Post-COVID effects on the larynx: an SLT perspective

In this episode, our host, Natalie Watson, invites  Fiona Gillies, Emma Webber, and Sarah Wallace OBE, to discuss post-COVID effects on the larynx and the long COVID project run by the Royal College of Speech and Language therapists. 

The RC SLT project is led by a dedicated group of professionals working to create patient handbooks, fact sheets, and data collection tools. These resources aim to provide clinicians and patients with a deeper understanding of long COVID and its implications on speech and swallowing, aiding in effectively managing these complications.

The conversation continues, covering a critical care perspective and the trends emerging from patients admitted with COVID to ITU to post-critical care follow-up clinics to outpatient care and the presenting symptoms of long COVID who have not received critical care. What are the treatments available to offer? 

 COVID-19's impact on the larynx and the role of speech therapy in recovery is a complex and rapidly evolving area. More research and data to further understand the long-term effects of COVID-19 on the larynx is required and will be instrumental in guiding future treatment approaches and enhancing patient outcomes.

Input into new long COVID guidance | RCSLT

We hope you enjoy listening. 

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Transcript

We know from research and papers that have looked at follow up of ICU patients that they remain dysphagic, dysphonic, with upper airway obstruction and a much higher rate of glottic and tracheal stenosis. Even though the ICU numbers are now very small, in terms of COVID admissions because of vaccination programmes, we know that even without being in ICU, these problems are there. Without hospitalisation these problems with voice and swallowing are there. But it's not always consistent. That makes an awful lot of sense when you think about how COVID enters the body, how the virus gets in, and the proliferation of inflammation and irritation to those ACE-2 receptors, where it enters the pharynx and larynx and the upper airways.

Natalie Watson
Welcome to BLA Connections, A Clear Voice. I'm your host, Natalie Watson, and I'm delighted to bring you discussions and insights from experts from across the globe on all things laryngology.

In today's episode, we explore long COVID, or post COVID effects, on the larynx from the perspective of Speech and Language Therapists. Fiona Gillies is a highly specialist speech and language therapist. She is the clinical lead for voice therapy in Whittington health and also works at the Royal ENT hospital, part of UCLH in London. She is an advisor for the Royal College of Speech and Language Therapists Long COVID Working Party and a member of the RC SLT Upper Airways Clinical Excellence Networks. Fiona also lectures at the Institute of Sports, Exercise and Health at University College London. Fiona will take us through the impact and presentation of long COVID from the outpatient clinic perspectives on upper airway disorders.

Emma Weber is the project lead for the Royal College of Speech and Language Therapists for long COVID, and will be able to provide an insight on project management support from an organisational perspective.

And last but not least, Sarah Wallace OBE, is a speech and language therapist specialising in critical care patients and dysphagia, and is an honorary senior lecturer in the Division of Infectious Immunity and Respiratory Medicine School of Biological Sciences, Faculty of biology, Medicine and Health at the University of Manchester. Sarah is a speech language therapy lead for the National tracheostomy safety project, and RC SLT specialist advisor for critical care dysphagia and FEES. And as part of the RC SLT tracheostomy Clinical Excellence Network.

Today, we'll talk about long COVID from the critical care perspective.

Thank you all so much for joining us today.

So starting with you, Emma, tell us a little bit about the long COVID project run by the Royal College of speech language therapists.


Emma Weber
Thanks, Natalie. So I came to the RC SLT in March last year, and eventually set up a working group that consisted at the time of 16 speech language therapists who wanted to help make a change, and support the other clinicians out there working with long COVID. After we all got together, we came up with three main areas of focus, and that was to support the SLTs, raise awareness, and a data collection group.

As we've gone along, we've come up with unidentified projects that should be worked on straightaway. So the inflight projects we have at the moment: We've got a triage of questions for different organisations, just to stop any patients from falling through the gaps. We're devising some fact sheets at the moment on voice, upper airways, and reflux. Another one for swallowing and throat sensitivity, and another one on communication.

We're also working with the Living With app, devising a module on all the speech and language therapy needs in long COVID. We're working on some COVID guidance because there isn't any currently, and also a patient handbook as well. Also, we've set up a regular peer support bimonthly session on the Eventbrite platform. We meet bimonthly and discuss areas of interest, and that's around voice treatments and interventions.

