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BackTable / ENT / Article
Diagnosing Voice Disorders: An In-Depth Guide
Iman Iqbal • Updated Jan 20, 2025 • 39 hits
Diagnosing voice disorders can be a complex process, as patients often present with a wide range of symptoms. Clinicians must ask the right questions and perform a thorough physical exam to identify the underlying cause. Understanding whether the issue is functional or anatomical and discerning the true nature of the complaint is critical. For singers, whose voices are integral to their livelihood, voice problems can be particularly impactful, requiring more specialized diagnostic techniques like videostroboscopy to assess the vocal folds in detail.
This article covers the different diagnostic tools and techniques used to evaluate voice disorders.. This article features excerpts from the BackTable ENT Podcast with otolaryngologist, Dr. Mark Williams. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.
The BackTable ENT Brief
• Voice disorders can range from subtle issues like vocal fatigue to more pronounced problems such as hoarseness, which requires detailed evaluation.
• Clinicians need to distinguish between symptoms like breathiness, roughness, pitch loss, and pain to determine whether the voice issue is functional or anatomical.
• Videostroboscopy, an advanced diagnostic tool, provides slow-motion visualization of vocal fold vibration, offering insights into their elasticity, stiffness, and potential lesions.
• There are two main methods for conducting videostroboscopy: rigid laryngoscopy (providing better resolution) and flexible fiber-optic scope (allowing for normal speech during the procedure).
• Important aspects of videostroboscopy include evaluating the smoothness of the vocal folds, glottal closure, mobility, mucosal wave, and the regularity of vibration.
• Physical exams for voice disorders include evaluating posture, nasal congestion, hypertrophy of nasal turbinates, enlarged tonsils, and signs of reflux (e.g., heartburn or throat clearing).
• Palpation of the strap muscles and thyrohyoid membrane helps identify muscle tension dysphonia, which can arise from compensatory behaviors after an initial vocal issue.
• Singers should be evaluated differently from non-singers, taking a more detailed history and utilizing videostroboscopy as the primary diagnostic tool to assess vocal fold function under singing conditions.
Table of Contents
(1) Evaluating Voice Disorders
(2) Laryngeal Videostroboscopy: A Key Tool for Assessing Voice Disorders
(3) Key Physical Exam Findings in Voice Disorder Evaluation
(4) Evaluating Hoarseness in Singers vs Non-Singers
Evaluating Voice Disorders
Voice patients present with a broad spectrum of issues, ranging from subtle complaints to more overt symptoms. Some individuals may experience vocal fatigue, diminished pitch range, or decreased vocal agility, often due to inactivity or changes in their vocal usage.
The evaluation of a voice issue begins with understanding the patient’s description of their symptoms. Patients often describe their issues broadly as "hoarseness," but this term can encompass a wide range of symptoms. Clinicians must dig deeper to discern whether the problem is related to breathiness, roughness, pitch loss, or pain. Questions about the timing and duration of symptoms—whether they occur in the morning, evening, or after prolonged use—are critical to gathering more specific information. This helps the clinician determine whether the issue is functional or anatomical.
In some cases, the patient’s reported symptoms may not align with what is heard during the consultation. For example, a patient may claim to have hoarseness, but their voice might sound perfectly clear. In such situations, further diagnostic steps, like flexible laryngoscopy or videostroboscopy, may be necessary to investigate potential issues in the vocal folds. In particular, singers often present with vocal fatigue or difficulty transitioning between vocal registers, and it may require more specialized testing to uncover the underlying problem, especially when symptoms do not align with the clinician’s auditory perception of the voice.
[Dr. Gopi Shah]
Dr. Williams, how does a voice patient present to you in your clinics?
[Dr. Mark Williams]
Voice patients present a variety of different ways for me, especially being here in Nashville. In Nashville, we have voice patients who aren't presenting for voice problems, even for that matter. They're singers. You can throw a coin into a group of people and that same coin hit about five singers before it hits the ground. They're presenting with every problem that they have.
Many of the patients that I see that specifically have voice issues are coming in for a wide range of problems. They're having difficulty with singing and'or speaking. Then we have even those patients who present with very subtle voice issues, and we're seeing a little bit more of that now that people have been inactive and not singing much over the past year with the pandemic. We see people, their voices have become deconditioned. They're presenting and saying, "Man, after I'm singing a song or two, I'm spent. I'm having early vocal fatigue." These more subtle voice issues, or "I'm losing a little bit of my pitch range" are presenting. These subtle complaints are more prevalent now than they had been in the past.
