Anchor pitch - Reading
The patient reads a paragraph out loud in a comfortable voice, using the same paragraph for every exam. It may be boring, but I record the same passage on every exam so when the patient returns in the future, it is very easy to compare.
Reading is admittedly a mixture of voice and speech, but this accomplishes several things. Reading relaxes the patient and takes the focus away from the examination – most patients start out with a great deal of anxiety.
A patient may be anxious about what foul tasting medicine I am going to put in her throat, how big the tube is that I am going to put in her nose and how much the exam will hurt. These fears are not irrational, as many patients who visit have been examined previously and the medicine did taste terrible, the exam was very uncomfortable or even painful and they may have gagged terribly.
While I have not solved the taste issue, only ameliorated it, the pain issue should be nonexistent. Lidocaine is an excellent topical anesthetic. Combined with a decongestant and some flavoring, the most a patient should experience is a light internal pressure during an exam with an endoscope. For the terrible gagger, with a combination of topical anesthesia and the patience to allow the anesthetic sufficient time to work, there is no one I have not been able to examine.
Gagging can be completely psychological. A few patients gag at the sight of an endoscope, but there are some techniques for getting around the mind.
Anyway, starting out with a simple reading task puts most people at ease.
Second, by listening to speech, I determine the approximate average speaking pitch by matching the voice with a note on the piano. It is not absolutely necessary to know the precise pitch, though there are apps that can do that. I am generally looking for an approximation. Indeed we typically modulate our comfortable speaking pitch over several notes to convey emotion. Good storytellers modulate a great deal but there will be an approximate central pitch. We use only a very small portion of our vocal range in daily speech.PitchLab for the iPhone) offer a spectrogram that quickly reveals the pitch, so even the laryngologist with a poor ear for pitch can determine the comfortable speaking pitch, as well as other parameters. Pitch does fluctuate while reading (left: spectrogram for a patient's voice). The examiner can hum the most common pitch they are hearing into the phone (right: I am humming to match pitch) to obtain a clearer reading of the central reading pitch.
Third, the reading task allows time to listen and determine if there are any speech impairment issues. Problems with the rate of speaking or poor enunciation become audible while reading. The vocal issue or the hoarseness may not be discernable during reading, but I can decide whether speech is a problem.
Fourth, a degree of severity may be deduced. Hoarseness audible during reading cues the astute examiner to fairly severe breathiness or severe roughness at the comfortable speaking pitch. That is, audible roughness or breathiness heard over a background of spoken words, at the comfortable speaking pitch, signals a significant amount of air leak or a significant amount of irregular vibration.
Fifth, the examiner may begin forming a differential diagnosis. For example, if the comfortable speaking pitch during a reading task is elevated above the typical range for the patient’s gender, such as speaking in a falsetto, atypical recruitment of the cricothyroid muscle may be deduced. If the individual is incapable of reading at a normal pitch, elevated pitch may hint at a neurologic weakness of the recurrent laryngeal nerve with compensation from the superior laryngeal nerve's innervation of the cricothyroid muscle.