claudio milstein, ph.d.,ccc-slp

Published on July 27, 2016

Pleased to post an interview with Dr. Claudio Milstein, Ph.D. CCC-SLP. He is the director of Cleveland Clinic Voice Center. #fellowshipofthelarynx


TVF: Where do you currently practice and teach?

CM: I work at the Voice Center of the Head and Neck Institute at the Cleveland Clinic. I am very fortunate to work with fantastic colleagues at one of the best voice centers in the country.


TVF: Where did you complete your medical training?

CM: I started medical school in Buenos Aires, Argentina. Then I transferred to a Speech-Language Pathology (SLP) degree at the University of Buenos Aires because I thought that SLP degree would have answers about voice that I was looking for. After graduation, I worked several years as a clinician and taught voice courses at the University of Buenos Aires, and at the National School of Drama.


TVF: How did you become interested in “voice”?

CM: My interest in voice comes from theater. In Argentina, I got involved in theater at age 16. I was a part of a company of young actors and directors in a very well established, independent theater; Teatro Payro which is still running to this day. We worked professionally for 10 years. It was a great experience. I was always fascinated by the actors and singers voices, what they can do technically, and the ability to convey emotion through human voice. That interest is what set me off on this life-long interest in voice and the larynx.


TVF: Why did you switch your degree from medicine to SLP?

CM: I thought speech pathology would have all the answers that I wanted about voice but soon after I switched, I realized that it had no answers whatsoever!. So I finished my degree knowing no more about the voice than I knew coming in. Nonetheless, I started teaching Voice for Actors and Singers at the National School of Drama. I realized I didn’t know much, but my classes became a sort of an experimentation lab, and my open minded students were happy to embark in voice exploration exercises. The more experimentation we did, the more questions I had about the mechanism that allowed them to produce those incredible vocalizations.


TVF: What prompted your move to the United States?

CM: Well, this is an interesting story. In Argentina, I met Mara Behlau who runs a very well-known voice clinic in San Paolo, Brazil. She invited to come and spend some time in her clinic. It was a wonderful experience. She told me: “Claudio, based on what I see you do and your interest, I think you really enjoy attending “The Voice Foundation” meeting in Philadelphia. She also planted the idea in my mind that I should pursue a PhD in the United States. At the time that sounded all very new to me, but I took her up on her recommendation and attended my very first Voice Foundation meeting in 1991. I met a lot of phenomenal people and again was encouraged me to pursue a doctorate in voice in the United States. So, as you see, Mara Behlau was instrumental in shaping the course of my future career.

I travelled around the country, visiting different voice programs, and finally chose the University of Arizona. I wanted to work with Tom Shipp who is the pioneer of the early EMG studies that looked at laryngeal muscle function during phonation. Tom took me under his wing, and under his direction I had a great three years at the Univ. of Arizona, where I had the privilege to learn from masters like the great Audrey Holland, Tom Hixon and Jenny Hoit. I really cherish those formative years at the University.


TVF: Tell me about your research.

CM: I am interested in the problems of the larynx that affect voice and breathing when there are no signs of pathology or damage. In other words, something is “off” in the way mechanism works, but you cannot see inflammation, lesions, or nerve problems that can explain what’s wrong. You know, the larynx is an exquisitely complex organ, with very sophisticated voluntary motor control. This small organ is in charge of many functions. It protects the airway, so bugs, foreign objects, food or liquid do not get into the lungs. It is very important part of the swallowing mechanism. It is an important part of the respiratory system, helping to develop lung volume even before we are born. It regulates how much air can go in or out of the lungs. It can stabilize the chest for pulling or bearing down. Oh, and there is something else that it can do, I almost forgot…. It produces sound for speaking and singing! All these things are controlled by such a small organ, so anything that goes wrong with it, it can affect any of these functions.


And altered function in the absence of pathology is what interests me. For example, some patients can lose the ability to engage the vocal cords to produce sound, so they become very hoarse, or unable to speak or swallow. Some patients can become so sensitive to smells, that just a brief exposure to cleaners or perfumes can set them off on attack of severe cough, inability to breathe, often ending up in the emergency room. We see healthy young patients who get very short of breath or even pass out when they play sports. These problems are debilitating, they affect the patient’s quality of life, and can often lead to disability, social isolation and depression. In all of these, there is a “short circuit” or alteration in the function of the larynx. I find these conditions very intriguing. My research interests have focused on these problems, trying to understand the pathophysiology, and to improve treatment methods that can restore normal function and get patients back on track. Being able get patients back to normal has been, and still is, one of the most rewarding aspects of my entire practice.


TVF: How do you hope your research will be applied in the clinical field?

CM: My research has a direct clinical application, as it focuses on improving treatment options and developing programmatic therapy techniques that can help patients suffering from these disorders. I am interested in the effectiveness of treatment options, their reproducibility, and in the education of other professionals, so that these therapies become widely available.


TVF: How can one bridge the gap between basic science and clinical application?

