Comprehensive physical examination is essential when evaluating patients. Often it includes objective voice assessment and measures along with strobovideolaryngoscopy. In all cases physical examination involves a thorough examination of the ears, nose, throat, neck, posture, cranial nerve function (usually), and assessment of the patient’s general (systemic) physical condition. Performance assessment usually should be included for professional voice.
Physical examination
A detailed history frequently reveals the cause of a voice problem even before a physical examination is performed. A comprehensive physical examination, often including objective assessment of voice function, also is essential, however . Physical examination must include a thorough ear, nose, and throat evaluation and assessment of the patient’s general physical condition. A patient who is extremely obese or seems fatigued, agitated, emotionally stressed, or otherwise generally ill has increased potential for voice dysfunction. This dysfunction could be attributable to any number of factors: altered abdominal support, loss of fine motor control of laryngeal muscles, 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 abdominal musculature is suspect as cause for dysphonia. Some conditions, such as pregnancy, are obvious; however, a sprained ankle or broken leg that requires the singer to balance in an unaccustomed posture may distract him or her from maintaining good abdominal support and thereby result in voice dysfunction. A tremorous neurologic disorder, endocrine disturbances such as thyroid dysfunction or menopause, the aging process, and other systemic conditions also may alter the voice. The physician must remember that maladies of almost any body system may result in voice dysfunction, and the doctor must remain alert for conditions outside of the head and neck. If the patient uses his or her voice professionally for singing, acting, or other vocally demanding professions, physical examination should also include assessment of the patient during typical professional vocal tasks. For example, a singer should be asked to sing. Evaluation techniques for assessing the performance mechanism are described in greater detail elsewhere .
Complete ear, nose, and throat examination
Examination of the ears must include assessment of hearing acuity. Even a slight hearing loss may result in voice strain as a singer tries to balance his or her vocal intensity with that of associate performers. Similar effects are encountered among speakers, but they are less prominent in the early stages of hearing loss. This observation is especially true of hearing losses acquired after vocal training has been completed. The effect is most pronounced with sensorineural hearing loss. Diplacusis, distortion of pitch perception, makes vocal strain even worse. With conductive hearing loss, singers tend to sing more softly than appropriate rather than too loudly, and this is less harmful.
During an ear, nose, and throat examination, the conjunctivae and sclerae should be observed routinely for erythema that suggests allergy or irritation, for pallor that suggests anemia, and for other abnormalities, such as jaundice. These observations may reveal the problem reflected in the vocal tract even before the larynx is visualized. Hearing loss in a spouse or family member may be problematic also if the voice professional strains vocally to communicate.
The nose should be assessed for patency of the nasal airway, character of the nasal mucosa, and nature of secretions, if any. A patient who is unable to breathe through the nose because of anatomic obstruction is forced to breathe unfiltered, unhumidified air through the mouth. Pale gray allergic mucosa or swollen infected mucosa in the nose suggests abnormal mucosa elsewhere in the respiratory tract.
Examination of the oral cavity should include careful attention to the tonsils and lymphoid tissue in the posterior pharyngeal wall and to the mucosa. Diffuse lymphoid hypertrophy associated with a complaint of scratchy voice and irritative cough may indicate infection. The amount and viscosity of mucosal and salivary secretions also should be noted. Xerostomia is particularly important. The presence of scalloping of the lateral aspects of the tongue should be noted. This finding is caused commonly by tongue thrust and may be associated with inappropriate tongue tension and muscle tension dysphonia. Dental examination should focus not only on oral hygiene but also on the presence of wear facets suggestive of bruxism. Bruxism is a clue to excessive tension and may be associated with dysfunction of the temporomandibular joints, which should also be assessed routinely. Thinning of the enamel of the central incisors in a normal or underweight patient may be a clue to bulimia. It may also result from excessive ingestion of lemons, which some singers eat to help thin their secretions.
