Weekly Teaching Tip – July 18, 2016
by Dr. Curt Stock, ENT
It has been awhile since I reviewed what to expect when a patient comes into the Voice Clinic for an evaluation. I thought it would be a good time to review this again.
Most frequently I see the patient on the first visit in my general ENT clinic . This encounter is somewhat different as I approach this more from a complete ear, nose, throat and neck evaluation.
1. After taking a complete medical history about all aspects of the patients medical care, I then do a full ENT exam, this includes for the voice or reflux patient a flexible laryngoscopy looking for any physical and anatomical problem. This would include findings nodules, vocal fold paralysis , cysts etc.
2.Usually the next step is referral to the Voice Clinic for evaluation by myself and our SLPs (usually Anna Siciliano) as a team. On occasion the Voice Coach is present as well as our Singing Therapist (usually my wife Teri). Here the visit is focused on the voice and all contributors to having a healthy voice. All medications, occupations and life styles (tobacco, alcohol, drugs, voice use) are reviewed.
3.The patients fill out a Voice Handicap Index and Dyspnea Index.
4. The patient reads for us passages requiring different voice tasks, usually the Rainbow Passage.
5. We have them vocalize Ah and Ss for as long as possible which helps us predict pathologies such as vocal lesions versus paralysis.
6. The patient will sing for us and do scales through their first bridge. Then we will do stroboscopy with a Rigid 70 degree scope. Using the strobe light we can assess movement, undulation, closure and symmetry.
Interesting case: Last week I saw some very small nodules on flexible scope on a patient who had just returned from one of the major US voice competitions. When observed on stroboscopy there was much more swelling on the undersurface of the vocal fold. This was much more clear with the strobe than the flexible scope. I was surprised when talking to this person, that she felt like this mild vocal swelling defined her and really didn’t want to change much with her voice. She just wanted to make sure there was no serious damage before going on tour the next week.
Now back to the topic at hand.
7. Once all this is completed we then discuss treatment as a team. Example if there is presbylarnx, can the patient benefit from therapy or will they need a vocal fold injection? Have the vocal fold nodules responded to therapy or do they need excision? Is the patient with vocal fold weakness happy with their progress after therapy or will they need an injection augmentation or even a Thyroplasty (moving the vocal fold over to the midline surgically)? The important concept here is that these decisions are made with the input of the patient, Speech Language Pathologist and Physician as well as the Singing Therapist when present. We usually spend 30-45 minutes as a Team and then the patient will have some counseling on diet or start with voice therapy.
Hope this is helpful. Cant wait for the October Voice Conference in Atlanta!!!!!!