All scopes are not created equal

I actually meant to post this sooner, but life got the better of me.  This is a reply to a question I had on a classical singer forum, so I thought it would be nice to have it up for others to read.


So the question basically was:  If I had gone to one ENT who didn't find anything, why did the next guy I see find the paresis?  What the heck was up with that first ENT anyway?


First, about that first ENT I saw:  In all truth, he was being very nice to a singer without any insurance and tried to save me money by not turning on the camera to really see my folds in action.  He mainly just looked at the folds themselves, saw the nice, whitish-color to them while I was breathing, and said I was good.  He hardly had me phonate at all and when I went to the next guy, the paresis really only showed up after a bit of phonation.  The next guy was expensive, but thanks to a crappy day-job, I had insurance when I saw him.)

Well, unfortunately for us professional-voice-users, not all ENTs are equal and a laryngoscope is not equal to a videostroboscope of the folds. Now, the laryngoscope gives one a nice view of the folds themselves, but to really see the folds and muscosal lining during phonation in detail, you really need the strobe light effect with the stroboscopy. The reason is that the folds vibrate simply too fast to see the subtle movements of the lamina propria and fold vibration without the strobe light breaking up the image enough to make it seem like it's in "slow motion." As I said above, the first ENT did not ask for any extensive phonation. However, my folds always were healthy and "normal" looking themselves since I hadn't had any secondary pathologies like hemorrhages or nodes, and my muscosal wave was always good as well. It was the muscle action during phonation that showed the effects of the paresis. The second ENT I went to looked at an HD video of my folds during silent breathing, onset attacks, sustained phonation, and pitch changes (basically a glide up and down the pitch range) usually all on /i/...(I'm not sure why, but I assume it has something to do with keeping the tongue in an advanced, or forward, position so it doesn't interfere with the camera in your throat.)  The video was displayed on a big flat-screen TV behind me while his assistant handled the camera.  This allowed him to see a lot of detail from this examination that the other ENT hadn't been able to see. I suspect another different in the two ENTs I saw was the assumption made that my voice would be healthy based on my speaking voice.  The second ENT stated, after the diagnosis, that he was a bit shocked to see the paresis since he couldn't hear it much in my speaking voice at all.  I wonder if the first ENT made a similar assumption and just figured there wasn't going to be much to see in there.  Guess I'll never actually know... From what I've heard from some SLPs in my area, the videostroboscope is what is necessary to accurately diagnosis muscle tension dysphonia and spasmodic dysphonia as well as paresis (since it's not full-on paralysis). It just allows a much clearer picture...sort of like the difference between watching a movie on VHS on a hand-held screen compared to watching it on blue-ray on a big-screen. (I actually observed a session with a lady who the SLP suspected had spasmodic dysphonia,http://en.wikipedia.org/wiki/Spasmodic_dysphonia, but since this SLP works through a hospital and uses their ENT, she had to work on getting the woman referred out to one of the three ENTs in my area that have the videostroboscopy technology so the SLP could get an accurate diagnosis to treat.)  So my main advice to anyone thinking they need to see a doctor:  go to one who regularly works with professional (high-level if possible) singers and who has the latest equipment.  Those ENTs should take more time and care with your diagnosis and the videolarngostroboscopy will allow a more accurate picture of your laryngeal function than the regular laryngoscope will.  Unfortunately for those of us without insurance, the newest technology does come with an increase in cost, but if you can afford it, it can save you a lot of time and headache wondering why the heck your voice just doesn't work right.