Giving Voice A

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"C an you com e by T able Seven? T hey have som e editsfor the chicken."

attached to an endoscope, it produces

startlingly clear color images of the

vocal cords' wavelike ripples. Earlier

devices could not accurately capture

the vocal cords' fastest movements; the

new camera, which can shoot ten thou-

sand frames a second, allows Zeitels to

see precisely how a tumor affects themotion of a patient's vocal cords. In

2002, Zeite1s and Hillman published

one of the first objective studies of pho-

nosurgical results in singers, analyzing

a hundred and eighty-five performers

by comparing images of their vocal

cords before and after surgery, along

with sound recordings. Of the hun-

dred and twenty-seven singers who re-

turned for analysis, a hundred per cent

had zero or minimal perturbation. A11

the singers in the study returned to

performing.

On aT uesday morning last Novem-

ber, Scott Flaherty, the retired

opera singer, lay on a gurney in an al-

coveoutside an operating room atMas-

sachusetts General Hospital, about to

go into surgery. At around ten o'clock,

Zeitels, dressed in blue scrubs and

surgical cap, arrived after finishing an-

52 THE NEW YORKEft, MARCH 4-,2013

• •

sleep but also given a paralyzing agent.

Zeite1s sat at the end of the bed, Fla-

herty's head upside down in front of

him. With a practiced gesture, he

slipped the laryngoscope down Fla-

herty's throat.

He grasped the handles of a stereo

microscope and adjusted it until he

could see the vocal cords clearly. A

camera on the microscope projected

Zeite1s'sview onto two large screens on

the walls. Whitish pink, with a translu-

cent sheen, the vocal cords were open,

forming an inverted V. To the un-

trained eye, they looked healthy-no

lumps or masses. But Zeite1s, seeing

thern under high magnification and

bright1y lit, spotted something. "He's

hitting pretty hard," he said, pointing

with a forceps to an area on the right

cord, where a series ofvertical striations

were faint1yvisible. He sounded slight1y

heartened. "There's a big varix"-a

swo11enblood vesse1-"from co11ision

trauma on the left side. 1 think 1'11start

on the right vocal cord, because it looks

a little worse."

Zeite1s began with a procedure that

he developed in his twenties, and

which is now a standard part of voice

surgeries. To facilitate removal of a

growth, he injects a saline solution

under the vocal membrane. This puts

the membrane under tension, making

it easier to slice open, and limits trauma

to the delicate vibratory tissue under-

neath. As Zeitels injected the saline,Flaherty's membrane ballooned dra-

matically. 'Wow," Zeite1s said. "He's

really boggy. Singers have a really e1as-

tic layer." He touched the cord with a

forceps. "Dead center, he's got scar,"

he said. "The question is, am 1 going

to be able to remove it? It's such a

long zone."

He took up his microsurgical tools,

flimsy-Iooking instruments with seis-

sors-like handles and foot-Iong exten-

sion shafts thinner than knitting nee-

dles. One was a minuscule forceps with

tiny serrations on its jaws; the other

was a miniature scalpel. He positioned

his e1bowson the armrests of the oper-

ating chair and passed the instruments

down the laryngoscope. His gloved

hands were surprisingly small, with ta-

pering fingers. He light1ypalpated the

vocal cord with the instruments. "He

can still do stuff as a singer that tons of

other operation. "Ready to go?"he asked.

''Yes,'' Flaherty said. "1'm just eager

to get on with it."

Zeitels patted his shoulder and

smiled, then went down the hall, out

of earshot. He admitted to feeling un-

easy. He did not like facing surgery

when there was no clear target. Ear-lier, he had told me about the array of

psychological voice ailments, ranging

from self-induced hoarseness and lar-

yngitis to "puberphonia," a condition

in which grown men speak at an

artificially high pitch; the syndrome is

'sometimes psychological, brought on

by fear of the voice changes of adoles-

cence. "I'm not putting Scott in the

psychosomatic category," Zeite1s said.

"The exam showed something, but you

can't completely rule out a mental

componen t." He seemed close to ques-

tioning the operation. "Going into

this, 1 don't know the outcome," he

said. "Which is not where you want to

be as a surgeon."

Flaherty had been moved into the

O.R., and lay supine on an operating

bed. The tiniest reflexive movement

during microsurgery would be disas-

trous, so he had been not only put to



ment of otolaryngology. Since thefifties, Strong and his team-which in-c1uded a Hungarian émigré namedGezaJako and a gifted resident namedCharles Vaughan-had helped rein-vent the tools oflaryngology. They hadpioneered the use of stereoscopic mi-croscopes, and, in 1971, they used acarbon-dioxide laser to cut a growthfrom a patient's vocal cord-the firsttime a laser was used to remove tissuefrom the body. Bob Hillrnan, a speech

pathologist who worked in the depart-ment, says that the atmosphere wasideal for someone like Zeitels, "whodoesn't think like other people. Hemoves sideways with ideas, makesjumps. Strong encouraged that; otherdoctors would have said, 'Shut up. Youdo it like this.'"

