Dr. Morton Cooper reports outstanding results with Papillomatosis by Direct Voice Rehabilitation (DVR). Dr. Cooper’s success and cures of this condition was detailed in his textbook Modern Techniques of Vocal Rehabilitation in 1973. From that time on Dr. Cooper reports faster results because of discoveries he has made with locating the right pitch of voice, the right placement of voice, the better way to breathe right for speaking, and focus in on the voice image and voice identity which he finds are all key to successful voice rehabilitation.

Dr. Cooper served on the staff and faculty of the UCLA Medical Center from 1961 to 1969. Dr. Cooper ran the Voice and Speech Clinic for the medical center. His Chairman of the Head and Neck Division wrote: “Dr. Cooper is the best speech pathologist I know.” Dr. Cooper has been in the field of voice rehabilitation specializing in voice care for all types of voice problems for forty-five years.

Two of my doctrinal Ph.D. proposal studies had been rejected. I had taken a two-week course with Dr. Nathaniel Levin at Miami University Medical Center, author of Voice and Speech Disorders: Medical Aspects in esophageal voice training. (Dr. Pressman had gotten two slots for me and my wife Marcia.) At the close of the two-week course to complete the program for certification, everyone in the course was required to write a paper on some topic. I had no topic in mind. Dr. Levin asked me, “Have you seen an interesting case at UCLA Medical Center?” I mentioned a young boy of 12 who had biopsied papillomatosis of the vocal cords diagnosed by the Head and Neck Division. The growth disappeared after my program of DVR. I knew nothing of papillomatosis of the vocal cords being incurable. Dr. Levin said, “Write it up.” I did and then proposed a clinical study of vocal cord papillomatosis as a doctoral dissertation. Dr. Pressman assured me “papillomatosis was hopeless.” There were no cures by any medical intervention. Ullman in 1923 had done a study on ten cases of papillomatosis. He found the condition was due to a virus. Ullman’s position became the prevailing medical view despite the medical findings of Scott and Ferguson, and Paul Hollinger, who criticized Ullman’s study as flawed. I asked Dr. Pressman to help me fulfill the Ph.D. requirement for original research. “Okay,” he said. “Go ahead.” Dr. Pressman had the Head and Neck Division check out 34 biopsied cases of vocal cord papillomatosis. Nine cases were agreeable to undergo the study. Dr. John Snidecor set up the clinical study. Nobbi Isshiki, MD, later to become world famous for his thyroplasty surgical procedure, handled the spectrographic analysis. Papillomata of the vocal cords is a serious organic growth, a premalignancy that could lead to cancer of the vocal cords. In my 1964 doctoral dissertation, I found prolonged deep throat speaking was contributing to voice stress, strain, fatigue and, eventually, pre-malignant organic growths on the vocal cords. I changed the pitch, tone focus, and breath support (all wrongly used) of these patients. Following three months of DVR three times per week, five out of the eight patients had a reduction or an elimination of the condition. Dr. Pressman was unbelieving. He was aware the faculty and staff of the Head and Neck Division had reviewed the vocal cord papillomatosis before and after. “It is an amazing finding,” Dr. Pressman told me. Dr. Pressman asked me to apply for a grant. “But chief, you said it was pointless.” Dr. Pressman sighed and waved me out of his office. “Do it.”

That study was published in the Journal of Speech, Language and Hearing, 1971 peer-reviewed. It also involved the extraordinary concern of the President of the American Speech-Language-Hearing Association (ASHA) to undertake an investigation involving the success of the study. ASHA contacted the Head and Neck Division to verify that medical doctors had indeed checked out the vocal cords before DVR and after DVR to verify the reduction or elimination of the papillomatosis on the vocal cords. Also for documentation the papillomatosis had been biopsied; it was biopsied papillomatosis. The Head and Neck Division confirmed the amazing findings. The publication was a landmark study. A patient in that study sought me out 25 years later to thank me for my help in directing him to a normal voice by DVR; he had had no papillomatosis since 1964.

