Teen Sings After Complex, Rare Airway Surgery

Voice and Swallow Program at Stanford Children’s collaborates to restore young woman’s full voice

Grace Overman has always loved to sing. It gives her energy and joy, more than any other activity.

That’s why losing her voice was so tragic.

With each year in middle school that passed, the quiet, confident teen found it harder and harder to talk and breathe. It got to a point where she had to speak an octave lower than normal just to be heard and to keep her voice from breaking.

“I would have to stop and take breaths between words, and I wasn’t able to hold notes like I used to. It was frustrating,” the 15-year-old from Fiddletown, California, says.

Grace is the epitome of the saying, “Still waters run deep.” Her mom, Kristen Van Kempen, calls her an old soul.

“Because Grace isn’t an incessant talker, when she speaks, people listen. And she’s extremely driven. When she decides to do something, she gives 200%,” Kristen says.

A history of vocal cord problems

Grace was born prematurely at 25 weeks. During patent ductal arteriosus surgery at her local hospital—the closing of a natural opening between the heart and lungs at birth—she developed a paralyzed vocal cord. At 3 years of age, she underwent surgery to restore nerve signals to her vocal cord.  

“Grace did really well when she was young, but then she hit her teenage growth spurt. She was no longer able to close her moving vocal cord against her paralyzed one,” says Karthik Balakrishnan, MD, MPH, otolaryngologist (ENT) and surgeon in chief at Stanford Medicine Children’s Health. “As she grew, she developed a gap, and her voice got worse.”

Coming to Stanford Children’s for care

Kristen was concerned that the problem Grace had as a newborn was returning, once again, to haunt her. Kristen struggled to find the right care for Grace, because her situation was unique. After trying solutions close to home, she was referred to Dr. Balakrishnan for care by a colleague at a hospital across the nation.

Grace was seen in the Voice and Swallow Program, a part of the nationally renowned Aerodigestive and Airway Reconstruction Center at Stanford Children’s. She received an evaluation from a multispecialty team of otolaryngologists and speech-language pathologists who collaborated very closely to determine the best care approach to meet her unique needs.   

“From the minute we met Dr. Balakrishnan and the team, we knew they were knowledgeable and kind. From there on out, we had only positive experiences at every turn,” Kristen says. “We have never stayed at a hospital before that gave us a 100% positive experience.” 

At Grace’s first appointment, Dr. Balakrishnan performed a flexible fiberoptic nasolaryngoscopy and video stroboscopy. In simple terms, a small high-definition camera was inserted through her nose to view the voice box and gain a full understanding of her paralyzed vocal cord. Rhona Galera, CScD, CCC-SLP, a speech-language pathologist and member of the Vocal Cord Dysfunction Clinic, also performed a comprehensive voice evaluation—something that’s done before and after surgery to gauge improvement.

Grace was diagnosed with a moderate voice disorder, evident in her voice evaluation, which showed reduced pitch range; low volume; and a breathy, raspy voice quality. Additionally, she had muscle tension because she was overusing her throat muscles to compensate.

“We also completed a quality of life questionnaire, which showed that Grace’s day-to-day activity was affected. She wasn’t able to sing, and she wasn’t fully participating in the classroom because of her voice,” Galera says.

In the Voice and Swallow Program, the team works very closely with patients and families to gain a solid understanding of what matters most to them in terms of outcomes. They asked questions like these: Did Grace value singing over her favorite sport, soccer? What did she ultimately want to achieve?

“Grace and her mother did a great job advocating for what they hoped for, which gave us a good understanding. That shared decision-making with the patient and family is very important,” Dr. Balakrishnan says. “Not that we planned to sacrifice soccer or singing, but it helped us to know how to best proceed.”

Reassembling the back of her voice box 

As one of the most advanced multispecialty clinics in the western United States, the Voice and Swallow Program has extensive experience performing complex surgeries for voice, breathing, and swallowing problems. This means that they’re skilled at working to maintain holistic strength in the entire area. You don’t want to gain ground in one area, like voice, and lose it in another, like breathing. 

“When operating on the airway, all three key functions—voice, breathing, and swallowing—need to be considered and balanced very carefully and precisely,” Dr. Balakrishnan says.  

The team offered the family three options when it came to surgery, all minimally invasive, meaning that they could enter through the mouth or nose rather than through the neck. Two were simpler but would likely not provide as good of an outcome. The third was an unusual, rare, and complex surgery, with a risk of compromising swallowing, but it had a bigger possibility of fixing Grace’s voice problems permanently.

Grace and her family chose the more complex surgery. It helped knowing that Dr. Balakrishnan was a known national expert in the surgery.

“It’s rare to perform this surgery. Only a few pediatric Aerodigestive and Airway Reconstruction Centers offer it, but I’m pleased to say that we’ve done several,” Dr. Balakrishnan says. “It is a more aggressive surgery, where we essentially take apart the back of the voice box and put it back together.”  

During the complicated surgery, Dr. Balakrishnan carefully narrowed the gap in Grace’s voice box just the right amount, so it wouldn’t compromise her ability to breathe. It was a total success.

“I remember Dr. Balakrishnan coming in after the surgery and saying, ‘Everything went as well as I hoped.’ That was so exciting to hear,” Grace says.

A great outcome for Grace

Once the swelling went down a few days after surgery, the improvement in Grace’s voice was obvious. Kristen and Grace will never forget what Dr. Balakrishnan said next. 

“He told us that Grace was not done improving yet, not even close. Hearing him say that was a big deal,” Kristen says.

After spending five days in the hospital recovering, Grace went home. Because she lives three hours away, she met with Galera, her speech-language pathologist, virtually. The two made great improvement over time. She also received private voice lessons.

“From her initial voice evaluation to her final one, her pitch range doubled and her respiratory capacity improved,” Galera says. “It’s so wonderful, given her love for singing.” 

Using her voice onstage and in life

Grace recently tried out for and was chosen to be in her high school musical Legally Blonde, a Broadway hit. As a new freshman, she’s in the ensemble and rehearsing twice a week.

“I really love theater. Getting to act is really fun—pretending to be someone else in costume and everything,” she says. “It’s really exciting to perform in front of people and see the audience’s reaction.”

Today, Grace has full range of her voice. She completely trusts that it won’t break or become hoarse onstage. When she’s not singing, she loves to write, read, and play soccer. 

“Grace is very brave. She has been a fighter since the day she was born. She fought along next to me to get the surgery, and she is the one who did all the work,” Kristen says. 

Through tears, Kristen describes a new confidence she sees in Grace since the surgery. She’s extremely proud of her daughter for giving her all to recovering and always being diligent with her voice exercises. Galera agrees, saying that because Grace was so willing to participate in speech therapy and voice lessons, she made a big impact on her functional outcomes after surgery.

“Grace literally found her voice and the use of it,” Kristen says. “It’s a year later, and her voice is strong, and we are so grateful. The care at Stanford Children’s was absolutely phenomenal.”

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