physical examination of voice

Otolaryngol Clin N Am

40 (2007) 953–969

Physical Examination of VoiceProfessionals

Robert T. Sataloff, MD, DMA*,Mary J. Hawkshaw, BSN, RN, CORLN,

Venu Divi, MD,Yolanda D. Heman-Ackah, MD

Department of Otolaryngology–Head and Neck Surgery, Drexel University College

of Medicine, 1721 Pine Street, Philadelphia, PA 19103-6771, USA

Physical examination

A detailed history frequently reveals the cause of a voice problem evenbefore a physical examination is performed. A comprehensive physical ex-amination, often including objective assessment of voice function, also is es-sential, however [1–3]. Physical examination must include a thorough ear,nose, and throat evaluation and assessment of the patient’s general physicalcondition. A patient who is extremely obese or seems fatigued, agitated,emotionally stressed, or otherwise generally ill has increased potential forvoice dysfunction. This dysfunction could be attributable to any numberof factors: altered abdominal support, loss of fine motor control of laryngealmuscles, decreased bulk of the submucosal vocal fold ground substance,change in the character of mucosal secretions, or other similar mechanisms.Any physical condition that impairs the normal function of the abdominalmusculature is suspect as cause for dysphonia. Some conditions, such aspregnancy, are obvious; however, a sprained ankle or broken leg that re-quires the singer to balance in an unaccustomed posture may distract himor her from maintaining good abdominal support and thereby result in voicedysfunction. A tremorous neurologic disorder, endocrine disturbances suchas thyroid dysfunction or menopause, the aging process, and other systemic

This article is modified from: Sataloff RT. Professional voice: the science and art of

clinical care. 3rd edition. San Diego (CA): Plural Publishing, Inc.; 2006. p. 343–53; with per-

mission.

* Corresponding author.

E-mail address: [email protected] (R.T. Sataloff).

0030-6665/07/$ - see front matter � 2007 Elsevier Inc. All rights reserved.

doi:10.1016/j.otc.2007.05.004 oto.theclinics.com

mailto:[email protected]

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conditions also may alter the voice. The physician must remember that mal-adies of almost any body system may result in voice dysfunction, and thedoctor must remain alert for conditions outside of the head and neck. Ifthe patient uses his or her voice professionally for singing, acting, or othervocally demanding professions, physical examination should also include as-sessment of the patient during typical professional vocal tasks. For example,a singer should be asked to sing. Evaluation techniques for assessing the per-formance mechanism are described in greater detail elsewhere [4–10].

Complete ear, nose, and throat examination

Examination of the ears must include assessment of hearing acuity. Evena slight hearing loss may result in voice strain as a singer tries to balance hisor her vocal intensity with that of associate performers. Similar effects areencountered among speakers, but they are less prominent in the early stagesof hearing loss. This observation is especially true of hearing losses acquiredafter vocal training has been completed. The effect is most pronounced withsensorineural hearing loss. Diplacusis, distortion of pitch perception, makesvocal strain even worse. With conductive hearing loss, singers tend to singmore softly than appropriate rather than too loudly, and this is less harmful.

During an ear, nose, and throat examination, the conjunctivae andsclerae should be observed routinely for erythema that suggests allergy orirritation, for pallor that suggests anemia, and for other abnormalities,such as jaundice. These observations may reveal the problem reflected inthe vocal tract even before the larynx is visualized. Hearing loss in a spouseor family member may be problematic also if the voice professional strainsvocally to communicate.

The nose should be assessed for patency of the nasal airway, character ofthe nasal mucosa, and nature of secretions, if any. A patient who is unableto breathe through the nose because of anatomic obstruction is forced tobreathe unfiltered, unhumidified air through the mouth. Pale gray allergicmucosa or swollen infected mucosa in the nose suggests abnormal mucosaelsewhere in the respiratory tract.

Examination of the oral cavity should include careful attention to thetonsils and lymphoid tissue in the posterior pharyngeal wall and to the mu-cosa. Diffuse lymphoid hypertrophy associated with a complaint of scratchyvoice and irritative cough may indicate infection. The amount and viscosityof mucosal and salivary secretions also should be noted. Xerostomia is par-ticularly important. The presence of scalloping of the lateral aspects of thetongue should be noted. This finding is caused commonly by tongue thrustand may be associated with inappropriate tongue tension and muscle ten-sion dysphonia. Dental examination should focus not only on oral hygienebut also on the presence of wear facets suggestive of bruxism. Bruxism isa clue to excessive tension and may be associated with dysfunction of thetemporomandibular joints, which should also be assessed routinely.