The neck should be examined for masses, restriction of movement, excess muscle tension or spasm, and scars from prior neck surgery or trauma. Laryngeal vertical mobility is also important. For example, tilting of the larynx produced by partial fixation of cervical muscles cut during previous surgery may produce voice dysfunction, as may fixation of the trachea to overlying neck skin. Particular attention should be paid to the thyroid gland. Enlargement of the gland may signal subclinical hypothyroidism or thyroiditis, both of which can affect the vocal folds, their vibratory function, and the integrity of the laryngeal nerves, in some cases contributing to paresis and paralysis of the superior or recurrent laryngeal nerves. Examination of posterior neck muscles and range of motion should not be neglected. Neck muscle spasm, decreased range of motion, and cervical spine abnormalities can contribute to increased neck tension and hyperfunctional voice behaviors. The cranial nerves should also be examined. Diminished fifth nerve sensation, diminished gag reflex, palatal deviation, or other mild cranial nerve deficits may indicate cranial polyneuropathy. Postviral, infectious neuropathies may involve the superior laryngeal nerve and cause weakness of the vocal fold muscle secondary to decreased neural input, fatigability, and loss of range and projection in the voice. The recurrent laryngeal nerve is also affected in some cases. More serious neurologic disease may also be associated with such symptoms and signs.
Laryngeal examination
Examination of the larynx begins when the singer or other voice patient enters the physician’s office. The range, ease, volume, and quality of the speaking voice should be noted. If the examination is not being conducted in the patient’s native language, the physician should be sure to listen to a sample of the patient’s mother tongue also. Voice use is often different under the strain or habits of foreign language use. Rating scales used to describe the quality of the speaking voice may be helpful . The classification proposed by the Japanese Society of Logopedics and Phoniatrics is one of the most widely used. It is known commonly as the GRBAS Voice Rating Scale .
Physicians are not usually experts in voice classification. Physicians should at least be able to discriminate substantial differences in range and timbre, however, such as between bass and tenor, or alto and soprano. Although the correlation between speaking and singing voices is not perfect, a speaker who has a low, comfortable bass voice who reports that he is a tenor may be misclassified and singing inappropriate roles with consequent voice strain. This judgment should be deferred to an expert, but the observation should lead the physician to make the appropriate referral. Excessive volume or obvious strain during speaking clearly indicates that voice abuse is present and may be contributing to the patient’s singing complaint. The speaking voice can be evaluated more consistently and accurately using standardized reading passages , and such assessments are performed routinely by speech-language pathologists, phoniatricians, and sometimes by laryngologists.
Any patient who has a voice complaint should be examined by indirect laryngoscopy, at least. It is not possible to judge voice range, quality, or other vocal attributes by inspection of the vocal folds. The presence or absence of nodules, mass lesions, contact ulcers, hemorrhage, erythema, paralysis, arytenoid erythema (reflux), and other anatomic abnormalities must be established, however. Erythema and edema of the laryngeal surface of the epiglottis is seen often in association with muscle tension dysphonia and with frequent coughing or clearing of the throat. It is caused by direct trauma from the arytenoids during these maneuvers. The mirror or a laryngeal telescope often provides a better view of the posterior portion of the endolarynx than is obtained with flexible endoscopy. Stroboscopic examination adds substantially to diagnostic abilities ( Fig. 1 ). Another occasionally helpful adjunct is the operating microscope. Magnification allows visualization of small mucosal disruptions and hemorrhages that may be significant but overlooked otherwise. This technique also allows photography of the larynx with a microscope camera. Magnification may also be achieved through magnifying laryngeal mirrors or by wearing loupes. Loupes usually provide a clearer image than do most of the magnifying mirrors available.
A laryngeal telescope may be combined with a stroboscope to provide excellent visualization of the vocal folds and related structures. The authors usually use a 70° laryngeal telescope, although 90° telescopes are required for some patients. The combination of a telescope and stroboscope provides optimal magnification and optical quality for assessment of vocal fold vibration. It is generally performed with the tongue in a fixed position, however, and the nature of the examination does not permit assessment of the larynx during normal phonatory gestures.
Flexible fiberoptic laryngoscopy can be performed as an office procedure and allows inspection of the vocal folds in patients whose vocal folds are difficult to visualize indirectly. In addition, it permits observation of the vocal mechanism in a more natural posture than does indirect laryngoscopy, permitting sophisticated dynamic voice assessment. In the hands of an experienced endoscopist, this method may provide a great deal of information about speaking and singing techniques. The combination of a fiberoptic laryngoscope with a laryngeal stroboscope may be especially useful. This system permits magnification, photography, and detailed inspection of vocal fold motion. Sophisticated systems that permit flexible or rigid fiberoptic strobovideolaryngoscopy are currently available commercially. They are invaluable assets for routine clinical use. The video system also provides a permanent record, permitting reassessment, comparison over time, and easy consultation. A refinement not currently available commercially is stereoscopic fiberoptic laryngoscopy, accomplished by placing a laryngoscope through each nostril, fastening the two together in the pharynx, and observing the larynx through the eyepieces . This method allows visualization of laryngeal motion in three dimensions. It is used primarily in a research setting, however.
