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

Dr. Howell working with Charles Farbos de Luzan, PhD aerospace engineering at work in the laryngeal biomechanics lab.

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.