Optimal exam

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Complete & adequate voice exam

Three part voice exam

Almost every type of physician-patient interaction begins with a history of the problem. The physician says, “Tell me what happened.” In laryngology, three things are accomplished simultaneously during the history. This history offers a great many clues about likely types of voice disorders based on when the hoarseness started, simultaneous events at the onset, the duration, the severity, changes with use and simultaneous breathing or swallowing problems. Secondly, the examiner gets to begin hearing the conversational voice for a period of time. Third, the patient highlights preconceived perceptions of her problem, which are also important for the physician to address later in the exam.

 People who talk a lot will suffer from a different set of problems than people who are naturally quiet. People who lose their voice suddenly after yelling will have a different problem from those who lose it slowly over time. 

The history is the first of a three part examination:

  1. History,
  2. Vocal capabilities testing,
  3. Visual exam.

A three part examination has the same value as navigation at sea by triangulation. With only one point of reference, the sailor will know only the bearing or direction toward something, and with two points of reference she might be able to narrow her location on the map to a few possibilities, but with three references, the sailor can be almost certain of her exact location. Likewise, when all three portions of the laryngeal exam point to the same problem, the physician can say with great assurance, “This is the likely diagnosis.”

History

A medical history is fairly standardized across medical specialties. I use an intake form to collect details relevant to hoarseness before I visit with the patient. 

Laryngology - Voice History & Physical Exam intake form

During the office visit, I want my attention to be focused on hearing the patient’s story. I not only want the details about when, where and how the vocal impairment seemed to start, but I want to hear this story from the patient directly. 

  • The telling of the story gives me a sense of the patient’s priorities in terms of solving the problem. 
  • I am also actually hearing the problem as they use their voice to tell me the story. 
  • I get a sense of the patient’s preexisting biases that I may need to deal with.

One of the areas I find very useful is what the patient recalls from seeing each physician before me. Even if I have the actual physician’s notes of the prior appointment, I still want to hear what the patient recalls. I will then know if I need to address some preexisting bias.

For example, many times during a history a patient tells me that he is hoarse because of GERD. He just has not improved on treatment directed at GERD, so he believes he just hasn’t had sufficient treatment. Even if I don’t believe GERD has anything to do with his hoarseness, at the end of my exam I need to not only tell the patient about my recommended treatment, but I also need to address his belief in GERD as a cause of his problem.

It is helpful to have a standardized intake form so that potential important information is not missed. I assess talkativeness, loudness and work vocal use, three areas that may not be in a typical otolaryngology intake form.

Physical examination form

This is a guide for areas I typically attend to during an examination.

Laryngology - Voice Physical Exam documentation form

Vocal committments 

Vocal committments refer to how much time the individual devotes to singing. 

ENT exam 

ENT exam is a general overview of the head and neck region.

Laryngeal Acoustic Testing - Vocal Capabilities

I elicit a battery of vocal tasks and record them. These are described in a subsequent chapter on Vocal Capabilitie. Usually I will have a focused differential diagnosis after this point in the exam.

Endoscopy & stroboscopy

I use the information obtained in the history and during the vocal capabilities assessment to focus my endoscopy on the likely area of vocal pathology.

In a subsequent chapter, I discuss options for endoscopically examining vocal cord structure and function.

Summary

This three-part exam leads to confident diagnosis.