Abstract
Diagnostic management of the cause of the hoarseness is determined by the fact that phonation is integral, complex function of the whole body. At the very first one should always bear on mind that audio- vocal system is the basis of very complex interpersonal communication processing. Between the acoustic input and vocal output there is central nervous system with a number of parallel and sequential brain activities, mostly unexplained.
There should be balance between modern high technology methods and classical approach based on history, in modern laryngology. One equipped Voice Laboratory in Communication Disorders Care Center must have optimal diagnostic set:
history and clinical examination, psychoacoustic analysis of the voice, endovideolaryngostroboscopy, fiber optic endoscopes, objective acoustic analysis, objective aerodynamic analysis, subjective evaluation of the voice.
There will be the expansion in the field of communication science in the future, with adequate ambulatory network, in cooperation with one referent institution.
Key-words: phonation, audio- vocal system, interpersonnal communication, voice laboratory.
Introduction
The change of the quality of the voice, usually called hoarseness, leads the patient to the secondary health care level, but the tertiary diagnostic level is often involve, too.
Some objective difficulties in visualizing the larynx lead patients to specialists or sub specialists, although most of the physicians are well trained during their medical school. Extreme gag reflex or specific aero digestive tract anatomy is often the reason that even ENT specialists are not able to see the larynx. Unfortunately, sometimes there is not enough skill in practicing this two century old method.
Advance in modern technology makes things easier, but only sub specialist departments can use this precious instrument. We must always bear on our mind that office based endoscope procedures have to be the gold standard in health care management and development of the health care system.
On the other side, there is the intention of neglecting traditional diagnostic steps, if somebody has endoscope instrument. The only successful diagnostic approach must incorporate traditional methods as well as modern technology, with all of its advantages and limitations.
History
Table 1- The part of R.T Sataloff questionnaire
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Do you have any pressing voice commitments ? |
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Tell me about the importance of your voice quality, and about your vocal career ? |
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How much voice training have you had ? |
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Under what kind of conditions do you use your voice ? |
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How much do you practice ? How, when and where do you use your voice ? |
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Are you aware of misusing or abusing your voice during singing ? |
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Are you aware of misusing or abusing your voice during speaking ? |
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Do you have pain when you talk or sing ? |
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Have you noted voice or bodily weakness, tremor, fatigue or loss of control ? |
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Do you have allergy or cold symptoms ? |
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Do you have breathing problems, especially after exercise ? |
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Have you been exposed to environmental irritants ? |
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Do you smoke, live with a smoker, or work around smoke ? |
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Do you have morning hoarseness, bad breath, excessive phlegm, a lump in your throat, or heartburn ? |
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Do you have troubles with your bowels or belly ? |
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Are you under particular stress or in therapy ? |
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Do you have menstrual irregularity or other hormonal changes or problems ? |
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Do you or your blood relatives have hearing loss ? |
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Did you undergo any surgery before the onset of your voice problems ? |
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What medications and other substances do you use ? |
Precious and quick history interview depends of general medical knowledge, ability to recognize the most important facts, conversation skills, even being excellent in typing, if you are not lucky to have somebody to do that for you.
You can take a history during the examination at the same time. Good practitioner has some kind of own specific questions in order to come to the correct facts.
You must know to listen what the patient says as well as to watch the way he is talking. The careful psychoacoustic analysis of the voice and speech, comparing with history, leads to correct diagnosis or to conclusion what to do in differential diagnosis.
There are questionnaires that patient have to answer before he come into the office, in modern communication disorders care centers.
Such questionnaire is given in Table 1 , one can use it to form some similar one (15).
There is tendency in the last decade to evaluate patients quality of life (1). Voice Handicap Index is one laryngological version. Its short modification, called VHI 10 is given in Table 2, it can also help in taking the precious history.
In modern info systems, windows with standard questions about abuses, allergic manifestations etc, are useful, too.
The old fashion rule- The History is Half of Diagnosis- has its place in the hoarseness management, too. Multidimensional nature of communication makes the phoniatricians office as the place of multilevel changes of information.