Years later, Paul, a chief salesman for a well known drug company appeared on my public TV program, Change Your Voice, Change Your Life reporting that my program of DVR had resulted in full recovery, a cure, of his voice from papillomatosis of the vocal folds. Paul had undergone surgical procedures on the vocal folds, but the growths were reoccurring. A five-year follow-up of his progress by DVR found him to be without further vocal fold problems. Paul’s voice was clear and normal in contract to the severe hoarseness he once had, and his impaired ability to project his voice. His tired inefficient voice was gone.

Another patient had the vocal cord papillomatosis surgically removed but the growths were returning. I worked with the patient. The growths regressed and disappeared. The ENT doctor commented “sensational.”

Letter from former patient diagnosed with Squamous Papilloma of the vocal cords.

To whom it may concern:

During the late 1970’s, I was diagnosed as having a squamous papilloma of the vocal cords. My speech was shot and for several years I had several surgeries all to no avail, talking caused pain and fatigue.
Eventually I saw Dr. Morton Cooper. I retrained my speaking through his coaching and repetition. Today occasionally when my voice becomes tired I go back to the old method and in a day or two I’m once again okay by practicing Dr. Cooper’s methods.

Sincerely,
Lawrence Spira, MD

The etiology of papillomatosis remains obscure. Three major theories which attempt to explain the etiology of papillomatosis of the vocal folds are virus infection, hormonal imbalance, and trauma or voice abuse and irritation.
Ullmann (1923) reports papilloma of the larynx was caused by a filterable virus. However, Ferguson and Scott (1944, p.478) write: “Ullmann’s series was small and poorly controlled, and his work has not been confirmed.” Holinger, Schild, and Maurizi (1968, p. 1468) report:

The results of many investigations point to viruses as the causal factor of papilloma. The evidence was thoroughly reviewed, but it has not been possible to duplicate work previously reported on the presence of a species-specific virus capable of producing growth of tissue cultures with regrowth after blind serial tissue culture passes.

Regarding the influence of the endocrine system, Rubin (1954) and Baker (1965) note that papillomata in children may stop growing and may even disappear at puberty. Other authors, including Majoro, Parkhill, and Devine (1964) and Dekelboum (1965) do not find evidence to support this hormonal theory.

The theory of voice misuse and abuse is discussed by Webb (1956, p. 877):

Probably the earliest theory of etiology which still has its adherents is that expressed by Bosworth in 1892, and by Browne even earlier. They believed that papilloma of the larynx is the result of chronic irritation. Brown traced more than half of a series of 26 cases to overuse of the voice. More convincingly, in a series of 300 cases. Fauvel found the greatest incidence among those whose work required special or excessive use of the voice, such as ministers.

Other authors who view chronic irritation or trauma as a possible etiological factor are Jackson (1960) and Dekelboum (1965) (adult papilloma). Voice abuse, such as shouting and competing with noise, is evident in the case histories of many patients seen by this author.

The most common symptom of papillomata of the vocal folds is hoarseness. The lesion is generally located on the vocal fold, according to Shanks (1958, p. 219) “usually at or near the anterior third or at the anterior commissure.” Ferguson and Scott (1944, p. 478) report: “The vocal cords are the most frequent sites, but the tumors may occur anywhere in the larynx.” They continue: “In children, the lesions are usually multiple, as opposed to the more frequently single adult form.”
Controversy exists as to the histopathological difference between childhood papillomata and adult papillomata. Although Bjork and Weber (1956) report a difference between laryngeal papillomata in the adult and in the child, Holinger, Schild, and Maurizi (1968), West, Boggs, and Holinger (1957), and Huizinga (1957) found no difference between the two types.
Types of treatment for laryngeal papillomata as listed by Holinger, Schild, and Maurizi (1968, p.p. 1469-1472) are:

1. Medical-topical and internal medications.
2. Immunological-vaccines.
3. Surgical procedures-forceps removal, tracheostomy, and thyrotomy.
4. Physical-thermal cautery, diathermy, radiation, cyro-surgery, and ultrasound.
   These methods of treatment have had varying success; however, follow-up reports have not substantiated the early favorable results of these treatments. At the present, surgery, estradiol, vaccines, and ultrasound are the most frequently used treatments.

