Foundations for Understanding voice

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A process for understanding voice and Diagnosing hoarseness

When something goes wrong with a voice, an individual typically says, “I am hoarse.” What do they mean by, “I am hoarse.”? Hoarseness is a common complaint and we will delve into the obvious and the nuance of what it means to be hoarse.

But why should this individual come see you, the voice professional? What can you discover about the cause of a hoarse voice that someone else cannot? What do you need to do to make an accurate diagnosis? Do you look in the mouth? Do you guess? Do you write a prescription for a pill?

Unfortunately, after saying, “I am hoarse,” getting an accurate diagnosis can be a long, tough process. An individual may see a family doctor, a speech therapist, a voice teacher and even several specialists. They may be told, “It will get better with time.” They may receive some type of treatment. They may persist in looking for answers when the hoarseness does not go away.

As a health care provider, if you have been guessing, or just passively doing what you were taught, what can you do to make your guess more educated? Are your patients coming back, but not really getting better as often as you would like? Can you really see the cause of hoarseness? Have you ever wondered if there really is a purple pill that can cure hoarseness?

I purchased an endoscope and a stroboscope and began filming vocal cords, trying to find something wrong with hoarse voices, finding a visible problem at times, but not consistently. Trying to learn more, I would take a week off from my practice to study with various laryngologists, seeing what I could learn and improve my skills. I visited one laryngologist in Chicago, Robert Bastian, and discovered a physician who had taught himself how to not only listen to a patient’s history, but also how to listen to and to hear her voice. 

I returned the following year to study with Robert for another six months. After that study, I limited my practice to only laryngeal disorders and soon became aware that I was able to hear voice problems before I made a video recording of the vocal cords with an endoscope. That was the beginning of when I felt like I was becoming a voicedoctor, when I could both hear and see voice disorders. This idea of hearing voice disorders became a key, unlocking hoarseness.

The key opens the door, but then you need to look, view and record the vocal cords vibrating inappropriately. Technology for imaging the vocal cords includes stroboscopic lighting, flexible endoscopes, rigid endoscopes, chipontip endoscopes, highdefinition cameras, digital recording, high definition monitors, highspeed cameras and selective color filters. A lot of money can be tied up in a voice laboratory with the latest technology.

Which is equipment is essential? Which equipment is optional? What should I start with? How do I put a voice laboratory together?

Visualizing vocal abnormalities benefits from a combination of equipment and expertise leading to a precise diagnostic view of functioning vocal cords. Let’s call high definition laryngologythe means that allow the examiner to optimize images, regardless if they are obtained with high or low technology or even lower quality equipment. An optimum combination of technique and equipment leads to a costeffective, high yield and accurate diagnosis for laryngeal problems. It also leads to an improved understanding of how the larynx actually functions normally, producing clear sound both for speaking and for singing. 

On voicedoctor.net, I present some of my ideas about voice disorders that, with regularity, trigger email from people with a voice problem. My patients tell me strikingly similar stories in the office. While each person’s story is her own, frequent themes are:

The explanation for my hoarseness doesn’t make sense.

I have tried so many treatments without success. 

I’m still taking this pill, but my voice isn’t any better.

After I listen to the patient’s story, listen to their voice put though a few paces and put a camera into their throat, visualizing a high definition video recording of the vocal cords vibrating inappropriately, I will combine all of this into an explanation. I show a patient her own vocal cords enlarged on a video screen and describe the impairment in easy to understand terms. I have the sense that the views of the moving vocal cords, coupled with this understandable explanation, often meets the initial needs of the hoarse patient. I understand the problem and she understands the problem. Frequently enough, the explanation leads further, to a remedy or a resolution. The explanation for the hoarseness makes sense. This understanding seems to be more than she has received before and consequently, I write this book so that more health care providers might come to understand hoarseness.

A patient will come to you because you understand their complaint. You also have the ability to focus the exam on their voice, elicit their hoarseness during the exam and then use appropriate tools to view the impairment. This combination is high definition laryngology. After explaining the impairment to the patient, in all likelihood, they will also trust you to manage the impairment, treating it if possible.

Layout of Diagnosis

In Part I, voice is defined and we sort out what we really mean when we say, “My voice is hoarse.” In effect, defining the difference between normal voice and abnormal voice. This will lay a straightforward foundation for how to think about hoarseness. 

In Part II, the reader will learn how to listen to the human voice with a goal of diagnsis, how to remove compensation and expose pathology using sound. Vocal disorders have patterns and the successful diagnostician will be able to recognize these patterns,

All of the cases on this site are from my experience. For privacy, any patient names are fictional. While the gender of the patient is unchanged in each case described, I try to randomly use male and female pronouns when referring to generic people or physicians.