955PHYSICAL EXAMINATION OF VOICE PROFESSIONALS

Thinning of the enamel of the central incisors in a normal or underweightpatient may be a clue to bulimia. It may also result from excessive ingestionof lemons, which some singers eat to help thin their secretions.

The neck should be examined for masses, restriction of movement, excessmuscle tension or spasm, and scars from prior neck surgery or trauma. La-ryngeal vertical mobility is also important. For example, tilting of the larynxproduced by partial fixation of cervical muscles cut during previous surgerymay produce voice dysfunction, as may fixation of the trachea to overlyingneck skin. Particular attention should be paid to the thyroid gland. Enlarge-ment of the gland may signal subclinical hypothyroidism or thyroiditis, bothof which can affect the vocal folds, their vibratory function, and the integrityof the laryngeal nerves, in some cases contributing to paresis and paralysisof the superior or recurrent laryngeal nerves. Examination of posterior neckmuscles and range of motion should not be neglected. Neck muscle spasm,decreased range of motion, and cervical spine abnormalities can contributeto increased neck tension and hyperfunctional voice behaviors. The cranialnerves should also be examined. Diminished fifth nerve sensation, dimin-ished gag reflex, palatal deviation, or other mild cranial nerve deficits mayindicate cranial polyneuropathy. Postviral, infectious neuropathies may in-volve the superior laryngeal nerve and cause weakness of the vocal fold mus-cle secondary to decreased neural input, fatigability, and loss of range andprojection in the voice. The recurrent laryngeal nerve is also affected insome cases. More serious neurologic disease may also be associated withsuch symptoms and signs.

Laryngeal examination

Examination of the larynx begins when the singer or other voice patiententers the physician’s office. The range, ease, volume, and quality of thespeaking voice should be noted. If the examination is not being conductedin the patient’s native language, the physician should be sure to listen toa sample of the patient’s mother tongue also. Voice use is often different un-der the strain or habits of foreign language use. Rating scales used to de-scribe the quality of the speaking voice may be helpful [11,12]. Theclassification proposed by the Japanese Society of Logopedics and Phoniat-rics is one of the most widely used. It is known commonly as the GRBASVoice Rating Scale [13].

Physicians are not usually experts in voice classification. Physicians shouldat least be able to discriminate substantial differences in range and timbre,however, such as between bass and tenor, or alto and soprano. Althoughthe correlation between speaking and singing voices is not perfect, a speakerwho has a low, comfortable bass voice who reports that he is a tenor maybe misclassified and singing inappropriate roles with consequent voice strain.This judgment should be deferred to an expert, but the observation shouldlead the physician to make the appropriate referral. Excessive volume or

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obvious strain during speaking clearly indicates that voice abuse is presentand may be contributing to the patient’s singing complaint. The speakingvoice can be evaluated more consistently and accurately using standardizedreading passages [14], and such assessments are performed routinely byspeech-language pathologists, phoniatricians, and sometimes bylaryngologists.

Any patient who has a voice complaint should be examined by indirectlaryngoscopy, at least. It is not possible to judge voice range, quality, orother vocal attributes by inspection of the vocal folds. The presence or ab-sence of nodules, mass lesions, contact ulcers, hemorrhage, erythema, paral-ysis, arytenoid erythema (reflux), and other anatomic abnormalities must beestablished, however. Erythema and edema of the laryngeal surface of theepiglottis is seen often in association with muscle tension dysphonia andwith frequent coughing or clearing of the throat. It is caused by directtrauma from the arytenoids during these maneuvers. The mirror or a laryn-geal telescope often provides a better view of the posterior portion of the en-dolarynx than is obtained with flexible endoscopy. Stroboscopicexamination adds substantially to diagnostic abilities (Fig. 1). Another oc-casionally helpful adjunct is the operating microscope. Magnification allowsvisualization of small mucosal disruptions and hemorrhages that may be sig-nificant but overlooked otherwise. This technique also allows photographyof the larynx with a microscope camera. Magnification may also be achievedthrough magnifying laryngeal mirrors or by wearing loupes. Loupes usuallyprovide a clearer image than do most of the magnifying mirrors available.

