Professional Documents
Culture Documents
40 (2007) 953–969
Physical examination
A detailed history frequently reveals the cause of a voice problem even
before a physical examination is performed. A comprehensive physical ex-
amination, often including objective assessment of voice function, also is es-
sential, however [1–3]. Physical examination must include a thorough ear,
nose, and throat evaluation and assessment of the patient’s general physical
condition. A patient who is extremely obese or seems fatigued, agitated,
emotionally stressed, or otherwise generally ill has increased potential for
voice dysfunction. This dysfunction could be attributable to any number
of factors: altered abdominal support, loss of fine motor control of laryngeal
muscles, decreased bulk of the submucosal vocal fold ground substance,
change in the character of mucosal secretions, or other similar mechanisms.
Any physical condition that impairs the normal function of the abdominal
musculature is suspect as cause for dysphonia. Some conditions, such as
pregnancy, are obvious; however, a sprained ankle or broken leg that re-
quires the singer to balance in an unaccustomed posture may distract him
or her from maintaining good abdominal support and thereby result in voice
dysfunction. A tremorous neurologic disorder, endocrine disturbances such
as thyroid dysfunction or menopause, the aging process, and other systemic
This article is modified from: Sataloff RT. Professional voice: the science and art of
clinical care. 3rd edition. San Diego (CA): Plural Publishing, Inc.; 2006. p. 343–53; with per-
mission.
* Corresponding author.
E-mail address: rtsataloff@phillyent.com (R.T. Sataloff).
0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2007.05.004 oto.theclinics.com
954 SATALOFF et al
conditions also may alter the voice. The physician must remember that mal-
adies of almost any body system may result in voice dysfunction, and the
doctor must remain alert for conditions outside of the head and neck. If
the patient uses his or her voice professionally for singing, acting, or other
vocally demanding professions, physical examination should also include as-
sessment of the patient during typical professional vocal tasks. For example,
a singer should be asked to sing. Evaluation techniques for assessing the per-
formance mechanism are described in greater detail elsewhere [4–10].
Laryngeal examination
Examination of the larynx begins when the singer or other voice patient
enters the physician’s office. The range, ease, volume, and quality of the
speaking voice should be noted. If the examination is not being conducted
in the patient’s native language, the physician should be sure to listen to
a sample of the patient’s mother tongue also. Voice use is often different un-
der the strain or habits of foreign language use. Rating scales used to de-
scribe the quality of the speaking voice may be helpful [11,12]. The
classification proposed by the Japanese Society of Logopedics and Phoniat-
rics is one of the most widely used. It is known commonly as the GRBAS
Voice Rating Scale [13].
Physicians are not usually experts in voice classification. Physicians should
at least be able to discriminate substantial differences in range and timbre,
however, such as between bass and tenor, or alto and soprano. Although
the correlation between speaking and singing voices is not perfect, a speaker
who has a low, comfortable bass voice who reports that he is a tenor may
be misclassified and singing inappropriate roles with consequent voice strain.
This judgment should be deferred to an expert, but the observation should
lead the physician to make the appropriate referral. Excessive volume or
956 SATALOFF et al
obvious strain during speaking clearly indicates that voice abuse is present
and may be contributing to the patient’s singing complaint. The speaking
voice can be evaluated more consistently and accurately using standardized
reading passages [14], and such assessments are performed routinely by
speech-language pathologists, phoniatricians, and sometimes by
laryngologists.
Any patient who has a voice complaint should be examined by indirect
laryngoscopy, at least. It is not possible to judge voice range, quality, or
other vocal attributes by inspection of the vocal folds. The presence or ab-
sence of nodules, mass lesions, contact ulcers, hemorrhage, erythema, paral-
ysis, arytenoid erythema (reflux), and other anatomic abnormalities must be
established, however. Erythema and edema of the laryngeal surface of the
epiglottis is seen often in association with muscle tension dysphonia and
with frequent coughing or clearing of the throat. It is caused by direct
trauma from the arytenoids during these maneuvers. The mirror or a laryn-
geal telescope often provides a better view of the posterior portion of the en-
dolarynx than is obtained with flexible endoscopy. Stroboscopic
examination adds substantially to diagnostic abilities (Fig. 1). Another oc-
casionally helpful adjunct is the operating microscope. Magnification allows
visualization of small mucosal disruptions and hemorrhages that may be sig-
nificant but overlooked otherwise. This technique also allows photography
of the larynx with a microscope camera. Magnification may also be achieved
through magnifying laryngeal mirrors or by wearing loupes. Loupes usually
provide a clearer image than do most of the magnifying mirrors available.