In the past, it was more like, "Hey, I'm literally hoarse. I'm having a lot of breathiness or this coarse sound to my voice and I can't do my falsetto." They used to be more complex or direct problems. Now they're more subtle and I have to figure out exactly, do you really have a voice problem or is there something anatomical or is it something more functional?
[Dr. Ashley Agan]
When a patient comes in and they are seeing you for hoarseness or something specifically related to voice, what does that evaluation look like? Can you walk us through key questions we need to be asking and what the exam and workup looks like?
[Dr. Mark Williams]
Yes. That's always the challenge for me. It's because when patients describe everything as hoarseness and so they don't know some of the finer descriptions that we have, I'll ask, "What's the problem?" They say, "I'm hoarse. I get hoarse all the time," and trying to get them to be a little bit more explicit about what they mean by hoarseness. Is it breathiness to the voice or is it that you have a more coarse or moist sound to your voice? Have you lost pitch range? You're no longer able to hit the notes that you were hitting or are they just not coming out clear? Are you feeling pain in the throat or have you lost some dynamic control and the agility of your voice?
We have to dig in a little bit more deeply with some of these particularly voice patients because they're just saying, "I'm hoarse." To me, it means almost nothing. As a clinician who specializes in voice, it means almost nothing because people's description of hoarseness is so wide. I know you're familiar when people say, "I've got the sinus." You're like, "What's your complaint? What's my sinuses?" Those are the two areas that challenge [crosstalk] me the most. I'm like, "Describe that a little bit more for me."
We have to help those patients describe what they're talking about. Is it just happening in the mornings when you wake up or is it happening-- Is it worse in the evening or you're fine in the morning then as the day progresses that it gets worse or-- We have to pull that information from our patients because they don't readily offer it and they probably haven't even thought about it until after I've started asking these questions.
[Dr. Ashley Agan]
Then do you ever find that as you go through the history with them, what they're describing to you, is there ever a discrepancy from your perception of what their voice problem is? Have you come on the same understanding of what they think is a problem and what you hear? Is there ever a difference in that?
[Dr. Mark Williams]
There's often a difference in that, and that determines for me exactly how I'm going to proceed with evaluating their larynx. For example, patients may come into the office and complain of hoarseness, and I'm listening to them communicate and speak to me, and their voice sounds just as clear as the clearest of day. I know in that moment that if I look at their vocal cords with a flexible laryngoscope or fiber optic laryngoscope, then I'm probably not going to see a lesion on the vocal folds.
Usually, our ability to perceive a voice disturbance with our ears just from talking with a patient will let me know whether it's worthwhile putting a flexible scope in on this patient. Rarely, do I see someone whose voice sounds normal to me. Rarely, do I see any anatomical pathology or nodules or polyps, or even for that matter, erythema of the vocal folds. It's those more subtle ones.
When I have singers come in, particularly, who seem to have a clear voice, and they're telling me that they're hoarse, I may actually have them sing to demonstrate where they're having the problem. Sometimes they're having problems with their passaggio changing from their full chest voice to their falsetto voice. We'll have them demonstrate where they're having problems. Because I'm not a trained singer myself, I don't try to get too much into that. I'll leave that to my voice therapist who is actually a trained-- she's a pedagogist, but she's also a speech-language pathologist who specializes in voice.
That is one of the things that I'll do to help uncover where the problem is. If everything sounds normal to me, I'm thinking immediately I'm going to proceed to videostroboscopy.
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Laryngeal Videostroboscopy: A Key Tool for Assessing Voice Disorders
Laryngeal videostroboscopy is an advanced diagnostic technique used to assess both the anatomy and function of the vocal folds. Unlike a typical flexible laryngoscopy, which mainly focuses on structural issues, videostroboscopy allows for the visualization of the vibratory motion of the vocal folds, which occurs too rapidly for the human eye to detect. A strobe light is synchronized with the vibration of the vocal folds, providing the illusion of slow-motion movement. This technique is particularly helpful for identifying issues related to the elasticity and stiffness of the vocal folds, as well as detecting subtle problems like vocal nodules or cysts.