A laryngeal telescope may be combined with a stroboscope to provide ex-cellent visualization of the vocal folds and related structures. The authorsusually use a 70� laryngeal telescope, although 90� telescopes are requiredfor some patients. The combination of a telescope and stroboscope providesoptimal magnification and optical quality for assessment of vocal fold

Fig. 1. Photograph of normal larynx showing the true vocal folds (V), false vocal folds (F), ar-

ytenoids (A), and epiglottis (E). (From Sataloff RT. Professional voice: the science and art of

clinical care. 3rd edition. San Diego [CA]: Plural Publishing, Inc.; 2006. p. 343–53; with

permission.)


vibration. It is generally performed with the tongue in a fixed position, how-ever, and the nature of the examination does not permit assessment of thelarynx during normal phonatory gestures.

Flexible fiberoptic laryngoscopy can be performed as an office procedureand allows inspection of the vocal folds in patients whose vocal folds are dif-ficult to visualize indirectly. In addition, it permits observation of the vocalmechanism in a more natural posture than does indirect laryngoscopy, per-mitting sophisticated dynamic voice assessment. In the hands of an experi-enced endoscopist, this method may provide a great deal of informationabout speaking and singing techniques. The combination of a fiberoptic laryn-goscope with a laryngeal stroboscope may be especially useful. This systempermits magnification, photography, and detailed inspection of vocal foldmotion. Sophisticated systems that permit flexible or rigid fiberoptic strobo-videolaryngoscopy are currently available commercially. They are invaluableassets for routine clinical use. The video system also provides a permanent re-cord, permitting reassessment, comparison over time, and easy consultation.A refinement not currently available commercially is stereoscopic fiberopticlaryngoscopy, accomplished by placing a laryngoscope through each nostril,fastening the two together in the pharynx, and observing the larynx throughthe eyepieces [15]. This method allows visualization of laryngeal motion inthree dimensions. It is used primarily in a research setting, however.

Rigid endoscopy under general anesthesia may be reserved for the rarepatient whose vocal folds cannot be assessed adequately by other meansor for patients who need surgical procedures to remove or biopsy laryngeallesions. In many cases this may be done with local anesthesia, avoiding theneed for intubation and the traumatic coughing and vomiting that may oc-cur even after general anesthesia administered by mask. Coughing after gen-eral anesthesia may be minimized by using topical anesthesia in the larynxand trachea. Topical anesthetics may act as severe mucosal irritants ina small number of patients, however. They may also predispose the patientto aspiration in the postoperative period. If a patient has had difficulty witha topical anesthetic administered in the office it should not be used in theoperating room. When used in general anesthesia cases, topical anestheticsshould usually be applied at the end of the procedure. If inflammation oc-curs, it will not interfere with performance of microsurgery. Postoperativeduration of anesthesia is also optimized. The authors have had the least dif-ficulty with 4% Xylocaine.

Objective tests

Reliable, valid, objective analysis of the voice is extremely important and isan essential part of a comprehensive physical examination [2]. It is as valuableto the laryngologist as audiometry is to the otologist [16,17]. Familiarity withsome of the measures and technological advances currently available is help-ful. This information is covered in greater detail elsewhere [5].

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Strobovideolaryngoscopy

Integrity of the vibratory margin of the vocal fold is essential for the com-plex motion required to produce good vocal quality. Under continuouslight, the vocal folds vibrate approximately 256 times per second while pho-nating at middle C. Naturally, the human eye cannot discern the necessarydetails during such rapid motion. The vibratory margin may be assessedthrough high-speed photography, strobovideolaryngoscopy, high-speedvideo, videokymography, electroglottography (EGG), or photoglottogra-phy. Strobovideolaryngoscopy provides the necessary clinical informationin a practical fashion. Stroboscopic light allows routine slow-motion evalu-ation of the mucosal cover layer of the leading edge of the vocal fold. Thisstate-of-the-art physical examination permits detection of vibratory asym-metries, structural abnormalities, small masses, submucosal scars, and otherconditions that are invisible under ordinary light [18,19]. Documentation ofthe procedure by coupling stroboscopic light with the video camera allowslater reevaluation by the laryngologist or other health care providers.