Table 2- V H I - 10
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My voice makes it difficult for people to hear me. |
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People have difficulty understanding me in a noisy room. |
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My voice difficulties restrict personal and social life. |
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I feel left out of conversations because of my voice. |
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My voice problem causes me to lose income. |
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I feel as though I have to strain to produce voice. |
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The clarity of my voice is unpredictable. |
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My voice problem upsets me. |
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My voice makes me feel handicapped. |
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People ask; What is wrong with your voice?“ |
Clinical evaluation
There is no doubt that the examination begins when the patient comes into the office, that lasts during the history asking, and that is not finished when patient leaves the office. There is auditive, visual and even olfactive inspection, in the case of hoarseness.
The important part of the clinical evaluation is the palpation of the neck. It consists of thyroid gland palpation, evaluation of sub mental, sub hyoid and perylaryngeal musculature rigidity. You can evaluate the level of larynx position in the neck by horizontal placement the fingers between cricothyroid membrane and fossa iugularis. The presence of absence of crepitating you can asses by gently moving the larynx left end right from the medial position. The palpation of the temporomandibular joint musculature is very important, too.
You have to evaluate the integrity of auditive apparatus, presence of rhino pharyngeal pathology, as well as the integrity of supraglottic resonator that include lips, teeth, tongue, hard and soft palate and all three pharyngeal levels.
More than 150 years there is no advantage in indirect laryngoscope technique. That is still very unpleasant experience for the patient, as well as for the physician, especially in the situation of no visible larynx.
Relaxed and experienced physician can relax the patient too and can perform an successful indirect laryngoscopy. You have to think of the possibility that the patient maybe have the fear of repeating unpleasant situation, just experienced in some other office. Sometimes is very useful to make the delay , patient is sitting in the waiting room, and can see other patient who tolerate the indirect laryngoscopy well. You can ask the patient to come next day, this author has an experience of some kind of transformation of the patient behavior, made on some kind of bilateral confidence.
There are some very important facts:
- the tongue protection- it is not only skilled placement of the gauze on the lower teeth when the tip of the tongue is on the hard palate. It is much more strong and gently pulling the tongue while pushing the mirror at the same time, in two way action- reaction manner. Enough pushing the angulus oris may help, or putting the handle of the mirror through no existing tooth place. Being too much gently is harmless for the patient and leads to prolongation of the examination;
- gag reflex- there is some reason that all the patients who can not make the nose breathing while their mouth is opened during the epipharyngoscopy, always change to the nose breathing during indirect laryngoscopy. This author finds this fact as the reason for the gag reflex. If you ask the assistant or the patient itself to close the nose with fingers, there comes automatically change to mouth breathing, gag reflex disappears, and you can see the larynx;
- movement symmetry- sometimes it is so hard to asses the symmetry of the movement of the both sides. It is very helpful to evaluate opening and closing of both piriform recesses, so you can make the correct diagnosis of laryngeal paresis or paralysis.
As a matter of fact, there must be great skill and well trained manipulation in performing the indirect laryngoscopy. It is not theory, but the true practice, when we are talking about so many steps and points (7) in indirect laryngoscopy. The maximal attention in every examination leads to less pitfalls.
If there is possibility of not visualizing the whole larynx, you have to make the control examination, or evaluation with modern instruments.
Modern technical tools
Rigid endovideolaryngostroboscopy
Ideally, this important instrument should be in every office, because of improvement of the quality of the examination, and because of the information of the vibratory properties of the vocal folds. Rigid endoscope should be always before the flexible endoscope.
There is essentially improvement of recognizing the smallest details, but also make the visualization of the larynx in cases when it is impossible to perform an indirect laryngoscopy. There are minimal chances for pitfalls because of:
- recognizing the organic lesion when the diagnosis is functional lesion;
- recognizing invisible scar or mucosal lesion;
- recognizing the Reinke edema, especially when asking the patient to make the paradox phonation;
- making the difference between nodules, polyp, cysts and so called contact lesions;
- making easier diagnosis of laryngeal paresis, as well as differential diagnosis between laryngeal paralysis and cricoarytenoid ankylosis; AND OF THE MOST IMPORTANCE- leading to early detection of malignant lesions.
