The panelists eventually agreed, after seeing stroboscopy footage that showed decreased mucosal wave on one side and lateral-to-medial blood vessels, that the problem seemed to be scarring.
Explore This IssueJune 2017
In scarring cases, Dr. Hogikyan said, “history often guides you because there’s an antecedent event, unfortunately, often iatrogenic.” He added, “This is an example of a diagnosis where stroboscopy really shines.” It allows you to see vibratory capacity of the vocal fold mucosa, and scarring usually causes mucosal stiffness, he said.
Dr. Johns noted the importance of looking for patients who may have experienced an acute laryngeal event and then continue to use and put a lot of strain on their voices. “Patients have a tendency to push through upper respiratory tract infections and acute laryngitis,” he said. “And unfortunately, based on how we’re built, we have no pain feedback in that type of illness. And yet with increased effort we can generate sound. … I can just continue using my voice, and I can strip and scar the lamina propria. It’s an awareness issue.”
Dr. Courey suggested getting patients to use both high and soft phonation on stroboscopy. “I think that, oftentimes, people think about getting stroboscopy only at modal pitch and intensity, and I think with these patients you bring out subtle vibratory abnormalities better with ranges of pitch.”
Case 2: Muscle Tension Dysphonia
Another case involved a 55-year-old woman with what the panelists described as a “laryngologic full house” for a year: globus, swallowing problems, voice problems, and shortness of breath. She reported that she had been hit on the head with a board at work. The panel agreed with Dr. Johns that the “strained, pressed quality” to the woman’s voice strongly suggested muscle tension dysphonia.
Discussing this problem with patients can be difficult, panelists said. They agreed that it is best to avoid the word “psychogenic” and instead describe the issue as “functional.”
Dr. Hogikyan said his approach is to tell patients, “It’s a good type of problem to have. Your voice structures themselves are healthy, but your body’s using them in an abnormal way. Another way to think about that would be posture. I can have good posture; I can have bad posture. If I have bad posture long enough, it becomes habitual. And your voice box is in a bad posture. And what we’re going to do is to try to get your body out of the abnormal posture.”
I think too often people will jump to drop in the scope to try to understand what’s going on. … I’d like to interrogate [the patient’s] vocal capabilities a little bit more [and] listen to some non-voice laryngeal tasks. —Norman Hogikyan, MD
He said this approach “takes burden off of the patient” and doesn’t imply they’re doing anything knowingly to alter their voice.