Vocal capabilities pattern matching

Reviewing the four Vocal Capabilities Pattern examples, we can begin to visually see that combining loudness and pitch reveal patterns.

Clear sound is coded in green. Roughness is encoded Red and Breathiness is encoded in Blue.

Vocal cord margin swellings

With impairments at low volume and high pitch we see a graph with audible pathology on the lower right side and that points toward vocal swellings.

Recurrent laryngeal nerve paresis

With vocal paresis of the anterior branch of the recurrent laryngeal nerve, findings will be most audible at low pitch and low volume, so in the lower left corner.

Vocal cord bowing

With vocal bowing, the pattern is of impairment at low volume, where there is not enough air to drive the vocal cords through a wide gap.

External compression of vocal cords

With external compression of the vocal cords, the pattern is of impairment at all volumes and both volume and range can be restricted.

These patterns orient us to predict what we will find on laryngoscopy. At a minimum, they will direct the examiner where to look and what task to ask the patient to perform while recording with an endoscope or a stroboscope. When the same person performing endoscopy performs these vocal elicitations, the process of differential diagnosis formulation that began during the history progresses during vocal capabilities testing. The examiner is beginning a visual thinking process about where to look for the sound impairment while listening to the vocal capabilities. The examiner is an audio engineer, seeking any impairment of the vocal signal, seeking any inappropriate introduction of noise into the voice. In my experience, these tests are sufficient to elucidate almost all vocal disorders. 

Every type of vocal impairment will have a characteristic pattern, not only in which quadrant the impairment is present, but the pattern of red (roughness) and blue (breathiness) will add to the character of the pattern. We can think of them as a Vocal Signature specific to a disorder. There are also very specific findings, such as onset delays, pitch breaks and flutter that further aid in the identification of a disorder. Many of these patterns are so distinct that the examiner can make a relatively accurate prediction of what will be found on laryngoscopy before looking.

I have been performing these tests often enough and long enough that I can often hear and identify voice problems just walking through a crowd. One of my hobbies is traveling and meeting new people. I hear the person’s accent and their vocal character, and then I can start to hear a vocal impairment if one is present. At some point into our conversation, I can make some predictions about where they are from based on the accent and what they are like socially based on whether I hear the attributes of vocal swellings. The accent of speech and the character of voice tell a lot about an individual, particularly if they are a member of the vocal overdoers or vocal underdoers of the world.

Secrets of listening for hoarseness – Vocal capabilities handout

Download the Laryngology – Secrets of Listening pdf file: Secrets of listening - 2020-01.pdf

I utilize this handout at lectures. It is a pdf file covering the same ground as the Vocal Capabilities section of this website, compiled into a 24 page, full-color booklet.


These examples are not enough to cover all the audible patterns that can be created by laryngeal disorders that cause hoarseness and, by definition, impair harmonic voice production. However, whatever pattern one hears, the vocal pattern should be explainable by the subsequent visual examination. In fact, this technique is self-teaching in that, when a new vocal impairment pattern is heard, the examiner who views the vocal cords endoscopically using the same vocal maneuvers that elicit an impaired voice on vocal capabilities testing, will often discover the reason for the vibratory impairment, even if it is new to the examiner. The examiner who records audio of vocal capabilities pattern matching will also have feedback to discover and learn when the phonatory system is altered during surgery on the vocal cords or in the vicinity of the motor nerve supply of the larynx, whether intentionally or unintentionally.


All vocal impairments can be described in terms of roughness and breathiness, the “R” and “B” of the GRBAS system. Roughness is typically diplophonia, although other quantities of multiple simultaneous pitches can be produced, all creating the perceived quality of roughnessBreathiness is unwanted air leak or air escape between vocal cords that do not completely approximate or are stiff. We can be more precise than simple grading of the amount of roughness and breathiness. A more accurate descriptive method is noting the onset of roughness and/or breathiness as present at high pitch, low pitch or at both. We can be even more precise and note the specific pitch at which diplophonia begins to be produced or breathiness become significantly noticeable, and then whether or not this condition is present from this onset pitch upward or this onset pitch downward. The most accurate record is to have dated audio and video recordings maintained for future review and comparison.

Utilizing the following parameters for vocal capabilities pattern matching; comfortable speaking pitch, maximum phonation time at comfortable speaking pitch, vocal range (lowest pitch, highest pitch), loudness capability, vegetative sound capability and vocal swelling test we can then define or describe the vocal signature of each patient with a complaint of hoarseness. This vocal signature orients the examiner to the where (vocal cord margins), when (pitch and volume) and what to observe for (gap or diplophonia) during recording of laryngoscopy and stroboscopy.

