62 Possible Lessons on Recovering Your Voice

1. Generally, people can't imagine the hardships. Though there are more dangerous medical conditions, losing your voice is a special category of hardship – tiring, isolating, discouraging. Day-to-day life without voice is much harder than people can imagine without suffering the problem themselves.

   If a website could extend sympathy, this one would.

2. The Largest Problem – Getting Stuck and Giving Up

   Thousands of people with voice problems have tried to find help, made little progress and finally have given up. Because people can live with voice problems, many do and sometimes for the whole of their lives – even from childhood.

3. Once diagnosed, most voice problems can be treated with some measure of success. Most cases can be improved and many effectively resolved.

4. Hardest Cases – Often Treatable

   Many of the hardest cases, including patients with hardly any voice, can be treated. Voices can be recovered.

5. Longest Cases – Often Treatable

   People suffering voice problems for 5, 10, 20, 30 years usually are treatable as well. Some improvement is highly likely.

6. Once Untreatable Cases – Increasingly Treatable

   Medical knowledge and technology in the field of voice care are advancing fast. Many cases not treatable a decade past now can be addressed, improved, even resolved.

7. Failed Surgeries – Often Correctable

   Some surgical procedures, by a bad turn of events, can create a voice problem to begin with. Other surgeries, intended to address a voice problem specifically, can produce complications – bringing the patient no help or worsening the condition altogether. Even these categories of surgical problems may be treatable a second or third time around. In the right physician's hands, a prior "problem surgery" often can be remedied.

8. Marginally Improved Cases – May Be Further Improved

   A very common phenomenon among voice patients is the problem of reaching a "plateau." The original problem may have been improved in part but the patient feels he has been "plateaued" at an unhappy level of voice, with no further improvement likely. These cases, too, very often can be improved with the right treatment.

9. "Giving Up," Not Incurable Condition, the More Common Problem

   The disappointing lesson is that difficult voice problems often require an epic journey – too many doctor appointments, too many treatments, too many blind alleys and failed approaches – before the right diagnosis is found. A frequent problem is that the patient becomes defeated along the way and largely gives up. For the large majority of cases, there will be a successful treatment if he or she "stays the course" long enough. Persistence turns out to matter here.

10. To say that the large majority of voice conditions can be treated is not to say totally cured. A right expectation may be that some voices can be recovered completely and others just improved – though typically meaningfully. In all cases, continuing care and treatment may be required.

11. Minority of Cases – No Fix at All

    Though they are the minority of cases – most highly uncommon – there are some voice conditions for which the medical profession has made little progress. The key here is much the same as for all voice problems – to avoid giving up hope too soon. The patient should make sure the diagnosis of untreatable condition is confirmed by a specialist likely to be certain in that judgment.

    In the case of "no fix at all", the patient should check back with voice specialists at some point because advances and improvements are continually being made in the field.

12. Voice Problem as Part of Larger Condition

    There are occasions in which a voice problem is one of the first symptoms of a much larger disease such as, cancer, stroke, multiple sclerosis (MS), Lou Gehrig's disease, amyotrophic lateral sclerosis (ALS), Parkinson's disease, or myasthenia gravis. This too is highly uncommon but, where diagnosed, the long-term prospects for the voice are as unhappy as the disease itself. (For more information, see Voice Dysfunction in Neurological Disorders, Laryngeal Atypia and Early Cancer and Laryngeal Advanced Cancer.)

13. The Occasional Terminal Disease

    The overwhelming majority of voice problems involve no urgent, degenerative, terminal disease. Chances are that the voice problem is "just a voice problem" – limited, benign, treatable. Still, there are forms of cancer that begin in, or move to, the throat, the larynx, the vocal folds. Some of the more troubling symptoms are identified in the chapters on cancer. These symptoms should be taken seriously and examined immediately. (For more information, see Laryngeal Atypia and Early Cancer and Laryngeal Advanced Cancer.)

I. Getting to Diagnosis

14. There are 20 to 30 diagnoses that most frequently cause voice problems. As each diagnosis may yield similar symptoms – hoarseness, loss of voice, major fatigue when speaking – isolating the correct underlying cause is difficult.

15. A Very Specific Diagnosis Essential to Treatment

There's no surprise here: The 20 to 30 most frequent diagnoses require different kinds of treatments. One patient with a hoarse voice may have partial paralysis of the nerves to the vocal folds requiring implants to push the vocal folds closer together if non-resolved. A second patient, with almost an identical hoarse voice, may have acid reflux affecting the vocal folds (without the typical heartburn) requiring only a long dose of an anti-reflux drug.