There are two primary methods for conducting a videostroboscopy: a rigid laryngoscope and a flexible fiber-optic scope. The rigid scope, which is inserted through the mouth, offers better resolution and is typically preferred for videostroboscopy due to the clearer image it provides. The flexible fiber-optic scope, which passes through the nose, is often used when the patient needs to speak normally during the procedure. This flexibility makes it easier to evaluate how the vocal folds function during natural speech or singing.
When documenting videostroboscopy results, clinicians focus on key aspects of vocal fold function, including the smoothness of their medial surface, the glottal closure, the presence of any lesions, and the mobility of the vocal folds. They also assess the mucosal wave and the regularity of the vocal fold vibration during the cycle. Additionally, vocal frequency is measured, with standard passages like the "rainbow passage" used to assess the patient's speech and pitch range during normal speaking and singing. These measurements are particularly useful for voice therapists in guiding patients back to healthier vocal habits.
[Dr. Mark Williams]
Laryngeal-videostroboscopy is a technique where we are able to look at not just the anatomy of the vocal folds, but also how they function as air moves through the vocal folds and sets them into vibration. The vocal folds will vibrate anywhere 80 times to 400 times or more per second. Obviously, that's too fast for the human retina to fix an image on. You can't actually see the vocal folds vibrate. What we'll do is we'll shine a strobe light on the vocal folds while we're looking at their functioning while the patient is phonating or creating voice.
That strobe light makes it appear that the vocal folds are vibrating in slow motion. What it's really doing is it's actually capturing different images of different stages of the vibratory cycle. It gives the illusion that the vocal folds are moving in slow motion. It usually gives us a little bit better resolution of the anatomy, but it also gives us a little bit of insight into the function of the vocal folds. You can find out if the vocal folds are a little too stiff or if there's some deficit of mucosal weight propagation and why the vocal folds aren't as elastic as they should be. That might be contributing to some of their voice issue as well.
It's a little bit more sensitive for picking up on things like nodules or distinguishing between a vocal nodule and a vocal cyst. The resolution, particularly if you do a rigid videostroboscopy, the resolution is a lot better. As you're aware, there are two different ways that we can evaluate the vocal folds. One is with a rigid laryngoscope and then the other one is with a flexible fiber optic one. Fiber optic one goes through the nose. The rigid one will go through the mouth. It's a 70 degree angle, has much better visualization. I prefer to use a rigid scope when I'm doing my videostroboscopies.
Technology has advanced where we can do what's called distal chip, where they put the chip in the distal end of the fiber optic laryngoscope and then you can do a stroboscopy that way. Which is, if you're trying to look at the dynamics of phonation and the voice production, it's much easier to do that with the flexible distal chip video laryngoscope. The reason being is because if we do the rigid one, we have to actually hold the patient's tongue while they phonate and it's a very artificial situation.
Whereas, if you had a flexible scope, you can put it through the nose and you can actually evaluate how they're-- what's going on with the larynx and the supraglottis and even for that matter, the hypopharynx, while they're actually speaking in a more normal manner. In fact, I participated in a graduate student's doctoral thesis research where we were evaluating a vocal technique in gospel music called squall. I don't know if you're all familiar with squall very much, but in gospel music, [squalls] that type of thing. It can be incredibly damaging to the vocal folds if you don't know how to do it properly.
In gospel music, it's a very moving and emotive type singing technique that really moves the audience and the listeners. Singers who have perfected that without causing damage to the vocal folds, we really want to know how to do that. Not many coaches know how to teach that technique. You obviously couldn't do that if you were holding someone's tongue with a rigid laryngoscope. We were fortunate to be able to use a flexible distal chip one to evaluate what structures were actually vibrating whilst singers were using that technique.
We found that different singers use different supraglottic structures and some people actually use their vocal folds and create sort of a fry of the vocal folds when they're singing. Obviously, that can be more dangerous and harmful to the vocal folds as opposed to some who were perhaps using their arytenoids to create the vibratory sound or the distortion in their sound. A flexible distal chip video laryngoscope stroboscope was able to be more effective in that regard. I wish I had the money in my private practice to have one of those things, but we had it for academic purposes and it worked for what it did for it.
In my practice, we use a rigid one, it gives us a better illusion and it's more affordable for people like me.
