Case study

History

Gabriella is a performer with nightly shows for another 4 weeks. She is having difficulty with her voice giving out by the end of each performance.  Even while I listen to her tell me her history, I can hear a husky quality to her voice.

Vocal Capabilities

This continues as she performs the reading task, although it can be difficult to distinguish the white noise at times with all the words and her robust volume. When she performs a maximum phonation time at her comfortable pitch, the air leak is fairly obvious. She runs out of air after 7 seconds, a very short time for anyone, much less a performer trained in vocal technique. From spontaneous speech, reading speech and maximum phonation time tests, I can begin to graph her voice. 

The dark circle represents a typical female speaking pitch. Her comfortable speaking pitch is G3, in the range of a typical female’s speaking pitch, so I have added a yellow circle to signify that her comfortable speaking pitch is normal. Then I painted a light blue area over this, representing audible air leak at this pitch.

I ask her to make sounds at several pitches, working up toward her highest pitch and again I hear air leak.

Wherever I hear air leak, I paint a blue area. At a soft reading volume she is leaking air at a number of pitches. As she goes up in pitch, her volume increases. This is a common and unintentional compensation that has developed over time.

Laryngoscopy

Even before I get out an endoscope to look at her vocal cords, I know that the cords are not closing together completely. There is a continuous flow of air throughout much of her vocal range. If I were to take a look at her vocal cords after this much of a vocal evaluation, I would see that the vocal cords never close on stroboscopy, even during the most closed phase portion of vocal cord oscillation.

Stroboscopic exam at pitch G3 (maximum closed phase). The dark areas are where the vocal cords never close at this pitch and represent air leak and likely turbulent airflow. The dark areas are the reason she is husky at her comfortable speaking pitch.

On the same exam her vocal cords are recorded during stroboscopy at a higher pitch – C5, and this still photo is extracted from the most closed phase at C5. Again, there are large dark areas representing continuous air leak and likely turbulent airflow generating white noise or huskiness.

Summary

Air leak or huskiness is one of the two major types of hoarseness. We diagramed air leak on a pitch vs. volume plot and the blue areas representing air leak on our vocal diagram will correspond to continuous dark areas during stroboscopy.

We have:

1. used a few vocal capabilities (reading, maximum phonation time, low and high pitch) to hear a specific vocal impairment – air leak.
2. diagrammed the impairment on a pitch vs volume plot which gave us a pattern.
3. correlated the audible finding huskiness with the endoscopic finding of incomplete closure of the vocal cords.

This particular pattern of air leak at low pitch and low volume along with air leak at high pitch and high volume is typical of large vocal swellings. The same pattern may also be typical of muscle tension, where the vocal cords are held apart by a competitive tension between the lateral cricoarytenoid muscles and the posterior cricoarytenoid muscles. 

We can (and should) test further vocal capabilities to maximally refine our differential diagnosis. I test all the capabilites mentioned in chapter 18 on each patient. Complete testing increases my ability to recognize patterns and not to miss an important finding.

We can (and should) perform endoscopy and stroboscopy to correlate our suspected audible findings with visual findings.