VIDEOSTROBOSCOPY - Rigid Transoral Approach as Above - note: flexible transnasal endoscopic viewing of the larynx (either fiberoptic or, now more commonly, distal chip) approach is generally a more useful examination for patients with movement disorders such as laryngeal tremor/spasmodic dysphonia/muscle tension dysphonia.

1. Procedure
   1. The larynx is imaged stroboscopically and recorded on videotape while the patient is instructed to produce a sustained /i/ sound as follows:
      1. Comfortable loudness, comfortable pitch
      2. Comfortable loudness, high pitch (falsetto)
      3. Comfortable loudness, low pitch (above glottal fry)
      4. Comfortable pitch, very soft
      5. Comfortable pitch, louder
      6. Comfortable pitch, loud as possible (without discomfort)
2. Documentation and Interpretation
   1. Scope used (the clinician notes one of the following)
      1. Flexible
      2. Rigid
      3. Both
   2. Type of examination (the clinician notes one of the following)
      1. Failed
      2. Endoscopy only
      3. Stroboscopy only
      4. Stroboscopy with EGG (electroglottography).
   3. Quality of examination (the clinician notes one of the following)
      1. Excellent
      2. Good
      3. Fair
      4. Poor
   4. Glottal closure (the clinician notes one of the following)
      1. Complete
      2. Inconsistent
      3. Incomplete
   5. Supraglottic compression (the clinician rates from 1 to 5 where 1 = none and 5 = severe)
   6. Mucosal wave (the clinician notes one of the following)
      1. 1 = normal
      2. 2 = small or absent
      3. 3 = great (excessive)
   7. Amplitude symmetry (the clinician notes one of the following)
      1. 1 = normal symmetry
      2. 2 = Left > Right
      3. 3 = Right > Left
      4. Right fold amplitude is rated by the clinician from 1 to 5 where 1 = normal amplitude and 5 = fixed (no vibratory movement)
      5. Left fold amplitude is rated by the clinician from 1 to 5 where 1 = normal amplitude and 5 = fixed (no vibratory movement)
   8. Phase asymmetry (the clinician rates from 1 to 5 where 1 = never irregular and 5 = always irregular)
   9. Vocal fold edge (the clinician rates from 1 to 5 where 1 = smooth/straight and 5 = rough/irregular)
   10. Adynamic segments (the clinician notes one of the following for each of the true vocal folds)
       1. None
       2. Adynamic segments noted
3. Diagnosis
   1. Primary diagnosis (consensus between the physician and speech pathologist)
   2. Secondary diagnosis (consensus between the physician and speech pathologist)
   3. Other observations
4. Recommendations
   1. Follow-up evaluation
   2. Vocal conservation
   3. Voice therapy
   4. OHNS follow-up
   5. Voice rest
   6. Referral to a singing teacher
   7. Other (described in detail where indicated)

CASE EXAMPLE OF NORMAL FEMALE VIDEOSTROBOSCOPY (transoral rigid) - see above

VIDEOENDOSCOPY FOR PATIENTS WITH VOCAL TREMOR OR SPASMODIC DYSPHONIA

1. Flexible Endoscopic Procedure
   1. Quiet breathing
   2. Sniff 3 times rapidly
   3. Prolonged sniff 2 times
   4. Glide /i/ from low pitch to high pitch
   5. Breathe - /i/ - breathe (repeat)
   6. /i/ repeat 7 times
   7. /si/ repeat 7 times
   8. /pi/ repeat 7 times
   9. /mi/ repeat 7 times
   10. /si-i/ repeat 7 times
   11. /I-si/ repeat 7 times
   12. Repeat the following sentences 2 different times
       1. We need meaning men
       2. She speaks pleasingly
       3. Peter will keep at the peak
   13. Count from 1 to 10
   14. Say the days of the week
   15. Say the months of the year
2. Interpretation
   1. Subjective interpretation of tremor, and glottic and supraglottic spasms performed by the speech pathologist and physician
3. Diagnosis
   1. Consensus diagnosis from the physician and speech pathologist recorded.

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REFERENCES

Baken RJ. Clinical Measurement of Speech and Voice. Boston, Mass: College-Hill Press; 1987.

Bless DM, Hirano M. Estimation of airflow and MTP as a clinical tool. Paper presented at: The American Speech, Language and Hearing Associate Convention. November 1982; Toronto, Canada.

Colton RH, Casper, JK. Understanding Voice Problems: A Physiological Perspective for Diagnosis and Treatment. Baltimore, Md: Williams & Wilkins; 1990: 165-210, 309-316.

Hirano M. Clinical Examination of Voice. New York, NY: Springer Verlag; 1981.

Karnell MP. Videoendoscopy: From Velopharynx to Larynx. San Diego, Calif: Singular Publishing Group Inc; 1994.

Titze IR. Principles of Voice Production. Englewood Cliffs, NJ: Prentice Hall; 1994.

Titze IR. Workshops on acoustic analysis: summary statement. Iowa City, Ia: The National Center for Voice and Speech; 1995.

Weinberg B. Diagnosis of phonatory based voice disorders. In: Meitus IJ, Weinberg B, eds. Diagnosis in Speech-Language Pathology. Baltimore, Md: University Park Press; 1983:151-182.