A laryngeal telescope may be combined with a stroboscope to provide ex-
cellent visualization of the vocal folds and related structures. The authors
usually use a 70 laryngeal telescope, although 90 telescopes are required
for some patients. The combination of a telescope and stroboscope provides
optimal magnification and optical quality for assessment of vocal fold
Fig. 1. Photograph of normal larynx showing the true vocal folds (V), false vocal folds (F), ar-
ytenoids (A), and epiglottis (E). (From Sataloff RT. Professional voice: the science and art of
clinical care. 3rd edition. San Diego [CA]: Plural Publishing, Inc.; 2006. p. 343–53; with
permission.)
PHYSICAL EXAMINATION OF VOICE PROFESSIONALS 957
Objective tests
Reliable, valid, objective analysis of the voice is extremely important and is
an essential part of a comprehensive physical examination [2]. It is as valuable
to the laryngologist as audiometry is to the otologist [16,17]. Familiarity with
some of the measures and technological advances currently available is help-
ful. This information is covered in greater detail elsewhere [5].
958 SATALOFF et al
Strobovideolaryngoscopy
Integrity of the vibratory margin of the vocal fold is essential for the com-
plex motion required to produce good vocal quality. Under continuous
light, the vocal folds vibrate approximately 256 times per second while pho-
nating at middle C. Naturally, the human eye cannot discern the necessary
details during such rapid motion. The vibratory margin may be assessed
through high-speed photography, strobovideolaryngoscopy, high-speed
video, videokymography, electroglottography (EGG), or photoglottogra-
phy. Strobovideolaryngoscopy provides the necessary clinical information
in a practical fashion. Stroboscopic light allows routine slow-motion evalu-
ation of the mucosal cover layer of the leading edge of the vocal fold. This
state-of-the-art physical examination permits detection of vibratory asym-
metries, structural abnormalities, small masses, submucosal scars, and other
conditions that are invisible under ordinary light [18,19]. Documentation of
the procedure by coupling stroboscopic light with the video camera allows
later reevaluation by the laryngologist or other health care providers.
Stroboscopy does not provide a true slow-motion image, as obtained
through high-speed photography. The stroboscope actually illuminates dif-
ferent points on consecutive vocal fold waves, each of which is retained on
the retina for 0.2 seconds. The stroboscopically lighted portions of the suc-
cessive waves are fused visually; thus the examiner is actually evaluating
simulated cycles of phonation. The slow-motion effect is created by having
the stroboscopic light desynchronized with the frequency of vocal fold vi-
bration by approximately 2 Hz. When vocal fold vibration and the strobo-
scope are synchronized exactly, the vocal folds appear to stand still rather
than move in slow motion. In most instances, this approximation of slow
motion provides all the clinical information necessary [5,19]. We use a mod-
ification of the standardized method of subjective assessment of strobovi-
deolaryngoscopic images, as proposed by Hirano and colleagues [20,21].
Characteristics evaluated include the fundamental frequency, the symmetry
of movements, periodicity, glottic closure, the amplitude of vibration, the
mucosal wave, the presence of nonvibrating portions of the vocal fold,
and other unusual findings. With practice, perceptual judgments of strobo-
scopic images provide a great deal of information. It is easy for the inexpe-
rienced observer to draw unwarranted conclusions because of normal
variations in vibration, however. Vibrations depend on fundamental fre-
quency, intensity, and vocal register. For example, failure of glottic closure
occurs normally in falsetto phonation. Consequently, it is important to note
these characteristics and to examine each voice under various conditions.
Aerodynamic measures
Traditional pulmonary function testing provides the most readily acces-
sible measure of respiratory function. The most common parameters mea-
sured include: (1) tidal volume, the volume of air that enters the lungs
during inspiration and leaves during expiration in normal breathing; (2)
functional residual capacity, the volume of air remaining in the lungs at
the end of inspiration during normal breathing, which can be divided into
expiratory reserve volume (maximal additional volume that can be exhaled)
and residual volume (the volume of air remaining in the lungs at the end of
maximal exhalation); (3) inspiratory capacity, the maximal volume of air
that can be inhaled starting at the functional residual capacity; (4) total
lung capacity, the volume of air in the lungs following maximal inspiration;
(5) vital capacity, the maximal volume of air that can be exhaled from the
lungs following maximal inspiration; (6) forced vital capacity, the rate of
air flow with rapid, forceful expiration from total lung capacity to residual
volume; (7) FEV1, the forced expiratory volume in 1 second; (8) FEV3, the
forced expiratory volume in 3 seconds; (9) maximal mid-expiratory flow, the
mean rate of air flow over the middle half of the forced vital capacity (be-
tween 25% and 75% of the forced vital capacity).
For singers and professional speakers who have an abnormality caused by
voice abuse, abnormal pulmonary function tests may confirm deficiencies in
aerobic conditioning or reveal previously unrecognized asthma [28]. Flow
glottography with computer inverse filtering is also a practical and valuable
diagnostic tool for assessing flow at the vocal fold level, evaluating the voice
source, and imaging the results of the balance between adductory forces and
subglottal pressure [17,29]. It also has therapeutic value as a biofeedback tool.