CM: It’s important to understand the pathophysiology of these disorders, what causes them, and where is the breakdown in the mechanism. We believe that there is impairment in the sensory component of laryngeal control, and this results in a hyperreactivity with impaired function, but how this happens is not clear. So research clarifying that would be very important.


TVF: What comes to your mind as one of the most pressing issues in contemporary voice disorders?

CM: Several issues, such as vocal fold repair after injury or a surgical resection, vocal fold scar. The lack of alternative treatment options for neurogenic voice disorders, such as spasmodic dysphonia. This can be a debilitating condition. We have been treating it with Botox injections for over 30 years, but this is a temporary treatment, not a cure, and it does not work for everybody. Not much has improved in this area in the recent decades.


TVF: Tell us about research that are being done now to address this issue in neurolaryngology.

CM: There are newer surgical techniques that can help some patients, there is research looking at implantation of a pacer into the nerves of the larynx to decrease or eliminate the involuntary movements, research to better characterize the cause and pathophysiology of these problems, and trials of new drug alternatives. We are cautiously optimistic that we’ll have better alternatives in the near future.


TVF: In your opinion, what are some of the most important advances made in the field of laryngology in the recent years that are “game changers”?

CM: Well, advances in injectable materials for vocal fold repair, tissue remodeling, 3-D printing that can be used to create perfect fit scaffolding for laryngeal repair, without the risk of rejection.


TVF: What is your vocal pet peeve?

CM: I have two. One, there is still no established voice care education in teacher training programs in the country. Teachers have a high risk for vocal fold damage because they have a very vocally demanding job. Many voice problems in teachers could be prevented or alleviated if there was a programmatic approach to vocal education during their formative years. A few classes focusing on vocal hygiene, vocal health and prevention in the curriculum of educators would really prevent voice damage in their future careers.


TVF: I actually think vocal care education should happen at an earlier stage of education. Earlier the better.

CM: Particularly when you are training teachers who are going to be talking many hours a day over a loud children and background noise with no amplification, it’s really sensible to educate them about voice. I know that there have been many attempts but there is no nationwide program to date.


TVF: What is the second vocal pet peeve?

CM: My other pet peeve is that so many voice and laryngeal problems are still being labeled as psychogenic when there is no proof that the patient has a psychiatric or psychological disorder. I think it is time for the field to move away from that kind of thinking. Often medical professionals diagnose a problem as psychogenic or tell a patient that “it’s in your head”, when they can’t find a clear organic etiology. This puts the stigma on the patient where there is no need to do that. Unless you can prove that the patient has a psychiatric or psychological disorder, don’t assume that any problem that has to do with breathing, swallowing, or voice without a clear etiology is psychogenic.


TVF: I think the frustration for clinicians is that many simply don’t know what to do.

CM: If you don’t’ know what to do, why put the burden on the patient by telling them that it’s in their head? Just say “I don’t know what to do so let’s help you find someone who can help you, or get another opinion.” Don’t jump immediately on the psychogenic wagon because that is really awful for the patient. Although there is a small percentage of patients that have that do have psychiatric component, the large majority of patients with functional dysphonia, functional dysphagia, or paradoxical vocal cord motion do not have a psychogenic component.

TVF: That is a very important advice. To be able to say “I don’t know, but let’s help you find someone who can help you.”


TVF: What is your most memorable voice case?

CM: I have lots of memorable cases. When you can restore a function that has been lost, and all of a sudden a patient that was not able to talk or breathe for years, can get back to normal with your help, memorable “moments” just happen. Often sharing tears of joy with patients and their loved ones. One that comes to mind, is a young father from Oklahoma, who had lost not only his voice, but the ability to mouth words, or move the muscles in his face. He had been to several of the most renowned medical centers in the country. He had normal neurological, psychiatric and psychological evaluations. He was even given a truth-serum test by a renowned neuropsychologist to elicit function, but this did not helped him. He was a well-adjusted father of 4, accountant with no previous medical history and no traumatic or triggering event. By the time he came to see us, he basically could not move a single muscle on this face, he couldn’t utter a sound, had a very odd posture, couldn’t blink or clear his throat on command, nothing. When I met him I thought this was obviously outside of my area of expertise. But there he was, in front of me so I decided to try something. So I performed my treatment for functional voice problems and got his vocal cords engaged again to start producing some sounds. I thought that was all I could do for him, but as soon as the vocal folds started working, like a cascading effect, he started to move his lips, jaw, and his face. Within 15 minutes he regained all of the functions he had lost in the last 4 years. It was a truly amazing. By restoring one function, all the other followed suit.


TVF: That is fascinating! Was he able to maintain the return of function?

CM: Yes! This was 5-6 years ago and I recently received a note from him telling me that he’s been doing just fine. I remember that after going home, he sent me a photo with his family and he had this huge smile on his face. He wrote in the back “my family has not seen me smile for years”. I’m not sure I understand well what happened, but the fact that I was able to help him get his life back was extremely rewarding.


