This book is by no means an exhaustive compendium of voice disorders, though it does propose that all hoarseness can be explained either in terms of air leak or an asymmetry of the vocal cords. The larynx contains a valve, the vocal cords, that affects the voice, breathing, and swallowing. Most problems with the larynx are amenable to discovery with a very similar examination as described throughout this book. So if you have a problem in your throat, seek out a detailed exam.
I find it less and less excusable for physicians, presumably scientists, to “believe in reflux” and unflinchingly prescribe a pill for a mechanical problem.
I suggest that “silent reflux,” GERD, and LPR as causes of hoarseness represent misunderstandings of the role of mechanics in vocal cord vibration. While I believe this misunderstanding on the part of physicians is one of omission and not likely intentional, I hope that if patients cajole physicians to provide a reasonable explanation, physicians will seek a better understanding of vocal mechanics.
Even when I follow up with a patient after a treatment, I always leave open the possibility that my treatment didn’t work. I ask: “Did the treatment work? Or are you the same? Or have you gotten worse with my suggested treatment?” I am well aware of the placebo effect of treatment, as well as the patient’s unfortunate desire to please me. Both the placebo effect and the patient’s desire to please their physician work to lead the patient to say they are better, even if they truly might not be improved. I try to give my patients permission to say that I was incorrect in my diagnosis.
For Patients
Don’t try to please your physician. That is not what you are paying for. Give an honest appraisal of what worked and what didn’t. When you are in the office, go ahead and let your voice sound bad — especially you, the singer. This is not the time to apologize and attribute your vocal problem to bad technique or not being warmed up. This is not an audition. Whatever sound comes out, let it come out. Maybe your problem is technique, but maybe the issue is a physical impairment of vibration. Don’t try to compensate. Compensation is the body’s natural reaction to a bad voice — and in fact a laryngologist’s principal diagnostic tool during an endoscopy is to remove compensation and expose the vibrating problem.
Don’t be afraid to question your doctor. He is not infallible. Does your doctor’s explanation make sense? If your physician isn’t reasonably willing to answer your questions in an understandable manner, seek care elsewhere. Just because he commands a high price doesn’t mean you cannot seek high value from his explanation and treatment.
For Physicians
If you are a physician, I hope this book offers you a plausible diagnostic algorithm for voice disorders. Even if you don’t have an endoscope, you now have a clinical way of thinking about voice disorders. You may develop an ability to hear husky and rough hoarseness. If you are prescribing anti-reflux medication for hoarseness, make the trial a reasonably short one. I hope you will also see the value in referrals to physicians who specialize in laryngology.
What you learned
- All hoarseness can be explained either as air leak (husky hoarseness) or as asymmetric vocal cord vibration (rough hoarseness) — this framework applies to every disorder described in the book.
- The placebo effect and patients’ desire to please their physician make it essential to ask direct outcome questions and to give explicit permission to report non-improvement.
- In the exam room, compensating for a bad voice is the enemy of diagnosis; the laryngologist’s job is to remove compensation and reveal the underlying mechanical problem.
- A physician’s explanation of your voice disorder should make mechanical sense — if it seems mystical or mysterious, the explanation may be contrived and a second opinion is warranted.