Strong, who is now retired, says thatit was immediately apparent that Zei-tels "was going to be a star." He listenedintently, absorbed information fast,had a feel for patients, and, perhaps

most notable, possessed remarkableskills in the operating room. Vocal-cord microsurgery imposes specialphysical demands on surgeons. The in-struments-miniaturized scalpels, for-ceps, and scissors-are attached tofoot-long handles that are extendeddown the throat. The tools are fa-mously unwieldy: the slightest move-

ment of the fingers is magnified at thetips. (Strong says that he could see hisown pulse shaking the instruments.)This, coupled with the fragility of vo-

cal-cord tissues, requires exceptionalsteadiness, coordination, and fine dig-ital motor control. Zeitels, Strong says,

possessed these in abundance, andwas also fuliy ambidextrous, a vestigeof his leatherworking classes. "1 couldnever have trained my hands to dowhat Steve is able to do with his,"Strong says.

Zeitels also had a creative bent. "Hewas figuring things out, thinking itover, then saying, 'Maybe we could doit another way,''' Strong told me. When

Zeitels finished his residency, he wentto work at a Veterans Affairs hospitalin Boston, operating on cancers of thehead and neck. There he designed andpatented several tools, including an un-usual kind of surgicallaryngoscope-the device that holds the throat openduring operations. Typical scopes had

an oval viewing area, even though thevocal cords, viewed down the throat,form a triangle. Zeitels's laryngoscopehas a triangular opening, allowing doc-

tors to see areas that had previouslybeen obscured. Trained with the oldequipment, Zeitels had been taughtthat cancers in the front of the vocalcords were especially deadly. "The rea-son was, they didn't see them in the firstplace," Zeitels says. "Theyattributed a biologic process

to the fact that they neversawthem!"

The vocal cords, madeup of layers of soft,

highly e1astic tissue, areoften compared to guitarstrings, but they do notproduce sound by stirring the air, as aplucked stringdoes. Instead, theyactas a valve, which rapidly opens andcloses, chopping airflow from the lungsinto pulses that are magnified by the

resonating chambers of the throat,nose, and mouth to become audiblesound. T o change the pitch, musclesand ligaments control the tension onthe vocal cords, speeding or slowingthe pulses.

A clear tone is the result of symmet-rical vocal cords with straight edges thatmeet evenly, without gaps. But the actof producing sound tends to militateagainst perfect symmetry. During nor-mal speech, the vocal cords clash about

a hundred times a second in men and

two hundred times in women; in an op-eratic soprano, they clash as many as athousand times a second. The collisionforces and shearing stresses can producebumps of scar tissue or calluses on thevocal cords. The result is breathiness,rasps, rattling, hoarseness, and othersound impurities, called perturbation.Most professional singers, in the courseof a career, sustain some injury to thevocal cords, much the way professionaltennis players get tears in the tendons oftheir elbows. "Singers are élite vocalath1etes," Zeitels says. "Plus, the peoplewho get to the top of the profession aredriven-they perform sick, they per-form tired." Because of their superiorbrain wiring, Zeitels says, singers adaptto small imperfections in a vocal cord,subconsciously retraining themselves to"sing around" lesions. Butwhen a node,

a cyst, or a polyp becomes big enoughthis kind of adjustment is no longerpossible.

In the early nineties, Zeitels was re-cruited by the Massachusetts Eye andEar Infirmary, the seat ofHarvard's ear,nose, and throat program, and there heoperated on his first singer. He liked thechallenges of the subtle and precise sur-geries, which played to his unusual

hand-eye coórdination.When he started in phono-

surgery, as voice restorationis called, some surgeonswere still crudely strippingoff growths with forceps-often leaving scar tissue, ora divot, in the vocal cord.Others used lasers, whichare precise and easy to con-

trol, but can create burns and scarringthat affect voice quality. The best re-sults, Zeitels learned, carne from the farmore difficult "cold instrument" surgery,of the type he had perfected as a c ancer

surgeon.Zeitels quick1y built a reputation for

restoring damaged voices. He becamea consulting laryngologist for the Berk-lee College ofMusic, the Boston LyricOpera, and the Boston Symphony Or-chestra. He also recruited Bob Hill-man, the pathologist from Strong'sgroup, to measure outcomes. Today,Hillman is a co-director, with Zeitels,of the Voice Center. He says that Zei-tels is rare in seeking objective mea-sures of surgical results. "In clinical

write-ups of vocal surgery, surgeonswould say, '1was happywith the voice,and so was the patient,''' he says. "Steveinsisted on rigorous, objective analysis."Zeitels keeps a record of each phono-surgery, with a camera rigged to hismicroscope. Between 1992 and 2001,he shot more than forty thousand pho-tographs, many of which he includedin a book called the "Atlas of Phono-microsurgery." He and Hillman alsotest results. Hillrnan's clínical research

lab includes a soundproofed chamber:a room suspended within a room, withan inch of air between the walls to in-sulate the interior from low-frequencyvibrations, including those of the sub-way eleven stories below. The chamberis equipped with an ultrahigh-speeddigital video camera developed forcrash tests and ballistics studies. When

THE NEW YOI\KEJ \,MAI\CH 4, 2013 51



with the greatest vocal control in earlyhuman societies became religious lead-ers. "It's primal," Zeitels said. "A com-plex neural motor function creating hap-piness, elation, sadness-whateverhappens to human beings when they lis-ten to music. It lifts them."

After the consultation, Flaherty told

me something similar, as he explainedwhy teaching was no longer satisf)ring.'Tve grown a little tired of just talkingabout it," he said. "1 mean, when you

sing you're giving voice to your soul."Although Flaherty had elected to have

the procedure, Zeitels still had to decidewhether the benefits outweighed therisks. He could see what Flaherty hadlost. "He says he doesn't have expecta-tions-that it's O.K. if the operationdoesn't work," he told me. "But there's asadness in him. You can see it." Zeitelsdecided to go ahead with the surgery.