Stroboscopy does not provide a true slow-motion image, as obtainedthrough high-speed photography. The stroboscope actually illuminates dif-ferent points on consecutive vocal fold waves, each of which is retained onthe retina for 0.2 seconds. The stroboscopically lighted portions of the suc-cessive waves are fused visually; thus the examiner is actually evaluatingsimulated cycles of phonation. The slow-motion effect is created by havingthe stroboscopic light desynchronized with the frequency of vocal fold vi-bration by approximately 2 Hz. When vocal fold vibration and the strobo-scope are synchronized exactly, the vocal folds appear to stand still ratherthan move in slow motion. In most instances, this approximation of slowmotion provides all the clinical information necessary [5,19]. We use a mod-ification of the standardized method of subjective assessment of strobovi-deolaryngoscopic images, as proposed by Hirano and colleagues [20,21].Characteristics evaluated include the fundamental frequency, the symmetryof movements, periodicity, glottic closure, the amplitude of vibration, themucosal wave, the presence of nonvibrating portions of the vocal fold,and other unusual findings. With practice, perceptual judgments of strobo-scopic images provide a great deal of information. It is easy for the inexpe-rienced observer to draw unwarranted conclusions because of normalvariations in vibration, however. Vibrations depend on fundamental fre-quency, intensity, and vocal register. For example, failure of glottic closureoccurs normally in falsetto phonation. Consequently, it is important to notethese characteristics and to examine each voice under various conditions.

Other techniques to examine vocal fold vibration

Other techniques to examine vocal fold vibration include ultrahigh-speedphotography, EGG, photoelectroglottography and ultrasound glottogra-phy, and most recently videokymography and high-speed video (digital or


analog) [22]. Ultrahigh-speed photography provides images that are in trueslow motion, rather than simulated. High-speed video offers similar advan-tages without most of the disadvantages of high-speed motion pictures. Vid-eokymography offers high-speed imaging of a single line along the vocalfold. EGG uses two electrodes placed on the skin of the neck above the thy-roid laminae. It traces the opening and closing of the glottis and can be com-pared with stroboscopic images [23]. EGG allows objective determination ofthe presence or absence of glottal vibrations and easy determination of thefundamental period of vibration and is reproducible. It reflects the glottalcondition more accurately during its closed phase. Photo electroglottogra-phy and ultrasound glottography are less useful clinically [13].

Measures of phonatory ability

Objective measures of phonatory ability are easy to use, readily availableto the laryngologist, helpful in treatment of professional vocalists who havespecific voice disorders, and are useful in assessing the results of surgicaltherapies. Maximum phonation time is measured with a stopwatch. The pa-tient is instructed to sustain the vowel /a/ for as long as possible after deepinspiration, vocalizing at a comfortable frequency and intensity. The fre-quency and intensity may be determined and controlled by an inexpensivefrequency analyzer and sound level meter. The test is repeated three timesand the greatest value is recorded. Normal values have been determined[13]. Frequency range of phonation is recorded in semitones and documentsthe vocal range from the lowest note in the modal register (excluding vocalfry) to the highest falsetto note. This range is the physiologic frequencyrange of phonation and disregards quality. The musical frequency rangeof phonation measures lowest to highest notes of musically acceptable qual-ity. Tests for maximum phonation time, frequency ranges, and many of theother parameters discussed later (including spectrographic analysis) may bepreserved on a tape recorder or digitized and stored for analysis at a conve-nient future time and used for pre- and posttreatment comparisons. Record-ings should be made in a standardized, consistent fashion.

Frequency limits of vocal register also may be measured. The registers are(from low to high) vocal fry, chest, mid, head, and falsetto. Classification ofregisters is controversial, however, and many other classifications are used.Although the classification listed above is common among musicians, atpresent most voice scientists prefer to classify registers as pulse, modal,and loft. Overlap of frequency among registers occurs routinely.

Testing the speaking fundamental frequency often reveals excessively lowpitch, an abnormality associated with chronic voice abuse and developmentof vocal nodules. This parameter may be followed objectively throughouta course of voice therapy. Intensity range of phonation (IRP) has proveda less useful measure than frequency range. It varies with fundamental fre-quency (which should be recorded) and is greatest in the middle frequency

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range. It is measured in sound pressure level (SPL) in reference to 0.0002 mi-crobar. For normal adults who are not professional vocalists, measuring ata single fundamental frequency, IRP averages 54.8 dB for males and 51 dBfor females [24]. Alterations of intensity are common in voice disorders, al-though IRP is not the most sensitive test to detect them. Information fromthese tests may be combined in a fundamental frequency-intensity profile[13], also called a phonetogram.

