Dr. Rebecca Howell’s Circuitous, Yet Serendipitous, Path to Laryngology

Rebecca Howell, MD, is a laryngologist who built one of the country’s most comprehensive voice and swallowing programs—three National Institutes of Health (NIH)-funded labs, a fellowship, a multidisciplinary team—on a foundation of small con-nections, borrowed ideas, and a conviction that the ability to communicate is inseparable from the quality of a human life.

Before every softball game she played growing up, Dr. Howell’s father told her the same three things: Do your best, have fun, play hard. Her brother followed that advice all the way to the pitcher’s mound for the Milwaukee Brewers and the Cleveland Indians. Dr. Howell followed it into medicine, and eventually into the operating room, the research laboratory, and the fellowship program she has built at the University of Cincinnati.

Dr. Howell had a grandfather and an uncle who were primary care doctors, but no surgeons anywhere in the family, and no women physicians, either.

She came to laryngology sideways, so to speak, through a handshake fellowship deal and a series of small connections she could not have predicted. But the philosophy has never changed.

Today, she directs the Voice and Swallowing Division at the University of Cincinnati, overseeing three NIH-funded research laboratories (in voice biomechanics, airway science, and dysphagia), a laryngology fellowship, and a practice that routinely runs behind schedule because she refuses to cut a patient’s visit short.

Dr. Howell developed a framework called VAPER for approaching high vagal injury as a constellation of anatomical ports—a procedure her residents nicknamed “the dysphagia Whipple.” She lost both her father to glioblastoma and her partner, Sid Khosla, MD, within six months of each other and emerged with a sharper sense of her own humanity. When she talks about what drives her, she deflects the credit. “I couldn’t care less whose name it is,” she said. “I just want to keep growing and making my team bigger and stronger. I rarely extend people’s lives, but very often I extend their quality of life. Voice and swallowing are so central to that.”

This interview was condensed and edited for clarity.

Dr. Rapoport: You’ve described trying to avoid surgery—and even medicine—for much of your early training. How did ENT find you?

Dr. Howell: I always came back to medicine, but I also tried hard not to. I finished my general surgery rotation and thought, thank goodness that’s over. Then, during my pediatric rotation, I started asking to observe C-sections, and something clicked. I went to a chief resident and said, “I don’t like general surgery. What else is there?” He said try ENT and urology. I tried both. ENT just fit—the people, the work, the variety. Someone told me in medical school, “You’ll end up somewhere where you really like the people, and then you’ll learn to love the material.” That turned out to be exactly right for me.

Dr. Rapoport: And within ENT, laryngology in particular. How did that happen?

Dr. Howell: In residency, I noticed I was always happy to do the cases everyone else avoided: thyroplasties or holding the scope for office vocal fold injections. My chairman, Steve Bielamowicz, MD, was wonderful about fostering that. Then I gave birth to my oldest daughter in my fourth year of residency, which was not the plan. I put fellowship aside, interviewed for private practice positions, but continued to come back to the joy I felt in laryngology.

At an Academy [American Academy of Otolaryngology–Head and Neck Surgery] meeting, at one of the hands-on vocal fold injection courses, Nancy Baumann, MD, a pediatric otolaryngologist at Children’s National Medical Center in Washington, D.C., introduced me to Gregory Postma, MD, a laryngologist at the Medical College of Georgia. Dr. Postma later mentioned to me that his fellow at the time was completing a two-year military fellowship, one year of which was focused on research. As a result, he had a clinical fellowship slot open that he needed to fill. He offered it to me personally, so I never went through the fellowship match process—it was a handshake deal. For years afterward, I would meet laryngologists who would say, “I don’t think we’ve met.” I’d say, “You’re right, we’ve never met!”

Dr. Rapoport: Laryngology sits at such a particular intersection of technical precision and deeply human outcomes. Is there a moment that crystallizes that for you?

Dr. Howell: I rarely extend people’s lives, but very often I extend their quality of life. I had a recurrent respiratory papillomatosis (RRP) patient—a physically strong man—who would close the door to my office and weep because his voice didn’t portray who he was. The unpredictability was devastating. My Parkinson’s patients are the same: When they can’t be heard, they stop trying. They slowly step back from social life. Similarly, with swallowing, nobody wants to sit at a table with a spit cup. If I can get someone to take a sip of coffee at a family dinner without feeling humiliated, that is a win. That is the work. It’s also why my clinic always runs late. I tell patients upfront, if timeliness matters to you, I am not your doctor. But when I’m in that room with you, you have my undivided attention.

