Academic journal article Journal of Singing

What to Expect during a Visit with a Voice Doctor. Part II: The Examination

Academic journal article Journal of Singing

What to Expect during a Visit with a Voice Doctor. Part II: The Examination

Article excerpt

[The first part of this article reviewed current concepts in acquiring a medical history, in order to help singers recognize what they should expect when visiting a physician who professes expertise in voice. Part II reviews the physical examination and some of the tests that commonly accompany an expert voice team assessment.]


FOLLOWING THE HISTORY, the physician will perform a physical examination, which includes examination of the entire ear, nose, throat, head, and neck region.1 Included in this evaluation should be an assessment of hearing function. This should include at least examination with a tuning fork, and if indicated, a formal hearing test (audiogram). After the head and neck are examined, a detailed assessment of the larynx is usually performed.

Evaluation of the larynx usually involves evaluation of the movement of the vocal folds during speech, singing, and other tasks, and evaluation of the vibratory function of the folds. Vocal fold movement is usually best assessed with a flexible, fiberoptic laryngoscope with continuous light, and assessment of vocal fold vibration is usually assessed with stroboscopic light, using either a flexible laryngoscope, a rigid laryngoscope, or both.

Flexible Laryngoscopic Examination

A flexible laryngoscope is a thin, lighted telescope (endoscope) that is placed through the nose and into the throat and usually does not cause pain, although it may cause a slight discomfort in the nose. The patient is seated and awake during the examination. The flexible laryngoscope allows the physician to see the larynx in its natural position, without the distortion that sometimes occurs with holding the tongue forward for mirror and rigid telescopic examinations. In viewing the larynx in its natural position, the physician can assess changes in laryngeal muscle tension while the patient is talking or singing. There are certain vocal maneuvers that the otolaryngologist/laryngologist will ask the patient to perform during the flexible laryngoscopic examination. These include various tasks of talking, singing, and whistling. While the patient is performing these maneuvers, the otolaryngologist/laryngologist is evaluating the motion and mobility of the vocal folds.

The patient will be asked to perform several tasks that require stretching and lengthening the vocal folds. These tasks may include counting at several different pitches and/or sliding from a low pitch to a high pitch while saying the sound /i/. If there is a primary problem in the superior laryngeal nerve, this will be evidenced by an inability to lengthen the vocal fold with high-pitched phonation. If the weakness is severe, there can be a tilt of the larynx towards the side of the weakened superior laryngeal nerve and/or cricothyroid muscle. The larynx tilts toward the side of the weakness on lengthening because the cricothyroid muscle on the normal side pulls the thyroid cartilage anteriorly (forward) and down toward the cricoid cartilage; the paretic cricothyroid muscle is weak and pulls the thyroid cartilage to a lesser degree, resulting in tilting of the larynx towards the side of the weak superior laryngeal nerve and cricothyroid muscle.

If there are problems with both superior laryngeal nerves, there will be limitations in the ability to produce a high pitch and in the ability to stretch the vocal folds on both sides. This diagnosis may be somewhat difficult, especially if both nerves are injured to the same degree. Both vocal folds will have limitations in their abilities to stretch, making the ability to see subtle abnormalities difficult for the examiner. Occasionally, with superior laryngeal nerve paresis, there is seen an abnormality in the ability of the vocal fold on the affected side to adduct (bring the vocal folds towards the midline). Sluggish adduction of the vocal fold is best seen when the patient tries to engage in vocal maneuvers that involve a rapid movement of the vocal folds. …

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