J \ t the Voice Center, the walls ofnhe reception area are lined with

signed photographs of singers whohave been treated there. Since the earlynineties, Zeitels has restored the voices

of hundreds of performers: StevenTyler, Keith Urban, Roger Daltrey,Cher, Lionel Richie, James Taylor,and scores of opera singers and Broad-way belters, aswell as sportscasters, ac-tors, teachers, and other professionalswho depend on their voice to make aliving. But within the profession of.otolaryngology-vthe study of ear,nose, and throat disorders-Zeite1s isalso known as a prolific medical in-novator, who has developed influential

treatments for larynx cancer and otherthroat diseases. Unlike most special-ists, he practices both voice-restorationsurgery and cancer surgery, which re-quire very different degrees of finesse;he compares the forrner to fencing, thelatter to "a fight with a club." Awayfrom the operating theatre, he main-tains a research laboratory, publishescopiously, lectures, trains fellows, andis developing a synthetic material topatch damaged vocal cords-"theHoly Grail," as he puts it, of voice

restoration.Zeitels is sometimes criticized by

colleagues for the unorthodox nature of

'Uyparents decriminalized sugar. »

his practice, and for the attention it getsin the press. (He argues that publicity isnecessary in order to raise funding forresearch.) In 2007, Dr. Eugene Myers,a chairman emeritus of otolaryngologyat the University ofPittsburgh Schoolof Medicine, successfu11ypleaded Zei-tels's case when he served on a HarvardMedical School committee thatwas de-bating whether to promote Zeitels tofu11professor. "1 said, 'Listen, did yau

ever see the movie "Amadeus"?'" Myers

told me. "Tome, Steve is like Mozart.Creatives are edgy, they're not regularpeople." Julie Andrews, whom Zeitelshas treated, notes his compulsive enthu-siasm for his field, which, she says, lendshim a "Peter Pan" quality: "1 know ofnobody else who eats, breathes, sleeps,thinks, and talks about vocal. cords-non-stop."

When Zeite1s was growing up, inNew Rochelle, his father, an ortho-dontist, pushed him to go into medi-cine. Zeite1s wasn't sure; he liked sci-

ence, but he had competing interests.At ten, he heard a friend' s copy ofTheWho's "Tommy" and became fasci-

nated with music. Soon hestartedplaying guitar, and in the coming yearshe attended, he says, "hundreds of rockshows." In his teens, he took a coursein leatherworking, sewing bags andbelts and carving leather replicas ofalbum covers by his favorite musi-cians-Joni Mitchell, Traffic, theRolling Stones-to sell at street fairs.

In1975, when Zeitels was sixteen,his father enrolled him in an experimen-

tal educatiorial program for giftedyoungsters who intended to go intomedicine. "1had my own apartment ina dormitory as part of HahnemannHospital, in Philadelphia," Zeitels says.'We didn't have assigned teachers. Wehad to go to local Philadelphia universi-ties and ask professors." The next year,he was accepted on scholarship intoBoston University's accelerated six-year

medical program, graduating with an

M.D. in 1982.He knew that he wantedto be a surgeon-he loved working withhis hands-but he couldn't decide on aspecialty. His older brother, a plasticsurgeon, told him to seek out the mostesteemed surgeon at B.U.: "He'll knowwhatto do."

Zeite1s made his way to Dr.\Stuart

Strong, the head of the school' s depart-



One day in 2008, Scott Flaherty feltsomething go wrong in his throat.

A retired opera tic tenor who was work-ing as a teacher, Flaherty had beenyelling instructions over twenty-fivestudents singing in full voice. "It was in-jured then, and 1was quite aware ofit,"he says. His' speaking voice took on aslight rasp and, when giving classroomdemonstrations, he could no longermove seamlessly from a low to a highregister. His voice tired easily. The dis-ability did not greatly affect his teach-ing, but it became a concern, last fall,when he began to think about returningto the stage.

Flaherty had had an unconventionalcareer as a singer. As a teen-ager, in An-dover, Massachusetts, he discoveredthat he could sing onlywhen he was re-cruited to perform in a high-school mu-sical. He had no formal training, anduntil he was twenty his paid work waslimited to Elvis irripersonations, per-forming in rock bands, anda job as asinging waiter. Then a co-worker per-suaded him-"almost as a joke," hesays-to audition for Beverly Sills at the

New York City Opera. Flaherty hadnever seen an opera, and could not readmusic; he learned his piece by ear, froma recording by Plácido Domingo. Hepassed the audition, and toured theworld for more than a decade, singingmajor dramatic roles.

In 2001, when Flaherty was thirty-six, his wife became pregnant. Eightmonths later, the World Trade Centerwas attacked; Flaherty was in HongKong, singing the lead in "Il T rovatore,"and for hours he was unable to contact

his wife, He decided to retire from per-forming, so that he could stay close tohome as his daughter grew up. Hestarted teachingvoice at New York Uni-versity's Tisch School of the Arts and atthe Actors Studio. But, as his daughtergrew older and became more indepen-dent, he began to think about perform-

48 THE NEWYOI\KEI\,MAI\CH 4, 2013

DEPT. OF A I\T5 AND 5CIENCE5

GIVING VOICE

A su rge on pioneers methods to help singers sing ag ain.