Glottal efficiency (ratio of the acoustic power at the level of the glottis tosubglottal power) provides useful information but is not clinically practicalbecause measuring acoustic power at the level of the glottis is difficult. Sub-glottic power is the product of subglottal pressure and airflow rate. Thesecan be determined clinically. Various alternative measures of glottic effi-ciency have been proposed, including the ratio of radiated acoustic powerto subglottal power [25], airflow intensity profile [26], and ratio of theroot mean square value of the AC component to the mean volume velocity(DC component) [27]. Although glottal efficiency is of great interest, none ofthese tests is particularly helpful under routine clinical circumstances.

Aerodynamic measures

Traditional pulmonary function testing provides the most readily acces-sible measure of respiratory function. The most common parameters mea-sured include: (1) tidal volume, the volume of air that enters the lungsduring inspiration and leaves during expiration in normal breathing; (2)functional residual capacity, the volume of air remaining in the lungs atthe end of inspiration during normal breathing, which can be divided intoexpiratory reserve volume (maximal additional volume that can be exhaled)and residual volume (the volume of air remaining in the lungs at the end ofmaximal exhalation); (3) inspiratory capacity, the maximal volume of airthat can be inhaled starting at the functional residual capacity; (4) totallung capacity, the volume of air in the lungs following maximal inspiration;(5) vital capacity, the maximal volume of air that can be exhaled from thelungs following maximal inspiration; (6) forced vital capacity, the rate ofair flow with rapid, forceful expiration from total lung capacity to residualvolume; (7) FEV1, the forced expiratory volume in 1 second; (8) FEV3, theforced expiratory volume in 3 seconds; (9) maximal mid-expiratory flow, themean rate of air flow over the middle half of the forced vital capacity (be-tween 25% and 75% of the forced vital capacity).

For singers and professional speakers who have an abnormality caused byvoice abuse, abnormal pulmonary function tests may confirm deficiencies inaerobic conditioning or reveal previously unrecognized asthma [28]. Flowglottography with computer inverse filtering is also a practical and valuablediagnostic tool for assessing flow at the vocal fold level, evaluating the voicesource, and imaging the results of the balance between adductory forces andsubglottal pressure [17,29]. It also has therapeutic value as a biofeedback tool.


The spirometer, readily available for pulmonary function testing, can alsobe used for measuring airflow during phonation.

Air volume is measured by the use of a mask fitted tightly over the face orby phonating into a mouthpiece while wearing a nose clamp. Measurementsmay be made using a spirometer, pneumotachograph, or hot-wire anemom-eter. The normal values for mean flow rate under habitual phonation, withchanges in intensity or register, and under various pathologic circumstances,were determined in the 1970s [13]. Normal values are available for adultsand children. Mean flow rate also can be measured and is a clinically usefulparameter to follow during treatment of vocal nodules, recurrent laryngealnerve paralysis, spasmodic dysphonia, and other conditions.

Glottal resistance cannot be measured directly, but it may be calculatedfrom the mean flow rate and mean subglottal pressure. Normal glottal resis-tance is 20 to 100 dyne s/cm5 at low and medium pitches and 150 dyne s/cm5

at high pitches [25]. The normal values for subglottal pressure under varioushealthy and pathologic voice conditions have also been determined by nu-merous investigators [13]. The phonation quotient is the vital capacity di-vided by the maximum phonation time. It has been shown to correlateclosely with maximum flow rate [30] and is a more convenient measure. Nor-mative data determined by various authors have been published [13]. Thephonation quotient provides an objective measure of the effects of treatmentand is particularly useful in cases of recurrent laryngeal nerve paralysis andmass lesions of the vocal folds, including nodules.