So we've got lots of things going on amongst the group. All of these things will be uploaded onto the RC SLT website so that patients, or the clinicians, and members, can access them. We also have a data collection tool that's out at the moment as well. And that will help support services at local levels, and the profession widely. We help to collect data that will help support patient care and decision making. It's developed to assist service leads and managers with planning, making business cases for funders and commissioners, about the impact of SLT and the need to continue to fund services for long COVID.


Natalie Watson
What great work I mean, that sounds just absolutely amazing and well done, As a Royal College for creating that, and a working party, it's just definitely exactly what we need. We need to have good consensus with patient advice sheets, you know, written by experts who are dealing with this all the time. So yeah, really amazing. So apart from people listening in to the webinars that you do bi monthly, how can people get involved if they want to be more active in that group?


Emma Weber
We're always looking for data. And the thing is that we found that some speech language therapists are collecting their own data within their own clinical areas, so that's always really helpful. They can contact info@rcslt.org, or they can contact myself directly.


Natalie Watson
Brilliant, what we'll do is, we'll put those in the show notes, so that everyone can access those after the podcast. And so that if you do have any questions, you can email them directly.


Emma Weber
We're also looking for SLTs working in a long COVID setting with children and young people, that's an area that we haven't got much information or connections with. So if there's anybody listening, that is connected with, or is in contact with people in the children and young people area, with long COVID, that'd be really, really helpful.


Natalie Watson
Brilliant, so shout out for all those paediatric SLTs out there, do get in touch. So Sarah, let's head on to you. From the critical care perspective. Are you seeing any trends from the patients that have been admitted with COVID to ITU and long COVID in the larynx?



Sarah Wallace
I think we can all agree that right from the beginning of the pandemic, if I may just reflect back, laryngeal complications, laryngeal upper airway problems, voice and swallowing problems, have been a really, really big issue with COVID. And we've seen a change over time because of the way that we've changed the way we manage patients. So initially, when they were intubated for really, really long periods and tracheostomy was delayed, there was an awful lot of intubation trauma. And what we've seen over time is that with tracheostomy management returning to normal, we're still seeing laryngeal issues. And problems we saw initially, were actually a little bit atypical. So I noticed early on when I started to scope patients again, on ICU, that there were multiple laryngeal issues rather than just a vocal cord palsy. There was lots of erythema, lots of granulomas, lots of issues with cord ulcerations, cysts, and strange things that made us all sit up and think what the heck is COVID doing to the larynx on top of the usual ICU, intubation issues, and neurogenic issues as well.

We wrote a paper actually about the larger complications that we were seeing. And what is worrying, is that the problems can be quite persistent. Again, we know from research and papers that have looked at follow up of ICU patients, that they remain dysphagic, dysphonic, with upper airway obstruction and a much higher rate of glottic and tracheal stenosis. And I myself have seen patients who had ended up having long term tracheostomy because of persistent and worsening stenosis. And even had patients readmitted to ICU.

One gentleman I can think of only a year later, with respiratory failure, stridor, and patients are turning up back in A&E, it's stridor with worsening scarring and fibrosis of the larynx over time. So we know the risks for upper airway problems, stenosis are much much higher in this group. Because of, I think, the combination of COVID plus all the ICU interventions. And, hypersensitivity in the larynx, which is a little bit again, atypical. What we normally see in ICU patients who've been tubed is desensitisation, and silent aspiration and dysphagia, and those issues. But what we see often in the COVID group, and I noticed this fairly early on, was hypersensitivity, as well as loss of taste and smell, which obviously affect the ability to eat and drink properly. And at discharge from ICU, a lot of our patients' swallowing problems have mostly resolved, and often they still have voice problems. But at that point, they're not particularly bothered about it because they just want to get home.

I'd set the follow up stage when they have their attendance at the ICU follow up clinic, that they then start to say actually, you know, I can't eat and drink a normal meal. I've got this feeling of a lump in my throat, globus sensation, or things seem to be sticking a bit. And I've got a really really tickly throat, and a cough and my voice fades by the end of the day. So they're coming back to us, as you said, through follow up, and obviously I think it's impacting patients' daily life once they've got back to normal function.