B Y JOHN COL APINTO

ing again. With careful technique, hestill had most ofhis range, and, at forty-eight, he believed that he had ten good

years in him. When he tried his old rep-ertoire, though, his vocal injury made itimpossible to sing fluently. He had offersto return in prestigious roles, but "1knew1wasn't able to do those," he said. "For afew years now, this has plagued me andmade me very unhappy."

Last N ovember, Flaherty travelled toBoston to meet with Dr. Steven Zeitels,the founder and director of the Massa-chusetts General Hospital's Center forLaryngeal Surgery and Voice Rehabili-tation. A surgeon and a Harvard Med-ical School professor, Zeitels, in 2011,operated on the singer Adele, removingfrom her vocal cord abenign polyp thathad reduced her voice to a raspy whis-per. Three months after her operation,

Adele débuted her restored voice at theGrammy Awards, with a rendition ofher hit "Rolling in the Deep," andthanked Zeitels from the stage-a mo-ment that helped cement his reputationas one of the most skilled throat sur-geons in the world. In the following

weeks, he received a hundred messagesa day from ailing patients everywhere,Flaherty took a seat in one of the

Voice Center's examiningrooms, and afew minutes later Zeitels arrived. Astocky man of fifty-five, whose frizzyred hair, freckles, and goatee recall thecomedian Louis CK, Zeitels has awarmand chatty bedside manner, with noneof the imperiousness often associatedwith surgeons. "How are you feeling?"he asked. "Fine-a little nervous," Fla-herty said.

Flaherty was scheduled for surgerythe next morning, and he and Zeitelshad to make a final decision aboutwhether to go through with the proce-dure. Although Flaherty's voice prob-lems suggested a benign growth on avocal cord, an exam two months earlierhad shown no such growth. Zeitels,

who suspected hidden scarring beneaththe membrane that covers the vocalcord, warned Flaherty that an operation .

might not help-and could make hisvoice worse. "For informed consent," hesaid, "1need to make sure you fully un-derstand the risks."

Flaherty understood, but he wasconvinced that Zeitels was his onlychance at a return to opera-or, at least,to singing in a show with his daughter,who was now eleven years old and hadbegun training as a singer. "Ifit turns outto be a positive result, then I'm pleasedbeyond belief," Flaherty said. '1f it goesthe other way, it doesn't change where 1am right now. 1can still teach."

Great singing depends on several fac-torso A smooth, pure tone calls for sup-ple vocal cords. A pleasing timbre is theresult of the specific anatomy of thethroat, chest, and head, which ampliíyand shape the sound. But Zeitels pointsto another critical component: the braincircuitry that controls the vocal cords.The recurrent laryngeal nerve has someof the most complex and dense wiring inthe body, roughly fifty times as dense as

the nerves to the hand or the tongue--the result, perhaps, of an evolutionaryadaptation that turned a simple valve forpreventing food from going down theairway into an instrument of speech, and. of songo Zeitels, in his office, demon-strated by swooping his voice from lowto high, like a slide whistle. That act, heexplained, requires a complex interplaybetween the ligaments and muscles thatrun through the vocal cords, stretchingthe vibratory layers. In a movement sim-ilar to varying the tension on an elastic

band, the stretching changes the cords'vibrations from roughly seventy-five tofifteen hundred cycles a second almostinstantaneously-and on a pitch deter-mined in the singer's cerebral cortex."Nothing transmits motor function withmore speed and precision," Zeitels said.For this reason, he theorizes, the people

-----,---~-



otners cant do, z.eiteís saldo "rfe Justcan't do what he wants to do. This isnot a badly injured vocal cord. He justthinks it's holding him up-and hemay be right."

The vocal cord is encased in a thinouter membrane called the epithelium,which vibrates in tandem with the ge-latinous layer below. Polyps, cysts, andnodes grow beneath the epithelium,adhering to its underside. The bestsurgical results derive from painstak-ingIy opening the epithelium andscooping out the mass with the abso-lute minimum of damage to any tis-sues. This is difficult, given the fragil-ity of the epithelium, which Zeitelsdescribed as having the consistency ofwet wrapping paper. "It's just six cellsthick," he said.

He cut a slit in the membrane, theneased it open. Beneath were manyshallow, tan-colored ridges. "These areall scar bands," Zeitels said. "Boy, that'sa war zone. That's all those years of

singing." Using miniature scissors, hesnipped away fibers of scar tissue.With his fingertips barely resting in

the instruments' holes, he moved all tenfingers ("like a piano player," he said),in motions so subtle that his handsseemed still. The screen showed that hewas performing hundreds of compli-cated, choreographed moves as hepeeled away jelly-like pieces. He thenused a "cup"-a set of forceps withhernispherical tips-to remove strandsof scar tissue attached to the epithe-

lium. In a teacher or an actor, Zeitelsmight have been content to removeninety per cent of the scarring, ratherthan risk tearing the epithelium. But,to restore an opera singer's pristinetone, every bit of scar tissue must be re-moved. He passed the cup over the ep-ithelium repeatedly. It grew so thin asto become transparento

"1 have to make a judgment abouthow far to go without cutting themembrane," he said. He reached tograsp the edge of the flap and missed ..

''I'm trying to grab that with one serra-tion. This is at a level of detail that 1haven't put in a paper. Insane numberof movements."

