It is always difficult to know how good your physician is going to be before your first visit. Word of mouth from patients who have been examined and treated carries a lot of weight — though bedside manner is often more effective in making patients happy than actual technical or diagnostic skill. What follows are the things it is reasonable to expect from a voice physician, and the signs that should prompt you to seek care elsewhere.
The History
The physician should interview you and find out your most important concerns. This is the beginning of the physician coming to understand your problem — putting the puzzle together. Most voice problems have a typical pattern to their development, and a careful history is the first piece of that puzzle.
Listening to Your Voice
The physician should listen to your voice and request that you do a variety of things with it. View this as you would a cardiac stress test. If you had chest pain and the emergency room doctor told you that your EKG was normal, would you accept that as a full explanation — or would you go to the heart specialist, who might ask you to exercise on a treadmill to reproduce the symptoms? A combination of soft and loud speaking, brief singing, a loud yell, checking high and low pitches, and seeing how long one can sustain a sound — these vocal activities help an astute listener identify key pieces of the puzzle. There are other vocal tasks that aid the trained ear as well.
Equipment and Examination
While your voice physician may start with a mirror exam of your throat, it should progress to endoscopic equipment that can view your vocal cords in detail. Endoscopes may be passed through the mouth or through the nose (after appropriate numbing) and attached to a camera that greatly magnifies the voice box for detailed viewing on a monitor. There is a significant difference in image quality between a fiberoptic endoscope and a chip-on-tip endoscope — and high definition endoscopes now offer considerably better detail than either.
Video recording equipment is essential. Things happen fast in the vocal folds and the human eye cannot always catch them. Recording the movements along with the sound allows the same task to be viewed, listened to, and correlated multiple times. After a brief orientation to the pictures of your vocal folds, you should understand how yours are behaving and why they are not behaving properly. Stroboscopy slows down the apparent high speed of vibration so that the detailed movement of the vocal cord edges can be seen during their hundreds of vibrations per second. Digital recording technology allows video to be reviewed at various speeds with a clear, streak-free image.
The Explanation
Your physician should take the time to review the video with you and arrive at a plausible explanation of what your problem is and how to treat it. It should make sense, even to you. The physician should be able to tell you things about your voice that make you feel: “Ah ha — he understands my problem.” The voice box is not mystical; it is mechanical, and mechanical things make sense. All the pieces of the puzzle should fit together.
Don’t hesitate to get a second opinion — especially if you are not clear on things, especially if your physician doesn’t specialize in voice issues, and especially if recommended treatments are not helping you.
Signs of Concern
If your physician uses the words “vocal cord stripping” in the context of your vocal cords, finish the visit, thank the doctor, and then look elsewhere for care. You do not want anyone stripping off the delicate lining of your vocal cords. Words like “delicate trimming” or “precise excision” are more reassuring; “scraping” or “stripping” are not.
If your physician saw a bump but cannot reasonably demonstrate how that bump is impairing your voice, that is a red herring. Bumps are not always the cause of a vocal problem — that is the problem with looking and not listening. A bump in a given place will cause a given change in your voice; if the change in the voice is not consistent with the location of the bump, the bump may not be the cause.
The Team Approach
Many institutions have instituted the “team approach” — one person takes your history, another looks at your vocal cords, another runs voice tests, and a physician comes in at the end to summarize recommendations. I think the game of chess might be a better analogy for voice problems than a group puzzle. Complex problems — like chess and like the voice — are often better played by a single astute player who sees the whole problem, rather than by a team whose insights are fragmented. Putting together patients’ behavioral patterns, audible changes in voice quality, and complex movements of the muscles and lining of the voice box takes a kind of intuitiveness that grows over time in a single experienced clinician. For now, you want a good physician with a great deal of interest in your voice.
What you learned
- A thorough voice examination requires listening to the voice under multiple conditions — soft, loud, high, low, sustained — before the endoscope is even introduced.
- Video recording plus stroboscopy is the standard of care; without it, transient findings are missed and the examination cannot be reviewed or shared.
- The physician’s explanation should be mechanical and comprehensible, not mystical; if it doesn’t make sense to you, ask for a clearer answer or seek a second opinion.
- “Vocal cord stripping” — yanking or scraping off tissue — is a technique that should no longer be in use; if it is proposed, seek care elsewhere immediately.
- A bump is only the cause of hoarseness if the location and type of the bump are consistent with the type and pattern of hoarseness the patient experiences.