An initial conversation
“Tell me what happened" or "Tell me what's troubling you”. The patient then tells the story about his or her voice problem. 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, et cetera.
- Secondly the examiner gets to begin hearing the conversational voice for a period of time.
- Third, the patient’s preconceived perceptions of their problem 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.
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.
Elicit the primary complaint of the patient so that I can focus during the examination.
Listen to the patient's version of events
During the office visit, attention is focused on hearing the patient’s story. Not only are the details about when, where and how the vocal impairment seemed to start important, but a direct telling of the story by the patient:
- Gives a sense of the patient’s priorities in terms of solving the problem.
- Hearing the vocal quality as they use their voice to tell the story (really the beginning of the examination).
- The patient’s preexisting biases are revealed and may need to be dealt with.
Voice issues should usually involve complaints about pitch, volume or clarity. Patients may not actually use these words. Volume and roughness qualities are voice issues that non-singers might typically complain of and pitch impairments, range limitation, clarity and register are issues singers may more likely notice.
A person might say, in addition to, "I am hoarse", something like "I can’t get loud enough to be heard in a restaurant" (volume problem) or "I sound like I have a “frog in my throat”" (clarity problem). A singer might say, “I am missing a few notes” (pitch issue).
Significant historical information from the patient includes:
At times, the patient thinks the exacerbation is the onset. Careful probing will often reveal a much longer duration of illness. Sudden vs slow onset characterize some disorders.
Obvious or believed causes
Events that were synchronous with or preceeded the onset of the voice problem may be considerd likely but not certain causes. Knowing what the patient believes is the cause is important to address after a diagnosis is reached, epecially if it is not in harmony with the patient's beliefs.
A pattern of symptoms develops because every disease is necessarily complex. In particular since the larynx plays a role in swallowing, breathing and speaking, a single change in structure or functional capacity will likely affect multiple symptoms. During the history then, if a few symptoms suggest a particular voice disorder, further questioning can probe for other symptoms that should be present in that particular complex.
Previous treatments and diagnoses
If the patient has already received an opinion or a treatment from another otolaryngologist, speech/voice therapist or any medical provider.
What does the patient recall of previous physician's opinions? This information can be used in conjunction with the actual physician’s notes from a prior appointment. Physician's notes are now filled with digital debris - fluff and litter that make them appear long and thoughtful or at least long. However, what the patient recalls from the visit is very important and was really the outcome of the visit.
For example, many times during a review of previous physican visits 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 (possibly heavily emphasized by the previous examiner) as a cause of his problem.
I sat on a jury once for a medical injury case. The injured person claimed that the automobile collision caused some numbness ever since that date. His lawyers brought in a family physician who testified that because of the timing (symptoms were first noticed after the accident) and a rehabilitation physician who gave a similar proposed reaoning for the symptoms. The lawyer for the other driver called in a neurologist who explained how this particular nerve worked, the anatomy of the nerve in the arm, how the nerve is most commonly injured by daily repetitive use and why the proposed forces from the automobile collision could not stretch the nerve in the way proposed by injured, his lawyer and his physicians.
I felt the specialist, the neurologist, best understood the injury claim, best explained why it probably did not occur and proposed a most likely alternative reason for the injury.
The bulk of the jury however felt that it was a 2 to 1 vote by the health care providers. Their explanations seemed to hold equal weight, so the jury's perceived likely reason was the collision (based on a democracy where all health care providers are created equal).
The external drive to speak has some role in voice disorders.
This is the vocal athletic portion of the history. Singing or vocal performance draws on much more of the voice's capacity than talking alone. Assesing the training, skill level, type of performance and quantity of athletic vocal cord use adds perspective to the voice disorder and vocal needs of the patient.
Tobacco consumption in the form of smoke has a known significant impact on the risk of vocal cord lesions. Vaping tobacco has an unknown interaction with the vocal cords. Smoking marijuana has an unknown impact.
How much fluid intake and how much diuretic intake (caffeine, alcohol) is present in the individual's daily life?
Directly surgeries may injure the vocal cords. Indirectly the endotracheal tube used for general anesthesia may injure the vocal cords.
Various medications may interact with the vocal cords.
- Proton pump inhibitors and H2 blockers may have been prescribed for the voice. If they are offering no benefit they might be discontinued.
- Inhaled steroids have a high risk of fungal laryngitis.
- Oral steroids, particularly with prolonged use, may induce some immune suppression.
What drugs should not be used.
A few neurologic disorders may genetically associated. Perhaps the entire family is loud and socially increases the risk of traumatic lesions.
Review of systems
There may be other elements of health that might play a role in the present voice disorder.
Perception of severity/motivation
This answers the question "Does the patient want only an explanation or do they actually desire intervention?" Because you can do surgery doesn’t necessarily mean that you should. Motivation may also supply clues that support the diagnosis of non-organic disorders.
Quantity & Intensity of use
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.
- Innate talkativeness or intrinsic drive to speak
- Innate loudness or intrinsic drive to overuse vocal cords
- Work: Extrinsic drive to speak