Diagnoses Are Changed...There Must Be Something in the Water

It's Research Tuesday again! There may be "Something in the Water" for Carrie Underwood for her to be changed, and the same is true for the diagnosis of many voice disorders following videostroboscopic evaluation. In this recent article in the Laryngoscope, Seth Cohen (no not the one from the OC), Nelson Roy, Mark Courey and others take a look at how important Videolaryngostroboscopy (VLS) is as an evaluation tool. They did this retrospectively for patients from 2004-2008, who had been evaluated by an otolaryngologist and then had a specialty voice evaluation with a VLS component within 90 days. Findings? Half of the patients had a change in diagnosis following a VLS. HALF! That's insane. I love examining vocal folds with my strobe light and rigid endoscope, and now I love it even more. If this examination can correctly identify disorders that would have been misdiagnosed otherwise, I'll shout it from the mountain tops! Strobes matter!

Think about the otolaryngologist. He sees 20-30 patients per day, and voice complaints usually result in a quick look with a flexible endoscope through the nose. This is to determine if there is something scary or not, and to determine the depth of evaluation necessity. The ENT will then usually refer the patient to a voice specialist for a videostroboscopic examination, or do it himself if he has the training, technology and time. He makes the best call he can for the technology and time he has, and when he knows the patient will benefit from further analysis, he refers. This is efficient.

What makes a videostroboscopy so much more comprehensive?

  1. It can be recorded and reviewed multiple times to educate the patient and to share with other care providers.
  2. It is magnified greater than a flexible endoscope, so you see the laryngeal vestibule in greater detail.
  3. The strobe light allows the vocal folds to be seen in motion. This helps us evaluate the vocal folds in five ways, as well as for color and structure.

This saves us money, it saves the patient money, and it saves insurance companies money. In this study, 83% of 125 individuals who had the diagnosis of acute laryngitis had their diagnosis changed to something different. This was not the only initial diagnosis, but it showed the biggest change. Difference in diagnosis means that there were differences in treatment patterns as well. This means that PPI's were only used when necessary, surgery wasn't performed if it wasn't necessary and voice therapy may have helped in many cases. I like the otolaryngologists I work closely with because they are very conservative when they treat. We provide voice therapy and wait and watch. Vocal folds are so delicate and unnecessary surgery could make a voice quality worse than what the person was complaining of. Each case is different, but many times voice therapy can make a huge difference and even help avoid surgery.

So what was being over diagnosed? Acute laryngitis and vocal fold paresis had a higher chance of being changed as a diagnosis than chronic laryngitis. Cancer and nonspecific dysphonia had less of a chance than chronic laryngitis. The article also states that ENT's are less comfortable with diagnosing specific voice disorders unless they are very visual in presentation, so even more reason for our specialty to shine. Get out there, stay educated on interpreting and strobe, people!

Source: Change in diagnosis and treatment following specialty voice evaluation: A national database analysis. Cohen, Seth; Kim, Jaewhan; Roy, Nelson; Wilk, Amber; Thomas, Steven, & Courey, Mark. Laryngoscope, 13 Feb 2015, doi: 10.1002/lary.25192

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.