He worked for several minutes. Themembrane grew more gossamer witheach pass of the cup. "Rich," Zeitelssaid to Dr. Richard Vivero, one of his

tellows, "ever seen somethmg like thisbefore?"

Vivero, watching the screen, saidthat he hadn't,

"It's getting really thin," Zeitels said."Yeeee."

After, a few final passes, Zeitels re-tracted his instruments. He used thelaser to deliver a microsecond of tar-geted heat-just enough to seal theblood vessels that fed the scar on the lefi:vocal cord-e-then pronounced the op-eration complete. "It went as well as itcan, but 1 don't know if this is goingto get him there," he said. Before theprocedure, he had considered remov-ing scar tissue from the left vocal cord,but now decided against it. "1want tostage them," he said. "See how hedoes."

Afterward, Zeitels talked about thepressure ofknowing that a wrong movecan end a singer's career. "The night be-fore, you feel it," he said. "Especially inthe case of someone like Adele, when

the press is phoning and people are allover the Internet and radio and TV dis-cussing it." But, he went on, "in the op-erating room it's just you and the tissue.I liken it to playing the finals at Wim-bledon. If you're the right kind of per-son, you actually perform better. Still,

you don't schedule two or three thingson the day you do an Adele. You needto create that mental space."

Dspite an increasing focus on sing-ers, Zeitels continues to oper-

ate on cancer patients. "You don't gothrough all this training to not take careof the life-threatening diseases," he toldme. With cancer surgery, the primarygoal is to cut away malignancies; voicequality is a secondary consideration. Ra-diation, too, can damage healthy tissueand, furthermore, can be used onlyopce. If the cancer recurs, the only op-tion is a partial or fulllaryngectomy-removal of the voice box. Zeitels hasperformed many laryngectomies, but, ashis work on singers sensitized him tothe importance of the human voice, hebegan to wonder if he could devisemethods for preserving the voices ofcancer patients, too.

In the early nineties, he began to in-vestigate ways to remove malignancies

on vocal cords while preserving healthytissue. The Harvard scientist JudahFolkman had discovered that he couldkill tumors by cutting off their blcodsupply, and Zeitels wondered if therewas a way to adapt the concepto Dr. R.Rox Anderson, a dermatologist, had de-

[E~.-: ~

-~". .. - -'.~

"Think how ill-informed 1 would be if we didn 'thave television. " .



veloped a laser treatment for removingport-wine-stain birthmarks from babies'skin. Anderson's laser attacked theblood vessels that fed the stain, using awavelength that was absorbed only byred blood cells. Could the laser kill theblood supply to vocal-cord tumors? "Itwas developed for maintaining the soft-ness and pliability of a baby' s skin," Zei-tels says. "So this seemed perfect forvocal cords."

Zeitels first used a laser on a cancer

patient in 2003, with great success (thepatient, who was facing removal of hislarynx, still has normal voice function),but he soon adapted the procedure totreat a common injury in singers: swol-len or ruptured blood vessels. Such in-juries ordinarily called for difficult andrisky surgery. But, by precisely calibrar-ing a kind of green-light laser called aKTP, Zeitels could destroy the dam-aged blood vessels without burninghealthy tissue.

Aerosmith's Steven Tylerwas one ofthe first singers Zeitels treated, in 2006.'1had done a show in Florida, and af-terward 1got into an argurnent with themonitor people, so 1 yelled at them-after a two-hour show," Tyler told merecently. He woke the next morninghoarse, and suspected that he had bro-ken a vessel in a vocal cardo He went tosee Zeitels, who sealed off the rupturedvein with the laser. "1 fell in love with

him when 1 asked him, 'How doessomebody become a surgeon?'" Tyler

told me. "He goes, '1don't know. 1usedto sew leather bags on CommonwealthAvenue.'"

In 2009, Aerasmith's bassist, TomHamilton, had a recurrence of Stage 3tongue cancer and was scheduled tohave his larynx and his tongue removed.Instead, he went to Zeitels, who usedthe KTP laser to kill the malignancies.This past November, Harnilton took abreak from the band's North American

tour to visit the Voice Center for acheckup. Zeitels examined his thraat

and gave him a clean bill of health tocontinue touring.

Hamilton, a tall, thin man dressed ina deconstructed Balmain jacket andblack jeans, lingered in the hallway afterhis checkup, chatting with Zeitels. An

earlier course of radiation therapy hadaffected nerves in his neck and tongue,so Harnilton has difficulty pronouncing

54- THE NEWYOI\K:EI\,MAI\CH 4-,2013

some words, but his speaking voice isotherwise clear. Zeitels mentioned howhard Tyler pushes his voice as a singer.

"Steven pushes himself harder inevery way," Harnilton said, dryly.

"Is there any band who has done thisas long and as frequently, ever?" Zeitels. asked.

"The Stones," Hamilton said."My impression is that they haven't

performed as frequently," Zeitels said.'Well, plus, you can hear how Jagger

just talks a lot of it," Hamilton said."Steven is singing the whole time."

