General ENT exam
I include a general ear, nose and throat examination for a few reasons. Many of the structures and nerves of the region are related. Perhaps the most well know example is otalgia or ear pain, where the sensory nerve within the ear and within the larynx reach the same location in the brain. The general exam begins by looking into the:
- Ears
- Nose
- Mouth
- Throat
While some of these areas may not seem too closely related to voice, they can be peripherally related. For example, the structures of the pharynx, mouth and nose alter resonance.
Then examining the structures in the neck:
- Salivary glands
- Thyroid gland
- Lymph nodes
- Laryngeal cartilages
Again, while some of these areas may not seem too closely related to voice, malignant tumors of the larynx can spread into the neck. The laryngeal cartilages can be palpated during phonation to assess muscle function.
And a neurologic exam of selected cranial nerves. In particular the neurology of cranial nerves VII through XII is densly compact centrally and thus closely related to voice.
Insurance protocol
In the US, insurance companies do not recognize an examination of the voice. Their reviewers are only trained to recognize content for a general ENT examination. Also, the reviewer for the insurance company is not reviewing the physician's reasoning, but rather views the exam as a point system. It is possible to look up the bullet points and if you don't have time, most electonic medical records will have them preprogrammed in. EM University has a very nice and concise form that includes all the dots needed. If the documentation does not score enough points on the general ENT examination, the bill is not paid no matter how thorough the laryngeal and voice examination. This approach to paying for exams combined with the ability of electronic health records to generate mind-numbing data has lead to exams overwhelmed with digital detritus.