[Dr. Gopi Shah]
Just to go to some basics, how do you document your strobe? Now, I remember, I think I might've asked you this in practice as well, because laryngology to me, it's something just so foreign still to a certain extent. Because unless you've really had time to shadow or watch a laryngologist and a speech pathologist in clinic in your training or maybe, in whoever's practice, to me, it's a very hard thing to quite understand. I know how I document my basic flexible laryngoscopy for dysphagia or stridor, but I don't know what-- how do you document, what's your note look like, I guess, or what are the things that you definitely always put down in your progress note?
[Dr. Mark Williams]
Videostroboscopy is one of those areas where there's a lot of subjectivity. I think voice, and measuring voice anyway, the GRBAS type assessments, a lot of this is so subjective that there's a lot of variability. If you are going to try to rate someone, the gravelliness, for example, or the roughness of someone's voice, one listener may rate it, zero, one or two, and then another person may do it a different number.
The same thing happens when we're evaluating the video strobe, but there are certain characteristics that we are always looking at. We're looking at the medial surface of the vocal folds, whether it's smooth or whether it's rough. I'm always documenting that. We're looking at glottal closure, whether or not there's complete glottal closure, anterior or posterior chink or gap in the vocal folds. Are there any lesions on the vocal folds? We're also looking at the mobility of the vocal folds, mucosal wave propagation. Does it seem like it's smooth and it's intact, or is it impeded somehow or another?
We're looking also at periodicity, whether or not the vocal folds are vibrating regularly with the videostroboscopy, or are there irregularities to the glottal cycle? Other things that I would document in there are going to be-- it's difficult to not have the template. It really helps to have a template right in front of you because you go through and you click each one of these things, and so I'm trying to remember what the template looks like in my head.
To answer your question, that's how I document it. I fill in the blanks on the template, [laughter] but the level of the vocal folds too, whether or not they're equal or not. We look at what phase predominates, whether the closed phase or the open phase, the glottal phase, glottal appearance or apparatus, whether it spends more time open versus closed. Those are things that we do. Particularly, I'm also wanting to document what the fundamental frequency is. When I have patients always read a passage, it's a standard passage, and I measure--
[Dr. Gopi Shah]
The rainbow passage.
[Dr. Mark Williams]
[crosstalk] division of white light divided to many colors. Yes, exactly. That rainbow passage. We look to see what their speech frequency is. Then you ask them to sing. Then all of a sudden they're speaking right here, but then you have them say "E" or "Aa," they "Eee." You're like, "Wait a minute. In your normal speaking voice." "Okay. Eee." Okay, we're fine. "Okay. Aaa." We'll measure those as well because you can see some differences where people are normally speaking out at a higher pitch or lower pitch than they really should.
That's something that's helpful for my voice therapist. How exactly she used it, unfortunately, I don't know, but I do know that if you're speaking at a much lower pitch than you normally should, then that needs to be corrected. They will help to coach our patients back to that range.
Key Physical Exam Findings in Voice Disorder Evaluation
In evaluating voice disorders, the physical exam should assess posture, particularly during singing, as poor posture can exacerbate voice issues. The examiner should also look for signs of postnasal drainage, nasal congestion, and hypertrophy of nasal turbinates or enlarged tonsils, which can affect the resonating chambers involved in voice production. Additionally, symptoms of esophageal or laryngopharyngeal reflux, such as heartburn or throat clearing, should be checked by inspecting the posterior glottis for signs of irritation like pachydermia.
Palpation is another important part of the physical exam. If patients report pain after voice use, palpating the strap muscles and thyrohyoid membrane helps identify muscle tension dysphonia. Tenderness in these areas suggests that muscle strain is contributing to the voice disorder, often as a result of compensatory behaviors that develop after an initial vocal issue has healed.
[Dr. Gopi Shah]
Are there any other physical exam findings that are really key, that you're looking at when you're evaluating these patients?
[Dr. Mark Williams]
Yes. There are a variety of different things that can cause voice problems in patients. Of course, I'm also evaluating even-- especially if I have a patient singing, I'm looking at their posture when they're singing. Because that often can give you some clues into why they may be having a voice disturbance. One of the more easy things that I'm screening for early on is dissipation at post nasal drainage. Are they having signs and symptoms of esophageal or laryngopharyngeal reflux? As those will contribute to some voice dysfunction as well.
