Signs and Symptoms

The laryngeal complaints of patients may concern voice, swallowing, airway, or a combination. Dysphagia is covered in Chapter 5.4.2. Airway symptoms may occur with bilateral vocal fold immobility, significant paresis, or paradoxical vocal fold adduction. The features of the vocal concern that should be defined are onset, situational context, perceived quality, pitch, pitch control, fluidity, and stamina.

Differential Diagnosis

Neurologic issues involving the larynx may be either focal or systemic. Therefore, other neurologic features in the remainder of the body should be sought. The systemic diagnosis may have been already determined, or the vocal issue may be the first presenting sign of a new diagnosis. In general, neurolaryngeal illnesses may involve a lack of neuromuscular strength or mobility of the vocal folds or a discoordination of function. The former includes paresis, paralysis, atrophy, and incomplete glottic closure as well as diminished vocal support. These type of conditions may be acute losses (e.g., stroke, surgical injury) or degenerative (e.g., PD, amyotrophic lateral sclerosis [ALS]). The discoordination differential includes tremors, myoclonus, and dystonia.

History

As with many vocal disorders, patients may precisely self-define their vocal concern, but they also may have only a vague description of their problem. A careful history to define their issues includes the timing and situational onset of the symptoms, exacerbating and ameliorating factors, associated symptoms, and vocal quality.

Voice Exam

Evaluation of the voice by the trained listener is essential. This begins even as the patient is relaying their history. Nonlaryngeal factors should be noted, such as articulation issues or hypo- and hypernasality. Laryngeal issues include overall vocal quality (e.g., raspy, breathy, strained, spasmodic), severity of dysfunction, appropriateness of vocal pitch, and presence of voice or pitch breaks. Assistance in this assessment can be provided through the use of certain prepared readings. The most common of these is the “Rainbow Passage,” which contains balanced consonants and vowels:

When the sunlight strikes raindrops in the air, they act like a prism and form a rainbow. The rainbow is a division of white light into many beautiful colors. These take the shape of a long round arch, with its path high above, and its two ends beyond the horizon. There is, according to legend, a boiling pot of gold at one end. People look, but no one ever finds it. When a man looks for something beyond his reach, his friends say he is looking for the pot of gold at the end of the rainbow.

(Fairbanks G. Voice and articulation drillbook. New York, NY: Harper & Row; 1969.) Using predominantly voiced or voiceless phrases may also be of benefit, particularly in spasmodic dysphonia. Appropriate phrases for ad ductor spasmodic dysphonia include the following:

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  [Counting from 80 to 89]

  
  
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  “Eeee-eee-eee”

  
  
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  “We mow our lawn all year.”

  
  
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  “We eat eels every day.”

  
  
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  “We eat eggs every evening.”

  
  
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  “A dog dug a new bone.”

  
  
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  “Where were you one year ago?”

  
  
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  “We rode along Rhode Island Avenue.”

Appropriate phrases for ab ductor spasmodic dysphonia include:

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  [Counting from 60 to 69]

  
  
• 
  

  “See-see-see”

  
  
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  “The puppy bit the tape.”

  
  
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  “Peter will keep at the peak.”

  
  
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  “When he comes home, we′ll feed him.”

  
  
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  “Harry has a hard head.”

  
  
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  “Tap the tip of the cap, please.”

  
  
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  “Keep Tom at the party.”

Some vocal disorders are particular to certain tasks, while others are universal; having a patient sing a well-known tune such as “Happy Birthday” can help determine this fact. The next component, the neurolaryngologic examination, is best done with a flexible endoscope. This allows fluent speech and avoids the distortion and potential inhibitory effects of tongue retraction on direct or indirect laryngoscopy. The larynx should be observed at rest, during normal breathing, and during phonation. Appropriate adduction and abduction with phonation and respiration should be observed. The “/i/-–sniff” maneuver should elicit maximal abduction. Asymmetric or paradoxical vocal fold motion may indicate a paresis or dystonia. Rhythmic spontaneous or intention tremor of the larynx should be noted, as well as nonrhythmic myoclonus. Compression of the false folds and supraglottis represents excess use of accessory muscles, suggestive of muscle tension issues or dystonias. Quickly repetitive phonatory tasks (such as /i/–sniff, alternating /i/–/hi/, and /pa/–/ta/–/ka/) may make subtle paresis or discoordination more evident. Glissando (sliding low- to high-pitch /i/) can be used to assess tensioning function.