And you know, I think that we're not getting this under control, more and more patients are still having these issues. And even though the ICU numbers are now very small in terms of COVID admissions because of vaccination programmes, we know that even without being in ICU, these problems are there, without hospitalisation, these problems with voice and swallowing are there.

We talked about being vigilant about patients who had big granulomas. And then we were overwhelmed with the number of patients and weren't able to follow everybody up who we'd seen granulomas when we've done FEES, and worked with ENT. But I think those patients present back through A&E sometimes, with worsening airway issues, and worsening voice issues, later. So some of these things are presenting later, I think.


Natalie Watson
Yeah, you have the COVID waves, but you also had the waves of re-presentation, it was definitely where I was, working in London. We had the wave of the immediate. So the ones we had to deal with straightaway with big granulomas, who couldn't be de-cannulated. Or they couldn't immediately have a trackie and they had granulomas, etc. And then you had that second wave, maybe two to three months later after ICU discharge, where they were having increasing stridor or difficulty breathing. And they had the A&E admission, and then you find that they've got carotenoid joint fixation, plus or minus granuloma, plus or minus posterior glottic scar, plus or minus a subglottic abscess. We have three subglottic abscesses, I mean, rare as hen's teeth, pre COVID.


Sarah Wallace
Yeah, not so rare now. I think with the respiratory issues as well, and a lot of the ICU patients having, you know, ongoing, reduced respiratory function and fibrosis, we've got that additional issue that affects breath support for voice, and breathing pattern for voice, and also breath, swallow control, and problems with swallow, that is another ongoing feature.


Natalie Watson
It's a complete volcano mix of different things because they were obese, the majority of them, they had some kind of neuropathy, or hypersensitivity. They were coughing and choking with the granulomas and the dysphasia, and then they had the voice problems and the airway problems, to just top it all off! So yeah, I mean, these are things that we saw in large volumes right at the beginning, and thank goodness, these things are getting better. But three years down the line, we're still seeing patients, as you say with these problems, as they sometimes don't resolve ever so quickly.

Sarah Wallace
No, they're not. I still have patients now, who I saw from wave one, who, you know, one I can think of is a GP, who is still struggling to work full time, because of her dysphonia. These things have been permanent for some patients, even with a lot of therapy and intervention. And long term tracheostomies, unfortunately, in a few.


Natalie Watson
I mean, the morbidity has been absolutely massive, hasn't it? What screening questions in particular, you've alluded to both Emma, previously about this specific screening questions that you have from the RC SLT. And you actually did mention quite a few things that I would have expected to be in the screening questions. If we can share those in the show notes. That'd be great. But if you know some of them off the top of your head, what do you include?


Sarah Wallace
Right at the beginning, I was involved working with the Intensive Care society, on what was seen as a sort of urgent piece of work to develop a rehabilitation framework, not just for COVID patients, actually. And part of that was for myself and colleagues, to write a clear speech therapy framework, including screening questions. And then, that also evolved into a screening tool called Pickups, which is post intensive care syndrome screening, basically. And that's been subsequently validated, and we worked on that with the British society of Rehab Medicine as well.

So those tools are there in order to signpost, so for instance, for voice. The question is, have you or your family noticed any changes to your voice, such as difficulty being heard, altered quality of voice, your voice tiring by the end of the day, or an inability to alter the pitch of your voice? And then there's guidance. If it's yes, then you need to see ENT and speech therapy. And I think you're right about asking the right questions. Because patients we know underreport, and if you don't ask the right questions, you sort of miss these patients. Should I also explain what the others are?

So we have one for swallowing. Are you having difficulties eating, drinking or swallowing such as coughing, choking or avoiding any food or drinks? And then for laryngeal and airway complications, have you developed any changes in the sensitivity of your throat, such as troublesome cough, or noisy breathing? So simple, simple is usually best with these things. But just things to trigger, I think.