Rigid endoscopy under general anesthesia may be reserved for the rare patient whose vocal folds cannot be assessed adequately by other means or for patients who need surgical procedures to remove or biopsy laryngeal lesions. In many cases this may be done with local anesthesia, avoiding the need for intubation and the traumatic coughing and vomiting that may occur even after general anesthesia administered by mask. Coughing after general anesthesia may be minimized by using topical anesthesia in the larynx and trachea. Topical anesthetics may act as severe mucosal irritants in a small number of patients, however. They may also predispose the patient to aspiration in the postoperative period. If a patient has had difficulty with a topical anesthetic administered in the office it should not be used in the operating room. When used in general anesthesia cases, topical anesthetics should usually be applied at the end of the procedure. If inflammation occurs, it will not interfere with performance of microsurgery. Postoperative duration of anesthesia is also optimized. The authors have had the least difficulty with 4% Xylocaine.
Objective tests
Reliable, valid, objective analysis of the voice is extremely important and is an essential part of a comprehensive physical examination . It is as valuable to the laryngologist as audiometry is to the otologist . Familiarity with some of the measures and technological advances currently available is helpful. This information is covered in greater detail elsewhere .
Strobovideolaryngoscopy
Integrity of the vibratory margin of the vocal fold is essential for the complex motion required to produce good vocal quality. Under continuous light, the vocal folds vibrate approximately 256 times per second while phonating at middle C. Naturally, the human eye cannot discern the necessary details during such rapid motion. The vibratory margin may be assessed through high-speed photography, strobovideolaryngoscopy, high-speed video, videokymography, electroglottography (EGG), or photoglottography. Strobovideolaryngoscopy provides the necessary clinical information in a practical fashion. Stroboscopic light allows routine slow-motion evaluation of the mucosal cover layer of the leading edge of the vocal fold. This state-of-the-art physical examination permits detection of vibratory asymmetries, structural abnormalities, small masses, submucosal scars, and other conditions that are invisible under ordinary light . Documentation of the procedure by coupling stroboscopic light with the video camera allows later reevaluation by the laryngologist or other health care providers.
Stroboscopy does not provide a true slow-motion image, as obtained through high-speed photography. The stroboscope actually illuminates different points on consecutive vocal fold waves, each of which is retained on the retina for 0.2 seconds. The stroboscopically lighted portions of the successive waves are fused visually; thus the examiner is actually evaluating simulated cycles of phonation. The slow-motion effect is created by having the stroboscopic light desynchronized with the frequency of vocal fold vibration by approximately 2 Hz. When vocal fold vibration and the stroboscope are synchronized exactly, the vocal folds appear to stand still rather than move in slow motion. In most instances, this approximation of slow motion provides all the clinical information necessary . We use a modification of the standardized method of subjective assessment of strobovideolaryngoscopic images, as proposed by Hirano and colleagues . Characteristics evaluated include the fundamental frequency, the symmetry of movements, periodicity, glottic closure, the amplitude of vibration, the mucosal wave, the presence of nonvibrating portions of the vocal fold, and other unusual findings. With practice, perceptual judgments of stroboscopic images provide a great deal of information. It is easy for the inexperienced observer to draw unwarranted conclusions because of normal variations in vibration, however. Vibrations depend on fundamental frequency, intensity, and vocal register. For example, failure of glottic closure occurs normally in falsetto phonation. Consequently, it is important to note these 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-speed photography, EGG, photoelectroglottography and ultrasound glottography, and most recently videokymography and high-speed video (digital or analog) . Ultrahigh-speed photography provides images that are in true slow motion, rather than simulated. High-speed video offers similar advantages without most of the disadvantages of high-speed motion pictures. Videokymography offers high-speed imaging of a single line along the vocal fold. EGG uses two electrodes placed on the skin of the neck above the thyroid laminae. It traces the opening and closing of the glottis and can be compared with stroboscopic images . EGG allows objective determination of the presence or absence of glottal vibrations and easy determination of the fundamental period of vibration and is reproducible. It reflects the glottal condition more accurately during its closed phase. Photo electroglottography and ultrasound glottography are less useful clinically .