There is extreme importance in video recording because of:
- possibility of later consilliar team evaluation; - therapy evaluation through control examinations; - educative aspect, for the patient itself, as well as for the students; - medico legal aspect of documentation.
Fiber optic laryngoscopy
Full equipped office has a fiber optic system, which is very helpful in some situations, especially in children, when it is only possible method of larynx visualization.
It is important tool in evaluation of so called asthenic or hyperkinetic voice , as well as neurogenic disorders such as tremor, dystonia, dysarthria, parkinsonism. It is very important tool in swallowing evaluation as well as pharyngo esophageal sphincter tonus.
Before the endoscopy you must asses: - endo nasal status including the epypharyngeal level; - the position of the epiglottis and the tongue base; - the tongue base lymphatic tissue growth; - the moisture of pharyngeal mucosa and the presence of secretions.
The first step of endoscopy is evaluating of the physiology movement of the larynx during: - coughing, -sneezing, - whistling, -laughing, - deep inspiration, - quick antagonistic movements including the throat clearing.
The second step of endoscopy is evaluating of the voice function during:
- prolonged phonation, - continual speech.
The final step is singing voice quality evaluation during:
- continual vocal on up and down five-tone scale; - the loudest, moderate and the most silent voice; - quick staccato movements; - singing the preferable melody.
Multidimensional computer voice and speech analysis
Respecting all advantages and limitations of modern technology, it is very useful diagnostic tool, giving inter and intrapersonal follow up. Actually, the given results one has to evaluate in relationship, never as absolute facts. The validation and objectivity of the results is achieving by using several software programs in the same time.
Available programs give near thirty parameters, the new aspects of hoarseness, as well as classical, such are : - aerodynamic (maximum phonation time and s| z relation), - spectrogram, -electroglotogram, - phonetogram (voice range profile).
Computer analysis gives us graphic display of the voice quality, automatically compared with the database, altogether become the physician medical report. The detailed description of all of parameters is not in the focus of this article, that one can find in (18).
Additional analysis in positive history
Bacteriologic and mycological analysis, audiometric, logopedic status, psychological interview, neuropsychological test, allergologic test, functional pulmologic evaluation, ultrasound of thyroid gland and endocrinology evaluation, rheumatologic assessment, neurological assessment (including electromyography).
CT scan is very useful, especially multi-slice technique, in case of sub mucosal malignant spreading in order to recognize the border to the health tissue. For the fine differentiation of the tissues, especially in laryngeal framework involvement, NMR is indicated.
Finally, PET technology makes easier differentiation between postoperative scar and tumor recidivism. All methods mentioned above helps in achieving the gold diagnostic standard, and that is interdisciplinary approach. All members of multidisciplinary team can take a part in repeated consiliar analysis of the results of each individual, owing to the possibility of the reproduction from the database.
Office based practice
The microlaryngoscopy under general endotracheal anesthesia is method of choice in multidisciplinary approach. If there is possibility for indirect phonomicrosurgery, patients as well as physicians will choose less aggressive method. This fact is in connection with rising the number of elderly patients. It is amazing that the first steps in laryngology were made in office based practice, as it is described by Mackenzie, Brunings and Jackson.
The choice of the patient and preparing of the intervention must be very carefully, especially with local anesthesia, that has to be at least 15 minutes of the standardized steps. This approach gives the opportunity of laryngeal abrasive biopsy by endo- CD2 system. This transepithelial sampling under the basal membrane leads to the computer classification of every single cell, which allows us to escape from the repeated biopsies with scarring. Office based laryngoscopy and biopsy is allowed in case of:
- granuloma recurrence, - pedunculated polyps (if not hemangiomatosus), - enormous Reinke edema in order to secure the airway, - biopsy of the malignant lesion before the decision of radio or hemotherapy, - biopsy of malignant or benign lesions before the surgery when phonosurgical result is not expected.
