The diagnosis: Who Should Do it and Why.

If you are struggling to speak or sing there are a number of things that could be happening.  Please see an ENT (Ear Nose and Throat) doctor; preferably one who specializes in singers. Please don’t risk getting the wrong diagnosis.  Be a sleuth, do your research, find the right doctor!

Warning: If you know there is a problem with your voice, don’t settle for a diagnosis that indicates otherwise. I can’t tell you how many times I’ve heard singers with vocal problems tell me that a general practitioner, internist, or someone other than an ENT specialist found nothing wrong.  This diagnosis will not help and will likely exacerbate the situation.  Doctors that are not ENTs don’t have proper instruments to see a structural problem, nor do they understand voice disorders.  All they can do is hypothesize; that is not diagnosis. They should refer you to a specialist.
Recently, a woman came to my studio with with a hoarse voice. She has had this problem for quite a while. Her doctors could find nothing wrong and attributed the problem to stress.  I asked her if she had seen a doctor who specializes in singers; she said no.  After ten minutes of a vocal warm-up I could hear the hoarseness.  It is not my place to diagnose, but I can tell that this is a voice disorder.  The only thing that an arbitrary diagnosis like “stress” will do is cause more frustration and… STRESS!
A voice disorder can be caused by a structural abnormality, or by a functional abnormality.  It is extremely important to find a doctor who understands both structural and functional voice problems, or you may get the wrong diagnosis.  Always get a second, even a third opinion.
Here is a very enlightening article that I believe every vocalist should read, especially when seeking the right specialist for a voice disorder. It was  written by Dr.James P. Thomas, MD.  Dr. Thomas is an ENT who specializes in voice disorders, including singing, speaking, breathing, swallowing.  He is committed to raising awareness of the diagnosis and the surgeries available to treat voice and laryngeal disorders.  His practice is in Portland, Oregon.  His site is full of very important and enlightening information.

This article discusses how most laryngologists assess voice disorders and the importance of finding a doctor that can detect the visual as well as the functional vocal disorder.  He also discusses the potential problem with the very common reflux diagnosis.  This is extremely important information!  Please note a glossary of terminology used in the article precedes it.

Glossary

Algorithm: A step-by-step problem-solving procedure, especially an established, recursive computational procedure for solving a problem in a finite number of steps.

Esophageal reflux: A condition in which the stomach contents (food or liquid) leak backwards from the stomach into the esophagus (the tube from the mouth to the stomach). This action can irritate the esophagus, causing heartburn and other symptoms.

Etiology:  Cause, origin; specifically: the cause of a disease or abnormal condition .

Koch’s postulates: In 1890 the German physician and bacteriologist Robert Koch set out his celebrated criteria for judging whether a given bacteria is the cause of a given disease. Koch’s criteria brought some much-needed scientific clarity to what was then a very confused field.

More information.

Laryngologist: A physician who specializes in the diagnosis and treatment of disorders of the larynx.

Oscillation(of the vocal folds):  Sound is generated in the larynx by chopping up a steady flow of air into little puffs of sound waves.

Phonation:To utter speech sounds; vocalize.

“A laryngologist has an algorithm for understanding the larynx or voice box. The predominant algorithm in existence today and the one still being widely taught is visually identifying the abnormalities on the voice box and then attributing the complaint (hoarseness) to the visual anomaly. This algorithm is fraught with problems, not the least of which is that a visual non-regularity of the voice box is often only randomly associated with a functional change in the voice. I even see patients with big bumps on their voice box that do not need to be removed, because the bumps are not causing the patient’s complaints and are benign. The actual cause of the hoarseness is missed, and the hoarseness persists even after “treatment” because attention was focused on the visual problem and not on the problem generating the abnormal “voice.”

It is true that this visual algorithm has worked in many cases. Clearly a big lump on the edge of the vocal cords is  likely impairing the vibration of the vocal cords and thus the voice. So the algorithm works sometimes, but there is considerable room for improvement.

I believe there is a more suitable algorithm for understanding the voice and that it will one day replace our present visual assessment of the voice. If you think of the vocal cords as strings that vibrate (analogous to many stringed instruments from piano to violin to guitar) and when they vibrate without any interference, they produce what on paper would appear be a sine wave, a smooth curvilinear line oscillating about an axis. However, the vocal cords act more like a wind instrument than like a string instrument; they leak air when they are vibrating. The air passing between the vocal cords, air that is not involved in vibrating them, flows turbulently and generates white noise. That is, a whisper that involves no vocal cord motion at all, is almost completely turbulent air flow and thus white noise.

If we can imagine an opera singer performing an aria that is clear and smooth sounding to our ears, then nearly all of the air passing through the vocal cords is producing a very regular sine wave and there is almost no turbulent flow. Most phonations are in between these extremes of the aria and the whisper. Some amount of white noise is often well tolerated and considered part of a normal voice. For example a folk singer often leaks a fair amount of air while singing and we consider that breathy style a pleasant type of vocalization, depending on our musical taste. So air leaks can be a component of voicing. We can think of the pure oscillation as the signal – the desired part, the component of sound that we can say is a certain pitch on the piano, say middle C. We can think of the air leak as noise and describe a voice as having a certain signal to noise ratio (SNR). At some point as we increase the noise relative to the signal we start to call that sound hoarseness. The irregular part (noise) of the vibration may start to overwhelm the regular part of the vibration or signal.

Our brains are designed to filter out the signal from the noise. That is why we can listen to a radio station that is not entirely clear and still enjoy it to a degree. At some point, as we get farther away from a given radio station, depending on our level of interest in what we hear, we give up listening to it. That is analogous to the point at which a person with a “hoarse” voice seeks medical care.

This brings me to a third point. I have seen over 5,000 voice patients and I have attributed the cause of the hoarseness to esophageal reflux induced laryngitis in only two cases. There may be problems with my assumption. First almost every patient that I see for vocal troubles is already being treated for reflux with a medication called a proton pump inhibitor {eg: Omeprazole (brand names: Losec®, Prilosec®) Lansoprazole (brand names: Prevacid®, Zoton®, Inhibitol®)Esomeprazole (brand names: Nexium®) Pantoprazole (brand names: Protonix®, Somac®, Pantoloc®) Rabeprazole(brand names: Rabecid®, Aciphex®, Pariet®)} so perhaps everyone who would get better on the medication has already done so, and they do not come to see me, and I only see the failures (I do not really believe this).

On the other hand, I have never encountered an audible and visible vocal cord lesion that would resolve on the above medication and then recur when the medication stopped and resolve again when the medication was resumed – much as Koch’s postulates are utilized to determine whether a specific agent is truly the cause of a disease. Additionally, I nearly always find some other reasonable explanation for hoarseness or the change in the voice and upon treatment, the hoarseness resolves, convincing me that reflux is not the etiology of almost all voice disorders. Additionally, I have never seen a physician proponent of the reflux explanation of hoarseness ever stand up at a meeting, show me a video of a “red” larynx before treatment with a hoarse quality and then show me an after video of a “non-red” larynx without hoarseness.

So, if you have been diagnosed with reflux as the cause of your vocal disorder and especially if you are not improving, it is not likely that you need more of the medication or that you need an anti-reflux surgery to fix your hoarse voice. It is quite likely that you need a more precise diagnosis.”

Overview of Voice Disorders

Click here for a comprehensive overview of voice disorders for the layperson.