''Yup-he's intrepid," Zeitels said. In2007, Tyler participated in a National

GeographicTV special in which Zeitelsand Hillman wired him for measure-ment of vocal stress during a concert.As Tyler yowled songs like "DreamOn" and 'Walk This Way," his vocalcords smashed together more thanseven hundred thousand times-alarger dose of vocalization than aschoolteacher takes in an entire day.Zeitels says that Tyler is still able toperform after four decades of suchabuse because of a curious physicalanomaly. Many singers develop tempo-rary edemas-fluid retention under theepithelium-as they perform. Ordinar-ily, edemas stiffen in the course of aconcert, shutting down the voice. "Thecrazy thing about Steven' s vocal cords isthat the longer he went, the more pli-able the edema got," Zeitels told Ham-ilton. "So after the show he was more

pliable than ha1fway through. He has aparadoxical biologic reaction that al-lows him to keep going."

"Alongwith all the other paradoxes,"Hamilton said.

Zeitels lives in the Bastan suburb ofNewton, in a nineteenth-century

house decorated entirely-Iamps, wallhangings, furniture-with the work ofthe designer Gustav Stickley. (Hepointed out, with some chagrin, a mod-ern light fixture for which he had not

been able to find a suitable replace-ment.) On an upper floor, he showedme his archive of laryngology, assern-bled over decades of trawling flea mar-kets, thrift stores, and eBay. Zeitels hasused the trove to write scores of papersabout the pioneers of laryngology, andtoday is recognized as the field' s leadinghistorian. Floor-to-ceiling bookcases

lined the room. Stacks ofTupperwarecontainers held antique Iaryngologic in-strurnents, including a harpoon-like im-plement for shearing off diseased ton-sils, and a curved metal forceps with anend clamp which was used, in the eigh-teen-eighties, to hold a cotton swab im-pregnated with liquid cocaine-an earlymethod for subduing the gag reflex inpatients. There were boxes of crum-bIing textbooks, cartoons, old journalarticles, letters fram nineteenth-cenrury

otolaryngologists. "1study how thesepeople think," Zeitels says. 'What keptthem creative.".For much of Zeitels' s career, he was

toa absorbed in his work to maintain asociallife. In his mid-forties, he was stillunmarried. Then, in 20Ól, he went toChile, as a guest of the Chilean Societyof Otolaryngology, and met a local oto-laryngologist named Maria Hananias.They married in 2003. Maria, who isnot licensed to practice in the UnitedStates, looks after Zeitels's widowedmother, who lives with them, and theirchildren, a seven-year-old boy and afour-year-old girl. Maria told me that,

because of family duties and Zeitels'swork, they are mostly homebodies. But,in mid-November, the couple took anevening out to see The Who. The bandwas on tour playing its rack opera "O!1a-drophenia." The singer, Roger Daltrey,had given them tickets and backstagepasses.

Zeitels first treated Daltrey three

years ago, and the two have becomefriends. For a rocker, Daltrey had al-ways taken reasonable care of his in-strument, partly because of the chal-lenges presented by Pete Townshend'ssongwriting. "Pete was writing songswith lyrics that demanded to be under-stood so well---and in such high keys-that it was impossible to sing them likea normal rack singer," Daltrey told mea week before the show. "1 had to singthem a bit more operatically, and 1didtake lessons in vocal warmups." Never-

theless, on a solo tour in 2009 Daltreydeveloped voice problems. "It was .harder to get the high notes," he says .."And harder to get anything out ofit." A doctor in San Francisco referredhim to Zeitels, who saw discolorationson the epithelium that looked like aprecancerous condition called dyspla-sia. A biopsy carne back positive. That



December, Zeitels used the KTP laserto killthe problematic cells.Two monthslater, Daltrey sang with The Who atthe Superbowl halftime show.

Dysplasia recurs, so Daltrey hasperiodic appointments with Zeitels."On the whole, I'm singing better than

twenty years ago," Daltrey says-al-though he takes precautions with cer-tain notes, like the climactic high E on"Love, Reign O'er Me," the ballad thatends "Quadrophenia," "1 don't know if

I'll be going there anymore," he told me.The showwas at Boston's TD Gar-

den, and Zeitels and Maria had seatsclose to the stage. As they waited forThe Who to appear, Zeitels said thatit felt "surreal" to see performances by

singers he has operated on. WatchingDaltrey onstage, Zeitels responds as afan, he says. "1'm the ten-year-old kidagain who first heard 'Tommy'-1'mthat excited." But he also recalls everymove ofhis surgical instruments, know-

ing which parts of the vocal cord arecompromised, which vocal registers putparticular stress on a weak point. Seeing

"Tbe dirt is imported. "

• •

Adele perform at the Grammys was es-pecially nerve-racking, he said; it wasthe first time she'd sung in public sincethe operation, and she began with a dra-matic belting of the chorus of "Rollingin the Deep," with no backing instru-ments. "Totally silent theatre," he says.

He recalls turning to Maria, sitting nextto him, and whispering, "'1 can't believeshe's starting this in dead silence.' Hervoice was just exposed up there." Zeitelssays that he felt like neither a fan nor herdoctor. "It was like being her dad."

The Who played for two hours, andZeitels remained on his feet through-out. Daltrey's voice sounded thicker androugher-edged than it did in the sixtiesand seventies, but it had power andvolume, and as the night progressed hetook greater chances with it, throwingback his head and holding sustainedhigh notes. Near the end, the bandplayed "Love, Reign O' er Me," andDaltrey went for the climactic high- Eshriek in full voice-not cheating it witha falsetto. Zeitels looked at me withalarm and clutched his chest. "You're

THENEWYOI\KH., MAI\CH 4, 2013 55

thinking, O.K., will that hold?" he said,as we walked out with the crowd.

