David Walton (Count Almaviva) and Keely Futterer (Rosina) in Madison Opera’s production of The Barber of Seville (Photo by Ross Zentner)
Stretch, but don’t break, the voice — that’s the challenge for actors at American Players Theater (APT) in Spring Green, Wisconsin, who perform without microphones throughout the outdoor season. Along with swooping bats and singing whip-poor-wills, the “glory of the human voice,” as the New York Times put it in a 2024 write-up, is part of the magic of APT.
But what happens when those glorious voices falter?
Cue the laryngologists and speech-language pathologists (SLPs) within the Department of Otolaryngology-Head and Neck Surgery at the University of Wisconsin School of Medicine and Public Health. Laryngologists are physicians specializing in otolaryngology, sometimes referred to as “ear, nose and throat,” who have completed additional training in treating illnesses or injuries to the larynx, or voice box. SLPs assess, diagnose and treat communication and swallowing disorders.
“We have treated several APT actors over the years in the Voice and Swallow Clinic at UW Health,” said Susan Thibeault, PhD, SLP, Diane M. Bless endowed professor and vice chair for research in the department. “For many years we worked with the company to provide voice education and training, and we still offer baseline vocal fold screening, particularly for new actors or interns.”
UW’s laryngologists and SLPs also serve as the official voice care team for the Madison Opera, but their work goes far beyond Madison. Their patients include vocal performers from across the country and other professionals who rely on their voices — teachers, lawyers, pastors and politicians — as well as children and older adults with voice problems due to a range of diseases. For example, Alzheimer’s and Parkinson’s disease patients can experience vocal dysfunction, as well as those whose vocal folds (commonly known as vocal cords) were scarred or injured through disease or surgery, such as thyroid tumor removal.
“It may sound like a small thing, to have a voice problem,” said Dr. David Francis, professor of otolaryngology and the department’s vice chair of academic affairs and professional development. “But voice impacts quality of life, work performance and identity. When we lose our voice, it changes who we are.”
UW is known nationwide for its expertise in laryngology, the care of patients with voice, airway and swallowing disorders. The specialty is a key strength of the new Department of Otolaryngology-Head and Neck Surgery, which became the school’s 28th department in June after nine decades of growth and innovation as a division within the Department of Surgery. Besides laryngology, the new department includes experts in facial plastic and reconstructive surgery, head and neck oncologic surgery, rhinology (conditions of the nose and sinuses) and skull base surgery, otology (hearing issues) and neurotology (balance and cranial nerve disorders), and pediatric otolaryngology. Subspecialty experts frequently collaborate, since disorders of the ears, nose, throat, head and neck are often interrelated.
“Every day, people from Wisconsin and beyond receive life-changing care from our faculty surgeons and the broader clinical team, from cancer surgery to hearing restoration to helping people breathe, sleep and heal their voices,” said Dr. Sandra Lin, professor and chair of the Department of Otolaryngology-Head and Neck surgery. “Since 1930, UW’s otolaryngologists have been pushing the boundaries of basic and translational science, as well as clinical care, and we continue to grow in depth, breadth and excellence. Our expertise in voice disorders is an outstanding example of that excellence.”
Voice disorders affect approximately 7.6 % of Americans. That number is on the rise due in part to a rapidly aging population, fueling an urgent need for trained researchers to advance the study and understanding of voice disorders and help translate findings into treatment options.
Thibeault leads UW’s Voice Research Training Program, the only NIH-funded training program of its kind in the country. The program, housed within the Department of Otolaryngology-Head and Neck Surgery, prepares graduate students, postdoctoral researchers and surgery residents for rigorous careers in research, including designing, organizing, conducting and publishing studies related to voice disorders. Working with mentors like Thibeault, Francis and other voice, swallowing and airway experts, the program’s funded fellows work on basic or translational research projects and interact with clinicians in the Voice and Swallow Clinic.