Seventy, eighty, ninety percent of the work and time spent getting better may take place just in getting to the right diagnosis. This is a good investment of time.

16. Wrong or Partial Diagnosis Highly Common

    Some large number of patients, maybe the vast majority who are "stuck" with long-term voice problems, most likely have multiple voice problems or a "missing link" to the cause of the voice problem. As a way of lowering expectations at the beginning and preparing for a long, uphill journey, these patients should expect one, two, or even three "working" diagnoses that need to be sorted out before getting to the definitive diagnosis or combination of diagnoses. This is common. This is okay. The problem is summoning the energy to keep up the search.

17. Laryngitis as the "Catch All" Diagnosis

    There is a temptation among patients – and even some physicians – to diagnose voice problems as laryngitis or chronic laryngitis. This may not be helpful. Laryngitis means little more than a "hoarse voice"; it does not explain the underlying cause of hoarseness.

    A Critical Point

    A Voice Problem Beyond a Few Weeks Is Not Likely Viral Laryngitis

    What the layman thinks of as "laryngitis" – losing your voice with a cold or a flu – should not go on long. Viral laryngitis usually passes within two to three weeks of the rest of the symptoms of the cold or flu. If it doesn't, the problem is not likely viral laryngitis.
18. Avoiding Patient Fatigue

    Understandably, a patient may give up on the process after several doctor visits, several failed treatments. The best counsel, I'm afraid, is still "Don't give up." A right diagnosis is available and a good treatment likely.

19. Avoiding Physician Fatigue

    The voice field in medicine is a (very, very) narrow specialty. It is not possible for more general physicians, even ear, nose, and throat specialists (ENTs or otolaryngologists), to know the dozens of diagnoses for a bad voice. The problem to watch out for is the physician – even well intended – effectively giving up. A diagnosis of chronic laryngitis can be a clue to a physician's concern about not finding a more specific diagnosis. The counsel is not to give up; you may need to visit more physicians, physicians increasingly specialized in the problems of the voice.

20. Exact, Right Diagnosis Virtually Always Possible – Almost Always

    Physician voice specialists in the country will admit that there are a minority of cases that cannot be treated. Physician voice specialists also admit that there may be differing medical opinions. That said, reaching the right diagnosis is virtually almost possible. This is the single goal for the first stage of the journey. It is a goal worthy enough.

    The right diagnosis may be a combination. A patient's voice problem may be multifactorial, i.e., caused by different disorders present at the same time, each requiring specific treatment for effective and lasting voice care.

III. Need for a Specialist's Care?

21. As of this writing, there are about 5,000 medical conditions covered in medical databases. No single physician, no matter the intelligence and expertise and earnest compassion, can master even 10 percent of the known medical field.

22. Serious Voice Problems: The Very Narrowest Specialty

    While everyone suffers some voice problem from time to time, truly serious, long-term voice problems are relatively uncommon. Likely there are about 50 physicians in the country who spend a third of their time dedicated to patients with voice problems, although that cadre is increasing in number and training.

23. The Pyramid of Increasing Voice Care Specialization

    It is possible to think of the various doctors treating voice problems as organized in an inverted pyramid. The deeper down you penetrate, the more specialized the doctor becomes in problems of the voice.

    The Field of Doctors Treating Voice Problems in the United States, 2003
24. Not More Doctors, More Specialization

    Inevitably, the patient who is truly "stuck" with a long-term voice problem will (and probably should) see a large number of doctors. The short cut, if there is one, is not more doctors only, but also greater and greater specialization. In the end, as with other medical specialties, the toughest cases may best be diagnosed and treated by a subspecialist. Voice disorders will require that very uncommon physician – the voice specialist.

25. Beginning with a General Otolaryngologist

    Laryngology, the medical specialty focusing on voice care is a subspecialty of otolaryngology. Most voice problems, beyond the simple cold and flu, probably should be taken to an otolaryngologist. The overwhelming majority of voice problems can be resolved there.

26. Moving from General Otolaryngologist to Physician Voice Specialist

    As with most medical specialties, there are several subspecialties within the specialty of otolaryngology (ENT). These subspecialties focus on a greater degree of expertise for the diagnosis and/or treatment of particular ear/nose/throat disorders. One of these subspecialties, laryngology, focuses on disorders of the larynx or voice box.

