural disorders to an inflammatory disorders, neuromuscular disorders, but there is a big group of patients who have muscular tension imbalance in the larynx, which can cause voice change and all those four areas of the conditions or interlinked as well. So, Yes,

Jeremy: 21:15

I mean, We love diagnosis when we're dealing with performing issues and it's a real, this is the sort of skillset that speech and language therapists have, which is that ability to take in all of that information and diagnose. And there's a lot of information that you need to take in order to be able to do a reasonable diagnosis.

Gillyanne: 21:35

It's like a clustering, isn't it? You can't just be looking at one thing. You've talked all the way through about the importance of looking at the whole lifestyle, the pattern of how that person runs their life, including how many hours they work, et cetera, et cetera. It's very holistic in that sense.

Tor: 21:56

Yeah. So I mean, a speech and voice therapy case history will take at least an hour of time in that initial session to talk to people about everything from obviously the presenting condition and symptoms and the patterns of that how it started, how it's developed, but then medical history, medications, social history, lifestyle, work, voice use, vocal demands, the patterns of which people use their voices, stress and psychological history. And then obviously all the observation that goes into it as well. So, you know, You really have to get to know. People. And I do, that's what I love about it. You never know who's walking through the door and what their symptoms are going to be before they do. And yeah, of course the amount that can go into a voice disorder, the amount of different factors and influencing factors, precipitating factors is enormous really.

Gillyanne: 22:53

When you're listening to a voice and I'm just going to throw this at you and, if you don't want to go there say cause sometimes in, in our side of the profession, people will go for a lesson or they'll go to a master class. And they work with someone who says you've got a voice problem. And we always say, actually, you can't tell without looking, but let's assume someone's come to you who's maybe had some kind of a diagnosis or was coming to you specifically as an SLT. What do you listen out for when you're listening to a voice?

Tor: 23:28

So it will lots of influencing factors. We're biased by quite a few things when it comes to listening to a voice and what we might expect is actually the problem. So it depends where your, where at what stage you'll see the patient or that, that does for me. So for example, I may, in the context of a speech therapy appointment, they would have gone through ENT and I'll know the diagnosis. So I thought when I listened to a voice, I'll be listening and watching what they're doing and listening for various different parameters of abnormality within that voice. And in my head, I'm thinking if that's the diagnosis and what I'd expect, for example, with vocal cord paralysis, where one vocal cord isn't moving or isn't working properly because the vocal chords won't adduct or close fully, you would expect a voice that's quite breathy, quite weak. It wouldn't necessarily be rough, but that might be a bit of roughness. And if that's not, if I'm not hearing what I'm expecting, then I'm questioning what's going on here. Not everyone is the same, but you're with experience. You're get to know what you expect to hear based on the diagnosis. But more recently I've worked in a speech therapy-led two week wait clinic, where I've been the first contact for a patient coming from a GP with a voice disorder. And that really changed my thinking quite a lot because none of these people had been scoped or examined yet they've come in, fresh set of eyes on this disorder and you're going the other way. You're thinking oh I can hear breathlessness. I can hear roughness, it's intermittent, ooh, what am I going to see? And I'm starting to think and imagine what I might see. Not always right. Sometimes that you see very unexpected things.

Jeremy: 25:08

I love this because you're talking about filters and I talk about this all the time, which is when you already have a diagnosis from the department, then you put a filter on that says, this is the diagnosis I've been given. And this is what I would expect to see and here. And your, this is going to sound really callous, but it's not. It's like you have a ticklist. And you go, okay. That's that? That's that's actually that isn't there. That's quite interesting. And you've got that filter on. So you're processing the information with that filter in place. Whereas when you're in the two week clinic, you don't have that filter. You are, it's I have no idea of what it is. You're presenting me with you. So I'm listening. And then my tick list is almost much bigger because I go, all I'm doing now is I'm noticing what you're telling me. I'm noticing what you're giving me and I'm building my ticklist, if you like, rather than having it there. I love this whole thing about filters and diagnosis.

Gillyanne: 26:10

Yes. And the other thing I was thinking is that, the GP has referred. What's the benchmark for the GP, referring someone with having a potential voice disorder. This might be really useful for members of the public to know.

Tor: 26:25

So it varies. So ENT UK do have some clear guidance on their website, which might be interesting for people to look at, but a GP will make two types of referral into ENT. One of those will be a two week wait, which is under the suspected head and neck cancer pathway. Now that can be obviously quite terrifying for people who went to the doctor to talk about a voice change, not not thinking, you know, any point that it might be cancer. Um, Uh, Generally isn't, you know, much more people are referred through a two week wait then, not a very small percentage of those are going to have cancer, but it's the way the National Health Service works through the process of getting those people through quickly, because we don't know what's going on in the larynx until we have a look. So GPs will make the decision about a two week wait, based on various risk factors, um, both in someone's history, for example, whether they're a smoker, certain age or the symptoms that the GP is observing or hearing when they're in the appointment. So those two week wait patients, I was saying where people were suspected head and neck cancer. Um, Now there's a new and developing pathway through using the speech therapy profession to see these patients, because we know only a tiny percentage of them do actually have malignant pathology in the larynx. And speech therapy runs that clinic well, because we can see them through the history, the diagnostic and immediate advice and information that helps and send them on their way often with er, with enough, for to reassure, tell them what's going on, and then people can opt in to speech therapy if they need it later,

Gillyanne: 28:07

It's a really important role actually, isn't it. And obviously it's essential that we do rule out head and neck cancer, straight away. That's going to be very interesting and we'll look up that ENT UK. Gosh, how did you learn to specialise in voice?

Tor: 28:30

So I was very lucky where I started my first job. I, that my manager was the voice lead and we worked together very well it was a small voice caseload and I quickly made it known that was an area I was really interested in. You have to develop and come up with your own ways for developing your, your, your voice skills and your voice competencies. When you're studying as a speech therapist, you do, you have ENT lectures, you have voice disorder lectures, you learn the basics. And I was lucky enough to have a clinical placement in the voice department, ENT department, but not everyone does. And there's a lot of post-graduate learning that goes on, going to courses, doing learning on the job, alongside a clinical caseload and having supervision is vital. But everyone's process through that is slightly different.

Gillyanne: 29:23

It's interesting, isn't it? Because Joe Public doesn't realize that there isn't a clear pathway for a speech and language therapist to start specializing in voice. It's it's a bit like being a singing teacher

Jeremy: 29:35

very much like being a singing teacher where there is no clear pathway and you make your own.

Gillyanne: 29:41

Wow. So much to talk about. This has been great so far.

Jeremy: 29:45

Oh yeah. We're definitely having to two episodes for those. So we're going to stop there and we're going to bring Tor back next week. Tor, we'll see you then.

Tor: 29:53

See you then!

Jeremy: 30:06

This is a voice podcast with Dr. Gillyanne Kayes and Jeremy Fisher.