Microlaryngoscopy
When evaluating this method in the literature, you can not often find so called difficult intubations phenomena explanation. One must be worried by the fact that most of the anesthesiologists see the larynx of the each patient for the first time in the very critical moment of placement the endotracheal tubes. There is need for consiliar interdisciplinary approach . Anesthesiologist have to see the larynx during the indirect laryngoscopy performed by the surgeon before the intervention, just standing beside his right shoulder. If both of them can see the whole larynx, included the anterior commisurae, there is no chance for difficult intubations. If the whole larynx is not visible, you can expect intubations problems. Then both of the team members have to asses the degree of movement in atlantooccipital and temporomandibular joints, the tiromandibular distance and angle, the tongue and the jaw volume ratio, the patient obesity.
During the microlaryngoscopy, outside compression on thyroid cartilage is useful, adequate shape and size of the dyrectoscop, need for dilatation of ventricular folds above the glottis. Adequate magnification and illumination is very important in assessing of the color, elasticity and vascularisation of the epithelium. The angled telescope is useful in examination of the lower margin of the vocal fold as well as ventricles, or you can introduce the fiber optic endoscope through the rigid tubes. That is not rare behavior to work as quick as possible, without comfortable conditions. The phonomicrosurgeon must have a special chair, movable in all directions, with adapted hand support, as well as all other accessories that allows support for arm and back musculature in order to protect fine muscles of the forearms and hands.
Additional microlaryngoscopic diagnostic methods are narrow band imaging, contact and compact endoscopy, supravital color and autofluorescency, and practical use of so called hydrodysection. When the pathology is limited on the vocal fold, sub epithelial infusion of isotonic saline with the curved needle designed by Zeitels and Vaughan, can confirm the stroboscopic findings.
The most often pitfalls
The physician has to recognize what does it really mean when the patient is talking about hoarseness. It is very important to find the history about previous intubations, larynx or head and neck injury, previous interventions on the larynx, as well as the level of vocal abuse and training. You must never forget the possibility of additional occupation, it is not rare that retired person continue to work hard as a mason, or the professional singer who sing in pubs during the night, continue with daily work in telephone central.
Endovideolaryngostroboscopic examination of membranous portion of the vocal folds very often shows the postoperative scar as a reason for prolonged postoperative dysphonia. One must insist in looking for laryngeal paresis that can be the cause for recidivism after phonosurgical removing of some vocal fold mass. Sometimes we are not aware of the presence of amyloidosis, chondroma or similar rare conditions, when making the diagnosis of bilateral laryngeal paralysis.
During the microlaryngoscopy, the excellent orientation is of the most importance, by palpation of the lower, medial end upper surface of the both vocal folds, pulling the micro instrument in down-up direction in front, medial and back third of musculomembranous part of the vocal fold. This palpation allows assessing of the elasticity, shape and vascularisation of the pathologic and normal part of the vocal fold, helps in differentiation parakeratotic site from secretion. Neglect of the presence of the sulcus is the most frequent pitfall before phonosurgical exploration of the vocal fold mass, and contra lateral contact lesion, too. Three-dimensional examination of the sulcus and the scar is allowed by special ocular tomography and linear skin rheometer.
That is not rare condition of quick pulling out the dyrectoscop after glottis examination, so one can neglect the lesion on the laryngeal side of epiglottis, or deep in the ventricles, or on aryepiglotic fold, pyriform recesses or postcricoid area.
The future
Great expansion of the laryngology is expected, as well as advance in modern technology. Using of the flexible endoscope with distal chip or even flexible stroboscope will lead to better diagnostics, with expansion of office based practice.
That is not impossible that the secret of vocal fold vibration will be solved by using the ultra speed camera.
Advance in microlaryngoscopic techniques is achieved in training laboratories. The special designed automatic robotic systems in work with animal and cadaver models helps in tremor elimination and improvement of the precious work. The day of electronic microscope use in ultra precious laryngoscopes is not so far.
There is great expansion of phoniatrics in our country. Opening of regional phoniatric departments leads to establishing one referent institution called Communication Disorders Care Center.
The institution of Continual Medical Education allows practice in modern diagnostic methods. Every ENT department with everyday microlaryngoscopic practice should have endovideolaryngostroboscopy at least. The quality of work will be equalized between subspecialist and specialist level of the health care system, on that way.
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