    Voice disorders may best be treated by physician voice specialists whose clinical practice is focused on voice disorders. (For more information, see Voice Care Team.)

    A Good Test

    Diagnosis Within Three Visits or Three Weeks

    A very happy fact about voice problems is that almost all can be diagnosed, by a qualified physician voice specialist, virtually immediately – sometimes on-site, sometimes after a separate test or two, but almost always within three weeks or three visits. If diagnosis is taking longer than that, it may be prudent to seek an appointment with a dedicated physician voice specialist.
27. Embarrassment of Changing Doctors

    There's almost no adequate reassurance that can be given here. It's just difficult for a patient to explain he wants to seek a second opinion. Still, you should know this is very, very common. Further, if there is any area where a general physician or even an otolaryngologist should be forgiven for needing a further specialist called in, it is the narrow terrain of serious voice problems. Sorry the advice here is not more helpful.

IV. Search for the Specific Doctor

28. By far, the larger number of voice problems can be well-tended by an otolaryngologist. The conclusions that follow apply to those less common circumstances when the patient feels "stuck" and in need of a dedicated physician voice specialist.

29. No Easy Search

    Finding a true voice specialist in the United States is no easy matter. While there are tests and review boards to qualify doctors as specialists in some fields (cardiology, oncology, orthopedics and so forth), currently there is no official qualification for specializing in the voice in particular.

30. Measuring the Doctor's Focus – The "33% Test"

    Though the test is imperfect, you may wish to divide out that small number of otolaryngologists who spend a third of their time seeing patients with voice problems. This will yield a small field, almost certainly fewer than 60 physicians, maybe as few as two to three dozen.

    An Imperfect Test

    The 33% Test is no absolute standard, more a rough test for the average patient to seek out the dedicated specialists. Surely, there are otolaryngologists qualified for the most serious voice conditions, though the majority of their practices are not patients' voice disorders. There may be, as well, physicians more than 33 percent dedicated to the voice who, nonetheless, are not the right doctor for a specific voice problem.
31. The Larger Lesson – High Volume of Voice Patients

    Research has shown across many medical specialties that the quality of a physician's care improves with the number of similar patients seen. High-volume open heart surgeons, all things being equal, should yield better heart surgery results. The patient "stuck" with a serious or chronic voice problem may be well served finding those few doctors who see the greatest number of vocal patients.

32. Twenty Hours of Doing Your Own Research

    A hard moment in seeking medical help is when, or if, the patient decides to do his own research to find the right specialist. This work can be aggressive – many telephone calls, lots of technical reading – but likely will not require more than 20 hours of dedicated effort. Some layman's tips for research – truly nothing more than that – are offered below.

    Finding a Voice Specialist

    First "Leads" for the Patient's Own Research

    1. Medical Associations wherein some, most or all members are physician voice specialists [listed in alphabetical order] – all have websites

       • American Board of Otolaryngology [ABO or ABOto]
         http://www.aboto.org/
       • American Academy of Otolaryngology-Head and Neck Surgery [AAO-HNS]
         http://www.entnet.org/
       • American Laryngological Association [ALA]
         http://www.alahns.org/
       • American Broncho-Esophagological Association [ABEA]
         http://www.abea.net/
       • Voice Foundation
         http://www.voicefoundation.org/

    2. Choir Directors – Musical Directors – Singing Teachers: Major Choirs, Operas, Schools

       Across the course of their singing careers, almost all professional – or simply serious – singers will seek the medical care of a physician specializing in the voice. Taking care of their own singers, most choir directors, musical directors or creative directors of large choirs and opera companies will know the names of physician voice specialists. (The larger the choir or opera company, the better the chance the musical director will know a voice specialist.) A few phone calls (or e-mails) to such groups may start the research process.

    3. Major University Hospitals

       Some university hospitals and academic medical centers have created dedicated voice centers with one or more otolaryngologists focused on voice care. The problem here is a little "hit or miss." All university hospitals will have a physician to whom they refer voice problems. That is not to say, however, that the designated physician truly will be a voice specialist, dedicating some large portion of his practice to voice problems. Some of the largest and most famous academic medical centers in the country have no particular expertise in the voice.