“Our trainees learn that even when we are doing basic science, it’s very important for us to understand the problems from the clinical side, so we can help address those in our research,” said Thibeault, whose own research explores the development of disease and fibrosis in vocal folds.
Since it launched in 2009, the program has trained 41 graduate students, postgraduate trainees, and surgery residents, as well as 28 medical students who participated in short-term summer research. Many alumni of the program go on to lead labs at major academic institutions or medical centers, while also practicing as surgeons or speech-language pathologists.
Elizabeth DiRenzo, PhD, an associate professor of otolaryngology at Stanford University, completed a postgraduate fellowship with the program in 2014 under Thibeault’s mentorship. In addition to her clinical work, DiRenzo’s Stanford lab studies how exposure to inhalants like cigarette smoke and e-cigarette aerosol affects the vocal folds at cellular and molecular levels.
“We are looking for the moment in time when the vocal folds go from tolerating the challenge of inhalants, like smoke, to the breakdown stage that signals disease development,” DiRenzo said.
DiRenzo credited the Voice Research Training Program with providing outstanding preparation for her career. In Thibeault’s lab, she worked on translational research using animal models and cell-based models and observed how clinicians created a workflow that supported department research along with patient care.
“I developed a new scientific skill set during that program that I am still using today and teaching to the next generation of researchers,” she said.
Some of the trainees’ research projects have included developing a new way to measure airflow in children with voice disorders and exploring laryngeal high-resolution manometry — a diagnostic technique that uses a thin catheter to measure pressure patterns in the throat during swallowing and vocalization. Through projects like these, trainees gain an appreciation for the program’s interdisciplinary approach.
“This is team science,” Thibeault said. “Our trainers come from several different schools and multiple specialties, from biomedical engineering to head and neck surgery to communication sciences and disorders. That’s how we achieve success.”
Francis, a surgeon, mentors residents interested in voice who come through the Voice Research Training Program as part of their residency’s research requirement. They join Francis’s research on vocal cord paralysis, which is typically caused by injury to nerves during thyroid and other neck surgeries, and are introduced to a unique patient-reported outcome measurement tool developed by Francis and his team.
“Surgery for thyroid cancer is the most common cause of vocal cord paralysis,” said Francis. “Our lab has two important projects. One investigates how vocal cord paralysis affects people’s lives, and the other models thyroid cancer epidemiology for the entire U.S. population, helping us quantify rates of thyroid cancer overdiagnosis. Some cancers are so slow-growing that they never cause symptoms or consequences. Our goal is to show how resources can be better directed to patients who need cancer treatment, while avoiding unnecessary treatment for those with slow-growing cancers, thereby avoiding associated risks like vocal cord paralysis.”
While many trainees go on to become professors like DiRenzo, Thibeault said that trainees who become physicians gain unique skills that will serve them well in patient care, even if they don’t end up as physician scientists.
“Learning about research in a clinical practice is vital to becoming a good doctor,” she said.
Francis, who joined the faculty in 2017, pointed to the department’s longstanding culture (nurtured over decades by the Department of Surgery) as another important takeaway for trainees.
“People who come to work here tend to stay here. We attract quality residents and trainees who benefit from the amazing sense of camaraderie among the faculty and the kind and collaborative nature of the department,” he said. “We are training the next generation to have the same type of emotional leadership that we provide to them.”
Lin said that the impact of the department’s training program reverberates around the world, with UW-trained clinicians and scientists carrying on a tradition of excellence, collaboration, and integrity. As chair, Lin plans to continue building the department’s formidable research strengths and its mission-focused, people-centered culture.
“We want to diversify into new areas of research, education and care, hiring faculty who will not only contribute to our historic strength in voice research, but also build upon existing research into experimental devices and procedures, as well as research and clinical trials dedicated to people with head and neck cancer, hearing loss, dysphagia, Down syndrome and Alzheimer’s disease,” she said. “This is an exciting time to join our new department at UW–Madison. You could say this is our time to sing!”