Zeitels, Bashing his all-access pass,led Maria and me backstage to a green-room where the band's friends and fam-ily had gathered. Townshend arrivedand looked quizzically at Zeitels, who

introduced himself as Daltrey's throatdoctor. "Next time," Townshend said,leaning in close and making an upwardstabbing gesture, "go deeper and givehim some brain cells!" He laughed andstrode off.

In a large dressing room down thehall, Daltrey-a small, spry roosterwearing blue-tinted granny glasses andtwo thick w061 scarves, to ward offcolds-embraced Zeitels and Maria. "Itfeels fine," he said ofhis voice, "1'm a lit-tle tired." He complained about hav-ing to start each show with "The RealMe." "It gives me no onstage warmup.Zero to sixty." He was also daunted

by the heavy dose of singing he faced.The tour had three months to go. "Tomake this work, economically, you'vegot to go out four nights a week," he



naraer arrer a aay OrI. r our voice aoesn t

want to do it."Daltrey is sixty-eight, and much of

his vocal fatigue was a result of decadesof singing. But Zeitels stresses that vo-cal-cord tissue do es not deterioratewith age alone. '1t's tissue thathas beenon the earth longer and has been hitmore times," he says. The constantclashing stiffens and thins the tissues,leading to the roughened tone of oldersingers' voices-and, later, to thecreaky voices of the elderly. The colli-sion trauma reduces pliability-a majorcause of voice loss that doctors haveonly recently begun to attempt to solve."People weren't addressing this con-cept," Zeitels says. "It was hiding inplain sight."

Zeitels started to concentrate on pli-ability when he began treating JulieAndrews, in 2000. Three years before,Andrews had been performing in theBroadway musical "Victor Victoria"when she developed hoarseness. At

unaerwem surgery ror remova or a e-nign vocallesion. She emerged withpermanent damage that gave a rasp toher speaking voice and destroyed thepurity of her singing. (Andrews suedMount Sinai, and the suit was settledfor an undisclosed sum.) "It was devas-tating," she told me. "T o feel that thatwould never again come my way. Thehuge joy-apart from singing itself-isthe wonder of singing with a very bigsymphony orchestra. lt's ecstasy." Zeí-tels operated on her four times and im-proved her speaking voice but was un-able to restore her singing. Too much ofthe vibratory tissue under the epithe-lium had been removed, and much ofwhat remained was stiffened with scartissue. "1became intrepid, realizing that1needed to find a way to restore pliabil-ity," Zeitels says. "There was nothingthere for me to take out. You needed tosolve it by putting something in."

Other surgeons had tried such a tac-tic. Dr. Robert Sataloff, at Drexel Uni-

"I sti ll say it was worth itjust to s ee th e look on th e bank teller'sface. "

e pn a, na p neere a proce ure mwhich fat cells are implanted in a vocalcardo But in rare cases the fat turns toscar. In 2001, Zeitels approached Rob-ert Langer, an M.I.T. professor who isthe leading expert in creating "biosyn-thetics," including artificial skin. 'We

began discussions about how he, withhis group, resources, skills, could assistus," Zeitels says. The researchers con-sidered cryogenicaliy preserving tissuesand re-implanting them-they eventook cell samples from Andrews-butdiscovered that the body absorbed thetissues too quickly. Theywanted an im-plant that wouldn't degrade over time,but permanent substances are difficultto control once they're in the body. 'Wewere, intuitively, going for a home run,"Zeitels says. "Strategicaliy, that proba-bly wasn't the best way to go."

In 2003, Zeitels was having dinnerwith Andrews in Los Angeles, and she

told him that she'd be happy with atemporary solution. "I'd settle for six

weeks and come back and see youagain," she said. He began thinkingabout something placed under the epi-thelium that would work like collagen,filling out the tissues temporarily. Zei-tels brought the idea to Langer,who, in2006, hired a postdoctoral researchernamed Sandeep Karajanagi to designthe material. "It was obvious we hadto go to a synthetic," Karajanagi says."Those materials last long enough andhave a record of being able to pass theF.D.A." Karajanagi eventually settled

on a polymer called polyethylene gly-col (PEG), which is used in biomedicaldevices. "There are other choice s, butthose are not as flexible," he told me. Toachieve the right pliability, Karajanagimixed the polymer with another one hecalis PEG-with-sticky-ends. "By chang-ing the ratio of the two, 1can dial in anddial out the stiffness."

Karajanagi showed me a sample ofthe biogel when 1visited Zeitels's re-search lab at Massachusetts GeneralHospital-asuite that includes a ma-

chine shop and an animal operatingroom. On a workbench was a small,clear dome of gel, which Karajanagi ex-plained was more than ninety-five percent water. It was unexpectedly lightand elastic, offering no resistance when1touched it, but immediately snapping



back to its original shape when 1 re-moved my finger.

Karajanagi and the team test stiffnessby implanting the gel in calf's larynges,which they get fram local slaughter-houses, and attaching them to a syntheticwindpipe. The challenge has been to de-

sign a gel that' s soft enough to mimic thealmost liquid flutter of the vibratory mu-

cous membrane but tough enough to lastin the body. To test durability, they im-planted the gel in dogs, whose laryngesare similar to those ofhumans. 'We'regetting what we think to be a fairly effec-

tive eight weeks," Zeitels says.The next step is human trials, which

Zeitels hopes to start this year. If thetrials are successful, he says, the first re-cipients of the biogel will be cancer pa-tients who have had vocal-cord tissue

removed. lnevitably, he believes, singerswill use it, too, and it wiil make agingrockers like Daltrey and Tyler sound asthey did in their thirties. "lt's not 'ls itgoing to happen?'" Zeitels told me. "lt'swhen it's going to happen."