If each physician were to record the vocal capabilities of every patient before and after interventions to the vocal cords, and before and after interventions in the region of the recurrent laryngeal nerve, we would learn more about vocal injuries. We would more precisely learn when we are successful in altering the voice, since harmonic sound production is a successful outcome, not vocal cord appearance. Vocal capabilities pattern matching essentially tests the status of the laryngeal muscles, the status of the closure of the margins of the vocal cords, the flexibility of the vocal cord mucosa, as well as the status of the symmetry of the vocal cords.


1. Cohen SM, Pitman MJ, Noordzij JP, Courey M (2012) Evaluation of dysphonic patients by general otolaryngologists. Journal of voice : official journal of the Voice Foundation 26 (6):772-778. doi:10.1016/j.jvoice.2011.11.009

2. Thomas JP, Zubiaur FM (2013) Over-diagnosis of laryngopharyngeal reflux as the cause of hoarseness. Eur Arch Otorhinolaryngol 270 (3):995-999. doi:10.1007/s00405-012-2244-8

3. Isshiki N, Okamura H, Tanabe M, Morimoto M (1969) Differential diagnosis of hoarseness. Folia Phoniat 21:9-19

4. Hirano M (1981) Clinical Examination of Voice. Springer-Verlag, Vienna

5. Dejonckere PH, Lebacq J (1996) Acoustic, perceptual, aerodynamic and anatomical correlations in voice pathology. ORL; journal for oto-rhino-laryngology and its related specialties 58 (6):326-332

6. Sulica L (2014) Hoarseness misattributed to reflux: sources and patterns of error. Ann Otol Rhinol Laryngol 123 (6):442-445. doi:10.1177/0003489414527225

7.. Cohen SM, Garrett CG (2008) Hoarseness: is it really laryngopharyngeal reflux? The Laryngoscope 118 (2):363-366. doi:10.1097/MLG.0b013e318158f72d

8. Belafsky PC, Postma GN, Koufman JA (2002) Validity and reliability of the reflux symptom index (RSI). Journal of voice : official journal of the Voice Foundation 16 (2):274-277

9. Hopkins C, Yousaf U, Pedersen M (2006) Acid reflux treatment for hoarseness. The Cochrane database of systematic reviews (1):CD005054. doi:10.1002/14651858.CD005054.pub2

10. Koufman JA, Aviv JE, Casiano RR, Shaw GY (2002) Laryngopharyngeal reflux: position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg 127 (1):32-35

11. Turley R, Cohen S (2010) Primary care approach to dysphonia. Otolaryngology -- Head and Neck Surgery 142 (3):310-314. doi:10.1016/j.otohns.2009.12.022

12. Chandrasekhar SS, Randolph GW, Seidman MD, Rosenfeld RM, Angelos P, Barkmeier-Kraemer J, Benninger MS, Blumin JH, Dennis G, Hanks J, Haymart MR, Kloos RT, Seals B, Schreibstein JM, Thomas MA, Waddington C, Warren B, Robertson PJ, American Academy of O-H, Neck S (2013) Clinical practice guideline: improving voice outcomes after thyroid surgery. Otolaryngol Head Neck Surg 148 (6 Suppl):S1-37. doi:10.1177/0194599813487301

13. Rosen CA, Murry T (2000) Voice handicap index in singers. Journal of voice : official journal of the Voice Foundation 14 (3):370-377

14. Hogikyan ND, Sethuraman G (1999) Validation of an instrument to measure voice-related quality of life (V-RQOL). Journal of voice : official journal of the Voice Foundation 13 (4):557-569

15. Takahashi H, Koike Y (1976) Some perceptual dimensions and acoustical correlates of pathologic voices. Acta oto-laryngologica Supplementum 338:1-24

16. Dejonckere PH, Obbens C, de Moor GM, Wieneke GH (1993) Perceptual evaluation of dysphonia: reliability and relevance. Folia phoniatrica 45 (2):76-83

17. Kempster GB, Gerratt BR, Verdolini Abbott K, Barkmeier-Kraemer J, Hillman RE (2009) Consensus auditory-perceptual evaluation of voice: development of a standardized clinical protocol. American journal of speech-language pathology / American Speech-Language-Hearing Association 18 (2):124-132. doi:10.1044/1058-0360(2008/08-0017)

18. Thomas JP (2014) Assessment of the Professional Voice: The Three-Part Examination. In: Bhattacharyya AK, Nerurkar NK (eds) Laryngology. Otolaryngology - Head and Neck Surgery Series. Thieme Medical and Scientific Publishers Private Limited, a-12, Second Floor, Sector-2, Noida, Uttar Pradesh - 201 301, India, pp 315-323

19. Bastian RW, Keidar A, Verdolini-Marston K (1990) Simple vocal tasks for detecting vocal fold swelling. Journal of voice : official journal of the Voice Foundation 4:172