As you're aware, the voice requires three functioning systems, the respirator or the lungs, the phonator, the vibrator, the vocal folds. Then the resonator, everything above the vocal folds, so the throat, the teeth, the nose, the mouth, all of those things shape the voice, the sound that's created by air moving through the vocal folds. They shape that into an intelligible sound that we call voice. If there's a disturbance in any one of those three systems, then you're going to have a voice disturbance.
As part of our evaluation, we really do have to evaluate the entire person. If they have nasal congestion or turbulent hypertrophy, I'm even looking to see the size of people's tonsils because those things will actually impact the resonating chamber as well.
Most of my exam is directed toward looking for, or at least it's guided by the history. If you give me a history of post nasal drainage, I'm going to be looking in the oral pharynx to see if I see any evidence of that. If you give me history of esophageal reflux or heartburn symptoms or frequent throat clearing, globus sensation, cough with that, when I do my laryngoscopic examination, I'm going to look in the posterior glottis to find out if I see any pachydermia in that region.
Subtle findings sometimes can help to identify where the voice issue comes from for these patients. Often, we find that it's just muscle tension. We have a lot of patients who are having voice problems that started from something physiologic and then they compensated for it with a behavior. Because they've been talking through and singing through this for so long and they developed some compensatory behaviors that now the compensatory behaviors are causing more problems than the original pathology did after the original pathology healed. We have to get them working with a good voice therapist to break those compensatory behaviors, get voicing back to normal.
[Dr. Ashley Agan]
Is there anything on your laryngeal palpation exam? When you mentioned muscle tension, like when you palpate, are there certain parts of the laryngeal framework or the cartilaginous framework, I guess, that you palpate or check for? Do they have pain often? Is there stuff like that on your physical exam?
[Dr. Mark Williams]
As a matter of fact, I do. Patients who relay a history of pain, particularly after singing or after voice use, I'm specifically palpating their strap muscles and seeing if they're tender along the strap muscles, along the thyrohyoid membrane as well. Those things are key indicators that patients may have some muscle tension dysphonia. If you have that tenderness in those areas, I'm really thinking that muscle tension is at least contributing to some of your voice problems.
Evaluating Hoarseness in Singers vs Non-Singers
When evaluating hoarseness, singers should be assessed with a more detailed history, focusing on their vocal training, singing routines, and any upcoming performances, as their income and livelihood may depend on their voice. This added stress can exacerbate voice problems, so understanding these factors is important for managing their condition. Additionally, singers often experience more intense emotional reactions, like anxiety, which can contribute to worsening voice issues.
For singers, videostroboscopy is typically the preferred diagnostic tool, as it provides a more detailed assessment of vocal fold function. In contrast, non-singer patients may begin with a flexible scope, with videostroboscopy being considered later if needed.
[Dr. Ashley Agan]
Is there a difference in how you evaluate hoarseness in a singer versus a non-singer or is it pretty standard, or do you not even think of the groups that way?
[Dr. Mark Williams]
Oh no, I think of them that way. [laughter] I really do. With our singer patients, I do actually get a much more detailed history about what their training is, what their usual singing routine is, what are their upcoming and pending engagements, how is this impacting your income? Because for a lot of people who depend on their voice for their living, that added stress really can contribute to worsening voice problems with anxiety and other issues that come as a result of that. Yes, I do have to expand my interrogatories, I guess, and my history for my singer patients.
I usually do my videostroboscopies because they can take quite a bit of time and be pretty disruptive to the flow of patients. I usually schedule those in a specific appointment just for videostroboscopy. I typically do those on a Friday. If I have a singer patient who presents to me and I'm listening to them and their voice sounds normal, I automatically know that I'm going to videostroboscopy as opposed to even putting a flexible scope in their nose while they're in the office. Non-singer patients, I may start off with just using a flexible scope, but if you are a singer, I'm pretty much resolved to the idea that I'm going to do a videostroboscopy on you fairly early on.
Podcast Contributors
Dr. Mark Williams
Dr. Mark Williams is a practicing Otolaryngologist at his solo practice, Ear, Nose & Throat: Specialists of Nashville.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
Dr. Ashley Agan
Dr. Ashley Agan is an otolaryngologist in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2021, August 3). Ep. 28 – Music, Medicine, & Ministry [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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