Natalie Watson
I see a lot of similarity in that post radiotherapy cancer patients as well. And I think we could easily use those as little screens in the head and neck clinics, if any had neck clinicians are interested in this? I think because we're seeing this 10-15 years down the line post radiotherapy as well. And I think these are really important things to ask because as you say, like post COVID, post radiotherapy, post major life event, the most important thing for them, was to get out of ICU to get home. It's the same with cancer, you know, all they want is to be cancer free. And then, as soon as that episode is ended, they then can start to focus on different things. And other things matter to them, like the quality of their voice, how they can swallow? What type of exercise can they do? What's limiting them? Is it the airway? So all these resources will be available in the show notes, and we'll be able to access those later. Thank you, Sara.

So Fiona, we're going to come to you now, what do you normally see in the outpatient clinic when people are presenting with symptoms of long COVID in the upper airway, who really haven't been ill enough to go to critical care? But I'm sure we see a lot of them. So Fiona, what, what are those symptoms?


Fiona Gillies
Sarah's already alluded to some of these. And I think, of course, we're talking and focusing in this podcast on the larynx and upper airway disorders. But let's not forget that patients coming to see us, as speech language therapists, will also have difficulty, some of them with word finding difficulties, language, speech, cognition changes, but of course, we're focusing here on that the larynx, upper airway.

So the kinds of difficulties we're seeing, are really in the main ongoing dysphonia, and ongoing issues with dysphasia, but also not to ignore the upper airways issue. So we're seeing people who've got lots of hypersensitivity still. So in a similar pattern to that, which Sarah's already mentioned, we're seeing people who've got cough, either in the absence of talking, sometimes they're getting more coughing with talking, they're getting coughing and throat clearing, they are getting also issues around having a lump in the throat, so the Globus pharyngeal sensation, sometimes this is also in the absence of reflux. But as I'm sure we saw in the the increase in reflux presentations in the critical care side, we're seeing that ongoing in the outpatients, where patients perhaps never even noticed or never knew they had reflux, or never had it pre COVID, they've ended up with consistent reflux post COVID.

The swallowing presentation is quite interesting. So the kinds of things we're seeing are not necessarily what we would call a true dysphasia, where patients are necessarily aspirating their food and drink the wrong way. Although, of course, we are seeing those patients still, but in much, much fewer numbers then perhaps we'd anticipated, particularly with those non hospitalised patients, that's less common. But what we're seeing is people coming in saying to us, they still feel that food and drink is going the wrong way. They are coughing when they eat and drink. But on those odd occasions where we've gone and done an objective assessment, like a video fluoroscopy, or perhaps even a FEES. So an examination under endoscopy with food and drink.

We're not actually seeing any aspiration or penetration into the airway. But what people are reporting is the sense that food sticks, and they're sometimes avoiding eating certain consistencies. And it's usually things like the dry consistencies, the bitty things, or maybe the slightly more cohesive things like a piece of meat or bread. And we're finding that increasing numbers of younger people are having these difficulties, where perhaps they haven't even got any mechanical swallowing difficulties at all. And this often goes part and parcel with changes in allowance, because of course, let's not forget the first job of the larynx is of course for airway protection. Second job, of course for swallowing, and then third job for voice. So some of these patients are presenting with competent issues with their voice where they're telling us their voice is very croaky. I've coined a phrase I often use nowadays, which is ‘throat focused’. So it's where their voice is almost coming out like this, and it's sounding almost lower than their sort of modal range, but it's not always consistent. So it goes in line with their fatigue effects, so this relapsing and remitting fatigue issue they're having with their COVID. And they'll find that when they're more tired, and they're more rundown, their voice changes, it becomes croaky. But the interesting thing is, it's often fluctuating, it can improve, and it can go back to a normal, normal ish voice quality, although for many of them, it's never quite back to premorbid levels.

Sarah also mentioned some of the other kinds of slightly more subtle issues that we're seeing, and present later, of course, and in patients where they've not been hospitalised. So things along the lines of vocal fatigue, or particularly reduced vocal stamina, as in people feel they can't project over background noise, or their voice gets tired more easily. And also, of course, sensation changes. So they're often saying they feel that they've got too much mucus in the throat. And that's leading to this issue of throat clearing. That makes an awful lot of sense when you think about how COVID enters the body, how the virus gets in, and the proliferation of inflammation and irritation to those ACE-2 receptors, where it enters the pharynx, larynx and the upper airways.

