Models  |  Listening  |  Caution

It is hard to imagine treating the voice without studying the voice. By studying the voice, I mean learning to listen to the voice. Contrary to the belief of some, one does not need to be a singer to study the voice, only an observer. The study of singing is certainly a great benefit to the examiner who wishes to treat voice disorders, and if you have the time voice lessons can make you a better observer. At a minimum, treating voice disorders does require hearing and perhaps the ability to match pitch would make life easier.

This handbook describes a model for the voice examiner for diagnosis and treatment based on listening to the disordered voice. Visualization of the larynx is used for confirmation, more than diagnosis, of the disease process.

However, many physicians today treat voice disorders relying primarly on a visual model. In my experience, the visual model leads to over treatment, under treatment and at times complete failure to diagnose disease that is not easily visualized.

First, the visual model as I have observed it in practice. It is based on other areas of otolaryngology, perhaps most closely trying to emulate the otologic model. It consists of four basic components. They are 1) history, 2) general ENT examination, 3) videostroboscopy and then send the patient for 4) «objective voice measure» testing. This «objective voice measure» is trying in some way to be the correlate of an otologist’s audiogram.

The Voice Oriented Examination as first proposed by Robert W. Bastian has three parts. They are 1) history, 2) vocal capability battery and 3) videolaryngoscopy. It is seldom necessary to order additional tests. When they are ordered they are typically complementary tests and not the «objective voice measures» referred to above. Examples would be x-rays that complement the clinical exam.

I believe the visual model has several traps.

1. Objective voice measures have yet to be standardized the way the audiogram has. In audiology, the examiner has control over the stimulus and the patient responds. The stimulus is controlled by the examiner and can be repeated with great consistency. The response can be measured even with the patient unconscious as in an Auditory Brainstem Response test.
   In voice, the examiner has less control, since they are now measuring the stimulus, rather than the response. The examiner can attempt to elicit a wide array of stimuli from the patient, but the patient may have a difficult time making each stimulus exactly the same. Controlling pitch, volume, subglottic pressure, and articulation is difficult, after all, isn’t that why many of us sing so softly at church.
2. If you are not certain what the patients voice disorder is at the end of the history, it is likely you will miss or misinterpret findings on the videostroboscopy examination. You may even find a visible lesion that has nothing to do with the patients problem as videostroboscopic images in the absence of voice data is notoriously overread(Phillipe Decjonckere, Presentation, Voice Foundation Conference, June 1998).
3. Since objective voice measures are seldom or never actually used for decision making in practice, they are a great financial burden on the health care system.

The advantages to understanding and using the Voice Oriented Examination model are incisiveness, cross checking and constant orientation to the voice disorder at hand. By maintaining this orientation the patient will always leave the office with the proper diagnosis and the physician will never feel lost. Unnecessary testing is avoided. Medical costs are kept under control. How could you beat that?

Models  |  Listening  |  Caution