Measures of phonatory ability
Objective measures of phonatory ability are easy to use, readily available to the laryngologist, helpful in treatment of professional vocalists who have specific voice disorders, and are useful in assessing the results of surgical therapies. Maximum phonation time is measured with a stopwatch. The patient is instructed to sustain the vowel /a/ for as long as possible after deep inspiration, vocalizing at a comfortable frequency and intensity. The frequency and intensity may be determined and controlled by an inexpensive frequency analyzer and sound level meter. The test is repeated three times and the greatest value is recorded. Normal values have been determined . Frequency range of phonation is recorded in semitones and documents the vocal range from the lowest note in the modal register (excluding vocal fry) to the highest falsetto note. This range is the physiologic frequency range of phonation and disregards quality. The musical frequency range of phonation measures lowest to highest notes of musically acceptable quality. Tests for maximum phonation time, frequency ranges, and many of the other parameters discussed later (including spectrographic analysis) may be preserved on a tape recorder or digitized and stored for analysis at a convenient future time and used for pre- and posttreatment comparisons. Recordings 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 of registers is controversial, however, and many other classifications are used. Although the classification listed above is common among musicians, at present 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 low pitch, an abnormality associated with chronic voice abuse and development of vocal nodules. This parameter may be followed objectively throughout a course of voice therapy. Intensity range of phonation (IRP) has proved a less useful measure than frequency range. It varies with fundamental frequency (which should be recorded) and is greatest in the middle frequency range. It is measured in sound pressure level (SPL) in reference to 0.0002 microbar. For normal adults who are not professional vocalists, measuring at a single fundamental frequency, IRP averages 54.8 dB for males and 51 dB for females . Alterations of intensity are common in voice disorders, although IRP is not the most sensitive test to detect them. Information from these tests may be combined in a fundamental frequency-intensity profile , also called a phonetogram.
Glottal efficiency (ratio of the acoustic power at the level of the glottis to subglottal power) provides useful information but is not clinically practical because measuring acoustic power at the level of the glottis is difficult. Subglottic power is the product of subglottal pressure and airflow rate. These can be determined clinically. Various alternative measures of glottic efficiency have been proposed, including the ratio of radiated acoustic power to subglottal power , airflow intensity profile , and ratio of the root mean square value of the AC component to the mean volume velocity (DC component) . Although glottal efficiency is of great interest, none of these tests is particularly helpful under routine clinical circumstances.
Aerodynamic measures
Traditional pulmonary function testing provides the most readily accessible measure of respiratory function. The most common parameters measured include: (1) tidal volume, the volume of air that enters the lungs during inspiration and leaves during expiration in normal breathing; (2) functional residual capacity, the volume of air remaining in the lungs at the end of inspiration during normal breathing, which can be divided into expiratory reserve volume (maximal additional volume that can be exhaled) and residual volume (the volume of air remaining in the lungs at the end of maximal exhalation); (3) inspiratory capacity, the maximal volume of air that can be inhaled starting at the functional residual capacity; (4) total lung capacity, the volume of air in the lungs following maximal inspiration; (5) vital capacity, the maximal volume of air that can be exhaled from the lungs following maximal inspiration; (6) forced vital capacity, the rate of air flow with rapid, forceful expiration from total lung capacity to residual volume; (7) FEV 1 , the forced expiratory volume in 1 second; (8) FEV 3 , the forced expiratory volume in 3 seconds; (9) maximal mid-expiratory flow, the mean rate of air flow over the middle half of the forced vital capacity (between 25% and 75% of the forced vital capacity).
For singers and professional speakers who have an abnormality caused by voice abuse, abnormal pulmonary function tests may confirm deficiencies in aerobic conditioning or reveal previously unrecognized asthma . Flow glottography with computer inverse filtering is also a practical and valuable diagnostic tool for assessing flow at the vocal fold level, evaluating the voice source, and imaging the results of the balance between adductory forces and subglottal pressure . It also has therapeutic value as a biofeedback tool.
The spirometer, readily available for pulmonary function testing, can also be used for measuring airflow during phonation.
Air volume is measured by the use of a mask fitted tightly over the face or by phonating into a mouthpiece while wearing a nose clamp. Measurements may be made using a spirometer, pneumotachograph, or hot-wire anemometer. The normal values for mean flow rate under habitual phonation, with changes in intensity or register, and under various pathologic circumstances, were determined in the 1970s . Normal values are available for adults and children. Mean flow rate also can be measured and is a clinically useful parameter to follow during treatment of vocal nodules, recurrent laryngeal nerve paralysis, spasmodic dysphonia, and other conditions.