J \ fter phonosurgeries, Zeitels insistsnhat his patients maintain threeweeks of total silence, to avoid damag-ing the vocal cords as they heal. For thefirst week after Scott Flaherty's opera-tion, he stayed with his sister in New

Hampshire, sleeping in a guest room atthe top of the house. "1was isolated, soit was pretty easy to stay quiet," he says."But one morning she woke me up and,because she startled me, 1answered. Myvoice was crystal clear."

Still, Flaherty was anxious for thetime to pass, so that he could find outdefinitively if the surgery had rescuedhis voice or irrevocablyworsened it. "Aswe approached the end of that three-week time, 1 did touch it a few times,"he admits. "1 spoke, varying the pitch alittle so there would be less strain." On

the day before the rest period ended, hecould not stop himself. "1 tried it outwith a little bit of singing in the shower-just individual phrases."

He heard a slight buzz. This discon-certed him, but he knew that it might be

a temporary side effect of a steroid ad-ministered during the operation. Pro-fessional singers who are suffering fromcolds sometimes take cortisone-asteroid-to get them through perfor-

mances, and those with well-trained

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ears are able to detect an "artifact" in thetone, Flaherty did not know ifhe' d been

given a steroid, but other symptoms-redness in his neck, heat in his face-suggested that he hado

His appointment was for two o'dockon a Tuesday, and he had booked a

morning flight from his home, inCharleston, The evening before, therewas a blizzard in Boston, and his flightwas cancelled. "1 jumpedinto the truck and drove allthrough the night," he toldme. He arrived in Boston atnoon, took a nap in his truckin the Voice Center parkinglot, and then went up to theeleventh floor. As he waitedin an examining room, oneofZeitels's feilows came in.

Flaherty asked if he'd beengiven a steraid during the operation.Hehad.

Zeitels arrived and asked, "How doesyour voice feel?"

Flaherty said, "Qyite good." He ad-mitted that he had tried some singingand heard a buzz, but that he hoped itwas due to the cortisone.

Zeitels examined his throat throughthe laryngoscope. "Wow, you healedgreat," he said. Then he asked Flahertyto sing.

Adele, on her first foilow-up, triedout "Rolling in the Deep," Zeitels toldme. When that went well, she pro-ceeded to sing the entire "21" album."She would try a song and say, 'O.K.,thatworked. Let's trythis one,'" Zeitelsrecalls. "1got a free a-capella concert inmy office. It was insane."

Flaherty found that he could not openhis mouth. After a decade in retirement,he had no idea what to sing. Zeitels sug-gested scales, but Flaherty found eventhat prospect daunting. "To sing any-thing without the thoughtfu1 manipula-tion that I've been doing for years almostparalyzed me," he said. He was most con-cerned about what opera singers refer toas the passaggio. "The passaggio is thatlittle zone between the upper middle andwhat we call the high voice, or the high

notes-the money notes, which we getpaid for," Flaherty says. "lt's the area ofgreatest technical coórdination with re-gard to registration-head voice, chestvoice. It's the area where the two start to

dovetail, where the muscular dominance

that produces the sound we hear in thebottom of the voice starts to yield itsinfluence to the set of muscles that pro-duce the head voice, the high notes. Thatarea is acutely ccordinated in a skiiledopera singer." Flaherty, despite his in-jury, still had his entire range. But, he

savs, "1 didn't have it without fatigue,without thoughtful technical manipula-

tion. So would it be there in just spon-

.~! taneously went to the top?"To test it, Flaherty found

himself trying a song that hedoesn't ordinarily sing. 'Whythis particular thing cameout 1have no idea," he says."But 1 know of two promi-

nent opera tenors, FrancoCorelli, who was my teacher,and Mario Del Monaco,

who was a famous tenor inthe fifties and sixties. Both said that 'OSole Mio,' because it is so popular, isnotrespected for its degree of difficulty. Itrequires as much skill as an aria. All of asudden, 'O Sole Mio' started coming outof my mouth!" He reached the passag-gio. "There should be a transparency-so we arrive at the high notes having thesame sound that we did down in themiddle of the voice," he says. 'When 1got into that zone, it worked, it coórdi-nated perfect1y. 1 stopped and said,

'That's the area. It worked beautifu11y.'And Zeitels goes, Weil, keep singing.'"

Flaherty sang phrases from Verdi' s"Oteilo." Then he sang 'Be My Love,'changing the key so that he climbed upto high B-flat above the staff, then Bnatural, and finally high e, before hecame down and stopped.

It will take months of retraining be-fore Flaherty knows whether his voicehas sufficient stamina and power to singhis repertoire according to his old stan-dard. But he knows already that enoughof his voice has been restored for himto someday sing in a musical with hisdaughter. "lf that opportunity presentsitself, I'm sure 1will be able to do that,"he says.

"Scott is doing things he couldn'tdo," Zeitels told me, after the follow-up,"That guy can sing. He almost blastedthe roof off" •

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A conversation withJohn Colapinto.

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