So we are still seeing people as I'm sure our ENT colleagues are, who've got ongoing, low grade kind of inflammatory processes going on within the throat, but it's often very subtle, and patients tell us I feel like my throat is inflamed. And they tell us they've got an ongoing sore throat. But yet actually, when they go and see one of our ENT colleagues, and they look under endoscopy, often, there's very little to see other than maybe a little bit of reflux. So Sarah mentioned this, this atypical pattern, I think, is what's most interesting in this population, is having a really kind of wide view as to what people are seeing, you know. We knew about the different clusters of symptoms in terms of, it's not just affecting one system of the body. it’s multifactorial, and multi systemic, and very much in the outpatient setting, I think we've got to keep an open mind as to what patients are telling us, because each of their presentations is very different.

And I'm fortunate enough, I do work in a specialist ENT hospital, and also a district general hospital, where we have a very experienced team of ear, nose and throat doctors who refer on, but for those people who perhaps don't have access to any ENT review, they might be getting referrals through from, say, the post COVID clinics if they exist within their area, within their services. And sometimes these are quite subtle. And it's as only as you've said already, asking the questions of, ‘Have you got voice change? Have you got swallowing changes?’ And also, let's not overlook that lots of this goes hand in hand with breathing pattern changes. And we're seeing this increase in breathing pattern disorders in patients in this population. And depending on the clinic setting you're in, you may or may not feel able as a speech and language therapist to work on your own, to work with this, or perhaps you've got a respiratory team that you're working alongside to help these people, but it's an overlapping picture. And one where yeah, I think we just need to do more to discuss it and describe it so that patients realise that some of their symptoms are related to their post COVID and present to GPS and/or for ENT to discuss.


Natalie Watson
Absolutely. I mean, this is now the third wave, isn't it? We've had the acute granuloma, we've had the acute stridor or the lingering dysphasia. But now this third wave is the voice and hypersensitivity of the larynx that we're seeing now. And it's tended to be like a year or two down the line.

Number one, they've probably been symptomatic since day one with all of this, but actually accessing healthcare has been the major problem with all the COVID backlog. So that's why we’re seeing them now, one to two years down the line. And they've been going around with, definitely from an ENT perspective, they've been going around with very little intervention and trying to just live with the symptoms. And the 90 day cough in some, and that the cough sometimes does go away. And I'd say probably the majority of people with COVID do completely resolve, but it's just that we don't actually have a grasp of how many people are left with these types of symptoms. But I would guess it's quite a few.


Sarah Wallace
It’s higher than you think. We just had a paper accepted actually at BMJ open respiratory, on prevalence of dysphagia and dysphonia, and cognitive communication problems actually, from data extraction from a post COVID study. So the post hospital COVID study. And I can't say too much about that just yet, because it's not published, but it is going to probably surprise people in terms of the prevalence numbers. So now we have some data, and that's really going to help us with establishing speech therapy services. But I think the other thing I was just going to pick up on there is around you saying about the delay sometimes, to people actually accessing services. And I think with COVID and long COVID, on top of that, then we have this anxiety that is created by people trying to cope on their own, and not necessarily knowing the right thing to do. And so I think it's making it more difficult to treat some of these problems, because of having to support people more because of the anxiety that developed around their issues. I don't know if you agree, Fiona?


Fiona Gillies
Very much so, and we know that COVID causes an immense amount of stress on the body, and I find on a daily basis, I'm saying to people, you know, this over-activated immune system, we know that it causes dysautonomia in a number of patients, and we've got an increase in PoTS and neurogenic symptoms as Sarah mentioned earlier, and the anxiety levels. And then coupled with the fact that many people will say to me that they don't feel that they're believed, because they look as if they're still the same person. They haven't got any sort of outer physical symptoms. But of course they've got these ongoing relapsing remitting physical symptoms, with voice, with swallow, amongst many other things. And I think that is causing people to either not come forward, or sometimes to not even recognise that they've got the subtle symptoms. And I think one of the issues that we've worked with the Royal College on is the fact that the speech and language therapists have not been recognised as part of the NICE guidelines, as being core members of the MDT in the original guidelines of who to refer to. And that's led to a reduced number of SLTs being present in some of the long COVID services that have been set up around the country. And as a result, the awareness of some of these subtler symptoms, often actually not though, let's swallowing difficulties, not subtle, but it means that there hasn't been such an access, and therefore patients are suffering in silence and feeling anxious, but not knowing who to turn to and whether or not their symptoms are particularly significant enough to seek help.