PHYSICAL EXAMINATION OF VOICE PROFESSIONALS 961
The spirometer, readily available for pulmonary function testing, can also
be used for measuring airflow during phonation.
Air volume is measured by the use of a mask fitted tightly over the face or
by phonating into a mouthpiece while wearing a nose clamp. Measurements
may be made using a spirometer, pneumotachograph, or hot-wire anemom-
eter. The normal values for mean flow rate under habitual phonation, with
changes in intensity or register, and under various pathologic circumstances,
were determined in the 1970s [13]. Normal values are available for adults
and children. Mean flow rate also can be measured and is a clinically useful
parameter to follow during treatment of vocal nodules, recurrent laryngeal
nerve paralysis, spasmodic dysphonia, and other conditions.
Glottal resistance cannot be measured directly, but it may be calculated
from the mean flow rate and mean subglottal pressure. Normal glottal resis-
tance is 20 to 100 dyne s/cm5 at low and medium pitches and 150 dyne s/cm5
at high pitches [25]. The normal values for subglottal pressure under various
healthy and pathologic voice conditions have also been determined by nu-
merous investigators [13]. The phonation quotient is the vital capacity di-
vided by the maximum phonation time. It has been shown to correlate
closely with maximum flow rate [30] and is a more convenient measure. Nor-
mative data determined by various authors have been published [13]. The
phonation quotient provides an objective measure of the effects of treatment
and is particularly useful in cases of recurrent laryngeal nerve paralysis and
mass lesions of the vocal folds, including nodules.
Acoustic analysis
Acoustic analysis equipment can determine frequency, intensity, har-
monic spectrum, cycle-to-cycle perturbations in frequency (jitter), cycle-to-
cycle perturbations in amplitude (shimmer), harmonics/noise ratios, breath-
iness index, cepstral peak prominence, and many other parameters. The
DSP Sona-Graph Sound Analyzer Model 5500 (Kay Elemetrics, Lincoln
Park, New Jersey) is an integrated voice analysis system. It is equipped
for sound spectrography capabilities. Spectrography provides a visual re-
cord of the voice. The acoustic signal is depicted using time (x axis), fre-
quency (y axis) and intensity (z axis) shading of light versus dark. Using
the band pass filters, generalizations about quality, pitch, and loudness
can be made. These observations are used in formulating the voice therapy
treatment plan. Formant structure and strength can be determined using the
narrow-band filters, of which various configurations are possible. In clinical
settings in which singers and other professional voice users are evaluated
and treated routinely, this feature is extremely valuable. A sophisticated
voice analysis program (an optional program) may be combined with the
Sona-Graph and is an especially valuable addition to the clinical laboratory.
The voice analysis program (Computer Speech Lab, Kay Elemetrics, Lin-
coln Park, New Jersey) measures speaking fundamental frequency,
962 SATALOFF et al
Laryngeal electromyography
Electromyography (EMG) requires an electrode system, an amplifier, an
oscilloscope, a loudspeaker, and a recording system [32]. Needle electrodes
are placed transcutaneously into laryngeal muscles. EMG can be extremely
valuable in confirming cases of vocal fold paresis, in differentiating paralysis
from arytenoid dislocation, distinguishing recurrent laryngeal nerve paralysis
from combined recurrent and superior nerve paralysis, diagnosing other more
subtle neurolaryngologic pathology, and documenting functional voice disor-
ders and malingering. It is also recommended for needle localization when us-
ing botulinum toxin to treat spasmodic dysphonia and other conditions.
Psychoacoustic evaluation
Because the human ear and brain are the most sensitive and complex an-
alyzers of sound currently available, many researchers have tried to stan-
dardize and quantify psychoacoustic evaluation. Unfortunately, even
definitions of basic terms, such as hoarseness and breathiness, are still con-
troversial. Psychoacoustic evaluation protocols and interpretations are not
standardized. Consequently, although subjective psychoacoustic analysis
of voice is of great value to the individual skilled clinician, it remains gener-
ally unsatisfactory for comparing research among laboratories or for report-
ing clinical results.
The GRBAS scale helps standardize perceptual analysis for clinical pur-
poses. It rates the vocal characteristics of grade, roughness, breathiness,
PHYSICAL EXAMINATION OF VOICE PROFESSIONALS 963
Outcomes assessment
Measuring the impact of a voice disorder on the function of an individual
in his or her normal activities of daily living has always been challenging.
