Almost every type of physician-patient interaction begins with a history of the problem. The physician says, “Tell me what happened" or "Tell me what's troubling you”. The story the patient tells about his or her problem is the history. In laryngology, three things are accomplished simultaneously during the history.
- This history offers a great many clues about likely types of voice disorders based on when the hoarseness started, simultaneous events at the onset, the duration, et cetera.
- Secondly the examiner gets to begin hearing the conversational voice for a period of time.
- Third, the patient’s preconceived perceptions of her problem are also important for the physician to address later in the exam.
People who talk a lot will suffer from a different set of problems than people who are naturally quiet. People who lose their voice suddenly after yelling will have a different problem from those who lose it slowly over time.
For this diagnostician this is the first of a three part examination:
A three part examination has the same value as three point navigation at sea. With only one point of reference, the sailor will know only the direction toward something, and with two points of reference she might be able to narrow her location on the map to a few possibilities, but with three references, the sailor can be almost certain of her exact location. Likewise, when all three portions of the laryngeal exam point to the same problem, the physician can say, with great assurance, “This is the likely diagnosis.”
My simplest first step is to eliminate speech problems. If the volume is loud enough and clear enough that people can hear the patient, but still not understand the words, the problem is likely a speech issue. Problems with language are speech issues. Rate and articulation issues are speech issues.
For example, a person with a cleft palate cannot close the palate completely against the back of the throat. Closing the palate completely against the back is required to make certain consonant sounds, otherwise air leaks out the nose and those sounds cannot be made. /p/, /t/, /k/ as well as /s/ and /sh/ are typical sounds requiring complete closure of the palate, channeling all of your air out the mouth. If you try to say “Pa, Pa, Pa” with the palate relaxed, air leaks out the nose and you sound to others like you have a cleft palate. From a physician standpoint, when I hear this nasal air leakage, I know to look at the palate. I really do not even need to look at the vocal cords. So hearing the problem directs me where to look.
If the problem is with consonants, vowels, words and sentences, the problem is likely not with the vocal cords.
Voice issues should usually involve complaints about pitch, volume or clarity. Patients may not actually use these words. Volume and roughness qualities are voice issues that non-singers might typically complain of and pitch, clarity and register are issues singers may more likely notice.
A person might say, in addition to, "I am hoarse", something like "I can’t get loud enough to be heard in a restaurant" (volume problem) or "I sound like I have a “frog in my throat”" (clarity problem). A singer might say, “I am missing a few notes” (pitch issue).
I use a Voice History form to gather the following information from the patient:
At times, the patient thinks the exacerbation is the onset. Careful probing will often reveal a much longer duration of illness.
Events that were synchronous with or preceeded the onset of the voice problem.
A pattern of symptoms develops because every disease is necessarily complex. In particular since the larynx plays a role in swallowing, breathing and speaking, a single change in structure or functional capacity will likely affect multiple symptoms. During the history then, if a few symptoms suggest a particular voice disorder, further questioning can probe for other symptoms that should be present in that particular complex. Later in this essay various symptom complexes are defined.
Perception of severity/motivation
This answers the question "Does the patient want only an explanation or do they actually want some intervention?" Because you can do surgery doesn’t necessarily mean that you should. It may also supply clues that support the diagnosis of non-organic disorders.
Previous treatments and diagnosis
If the patient has already received an opinion or a treatment from another otolaryngologist, speech/voice therapist or any medical provider.
Need to speak
- Innate talkativeness
- Extrinsic drive to speak
- Reflux or heartburn
- Other medical problems
Part two is vocal capabilities testing.