Sarah Wallace
That's despite WHO recognising these issues, and that people do need access to speech and language therapy in order to support them through these complex problems. So we've had a bit of a mismatch in terms of the national guidance, but we're hoping that with the data, we can address this, and that will then lead to better services and availability for patients we hope.


Natalie Watson
And an increased workforce for laryngology and SLT! The workload is already there! Let's talk positively about treatments. What treatments can we offer, because there'll be lots of patients listening to this podcast, clinicians, who just say, Okay, we've got all those symptoms, what can we do?


Sarah Wallace
I think when patients are in the ICU phase, a lot of our focus is on restoring voice and communication ability, because that has psychologically a lot of detrimental effects on somebody, when they're in that frightening environment. So we're working very hard to restore voice, and worrying less about quality of voice at that stage, and also to reestablish oral intake when the aspiration concerns resolve.

So I think we've managed in many cases to work with a combination of using FEES assessments, so we can see what the physiological problems are, and the structural problems. To use things like better reflux management, judicious use of steroids, sometimes where we've seen lots and lots of laryngeal edema, because that's been a feature. And then just combining that with dysphagia exercises to improve strength, because a lot of these ICU patients are just globally weak anyway. And COVID caused a lot of fatigue issues. So working on strength, and then compensation. So compensation is the sorts of things we always do, around advising people about certain diet modifications, and then other treatments, which are a little bit more unusual, things like pharyngeal electrical stimulation, where we can actually try to re sensitise the larynx, if it's on that end of the spectrum where it's become very desensate. That is not going to work for someone with hypersensitivity. Where there's hypersensitivity, it's about educating the patient that although they feel things might be going the wrong way, as Fiona was saying, we can show them the images endoscopic images, or the video fluoroscopy images and say, look, actually, things aren't going the wrong way. You just have an overactive sensory response, and then strategies to sort of support to talk to them about the sensory aspects, which Fiona knows a lot more about than I do.


Natalie Watson
So let's head over to Fiona, and let's find out what from an outpatient perspective, we look at.


Fiona Gillies
Absolutely, we can class them in two factors. One would be indirect work. So a lot of what we're doing to start with is validating people's lived experience and their symptoms. And that I think is an incredibly important part of our role. So having an understanding ourselves, and then educating people about why they've got the symptoms, what's happening, what are the mechanisms at play, and then giving them, as Sarah mentioned, sometimes day to day changes that they can make, maximising their kind of lifestyle factors, helping them to manage reflux, getting them to, quite frankly, try and desensitise the larynx by doing simple things like just using hot water only steam inhalations.

We may also be doing quite a big role. We are doing a big role in working with our MDT colleagues, signposting back to maybe our respiratory colleagues, if we've got concerns about breathing onto physiotherapy, if it's for breathing retraining. Certainly a lot of close liaison with ENT doctors. So for the service that I work in, I do receive referrals directly from the post COVID referrals unit, and where those patients have come, where they perhaps haven't been said originally in the referral that they've got voice changes, I'm referring them back into ENT, and having a discussion with ENT about that.

Then the kind of direct work we're doing. A lot of it is based on the existing knowledge that speech and language therapists have, because of course, voice therapy involves using increased breath support, reduction in strain and tension in the larynx in order to improve voice quality. So we're just transferring our knowledge and the skills we already have, the evidence based techniques such as some of the semi occluded vocal tract exercises, and transposing that into this population. And keeping it simple, bearing in mind that these patients are often seeing multiple clinicians. They might also be seeing an OT for fatigue management, having lots of ongoing medical management in terms of cardiac, and respiratory. So actually, it's also trying to keep the load quite light. So making it fairly practical. But yeah, definitely this balance of the indirect techniques and validation and education, versus direct behavioural therapy.


Natalie Watson
Brilliant. So in summary really, there's quite a lot that speech and language therapy, even alone, without any medications at all, can offer, which is absolutely excellent. So of course, the provision of SLT services for patients post COVID-19.