       Even so, a round of phone calls to the larger university hospitals, asking for "leads" to the nation's best-recognized voice specialists should yield results. You may want to ask, in particular, the advice of the chairman of the department of otolaryngology or the chief resident (physician in training) in "ENT" – ear, nose, and throat.

       There are over 100 academic medical centers in the United States. Information on each (including links to their respective websites) can be found on the public website of the national society of academic medical centers – the Association of American Medical Colleges.

       Association of American Medical Colleges
       2450 N Street, NW
       Washington, DC 20037-1126
       Phone: (202) 828-0400
       Fax: (202) 828-1125
       http://www.aamc.org/

    4. This website offers a layman's strategy to finding a voice doctor in our "Resources" section. It can be found here.
33. The Likely Case: Be Prepared to Travel

    The scarcity of dedicated physician voice specialists there are in the United States is an important factor that is difficult to overstress. Some of the country's largest cities, with populations in the millions, offer no doctor whose practice is largely dedicated to voice care. Most voice conditions do not require such specialization. If, however, your case does, the larger chance is that you will need to travel beyond your own state or region.

34. In the end, the patient's ability to know the professional expertise of a physician is limited, especially in as narrow and technical a specialty as the voice. Most patients can't know. The same holds true even for referring physicians.

35. Attributes of a Large Vocal Practice

    That a physician sees some large number of vocal patients is no guarantee of quality or technical expertise. Still, in the absence of a better measure, knowing whether a physician's practice – the doctor's time, the staff's training, the medical equipment available – is largely focused on vocal care may be helpful. Unquestionably, some number of voice disorders require this principal focus.

    Typical Attributes of Dedicated Voice Centers

    Physician voice specialist	Staffed by otolaryngologists who specialize in voice disorders
    Multidisciplinary voice care team [on-site or available by easy referral]	Speech-language pathologist Voice therapist Nurse Medical and surgical sub-specialists
    Specialized voice testing [on-site or available by easy referral]	Laryngoscopy: Rigid or telescopic laryngoscopy Flexible or fiber optic laryngoscopy Videostroboscopy Laryngeal electromyography Voice function testing Double-probe pH monitoring
    Specialized surgical procedures for voice disorders	Phonomicrosurgery Laryngeal framework surgery Neural re-innervation
    Physicians whose research has been published in peer-reviewed publications	Not a requirement, but a plus as with all medical specialties
    (For more information, see Overview of Voice Care Professionals, Laryngoscopy/Stroboscopy, Phonomicrosurgery, Reflux Laryngitis chapter section on pH monitoring.)

36. Final Caution: Subspecialization Even Among Specialists

    There is trouble enough for many patients simply finding a physician who specializes in voice conditions. The further problem, all but too much to handle, is that all physician voice specialists do not claim expertise in all voice conditions. There are deep spikes of subspecialization within the subspecialty – practices focused on one or more of the following: vocal fold cancer, vocal fold paresis/paralysis, reflux laryngitis, recurrent respiratory papillomatosis (RRP), laryngeal reconstruction-rehabilitation, spasmodic dysphonia and so forth.

    Once the patient has a specific diagnosis, it is always a worthy question to ask, "Doctor, if your family member had this condition, who would you suggest as the one or two or three best doctors in the country to handle the treatment?"

V. Various Medical Complexities

37. While it is true that most voice conditions do not involve more serious underlying problems, there are some symptoms worthy of a physician's immediate attention. A partial list of red flag symptoms is offered below.

    Red Flag Symptoms – Warranting Immediate Attention

    Any One of Five Symptoms

    
    

    1. Difficulty breathing – especially breathing in
    2. Coughing up blood
    3. Episodes of choking on food and liquid – aspirating, food getting stuck, food and liquid going down the wrong way
    4. Hoarseness and ear pain
    5. Gradual deterioration of the voice – greater and greater hoarseness or vocal fatigue setting in across weeks or months (with or without accompanying pain)

38. There is a growing view among some of the nation's most-respected physician voice specialists that most "stubborn and persistent" voice conditions involve more than one underlying problem or diagnosis. In this view, it's as if a single problem often may not be enough to reduce the larynx to chronic fatigue, hoarseness or significant trouble speaking. Rather, it's as if the voice struggles along at acceptable levels until the accumulation of voice problems puts the larynx "over the edge." Only then does the patient seek treatment.