Acoustic analysis

Acoustic analysis equipment can determine frequency, intensity, har-monic spectrum, cycle-to-cycle perturbations in frequency (jitter), cycle-to-cycle perturbations in amplitude (shimmer), harmonics/noise ratios, breath-iness index, cepstral peak prominence, and many other parameters. TheDSP Sona-Graph Sound Analyzer Model 5500 (Kay Elemetrics, LincolnPark, New Jersey) is an integrated voice analysis system. It is equippedfor sound spectrography capabilities. Spectrography provides a visual re-cord of the voice. The acoustic signal is depicted using time (x axis), fre-quency (y axis) and intensity (z axis) shading of light versus dark. Usingthe band pass filters, generalizations about quality, pitch, and loudnesscan be made. These observations are used in formulating the voice therapytreatment plan. Formant structure and strength can be determined using thenarrow-band filters, of which various configurations are possible. In clinicalsettings in which singers and other professional voice users are evaluatedand treated routinely, this feature is extremely valuable. A sophisticatedvoice analysis program (an optional program) may be combined with theSona-Graph and is an especially valuable addition to the clinical laboratory.The voice analysis program (Computer Speech Lab, Kay Elemetrics, Lin-coln Park, New Jersey) measures speaking fundamental frequency,

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frequency perturbation (jitter), amplitude perturbation (shimmer), har-monics/noise ratio, and provides many other values. An electroglottographmay be used in conjunction with the Sona-Graph to provide some of thesevoicing parameters. Examining the EGG waveform alone is possible withthis setup, but its clinical usefulness has not yet been established. An impor-tant feature of the Sona-Graph is the long-term average spectrum (LTAS)capability that permits analysis of longer voice samples (30–90 seconds).The LTAS analyzes only voiced speech segments and may be useful inscreening for hoarse or breathy voices. In addition, computer interface ca-pabilities (also an optional program) have solved many data storage andfile maintenance problems.

In analyzing acoustic signals, the microphone may be placed at the levelof the mouth or positioned in or over the trachea, although intratracheal re-cordings are used for research purposes only. The position should be stan-dardized in each office or laboratory [31]. Various techniques are beingdeveloped to improve the usefulness of acoustic analysis. Because of theenormous amount of information carried in the acoustic signal, further re-finements in objective acoustic analysis should prove particularly valuable tothe clinician.

Laryngeal electromyography

Electromyography (EMG) requires an electrode system, an amplifier, anoscilloscope, a loudspeaker, and a recording system [32]. Needle electrodesare placed transcutaneously into laryngeal muscles. EMG can be extremelyvaluable in confirming cases of vocal fold paresis, in differentiating paralysisfrom arytenoid dislocation, distinguishing recurrent laryngeal nerve paralysisfrom combined recurrent and superior nerve paralysis, diagnosing othermoresubtle neurolaryngologic pathology, and documenting functional voice disor-ders andmalingering. It is also recommended for needle localization when us-ing botulinum toxin to treat spasmodic dysphonia and other conditions.

Psychoacoustic evaluation

Because the human ear and brain are the most sensitive and complex an-alyzers of sound currently available, many researchers have tried to stan-dardize and quantify psychoacoustic evaluation. Unfortunately, evendefinitions of basic terms, such as hoarseness and breathiness, are still con-troversial. Psychoacoustic evaluation protocols and interpretations are notstandardized. Consequently, although subjective psychoacoustic analysisof voice is of great value to the individual skilled clinician, it remains gener-ally unsatisfactory for comparing research among laboratories or for report-ing clinical results.

The GRBAS scale helps standardize perceptual analysis for clinical pur-poses. It rates the vocal characteristics of grade, roughness, breathiness,


asthenia, and strain on a scale from 0 to 3. Modification of the GRBASscale using a continual line, with one end being most normal and the othermost abnormal, has been shown to produce reliable ratings that show goodintrarater and interrater reliability [33]. Grade 0 is normal, 1 is slightly ab-normal, 2 is moderately abnormal, and 3 is extremely abnormal [13]. Graderefers to the overall degree of voice abnormality. Roughness refers to whatmany describe as raspiness, the auditory impression of an irregularly peri-odic voice signal. Breathiness refers to the auditory perception of air leakageor escape mixed into the voice signal. Asthenia is the perception of vocalweakness or lack of power. Strain refers to the auditory perception of hyper-function. For example, a patient’s voice might be graded as G2, R2, B1, A1,S2, or on a continual scale from 1 to 100 as G-68, R-61, B-37, A-28, S-72.

Outcomes assessment

Measuring the impact of a voice disorder on the function of an individualin his or her normal activities of daily living has always been challenging.Recent advances have begun to address this problem, however. Validatedinstruments, such as the Voice Handicap Index (VHI) and the Voice RelatedQuality of Life (VRQOL) [34] are currently in clinical use, and are likely tobe used widely in future years [35]. Current trends and future directions inmeasuring voice treatment outcomes are discussed elsewhere [36].