Emma Weber
There's a government element here, as with a lot of other areas as well. The emphasis has shifted to other areas of government focus. So the long COVID cohorts are still there, and actually still growing. So funding allocated by the government is needed for a lot of the clinics that are funded or only funded until March next year. And there's no idea what will happen after that point. And I know that some of the speech and language therapists that I talked to, need to submit a business case towards the end of this year to bid for funding. And we just can't stress enough how needed this area is, not only as their existing case loads, but there's an additional patient cohort on top of everything now as well.


Fiona Gillies
And we're seeing patients who are coming back to us. Even today I saw a patient who had their third bout of COVID, and even though the first time they had voice change and breathing difficulties, they didn't have a cough, and now they've represented having been discharged with a cough. So it's not just a case of treatment, discharged, that's the end of the episode of care. We're seeing multiple reinfections having different symptoms each time.


Natalie Watson
Yeah the varied laryngeal manifestations of COVID-19 is just quite phenomenal, really, and I think it really has, it's probably the biggest shift of everyone's thought process of Speech and Language Therapists and laryngologists that any one disease has ever had. That, and the respiratory physicians. They've all come to the forefront of everyone's minds, you know, a group of people to really think actually, that they are quite valuable to have in your, in your hospital.


Sarah Wallace
And I think that is the silver lining in one sense for our profession, speech and language therapy, that has drawn attention to these problems that we've been talking about for years, and what we can do in terms of treatment, and the value that we add. But I think the problem is that the services are so ad hoc across the country, and so many patients don't have access to timely speech therapy. And, you know, in the ITU World, we know that rehabilitation is awful post ICU, generally speaking. And that's been another big push on the back of COVID. That the ICS and the RC SLT part of that, along with all the other professional organisations, are doing a lot of work to try to highlight the need for rehabilitation. And one of the things that we've done is set up an all party parliamentary group, to highlight the rehabilitation needs. And this has all been pushed forward because of what COVID has done, and how much we've learned, but also how much we need rehabilitation to prevent problems becoming chronic. Unfortunately, that's the bit of the situation we're in now with lots and lots of patients with chronic problems.


Fiona Gillies
And to add to that, the Royal College of Speech and Language Therapists produced a position paper back in 2015, which was updated in, I think it was 2021, which actually proposed that adult patients should have access in a timely manner to speech and language therapists for respiratory care. So they were talking about cough, and airways issues. And we haven't even mentioned some of the sort of rarer conditions that are coming, such as inducible laryngeal obstruction, or what used to be called paradoxical vocal fold movement, or vocal cord dysfunction. And so we're seeing an increase in that, and the RC SLT produced the position paper that said, people should have access to timely SLT input. But I guess it didn't really gain much momentum. And I know in the job I work in, in a district general hospital, we put forward a business case saying, we should have a therapist with these skill sets prior to COVID. And it got rejected because it was seen to be relatively small numbers and not a big deal. And then of course, COVID came around and suddenly the need for it was on the top of everybody's agenda. But interestingly now, after the sort of waves that we've seen have ended, it's fallen off the agenda again. And I think that's one of the reasons why we were so keen to talk about this on this podcast, to really keep it in people's minds that it's still there, it's still an issue. And actually, we do still need the funding and the provision for it both with ENT and working with SLT.


Natalie Watson
I mean, it's funny, isn't it? The general population, the government, everyone wants to forget about COVID now. They want to go on to the next agenda piece, they want to go to the next agenda item. They want to do recovery programmes, and enhanced working. And actually, we can't forget. It was a huge, huge thing that the whole world went through. And lots of people are still suffering. And there's lots we've learned from that. And as I said, you know, we've really seen the value of our disciplines. And we have to not shy away from the fact that we're actually very much needed, and people need us. And so if there is disparity of provision of SLT and laryngologists around, then we need to try and meet those demands.


Sarah Wallace
We do. And I think we sometimes have a bit of a detached feeling, don't we? That we're in one space as healthcare professionals dealing with this problem still, versus the general public who sort of have moved on in their own minds that COVID is done. And we know it's not done. And we know that lots of people are living with long COVID, and that that's increasing. I mean, just a couple of weeks ago, I checked the stats and over 3000 people were admitted that week to hospital with COVID. So it's still there, and it's still growing. And this is people of all ages, even young people. I have young people admitted to our cardiac ICU with heart failure for the first time with COVID now. So this is an ongoing concern. And we've learned a lot about what works in terms of treatment, as Fiona was saying, we have a lot of transferable treatments. And also we've developed amazing, amazing ways of collaborating much better I think, because MDT haven't we, about what works, you know, working together closely in airways, clinics, voice clinics, wherever ICU follow up or whatever?


