November 16, 2013

How to Describe Hoarseness?

At heart, physicians are science geeks. And when it comes to a raspy voice, one can go truly bananas in how exactly to describe how a raspy voice sounds.

For the layperson, when asked to describe a hoarse voice, one often gets imprecise answers to a question most feel ridiculous... I often get a blank look with an answer that goes something like "You know... raspy... it's not clear." Unfortunately, such a description is inadequate. Even when using more descriptors like deeper/higher than normal, onset delays, pitch breaks, breathy, click, tight, etc, more information is needed.

There are 2 fundamental ways to more precisely convey the characteristics of how a raspy voice sounds and to document change (better/worse) over time.

Method #1 - Perceptual Tests

Developed by Dr. Robert Bastian, I personal prefer this method as it is more intuitive and replicable by anybody including the patient.

1) Maximum Phonation Time (MPT) - How many seconds can a single note be sustained for with a single breath? This test provides a rough measure of lung capacity and how "breathy" a voice is. The more breathy a voice is, the lower the MPT.
2) Pitch Range - What is the lowest and highest note a person can say/sing (I use a piano keyboard). Provides information on how much vocal cord swelling and length is present (the more swollen the vocal cords are, the deeper the pitch just like a violin string). I also typically like the patient to glide up and down from their lowest and highest note as it provides some additional information on neurological/muscular control of their voice depending on how smoothly it is performed.
3) Swell Tests - Essentially, the test involves singing a song (I use Happy Birthday) very quietly an octave higher than your normal pitch. If onset delays or pitch breaks are heard, does suggest the presence of a small bump (nodule, cyst, polyp, etc) on the vocal cords.

One can also add documentation of yell, cough, throat-clearing, and speaking voice.

Method #2 - Objective Tests

This type of testing can only be performed with the help of instruments and provides "numbers" that can be documented. It is more difficult to "hear" the voice looking at just these numbers, but does provide a more rigorous way to actually "measure" the voice quality. There are now even iPhone apps that can obtain such data.

The basic measures include:
1) Shimmer - Measures how much variation in loudness is present. Think of a volume knob being turned up and down slightly. Normal is less than 3%.
2) Jitter - Measures how much variation in pitch is present. Think of going up and down on the equalizer slightly. Normal is less than 1%.
3) MPT is also measured.
4) Fundamental frequency (f0) - Measure of how high/low a person's voice sounds (pitch).

One can go crazy and also add intensity, glottal noise, ratio, tremor, spectrum, EGG-pitch, EGG-intensity, EGG-jitter, EGG-shimmer, EGG-noise, CQ, CQ perturbation, CI, CI perturbation, opening rate, etc.

Regardless of the method, with this type of information, the actual degree and characterization of the vocal quality can be measured, documented, and tracked over time. Also, when communicating with other health professionals, such measures provide for an efficient and understandable way to describe a patent's voice with a colleague.

Of course, from the patent's perspective, they "just want to sound better," but this is how professionals do it.

Fauquier blog
Fauquier ENT

Dr. Christopher Chang is a private practice otolaryngology, head & neck surgeon specializing in the treatment of problems related to the ear, nose, and throat. Located in Warrenton, VA about 45 minutes west of Washington DC, he also provides inhalant allergy testing/treatment, hearing tests, and dispenses hearing aids.

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