Recent advances have begun to address this problem, however. Validated
instruments, such as the Voice Handicap Index (VHI) and the Voice Related
Quality of Life (VRQOL) [34] are currently in clinical use, and are likely to
be used widely in future years [35]. Current trends and future directions in
measuring voice treatment outcomes are discussed elsewhere [36].
professional speakers, including actors (who can vocalize and recite lines),
clergy and politicians (who can deliver sermons and speeches), and virtually
all other voice patients. The singer’s stance should be balanced, with the
weight slightly forward. The knees should be bent slightly and the shoulders,
torso, and neck should be relaxed. The singer should inhale through the
nose whenever possible allowing filtration, warming, and humidification
of inspired air. In general, the chest should be expanded, but most of the ac-
tive breathing is abdominal. The chest should not rise substantially with
each inspiration, and the supraclavicular musculature should not be in-
volved obviously in inspiration. Shoulders and neck muscles should not
be tensed even with deep inspiration. Abdominal musculature should be
contracted shortly before the initiation of the tone. This contraction may
be evaluated visually or by palpation (Fig. 2). Muscles of the neck and
face should be relaxed. Economy is a basic principle of all art forms. Wasted
energy and motion and muscle tension are incorrect and usually deleterious.
The singer should be instructed to sing a scale (a five-note scale is usually
sufficient) on the vowel /a/, beginning on any comfortable note. Technical er-
rors are usually most obvious as contraction of muscles in the neck and chin,
retraction of the lower lip, retraction of the tongue, or tightening of the mus-
cles of mastication. The singer’s mouth should be open widely but comfort-
ably. When singing /a/, the singer’s tongue should rest in a neutral position
with the tip of the tongue lying against the back of the singer’s mandibular in-
cisors. If the tongue pulls back or demonstrates obvious muscular activity as
the singer performs the scales, improper voice use can be confirmed by positive
evidence (Fig. 3). The position of the larynx should not vary substantially with
pitch changes. Rising of the larynx with ascending pitch is evidence of techni-
cal dysfunction. This examination also gives the physician an opportunity to
observe any dramatic differences between the qualities and ranges of the pa-
tient’s speaking voice and the singing voice. A physical examination summary
form has proven helpful in organization and documentation [3].
Remembering the admonition not to exceed his or her expertise, the phy-
sician who examines many singers can often glean valuable information
from a brief attempt to modify an obvious technical error. For example, de-
ciding whether to allow a singer who has mild or moderate laryngitis to per-
form is often difficult. On the one hand, an expert singer has technical skills
that allow him or her to compensate safely. On the other hand, if a singer
does not sing with correct technique and does not have the discipline to
modify volume, technique, and repertoire as necessary, the risk for vocal in-
jury may be increased substantially even by mild inflammation of the vocal
folds. In borderline circumstances, observation of the singer’s technique
may greatly help the physician in making a judgment.
If the singer’s technique seems flawless, the physician may feel somewhat
more secure in allowing the singer to proceed with performance commit-
ments. More commonly, even good singers demonstrate technical errors
when experiencing voice difficulties. In a vain effort to compensate for
PHYSICAL EXAMINATION OF VOICE PROFESSIONALS 965
Fig. 2. Bimanual palpation of the support mechanism. The singer should expand posteriorly
and anteriorly with inspiration. Muscles should tighten before onset of the sung tone. (From
Sataloff RT. Professional voice: the science and art of clinical care. 3rd edition. San Diego
[CA]: Plural Publishing, Inc.; 2006. p. 343–53; with permission.)
dysfunction at the vocal fold level, singers often modify their technique in
the neck and supraglottic vocal tract. In the good singer, this usually means
going from good technique to bad technique. The most common error in-
volves pulling back the tongue and tightening the cervical muscles. Al-
though this increased muscular activity gives the singer the illusion of
making the voice more secure, this technical maladjustment undermines vo-
cal efficiency and increases vocal strain. The physician may ask the singer to
hold the top note of a five-note scale; while the note is being held, the singer
may simply be told, ‘‘Relax your tongue.’’ At the same time the physician
points to the singer’s abdominal musculature. Most good singers immedi-
ately correct to good technique. If they do, and if upcoming performances
are particularly important, the singer may be able to perform with a re-
minder that meticulous technique is essential. The singer should be advised
to ‘‘sing by feel rather than by ear,’’ to consult his or her voice teacher, and
to conserve the voice except when it is absolutely necessary to use it. If
a singer is unable to correct from bad technique to good technique
966 SATALOFF et al
Fig. 3. Proper relaxed position of the anterior (A) and posterior (B) portions of the tongue.
Common improper use of the tongue pulled back from the teeth (C) and raised posteriorly
(D). (From Sataloff RT. Professional voice: the science and art of clinical care. 3rd edition.
San Diego [CA]: Plural Publishing, Inc.; 2006. p. 343–53; with permission.)
Additional examinations
A general physical examination should be performed whenever the
patient’s systemic health is questionable. Debilitating conditions, such as
PHYSICAL EXAMINATION OF VOICE PROFESSIONALS 967
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