Natalie Watson
So now we've got all this information, what resources are available to clinicians and patients currently?
Sarah Wallace
Well, I'll start with something that I was involved with right at the beginning, in terms of the NHS, your COVID recovery website (https://www.yourcovidrecovery.nhs.uk/). So we've got content on there, which is still pertinent around swallowing and voice and communication issues.


Emma Weber
We've done the triage questions that Sarah reiterated. So that's actually on our website now already. We are planning on finishing the fact sheets over the next four weeks, so they should be on the website to access by the beginning of August.


Natalie Watson
And this is the RC SLT website, which in the show notes.


Emma Weber
Yes, and towards the end of the year will be the guidance and the patient handbook as well.


Sarah Wallace
And we also, because of the screening tool that we developed, the pickup screening tool, we've actually worked with the Royal College of GPs as well, in order to try and get those screening questions out there, so that they can use them when they have patients present them in their GP surgeries. GPs are obviously a key person to basically help them understand what to ask, and signpost to the right services.


Fiona Gillies
Yeah I mean, we're trying to produce a centralised resource on the RC SLT website. So almost a one stop shop for patients, and importantly also for clinicians, because it's one thing as a clinician, as a speech and language therapist, to work in a specialist team with either laryngologists present, or even the input from a post COVID service. But for those colleagues who work in smaller services, community services, having a resource that they can go to that they can trust, such as the RC SLT, is exactly what we're trying to produce, so that they've got one place to go, and they know they can trust it, and also share some of that information with patients. So we've got both clinicians handbooks, and also, as Emma mentioned earlier, patient handbooks, so we've got easy to read resources.


Emma Weber
The Living With App as well, will help healthcare professionals, won't it. That module should be available by the end of August.


Natalie Watson
Amazing. So there's lots to look forward to as well, lots out there. Any final words? I'm going to start with you Emma.


Emma Weber
I really hope that all the work that the working party that I have the pleasure of working with, I hope that all their work is acknowledged and noticed and makes a change. Because they really know their stuff. And they can see their boots on the ground. They can see what's happening day in and day out and they're the ones that we need to listen to.


Natalie Watson
And Sarah?


Sarah Wallace
I just feel I'm still fascinated by COVID and long COVID, and I'm still learning, but I think this is a fantastic opportunity to just talk about the work that we've been doing, and the new data that is coming out, and the new paper that's coming out of there, will help us to all appreciate just how prevalent these problems are, and what we can do about them. Thank you for the opportunity.


Natalie Watson
No problem. You're always welcome. And Fiona?


Fiona Gillies
I guess thinking of our ENT colleagues listening, I would like to say, just ask about those subtle symptoms that perhaps sometimes get overlooked. So we're talking about ongoing dysphonia, ongoing swallowing issues, and ongoing airways issues. The airways issues, of course, stick out like a sore thumb, if someone's coming to you with stridor, but perhaps some of those subtler symptoms, that often don't get mentioned because patients think it's nothing. I would be delighted if a colleague or two actually asks, or even sometimes asked, did you have COVID? And are you suffering with long COVID? Because sometimes I think we even forget to ask that nowadays. So that would be my take home message.


Natalie Watson
Amazing, especially in these long COVID clinics run by the chest physicians as well, if any are listening.

Well, thank you all so much for joining us today and sharing your individual experiences of long COVID from the Speech and Language Therapists perspective.
Sarah Wallace, Fiona Gillies, Emma Weber
Thank you. Thank you very much. Thank you very much. 

We hope you have enjoyed listening to BLA Connections, A Clear Voice. I have been your host Natalie Watson. Please do tune in this series, for more laryngology topics. We would also love to hear from you. Please feel free to email with any topics you would like us to explore, any questions you have, along with any suggested experts you would like to hear from. Also, if you'd like to contribute to these podcasts, please email inquiries@britishlaryngological.org
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