Szpunar (1967), in treating 107 patients with juvenile laryngeal papillomatosis, has had very good results in utilizing endoscopic removal and intralaryngeal injection of estradiol. Holinger, Schild, and Maurizi (1968) used as inactivated autogenous vaccine in 51 patients. Improvement was noted in 55 percent (28 patients); no change was observed in 25 percent (13 patients); 6 percent (3 patients) deteriorated; and adequate information was unavailable in 14 percent (7 patients). Ultrasound is discussed by Holinger, Schild, and Maurizi (1968, p. 1472):

Undoubtedly the most significant new modality has been the use of ultrasound for the treatment of laryngeal papilloma.. . . .

As with x-radiation, a final evaluation may not be possible for another 20 years. The effect of the ultrasound on nerve tissues and on the growth factors of the larynx is not known, and these important consideration cannot be ignored.

Radiation treatment for juvenile laryngeal papillomata has been found to be detrimental by Rabbett (1965) and Maier (1968).
Regarding the various types of treatment for laryngeal papillomatosis, Rosenbaum, Alavi, and Bryant (1968, p. 654) report:

Some patients have undergone more than 100 procedures for removal of laryngeal papillomas. Many types of therapy, including steroids, sex hormones, Aureomycin, irradiation, and autogenous vaccines, have been employed. The long list of therapeutic agents indicates a lack of consistent results from any.

Despite the many medical approaches to the treatment of laryngeal papillomatosis, the dictum of Holinger, Schild, and Maurizi (1968, p. 1462) remains: “Papilloma of the larynx continues to be an enigma.”

Since vocal fold irritation is one of the three major theories for the etiology of papillomatosis of the vocal folds, it is surprising that voice rehabilitation has not been a major means of treatment. Voice rehabilitation for papillomatosis of the vocal folds has been attempted by Brodnitz (1963) and Cooper (1964, 1971a). Brodnitz found such therapy “helpful.” A study begun in 1964 has completed by 1965 by Cooper (1971a) found that four of eight patients experiencing biopsied vocal fold papillomatosis revealed a reduction or a partial elimination of the condition following three months of voice rehabilitation.

A thorough discussion of these eight patients and comprehensive studies of the intensity, airflow rate, frequency, and quality, as well as an extended review of the literature can be found in Cooper (1964). The voice therapy for papillomatosis is the same as therapy for other organic growths. A discussion of therapy is also included in Cooper (1971a). One point regarding pitch needs to be emphasized. The habitual pitch level may be too high in some patients, although it is generally too low in most patients. A voice image usually exists in patients with papillomatosis.

Voice rehabilitation is not always considered applicable nor relevant by physicians for the containment, reduction, and/or elimination of this condition. Therefore, few patients are available for study and review. A number of patients with papillomatosis made good to excellent progress in voice rehabilitation in that there was a slight to extensive degree of reduction in the size and/or number of papillomata; however, by using the general criteria established for determining the therapy results (Part V), it was necessary to evaluate most patients as fair in that a portion of the growth remained. If the patients had remained in therapy for a longer period of time and had cooperated more fully in the program, it is believed that the final evaluation would have been good to excellent. Voice rehabilitation should be an integral part of treatment for vocal fold papillomatosis.

Of the 25 patients seen with papillomatosis, the following conclusions may be drawn regarding papillomatosis:

1. Of the 25 patients seen, 17 or 68 percent entered therapy.
2. Of the 17 patients entering therapy, 11 or 64.7 percent completed therapy.
3. Of the 11 patients completing therapy, 6 or 54.5 percent had long-term therapy and 5 or 45.5 percent had short-term therapy.
4. Of the 11 patients completing therapy, the results were good, 4 or 36.4 percent; fair, 7 or 63.6 percent.
5. The comparison between males and females seen: males, 14 or 56 percent; females, 11 or 44 percent.