How to Hear and See a Voice Problem
A standard medical exam has two parts: a history and a visual exam. I have argued before that this is insufficient for laryngology, and that a recorded voice examination belongs alongside them as a beneficial and for me, a required third element. For World Voice day I am presenting the benefit of this approach through a case study.
History. A 55-year-old high school coach is hoarse for six months, no longer able to sing in his upper range without the voice cutting out.
Previous general ENT exam. From a distance, his vocal cords looked normal.
My History. I elicit from him that he is a quiet man who uses his voice loudly at work, and he sings. He characterizes an impairment at the top of his singing range. Before I pick up an endoscope, that suggests to me a problem on the surface of the vocal cord.
My Ear. I aim to elicit a full panorama of his voice with my standard audio recording exam: speaking pitch, maximum phonation time, lowest and highest notes, loud and soft pitch phonations. Starting at the beginning of my recording, I note a comfortable speaking pitch around B2. He has a pretty short nine-second maximum phonation time, at least rather short for a healthy singer in his fifties, so he is spending a lot of air to make sound. His vocal range runs E2 to G4, 2.5 octaves. Yelling, his voice sounds crystal clear. The only really audible impairment appears at the top of his range, elicited at low volume, near G4 — and he avoids going there, because he does not like the sound. Patients may complain about their voice, but really hate to sound bad in my office, so I coax him into singing Happy Birthday very softly by letting him sing it loud first and then ask him to contrast that with a soft version. That is where I hear an onset delay and a double pitch.
My Technology. Now I know what to look for on my endoscopic exam, and I also know at what pitch I am most likely to reveal the problem. On plain endoscopy, a faint white plaque covers the central, medial surface of both membranous vocal cords. On stroboscopy, secretions pool at the center of the true cord instead of spreading evenly — the physics of a dampened vibratory segment. I then record with a 70 degree rigid endoscope, the camera turned 90 degrees, filling the video frame with the vocal cords horizontal. I record at a high pitch with low airflow. This reveals a swelling on the central, medial margin of the true cord. At this pitch, the swellings touch each other, vibration stops and the sound breaks. For further ease of perceiving the problem I stabilize the recording with an AI program and slow the video down which fairly clearly reveals the swelling that had been present in every image I captured.
For this lecture, I chose a small lesion for the purpose of revealing how I can find seemingly hidden vocal cord impairments. The sequence (history, audio recording, directed video stroboscopic exam) is the point, because it is repeatable. Take the patient complaint seriously, record the voice across its full range and volume, then bring the endoscope to the pitch where one hears the problem. Individuals who jump from the history to the visual exam tend to send this man home with a “normal exam.”