39. The Special Difficulty in Diagnosis

    Spotting multiple, simultaneous voice conditions is a highly sophisticated art, generally requiring the attention of a dedicated physician voice specialist. The practical problem for the patient and physician is that once a first problem has been identified, the natural temptation is to assume that explains the whole of the problem. The result often may be too simple a diagnosis, too simple a treatment, and some confusion when the problem does not resolve.

40. Needing to Treat Each Problem Separately

    When multiple and simultaneous voice problems are at work, it may be necessary to treat each problem separately to recover the patient's voice.

41. Common Clusters of Problems

    The experience of some of the busiest voice practices suggests there are some common clusters of voice problems, separate diagnoses that – for whatever reason – often are found together in chronic vocal conditions. Some of the more common clusters are listed below.

    Common Clusters of Voice Problems

    Cluster #1 High-demand voice user Vocal fold scarring Vocal fold nodules, polyps or cysts Resulting symptoms: hoarseness, vocal fatigue, effortful phonation	Cluster #2 Reflux laryngitis Vocal fold granuloma Resulting symptoms: hoarseness, frequent throat clearing, vocal fatigue, pain on speaking
    Cluster #3 Vocal fold paralysis Muscle tension dysphonia Resulting symptoms: hoarseness, breathiness, effortful speaking, vocal fatigue	Cluster #4 Spasmodic dysphonia Anxiety or stressful situation Muscle tension dysphonia Resulting symptoms: strained strangled breaks in voice or breathy breaks in voice
    Cluster #5 Smoking history Vocal fold cancer Resulting symptoms (any combination): hoarseness, past or present smoker, pain to ear, difficulty breathing	Cluster #6 History of endotracheal intubation Joint mobility problems Vocal fold scarring Paralysis or paresis Vocal fold granuloma Resulting symptoms: non-resolved hoarseness after intubation, pain on speaking
    Cluster #7 Excess voice use Vocal fold hemorrhage Resulting symptoms: acute severe voice loss following screaming/shouting (voice abuse) or performance or demanding voice use	Cluster #8 Psychogenic aphonia Physical and/or sexual abuse Resulting symptoms: "tip of the iceberg"; physician voice specialists have observed cases of complete loss of voice as presenting symptom of underlying abuse

42. Less than three to five percent of voice conditions are caused by vocal fold pre-cancerous lesions and cancer. The most common kind of vocal fold cancer is the squamous cell carcinoma. More importantly, the most common risk factor for vocal fold cancer is smoking – past or current.

    Precancerous lesions on the vocal folds or vocal fold atypia are more common. These lesions are thought to precede vocal fold cancer.

43. Possible Cancer Symptoms

    Though cancer can present in many ways, some of the more common clusters of symptoms for vocal cancer are:

    • Persistent hoarseness especially in a smoker or past smoker
    • Hoarseness + pain to the ear
    • Worsening hoarseness
    • Difficult or noisy breathing
44. Cancer Need Not Involve Pain

    Laryngeal and vocal fold cancer may or may not involve pain. Lack of pain is not an assurance of no cancer.

45. Diagnosing Vocal Fold or Laryngeal Cancer

    Using a scope placed down the throat, an otolaryngologist or voice specialist may be able to see visible signs of cancer including hemorrhagic lesions, growths protruding outwards, and growths immobilizing part of the vocal folds. To confirm a cancer diagnosis, the physician must do a biopsy, removing a portion or all of the growth for laboratory pathology testing.

46. Problem with Single Biopsies

    Increasingly, physicians are of the opinion that a single biopsy of a growth may not be enough to locate cancer within the growth – one sample may have "missed" the cancer. The better practice may be removal of the whole growth including a margin or edge of normal tissue.

47. Problem with a Simple "Yes" or "No"

    Not surprisingly, diagnosis may not be as simple as "cancer" or "no cancer." Areas of the larynx and vocal folds can have premalignant (precancerous) lesions. These early changes in the health of the tissue need to be addressed aggressively as well. (For more information, see Laryngeal Atypia and Early Cancer.)

48. Most Early Cancer Treatable with Voice Preservation

    Most early cancers of the larynx and vocal folds can be treated with preservation of the voice. Vocal fold cancer treatment and voice preservation are no longer incompatible. (For more information, see Laryngeal Atypia and Early Cancer.)

49. Avoiding Total Removal of the Larynx

    The traditional and conservative approach to more serious cases of laryngeal cancer has been to remove the larynx – leaving the patient without any natural voice, wholly dependent on a mechanical voice box. While still necessary in some cases, this is no longer the state-of-the-art practice at some of the largest voice centers.

