Diagnosis: The First Step in Treatment

Identifying the cause or causes of a voice disorder is the first key step in its treatment.

Key Information

Non-Recognition of Voice Disorders a Problem

Many voice disorders remain unidentified. Often, voice complaints are dismissed as "par for the course" for a cold, flu, or an allergy. Other times, voice complaints are not considered to be part of a voice disorder – especially if the complaints have been present for a long time or most of the patient's life.

Red Flag

If voice symptoms persist for more than two or three weeks after a cold or flu has gone away – especially if the patient is a smoker – an ear, nose, and throat physician specialist (ENT, otolaryngologist) or physician voice specialist (laryngologist) should be consulted right away.

"Hoarse Since Childhood" Should Be Evaluated

Even if a patient's voice has been hoarse since childhood, hoarseness – or any other voice complaint – should be evaluated by an otolaryngologist or laryngologist.

Accuracy in pinpointing the cause or causes of a voice disorder is essential to effective treatment.

• Proper treatment can be given only if the correct cause of the voice disorder is identified.
• If the voice disorder is caused by more than one cause, pinpointing all causes is critical for mapping out a comprehensive, effective treatment plan. Partial treatments will not be effective and will result in only partial or no improvement of the voice disorder.

Key Information

Overlooking Multiple Factors Results in Partial Treatments

Identification of all causes is necessary in the evaluation of a voice disorder. The identification of one cause does not rule out the possibility that there may be several interacting causes that contribute to a patient's voice disorder.

Medical + Non-Medical + Compensatory Mechanisms = Voice Disorder

Interacting causes may include medical causes, non-medical causes, and patient behaviors that compensate for voice problems. All can contribute and aggravate the voice disorder. More importantly, if all contributing factors are not addressed in the treatment plan, treatment cannot be fully effective, even if it is partially correct.

A Multi-Step Process

The diagnosis of a voice disorder follows a comprehensive and ordered sequence of steps.

1. Taking the history of voice disorder
2. Doing a comprehensive examination, including a head and neck exam and a laryngeal exam
3. Performing diagnostic tests

A physician takes the "history," or information regarding the voice disorder, by interviewing the patient. This history provides information that will help the physician determine the special focus of the examination and the need for particular tests. This history includes information on the following areas:

• The chief complaint of voice disorder – that is, the main problem that the patient is experiencing
• The description of:
  • How it occurred
  • When it was first noticed
  • How long it has lasted
  • How often it happens
• All other observations the patient has made regarding the voice problem, such as:
  • What usually triggers the voice problem
  • What helps the patient overcome the voice problem
• Detailed medical health evaluation including:
  • Review of possible precipitating causes
  • Voice use history
  • Prior evaluation and other treatments (if any)

A comprehensive examination (physical examination) is essential to the diagnosis of a voice disorder. A comprehensive examination includes the following:

• Head and neck examination
• Laryngeal examination
• Special tests

Examination of the head and neck region is important in investigating voice disorders. Voice problems can arise from nerve compression or damage elsewhere in the neck and head, from thyroid gland problems, or from other sources. In addition, laryngeal cancer can be associated with other head and neck tumors; although rare, laryngeal cancer is a life-threatening voice disorder that needs to be ruled out through examination.

Although physicians differ slightly in their diagnostic approaches and methodologies, in general the use of the different diagnostic methods proceeds in an orderly sequence with physicians progressing to the next examination until a diagnosis is determined. Diagnostic methods of laryngeal examination include mirror examination, rigid and flexible laryngoscopy, and videostroboscopy.

• A mirror examination is performed on a seated patient by placing a mirror in the back of the throat.
• By reflecting light down to the voice box, the otolaryngologist can visualize the patient's vocal folds and voice box structure.
• The examination can be done without special equipment, but it does have limitations.

• Magnified view of the voice box: The otolaryngologist can get a close-up, magnified view of the voice box structures by using specialized scopes to view the voice box (laryngoscopes). This allows the identification of abnormalities on the vocal folds and/or on surrounding areas. Images can be recorded on any media, including videotapes or digital tapes.
• Rigid laryngoscopy: As the name implies, a rigid scope is used in this procedure, which provides the clearest magnified view of the voice box. However, the tongue needs to be held by the examiner. Therefore, evaluation of the voice box in action (i.e., while the patient sings or speaks) cannot be done.
• Flexible laryngoscopy: A flexible viewing scope is passed through the nose to the back of the throat to offer a view of the voice box using fiberoptic technology. Flexible laryngoscopy does not hinder speaking or singing. Although the image is not as clear as that provided by the rigid laryngoscope, the flexible laryngoscope allows examination of the voice box in action (i.e., while the patient sings or speaks).
  
  (For more information, see Laryngoscopy/Stroboscopy.)

• Slow motion view of vocal fold vibration: Videostroboscopy combines flexible or rigid laryngoscopy with synchronized light pulses (strobe light) to obtain a slow motion view of the vibrating vocal folds. The images are recorded on video or other recording media so that they can be reviewed by the voice care team.
• Role of vocal fold vibration: The slow motion-like view of vocal fold vibration provides important information on the effects of a vocal fold abnormality on voice production. Vocal fold vibration is the core of sound production for speaking and singing. Documenting the state of vocal fold vibration is critical in the investigation of voice disorders, as well as in the evaluation of effectiveness of treatment plans.
• Videostroboscopy is especially useful in documenting the state of laryngeal vibration for later comparison – to follow the course of the voice disorder or to evaluate effectiveness of the treatment of the voice disorder.

Diagnostic Tests

Specialized tests may be necessary to fully investigate certain voice disorders. This is especially true when a voice disorder is complicated by multiple causes (multifactorial etiology). Examples of these tests are listed below.

Laryngeal Electromyography (LEMG)

LEMG is a specialized test that measures the electrical activity in laryngeal muscles. The LEMG exam provides specific information on the status of nerve inputs to voice box muscles. (For more information, see LEMG.)

Voice Lab Functional Testing
Analysis of sound parameters in voice: Different voice and speech parameters are evaluated through an acoustic analysis, which is done by a speech-language pathologist or other trained professionals on the voice care team.
• Acoustic analysis using computer-based techniques: Sophisticated technology is used to make voice recordings which are then analyzed by a computer to obtain quantitative measurements of voice abnormalities. These tests can be especially important in finding minor voice abnormalities that might not be perceptible to the unaided ear.
  
  
Test for Reflux

Prolonged double-probe pH monitoring analysis can determine the possible backflow of stomach fluids to the esophagus, throat, and voice box, which can cause a voice disorder. (For more information, see Reflux Laryngitis.)

Other Lab Tests
• X-rays, CAT scans, and MRIs are used to detect masses, tumors, abnormal calcifications, and/or airway passage problems.



Key Information

Frequently Overlooked Voice Disorders

Currently, the voice disorders most commonly missed are:

• Reflux laryngitis (For more information, see Reflux Laryngitis.)
• Laryngeal paresis (For more information, see Vocal Fold Paresis and Paralysis.)

Overdiagnosis of Voice Misuse as Cause


Although voice misuse or abuse is the most frequent cause of voice disorders, it should not become a "standard" diagnosis.

• Even if voice misuse is a clear cause of a voice disorder, other possible causes of voice disorders need to be investigated.

Advisory Note