Voice impairment and disability

Quantifying voice impairment and assigning a disability rating (percent-age of whole person) remain controversial. This subject is still not addressedcomprehensively even in the most recent editions (2001, 5th edition) of theAmerican Medical Association’s Guidelines for the Evaluation of Impairmentand Disability (The Guides). The Guides still do not take into account theperson’s profession when calculating disability. Alternative approacheshave been proposed, and advances in this complex arena are anticipatedover the next few years. This subject is discussed elsewhere [37].

Evaluation of the singing voice

The physician must be careful not to exceed the limits of his or her exper-tise, especially in caring for singers. If voice abuse or technical error is sus-pected, or if a difficult judgment must be reached on whether to allow a sicksinger to perform, a brief observation of the patient’s singing may provideinvaluable information. This observation is accomplished best by askingthe singer to stand and sing scales either in the examining room or ina soundproof audiology booth. Similar maneuvers may be used for

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professional speakers, including actors (who can vocalize and recite lines),clergy and politicians (who can deliver sermons and speeches), and virtuallyall other voice patients. The singer’s stance should be balanced, with theweight slightly forward. The knees should be bent slightly and the shoulders,torso, and neck should be relaxed. The singer should inhale through thenose whenever possible allowing filtration, warming, and humidificationof inspired air. In general, the chest should be expanded, but most of the ac-tive breathing is abdominal. The chest should not rise substantially witheach inspiration, and the supraclavicular musculature should not be in-volved obviously in inspiration. Shoulders and neck muscles should notbe tensed even with deep inspiration. Abdominal musculature should becontracted shortly before the initiation of the tone. This contraction maybe evaluated visually or by palpation (Fig. 2). Muscles of the neck andface should be relaxed. Economy is a basic principle of all art forms. Wastedenergy and motion and muscle tension are incorrect and usually deleterious.

The singer should be instructed to sing a scale (a five-note scale is usuallysufficient) on the vowel /a/, beginning on any comfortable note. Technical er-rors are usually most obvious as contraction of muscles in the neck and chin,retraction of the lower lip, retraction of the tongue, or tightening of the mus-cles of mastication. The singer’s mouth should be open widely but comfort-ably. When singing /a/, the singer’s tongue should rest in a neutral positionwith the tip of the tongue lying against the back of the singer’s mandibular in-cisors. If the tongue pulls back or demonstrates obvious muscular activity asthe singer performs the scales, improper voice use can be confirmed by positiveevidence (Fig. 3). The position of the larynx should not vary substantially withpitch changes. Rising of the larynx with ascending pitch is evidence of techni-cal dysfunction. This examination also gives the physician an opportunity toobserve any dramatic differences between the qualities and ranges of the pa-tient’s speaking voice and the singing voice. A physical examination summaryform has proven helpful in organization and documentation [3].

Remembering the admonition not to exceed his or her expertise, the phy-sician who examines many singers can often glean valuable informationfrom a brief attempt to modify an obvious technical error. For example, de-ciding whether to allow a singer who has mild or moderate laryngitis to per-form is often difficult. On the one hand, an expert singer has technical skillsthat allow him or her to compensate safely. On the other hand, if a singerdoes not sing with correct technique and does not have the discipline tomodify volume, technique, and repertoire as necessary, the risk for vocal in-jury may be increased substantially even by mild inflammation of the vocalfolds. In borderline circumstances, observation of the singer’s techniquemay greatly help the physician in making a judgment.

If the singer’s technique seems flawless, the physician may feel somewhatmore secure in allowing the singer to proceed with performance commit-ments. More commonly, even good singers demonstrate technical errorswhen experiencing voice difficulties. In a vain effort to compensate for


dysfunction at the vocal fold level, singers often modify their technique inthe neck and supraglottic vocal tract. In the good singer, this usually meansgoing from good technique to bad technique. The most common error in-volves pulling back the tongue and tightening the cervical muscles. Al-though this increased muscular activity gives the singer the illusion ofmaking the voice more secure, this technical maladjustment undermines vo-cal efficiency and increases vocal strain. The physician may ask the singer tohold the top note of a five-note scale; while the note is being held, the singermay simply be told, ‘‘Relax your tongue.’’ At the same time the physicianpoints to the singer’s abdominal musculature. Most good singers immedi-ately correct to good technique. If they do, and if upcoming performancesare particularly important, the singer may be able to perform with a re-minder that meticulous technique is essential. The singer should be advisedto ‘‘sing by feel rather than by ear,’’ to consult his or her voice teacher, andto conserve the voice except when it is absolutely necessary to use it. Ifa singer is unable to correct from bad technique to good technique

