Introduction: Voice
problems are common in patients these days. The major reason
being the stressful environment and changing life styles which
are getting common these days. The commonest cause of
voice disorder is voice abuse.
History taking: Before
pluinging directly into the history taking, it is always better to
listen to the patient's complaints in his or her own words.
This will give a vital insight into the expectation of the
patient. Over expecting patient may be so disappointed with
the results of therapy, they may even fall into a spell of
depression. The emotional component of the voice disorder must
always be kept in mind. The patient must
be carefully questioned pertaining to the following issues: 1.
The precise date of onset of the problem, whether it was abrupt or
gradual. 2. History pertaining to upper respiratory infections /
sinusitis. Without addressing the issue of focal sepsis the
treatment may not be successful. 3. The patient must be carefully
quizzed whether his voice was absolutely normal before
the trouble began 4. History pertaining to gastro
oesophageal reflux disease must be ascertained. i.e. presence
of burning pain the chest is one classic example. 5. The
patient's job, and the stress it puts on his or her voice
should be ascertained While speaking to the patient the voice of
the patient is carefully listened to and a recording is made
for subsequent comparison. A description of the voice
should also be included. The following descriptions could be
useful at a later date: 1. Whether the voice is low or high 2.
Whether it is loud or soft 3. Whether it is powerful or
weak 4. Whether it is clear, breathy or hoarse 5. Whether sharp or dull 6. Whether resonant
or falsetto 7. Whether relaxed or strained
The voice could
be grossly described as either hyperkinetic or
hypokinetic. Hyperkinetic voice: is a tense voice associated with
a forceful closure of glottis and a high subglottic
pressure. Hypokinetic voice: is a voice with very little energy
and associated with wastage of air from subglottis.
Posture: The posture adopted by the patient should be
carefully noted. It could be tense, relaxed or slouched.
Breathing habit: of the patient is also observed by noting the
movements of the abdominal wall, whether the accessory muscles of
respiration are active.
Examination of the nasal cavity is a
must. Nasal discharge if any must be documented. Post
nasal drip any must also be noted. Sine vocal cords are highly
mobile structures, they are likely to be infected when exposed to
secretions from the nasal cavity from above or from lungs
below.
Indirect laryngoscopy: is done
using a laryngeal mirror. The vocal cords and the ventricular
bands are carefully noted for any structural anomalies. Their
mobility is also assessed.
Radiological examination:
Should include 1. CT scan of para nasal sinuses - to rule out
sinus infections 2. Plain x-ray chest - to rule out bronchial
infections
Functional assessment of
voice: can be done by eliciting various kinds of voice
production. During the examination the way in which the
patient's voice changes in response to the following instructions
are observed: a. Coughing b. Phonating c.
Yawning
Factors causing voice disorders can be classified
under these three heads: 1. Emotional 2. Physical 3.
Functional
Subjective analysis of voice
can be done using Voice Handicap Index (VHI). This method was
devised by Jacobson in 1997. This is done by the
patient. They must assess their voice under three heads
(domains) i.e. Emotional (E), Physical (P), and Functional
(F). They must assess their voice under the above three heads
on a five point scale and grade as follows:
The scale starts
from 1 (which is never) Ends at 5 (Almost always). The scores
are tabulated under each domain and totalled.
Special
methods of examination:
I . Tape recording of the
voice: This has several advantages: a. It provides a base
line for future comparisons b. It will allow the examiner to
focus on features of voice and articulation c. These features can
be discussed with the patient and he can be made aware of the
problem and its magnitude.
II . Phonetogram: is also
otherwise known as pitch intensity profile. The examiner's
subjective assessment of the loudness, pitch and quality of voice
can be supplemented by this objective measurement. The
instrument used is costly but user friendly. The phonetogram
examiantion starts with a measurement of singing voice profile of
the patient. The patient can sing in a sustained tone freely
and measurement can be made. Alternatively, the examinee can
be requested to match tones produced by the examiner on a keyboard.
The measured values for pitch and intensity appear are plotted as a
graph for further study.
Figure
showing a phonetogram recording
The phonetogram
covers the entire frequency range, while a speaking voice uses only
part of the range. Hence speaking voice profile must be
separately measured by asking the patinet to count numbers in normal
voice and then in a tense voice mode. A sound level meter is
used to assess the level of sound generated by the patient for each
mode.
Different computer softwares are used for phonetogram
recording: Some of the common ones are
1. Dr.
Speech
2. Aeroplane II
3. lingWaves
III.
Stroboscopy: This is an excellent tool for examining the movements
of the vocal cords in their various phases.
The following
parameters can be assesed using stroboscope:
a. The
fundamental speech frequency of the patient
b. Periodicity:
It refers to the regularity of the successive vocal fold
movements
c. Symmetry: Normal vocal folds vibrate in a
symmetric manner
d. Glottic closure: During normal vibratory
phase the membranous portion of the vocal cord firmly apposes, while
the posterior glottic chink may be open.