Dr. Rapoport: You’ve built something remarkable in Cincinnati—three NIH-funded labs, a fellowship, a multidisciplinary team. How did that evolve?

Dr. Howell: I was very fortunate to join the late Dr. Khosla, who was the sole laryngologist here at the time, and had already started the laryngeal biomechanics lab. Sid and I used to joke that he was fantastic at hiring, and I was good at keeping the people he hired. Over time, Dr. Friedman joined as an amazing partner, then Dr. Dion came to continue the biomechanics work, and just before Sid passed, we hired Brittany Krekeler, a speech-language pathology PhD, who now runs our dysphagia lab. We now have three NIH-funded labs: airway, voice biomechanics, and swallowing. It wasn’t a master plan—it was always about asking, “What do we need next?” and then fighting to get it. I begged my first chair to let us be our own division. Then I begged for a fellowship. Each step opened the way to the next one.

Dr. Rapoport: Some of your most innovative work grew directly out of your speech pathologists. Can you talk about that dynamic?

Dr. Howell: When I arrived, the physician and speech pathologist saw patients separately. We changed that, creating true multidisciplinary clinics, everyone in the room together. And a lot of what I’ve done came from my speech pathologist saying, “Can’t you just inject there?” or “Can’t you stretch that?” And I’d think, actually, yes. My research scientists challenge me one way, my fellows challenge me another. It’s never adversarial. It’s always just, why do you do it that way?

Dr. Rapoport: Speaking of that, can you tell me about VAPER? I heard you talk about it at a laryngology conference last year. You called it “the dysphagia Whipple” at one point.

Dr. Howell: The name came from one of my residents, John Stafford, MD. He said, “This is everything you could possibly do to somebody at once, like a dysphagia Whipple.” Then Mike Yang, MD, the head of UT Health San Antonio Voice Center, and I were chatting at a conference and realized we’d each arrived at something similar independently, so we formalized it.

The underlying idea is that in high vagal injury, patients have a voice problem and a swallowing problem, but they almost always present for their swallowing issues. There are a series of anatomical ports to address in these patients: the velum, the glottis, and the hypopharynx. My speech pathologists talked about the velum as a port, the biomechanics lab talked about the glottis, and then Ashley O’Rourke’s pharyngeal manometry work put data behind what I’d been describing clinically. VAPER stands for Velum, Arytenoid, Pharynx, and Esophageal Repositioning—a framework for thinking about all of it at once rather than serially.

These patients are often desensate, so they tolerate awake procedures remarkably well. I started combining things I would previously have done in separate surgeries as I became more comfortable with awake office procedures, and it evolved from there, one patient at a time. I tell them these are static solutions for dynamic problems. We can realign things, but we can’t make them move again. Yet. The next frontier is sensory reinnervation, possibly a laryngeal transplant. That’s where the field needs to go.

Dr. Rapoport: You mentioned your father when talking about what inspires you to build and teach. Can you tell me about him?

Dr. Howell: My father wasn’t in medicine—he worked his way up from a manager at Sears to an executive at Home Depot. His approach to his team was always, Don’t ask anyone to do something you wouldn’t do yourself. I still use that. When my MAs are busy, I’ll help clean a room. He passed away three years ago from a GBM. Sid passed away the same year, within six months of my father. When Sid died, my world at work fell apart, too. I did executive coaching and some therapy. Someone asked me if one of your teammates was going through everything you’re going through, would you give them a hard time? Of course not. That was the moment I realized I had to give myself the same grace I’d give anyone else.

There’s a metaphor I return to often—the knots in a tree. Knots form during hardship, drought, disease, and stress. The wood around a knot is the hardest wood in the tree. If you have the courage to get through the hard things, they make you stronger. I hope that’s what I’m modeling for my fellows—not just technique, but how to be a physician who is also a full human being.

Dr. Rapoport: What advice would you give to a trainee who is still figuring out their path?

Dr. Howell: Pay attention to what makes you happy. You don’t have to know where it’s leading. I remember going back to work after a brutal stretch—new baby, exhausted, questioning everything—and having a day of laryngology with Dr. B. I came home happy. That was the signal. It wasn’t loud, but it was there. And everything is about connections and relationships. You never know who is paying attention or which conversation will matter years from now. Just keep showing up and stay open. The path has a way of finding you.   

Dr. Rapoport is an assistant professor at Georgetown University and the division chief of otolaryngology–head and neck surgery in the department of surgery at the Veterans Affairs Medical Center in Washington, D.C.