Glottal resistance cannot be measured directly, but it may be calculated from the mean flow rate and mean subglottal pressure. Normal glottal resistance is 20 to 100 dyne s/cm 5 at low and medium pitches and 150 dyne s/cm 5 at high pitches . The normal values for subglottal pressure under various healthy and pathologic voice conditions have also been determined by numerous investigators . The phonation quotient is the vital capacity divided by the maximum phonation time. It has been shown to correlate closely with maximum flow rate and is a more convenient measure. Normative data determined by various authors have been published . The phonation quotient provides an objective measure of the effects of treatment and is particularly useful in cases of recurrent laryngeal nerve paralysis and mass lesions of the vocal folds, including nodules.
Acoustic analysis
Acoustic analysis equipment can determine frequency, intensity, harmonic spectrum, cycle-to-cycle perturbations in frequency (jitter), cycle-to-cycle perturbations in amplitude (shimmer), harmonics/noise ratios, breathiness index, cepstral peak prominence, and many other parameters. The DSP Sona-Graph Sound Analyzer Model 5500 (Kay Elemetrics, Lincoln Park, New Jersey) is an integrated voice analysis system. It is equipped for sound spectrography capabilities. Spectrography provides a visual record of the voice. The acoustic signal is depicted using time (x axis), frequency (y axis) and intensity (z axis) shading of light versus dark. Using the band pass filters, generalizations about quality, pitch, and loudness can be made. These observations are used in formulating the voice therapy treatment plan. Formant structure and strength can be determined using the narrow-band filters, of which various configurations are possible. In clinical settings in which singers and other professional voice users are evaluated and treated routinely, this feature is extremely valuable. A sophisticated voice analysis program (an optional program) may be combined with the Sona-Graph and is an especially valuable addition to the clinical laboratory. The voice analysis program (Computer Speech Lab, Kay Elemetrics, Lincoln Park, New Jersey) measures speaking fundamental frequency, frequency perturbation (jitter), amplitude perturbation (shimmer), harmonics/noise ratio, and provides many other values. An electroglottograph may be used in conjunction with the Sona-Graph to provide some of these voicing parameters. Examining the EGG waveform alone is possible with this setup, but its clinical usefulness has not yet been established. An important 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 in screening for hoarse or breathy voices. In addition, computer interface capabilities (also an optional program) have solved many data storage and file maintenance problems.
In analyzing acoustic signals, the microphone may be placed at the level of the mouth or positioned in or over the trachea, although intratracheal recordings are used for research purposes only. The position should be standardized in each office or laboratory . Various techniques are being developed to improve the usefulness of acoustic analysis. Because of the enormous amount of information carried in the acoustic signal, further refinements in objective acoustic analysis should prove particularly valuable to the clinician.
Laryngeal electromyography
Electromyography (EMG) requires an electrode system, an amplifier, an oscilloscope, a loudspeaker, and a recording system . Needle electrodes are placed transcutaneously into laryngeal muscles. EMG can be extremely valuable in confirming cases of vocal fold paresis, in differentiating paralysis from arytenoid dislocation, distinguishing recurrent laryngeal nerve paralysis from combined recurrent and superior nerve paralysis, diagnosing other more subtle neurolaryngologic pathology, and documenting functional voice disorders and malingering. It is also recommended for needle localization when using botulinum toxin to treat spasmodic dysphonia and other conditions.
Psychoacoustic evaluation
Because the human ear and brain are the most sensitive and complex analyzers of sound currently available, many researchers have tried to standardize and quantify psychoacoustic evaluation. Unfortunately, even definitions of basic terms, such as hoarseness and breathiness, are still controversial. Psychoacoustic evaluation protocols and interpretations are not standardized. Consequently, although subjective psychoacoustic analysis of voice is of great value to the individual skilled clinician, it remains generally unsatisfactory for comparing research among laboratories or for reporting clinical results.
The GRBAS scale helps standardize perceptual analysis for clinical purposes. It rates the vocal characteristics of grade, roughness, breathiness, asthenia, and strain on a scale from 0 to 3. Modification of the GRBAS scale using a continual line, with one end being most normal and the other most abnormal, has been shown to produce reliable ratings that show good intrarater and interrater reliability . Grade 0 is normal, 1 is slightly abnormal, 2 is moderately abnormal, and 3 is extremely abnormal . Grade refers to the overall degree of voice abnormality. Roughness refers to what many describe as raspiness, the auditory impression of an irregularly periodic voice signal. Breathiness refers to the auditory perception of air leakage or escape mixed into the voice signal. Asthenia is the perception of vocal weakness or lack of power. Strain refers to the auditory perception of hyperfunction. 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.
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