Diagnosis and Treatment of Vocal Problems In Professional Voice Users: Part 2 of 2

Differential Diagnosis

For many professional voice users, the first symptoms that typically warrant a medical examination are a sudden change in voice, or persistent and/or unexplained hoarseness.

Because of the many potential causes of voice problems, a critical first step in diagnosing a patient is to take a comprehensive history and physical examination of the patient that includes an examination of both the head and neck areas and other areas of the body as indicated. Also essential is a full voice history that includes the level of voice training, voice demands, and environmental problems that may adversely affect the voice, said Dr. Sataloff.

According to Robert H. Ossoff, MD, DMD, Chairman of the Department of Otolaryngology at Vanderbilt University Medical Center in Nashville, specific questions that should be asked to singers include whether their range is normal for them or if they have problems with the upper or lower ranges, or whether the clarity of their voice is the same or has changed. Other questions should include whether the patient has noticed any specific vocal fatigue or loss of confidence in his or her singing.

Typically, such an evaluation of voice history includes a team approach that includes voice specialists such as a speech pathologist and singing voice specialist. Dr. Woo says he frequently refers a patient for a voice therapy evaluation to see if they have specific vocal faults that are associated with excessive functional overuse, such as using a voice gesture that is too aggressive or if the patient has too much tension in the neck. We work as a team effort in the voice center, he emphasized.

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Figure. Recognition of the particular needs of professional voice users has led to more intensive training for otolaryngologists who treat them.

For all three otolaryngologists, an essential part of a thorough examination is the use of strobovideolaryngoscopy, a diagnostic instrument that permits examination of the vibratory characteristics of the vocal fold that will detect subtle problems such as mild inflammation, subtle swelling of the vocal fold, white patches, or excessive mucus. This test is often coupled with different measures of air flow and with digital voice recordings, said Dr. Ossoff, who emphasized, If I would recommend only one specialized test, I would recommend strobovideolaryngoscopy.

According to Dr. Sataloff, if strobovideolaryngoscopy is used by an expert and can get very high-quality stroboscopic images, a number of subtle abnormalities along the vibratory margin of the vocal folds can be detected, such as small cysts, scars from previous injury, and other minor abnormalities. Early diagnosis of such abnormalities is critical, he said. Early diagnosis of serious problems such as vocal fold hemorrhage or mucosal tear allows early prescription of voice rest, and, we believe, a better chance of good spontaneous healing without scar formation and prolonged hoarseness, he said. For more minor problems, such as an upper respiratory infection, strobovideolaryngoscopy is important to determine whether a singer can still perform without doing damage to his or her vocal folds.