Diagnosis

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This website started as a handbook summarizing my studies during 1997 and 1998 (and continuously updated since) as I travelled and visited a number of otolaryngologists subspecializing in one tiny, but very important, area of otolaryngology - the voice.

It is a tiny area, of the body, but because the amount of knowledge in the field of medicine has ballooned so much, one can study a tiny area full time. At the time I finished medical school, I knew nearly every drug available by prescription in the United States. To me, this was one sign that an individual could have a grasp on the entire field of medicine. That has changed. Since then, I chose to study one small area of medicine: otolaryngology, that is, the study of diseases of the ear, nose and throat. And now I confine my studies to one small aspect of otolaryngology: laryngology - the study of disorders of the larynx or voice box.

Traditionally, otolaryngology and laryngology have approached the voice box from a structural or anatomic point of view. This has proven fruitful for much of the twentieth century particularly in the treatment of laryngeal cancer. However, in my travels I discovered physicians taking a novel approach to the larynx, a functional approach.

The larynx has at least three functions; breathing, airway protection during swallowing, and voice production. Almost every human depends on these functions, including voice production, every day; in fact all day, every day.

Traditionally (and tradition persists a very long time in the academic world), if a physician could see an abnormality with their eyes or with an x-ray or some other technology that could produce a visual image, a diagnosis was made and treatment was based on this diagnosis. This has led to some wonderful treatments of laryngeal disease.

However, just as pharmacology did not stand still after I left medical school - I suspect I only know far less than a quarter of the drugs that are now available more than 25 years later - so laryngology is not standing still. The concept of listening to detect disorders has only recently emerged. If the voice produces sound, then a problem with voice production is almost certainly likely to be heard.

A new paradigm in laryngology emerged that listens to the voice first and then looks for the problem. This has several advantages over traditional laryngology. First, if one can hear a problem with voice production, then it exists. If upon looking for that problem it is not easily seen then further and closer scrutiny is required until the problem is found. When the problem is not easily seen, a traditional laryngologist might diagnose your voice to be normal or your problem not serious enough to warrant any treatment at this point. The voice oriented laryngologist, since they hear the problem, persists until the correct diagnosis is made.

Second, the voice oriented laryngologist is not easily distracted by a visual anomaly that may play no role in the patient's current problem. In other words, a lump somewhere on the voice box may not require any treatment if it is not a cancer and it is not causing the patient's voice complaint.

Perhaps an analogy would be helpful. A daring sailor departs the known world and for the first time, as far as he knows, he sails east. Traditional thought might hold that the first landfall he would encounter would be his chosen destination. Then again, it might not be. Staying oriented would mean not assuming that the first landfall was his destination, as everything is not always as it appears. Later sailors, remaining more oriented in time and space would later describe a whole continent between the old world and the Indies.

I am not criticizing exploration or relying on initial visual impressions, but as time passes and knowledge increases, more orientation is necessary. The voice oriented laryngologist is not easily disoriented by visual findings.

Voice is the key to laryngology. Being a voice oriented laryngologist puts me in a very tiny group of people around the world. I hesitate to say how small a group this is, but it is my hope that more graduating medical students and laryngologists will adopt a voice oriented approach to disorders of the larynx.