TVF: What is that functional voice treatment?

CM: In the functional voice problems, there is an imbalance of muscle tension in the intrinsic and extrinsic laryngeal muscles. Patients can’t engage the vocal folds to vibrate in a normal way. The treatment consists in finding ways to re-engage the vocal folds, to improve the posture of the larynx, and to restore the delicate balance of muscle tension and coordination needed to produce a good sounding and effortless voice. This can be accomplished in different ways, but in my experience, manipulation of the laryngeal framework and muscles in conjunction with different vocal tasks works well and tends to produce good results in a short period of time.


TVF: As a voice specialist, what keeps you on your toes?

CM: My shoes? (laughs) I am fortunate to work with very challenging patients. I think there is always something new to learn whether it’s from a patient or colleague, from a student, an article or from a clinical experience. Keeping this attitude that there is always something to learn, and that every patient is a challenge, forces me to be on my toes and my job is never boring.


TVF: What do you think the next steps are in growing the field of laryngology and voice rehabilitation?

CM: 1) Technological advances that allow us to understand more about the function of the brain, and how it interacts with every function of the body.

2) Technological advances that allow us to look at the larynx with a level of detail that we have not had before. Whether it’s high speed, high definition, 3-D imaging.

3) Exciting research on tissue engineering, laryngeal pacing, and new cancer treatments.

4) Hoping for alternative options for neurolaryngology in the near future.

All of these can allow us to better identify problems, develop new treatment options, and take better and better care of our patients.


TVF: Who have been your most important/influential mentors?

CM: I have learned a lot from many people. But three very influential people in my career are Mara Belhau, Tom Shipp, and Robert Hillman.

Mara, who steered me in the direction of my current career-path by encouraging me to pursue a PhD in voice. Secondly, Tom Shipp, who I mentioned before, at the University of Arizona. He was not only my mentor but he became like a father figure to me. Both Tom and his wife Marilyn “adopted me” and I became part of their family. Tom was a fantastic human being and his early departure in 1999 was a traumatic experience for everybody that knew him. He was truly special and he died too soon. We all miss him very much. My third mentor is Bob Hillman. I owe a lot to Dr. Hillman. He was the kind of professional I wanted to become. He is so solid, brilliant, methodical, scientific, organized, and skilled. He was extremely generous to me, and has been an important role model. I have much gratitude for them, and I hope I have made them all proud.

TVF: I think they are more than proud of you!


TVF: What is your advice in mentoring future voice pathologist?

CM: Have the best Clinical Fellowship Year (CFY) experience that you can. The Clinical Fellowship year is the year that solidifies you as the professional that you are going to become. So don’t go for highly paid traveling positions where your supervision will be poor. Find a good mentor, one that will have time to dedicate to train you to become the best professional you can be. And be passionate about your work. With passion and skill, you’ll excel at what you do, and you’ll have a very rewarding career.


TVF: The “voice” community is a very tight knit group of medical professionals, pedagogues, scientists, and vocal performers of many genres. What can we learn from each other?

CM: We can learn a ton from each other. I have to talk about the Voice Foundation to answer this question. Before the Voice Foundation started, each of these professions were in silos, with poor cross-communication. The goal of the Voice Foundation was to bring together different disciplines of voice research, performance and voice care to help create a common language. It brought together Speech Pathologists, Pedagogues, Performers, ENTs, Singing and Acting teachers, Laryngologists and Voice Scientists, creating a forum to share ideas, learn together and advance the field in each respective area. Other organizations and conferences have taken up that model now so it’s not unusual, but at the time of the Voice Foundation’s first symposium in 1971, this was ground breaking, a meeting to foster communication between professions, promoting mutual understanding between the sciences and the arts. Still today it reminds us that we can learn so much from each other.


TVF: Who are your favorite singers?

CM: I don’t have a favorite “anything.” For me, it all depends on the mood. Whether its music, food, or films, there are some that can be perfect for a particular moment or occasion. I have a very eclectic taste, I can go from Brazilian music which I love, to Tango and Argentinian rock from the 70s and the 80s that I grew up with. Musical theater, classical music, opera, pop, rock. There are times where each one of these is “exactly what I need”.


TVF: What sparks “joy” for you as a person?

CM: Oh, so many things. I value my family that is very close, and the part of my family that is very far away, my wife, my dog, my time spent with friends, the wonders of nature, reading a good book, listening to music, watching a good film or an enlightening play. And above all, having learned to be thankful and take the time and awareness to appreciate it all.


CM: Before I go, I want to thank you Christina for giving me the opportunity to reflect on my career, and to publicly acknowledge the things and people I’m most grateful for. It’s been truly a great experience.

TVF: Claudio, on a personal level, I am being “schooled” on all kinds of things here…what it means to be a clinician, what patient care means, and you introduced valuable perspectives that I did not expect to hear . This interview has enriched and motivated me to be a better clinician. I hope that message comes across to the readers. Thank you very much for your time and generosity.