Fig. 2. Bimanual palpation of the support mechanism. The singer should expand posteriorly

and anteriorly with inspiration. Muscles should tighten before onset of the sung tone. (From

Sataloff RT. Professional voice: the science and art of clinical care. 3rd edition. San Diego

[CA]: Plural Publishing, Inc.; 2006. p. 343–53; with permission.)

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promptly, especially if he or she uses excessive muscle tension in the neckand ineffective abdominal support, it is generally safer not to performwith even a mild vocal fold abnormality. With increased experience andtraining, the laryngologist may make other observations that aid in provid-ing appropriate treatment recommendations for a patient who is a singer.Once these skills have been mastered for the care of singers, applyingthem to other patients is relatively easy if the laryngologist takes the timeto understand the demands of the individual’s professional, avocational,and recreational vocal activities.

If treatment is to be instituted, making at least a tape recording of the voiceis advisable in most cases and essential before any surgical intervention. Theauthor routinely uses strobovideolaryngoscopy for diagnosis and documenta-tion in virtually all cases along withmany of the objective measures discussed.Pretreatment testing is extremely helpful clinically and medicolegally.

Additional examinations

A general physical examination should be performed whenever thepatient’s systemic health is questionable. Debilitating conditions, such as

Fig. 3. Proper relaxed position of the anterior (A) and posterior (B) portions of the tongue.

Common improper use of the tongue pulled back from the teeth (C) and raised posteriorly

(D). (From Sataloff RT. Professional voice: the science and art of clinical care. 3rd edition.

San Diego [CA]: Plural Publishing, Inc.; 2006. p. 343–53; with permission.)


mononucleosis, may be noticed first by the singer as vocal fatigue. A neuro-logic assessment may be particularly revealing. The physician must be care-ful not to overlook dysarthrias and dysphonias, which are characteristic ofmovement disorders and of serious neurologic disease. Dysarthria is a defectin rhythm, enunciation, and articulation that usually results from neuro-muscular impairment or weakness, such as may occur after a stroke. Itmay be seen with oral deformities or illness also. Dysphonia is an abnormal-ity of vocalization usually caused by problems at the laryngeal level.

Physicians should be familiar with the six types of dysarthria, their symp-toms, and their importance [38,39]. Flaccid dysarthria occurs in lower motorneuron or primary muscle disorders, such as myasthenia gravis and tumorsor strokes involving the brainstem nuclei. Spastic dysarthria occurs in uppermotor neuron disorders (pseudobulbar palsy), such as multiple strokes andcerebral palsy. Ataxic dysarthria is seen with cerebellar disease, alcohol in-toxication, and multiple sclerosis. Hypokinetic dysarthria accompanies Par-kinson disease. Hyperkinetic dysarthria may be spasmodic, as in the Gillesde la Tourette disease, or dystonic, as in chorea and cerebral palsy. Mixeddysarthria occurs in amyotrophic lateral sclerosis (Lou Gehrig disease).The preceding classification actually combines dysphonic and dysarthriccharacteristics but is useful clinically. The value of a comprehensive neuro-laryngologic evaluation [40] cannot be overstated. More specific details ofvoice changes associated with neurologic dysfunction and their localizingvalue are available elsewhere [41–43].

It is extremely valuable for the laryngologist to assemble an arts-medicineteam that includes not only a speech-language pathologist, singing voicespecialist, acting voice specialist, and voice scientist, but also medicalcolleagues in other disciplines. Collaboration with an expert neurologist,pulmonologist, endocrinologist, psychologist, psychiatrist, internist, phys-iatrist, and others with special knowledge of, and interest in, voice disordersis invaluable in caring for patients who have voice disorders. Such interdis-ciplinary teams have not only changed the standard of care in voice evalu-ation and treatment but also are largely responsible for the rapid andproductive growth of voice as a subspecialty.

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