    In many cases, larynx cancer surgeons now are able to preserve the voice box while successfully removing all of the cancerous growth. The result typically can be to leave the patient with a usable voice without the need for a device in cases which otherwise might have left the patient with no voice at all.

    Urgent Second Opinion

    A physician's recommendation to have the larynx removed (a total laryngectomy) should trigger the search for a second opinion.

50. Patients commonly diagnose their own hoarse voices as laryngitis. Similarly, physicians may offer a diagnosis of laryngitis.

    The problem is that laryngitis simply means "inflammation of the larynx or voice box" manifesting itself as hoarseness. It does not uncover the underlying reason for the laryngitis. The work doesn't begin until the patient and physician search for the root cause of the "laryngitis."

51. Laryngitis With a Cold or Flu

    The most common form of hoarseness is caused by a viral infection resulting in the common cold or flu. While common, this form of laryngitis should not last long. The hoarseness almost always clears up within two to three weeks after the rest of the cold or flu symptoms are gone. If hoarseness continues long after the cold or flu, likely there is some problem other than the typical flu-related laryngitis, or complications may have occurred that require medical attention. This is especially true for smokers.

    Repeated Caution
    A Critical Point

    A Voice Problem Beyond a Few Weeks Is Not Likely Viral Laryngitis

    What the layman thinks of as "laryngitis" – losing your voice with a cold or the flu – should not go on long. Cold- or flu-related laryngitis usually passes within two to three weeks of the rest of the symptoms of the cold or flu. If it doesn't, there may be complications or another voice disorder that was worsened by the bout of the flu. Lingering horseness should not simply be ignored as something that will someday go away.

52. Other Causes of Laryngitis

    Beyond the cold or flu, there are numerous causes for hoarseness. Some of the more common causes are cited below.

    Common Causes of Hoarseness

    • Reflux laryngitis
    • Vocal fold scar
    • Damage to the vocal folds from excess talking or shouting – vocal fold hemorrhage
    • Vocal fold paresis
    • Vocal fold lesions
53. Side Problem of Cold or Flu – Vocal Fold Paresis/Paralysis

    Though the phenomenon is uncommon, a common cold or flu can leave the nerves serving the vocal muscles partially paralyzed (paresis). The thinking here is that, as with the herpes virus, the virus may affect the nerve and weaken it or deaden it altogether. The result is one or both vocal folds becoming weak or sluggish.

    Improvement in voice function can be achieved even if one has vocal fold paralysis (total paralysis). (For more information, see Vocal Fold Paresis / Paralysis and Laryngeal Electromyography [LEMG].)

54. Although voice rest is indicated in specific treatment situations, its role in treatment is usually only a part of the treatment plan. Though often prescribed, voice rest is not definitive treatment for most causes of voice disorder. Voice rest simply allows time for the vocal folds to recover on their own – from fatigue or swelling or irritation. The root cause of the voice disorder needs to be identified and specific treatment or treatments prescribed.

    Deciding on Voice Rest

    Voice Rest Usually Appropriate	Voice Rest Usually Not Helpful Current best practice: needs medical attention for voice problem
    Recovering from pushing the voice too long, too hard	Persistent hoarseness that was unresponsive to a three-week course of voice rest
    Recovering from vocal fold surgery	Worsening hoarseness
    Voice fatigue from overuse	Hoarseness + difficulty breathing in or swallowing
    Recovering from vocal fold hemorrhage	Hoarseness lasting longer than three weeks, especially in smokers

55. Limit of Three Weeks Vocal Rest – Usually

    As a practical matter, very few conditions require voice rest beyond two to three weeks. If the patient's voice remains fragile thereafter, some other cause should be examined and some other treatment should be pursued.

    One exception is vocal fold hemorrhage – wherein voice rest may be prescribed for a longer period in some cases. The distinction here is that a definite diagnosis has been made, and a physician voice specialist is following the patient's progress.

56. Months of Voice Rest a Red Flag
    Red Flag

    A patient advised to continue voice rest after two to three months likely should seek a second opinion from a physician voice specialist. Likely, the patient is suffering some problem for which rest is no complete answer.

57. For patients truly stuck with chronic voice problems, perhaps as many as 80% of the cases can be explained by one or a combination of five diagnoses.

    The Big Five Diagnoses

    1. Vocal fold scarring
    2. Reflux laryngitis