Logopedics Phoniatrics Vocology.

2005; 30: 90
/93

LPV FORUM

Does a specialist voice clinic change ENT clinic diagnosis?*

P. S. PHILLIPS, E. CARLSON & E. B. CHEVRETTON

Departments of ENT and Speech and Language Therapy, Guy’s and St Thomas’ Hospital Trust, London, UK
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Abstract
General ENT clinics lack the high quality diagnostic equipment and multidisciplinary advice that is available in the voice
clinic. We wished to find out if referral to a specialist voice clinic from general ENT consultant clinics resulted in a change
in diagnosis. Lists of voice clinic attendees were reviewed between January 2003 and May 2004. Notes were obtained for
20 patients who attended voice clinic after referral from a general ENT clinic: 3 had no diagnosis on referral to voice clinic, a
diagnosis was given after attendance; 8 had their referring diagnosis changed by attendance; and 9 had no change. The voice
clinic adds diagnostic value to the service available in general ENT clinics.

Key words: Diagnosis, voice clinic, voice pathology

For personal use only.

Introduction specialist voice clinic is usually not available to these

Treatment for vocal disorders involves different
therapeutic approaches, including voice therapy,
surgery, and medical therapy. Sometimes diagnosis
is straightforward and the treatment route is obvious,
but more often a number of professionals must be
involved in a consultative process that may span
more than one clinic visit. Voice pathology diagnosis
and therapy have been conducted in a multidisci-
plinary environment for some years; indeed this is
one of the central principles of voice therapy (1). In
the UK, patients usually receive definitive diagnosis
and treatment in the environment of the voice clinic.
This is a tertiary level clinic usually staffed by a
speech and language therapist and a laryngologist,
and perhaps other professionals including singing
teacher, physiotherapist, voice scientist, psychiatrist
or social worker (2).
However, the route by which the patient arrives at
the specialist voice clinic may involve referral from a
number of professionals, usually acting on their own,
often without specialist training in voice pathology.
The diagnostic equipment that is available in the
* Was presented at PEVOC6, 2005.
professionals (3). Also, investigation of suspected
laryngeal neoplasia may divert the patient down
other routes (4). Figure 1 gives some examples of
pathways to the voice clinic.
Patients who have been seen by general Ear, Nose
and Throat (ENT) surgeons do, however, often
arrive with a diagnosis relating to their voice
pathology. This is because direct or indirect laryn-
geal examinations may have been possible in the
general ENT clinic, and the general ENT surgeons
may feel they have enough information and experi-
ence of voice pathology to make a diagnosis.
Does an onward referral from a general ENT
clinic to the voice clinic then merely serve to confirm
the diagnosis and institute treatment, or does it
provide ‘added diagnostic value’ in terms of an
alteration in diagnosis? We wished to find out how
commonly referral to a specialist voice clinic from
general ENT consultant clinics resulted in a change
in diagnosis.
Research was conducted in a large London teach-
ing hospital. A voice clinic took place twice a month.
This clinic was staffed by an ENT consultant
and specialist registrar, and one or two speech
and language therapists with an interest in voice
pathology. The clinic took referrals directly from

Correspondence: P. S. Phillips, Departments of ENT and Speech and Language Therapy, Guy’s and St Thomas’ Hospital Trust, Borough High Street, London
SE1, UK. E-mail: seamusphillips@hotmail.com

(accepted 29 June 2005)

ISSN 1401-5439 print/ISSN 1651-2022 online # 2005 Taylor & Francis
DOI: 10.1080/14015430500233286
 Does a specialist voice clinic change ENT clinic diagnosis?
GP Accident + Emergency
Head and General ENT
Neck/Oncology General SLT Surgeon/clinic
Clinic
Voice Specialist SLT
Voice Clinic
Figure 1. Pathways to the specialist voice clinic.
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General Practitioners (GP), from other Speech and
language Threapists (SLT), and from other ENT
surgeons (at both specialist registrar and consultant
level).
Patient referral to the voice clinic was by letter to
the ENT department. Letters were received from
GPs, ENT surgeons and other doctors, and these
were prioritized and directed to the most appropriate
clinic by the consultants and specialist registrars.
For personal use only.
Thus a patient with a hoarse voice might have their
referral letter directed to the voice clinic; but often,
other ENT problems including neoplasia needed to
be excluded, and so the patient was referred to the
general ENT clinic, often as an urgent case.
The average number of patients seen in a session
was 12. Patients were seen in a dedicated clinic room
with all professionals present. All patients had a full
ENT and voice history taken, and all were examined
with a videostrobolaryngoscope (VSL). Images from
the VSL were viewed in real time by professionals on
a screen, and saved and replayed as necessary to aid
diagnosis. Discussions took place regarding diagno-
sis as a result, and a decision was reached amongst
the professionals as to the probable diagnosis and the
best form of treatment.
Methods and materials
Lists of voice clinic attendees were reviewed between
8 January 2003 and 26 May 2004. These lists
included identification details of the patient and
source of referral. Notes were obtained for those
patients who had been referred by another consul-
tant or specialist registrar ENT surgeon. These notes
were then reviewed and the exact referral source and
original referring diagnosis were noted, along with
the subsequent voice clinic diagnosis if the patient
had attended. Referring and final diagnoses were
classified under the following headings:
91
. Vocal cord nodules
. Oedema of cords
. Dysphonia ?cause
. Vocal cord polyp
. Vocal cord cyst
. Vocal cord palsy
. Reflux
. Muscle tension dysphonia
. Thickened, erythematous or irregular cords
. Phonatory gap
. Normal larynx
Results
In the period assessed, 32 voice clinics took place
with an average of 12 patients attending each clinic,
making a total of 384 patients. In this period, 28
patients were given appointments to the voice clinic
via referral from other ENT consultants or specialist
registrars, all of whom were based at Guy’s Hospital,
London. Of these patients, six did not attend. Notes
were not available for two patients. Of the remaining
20, 3 had no diagnosis on referral to voice clinic,
a diagnosis was given after attendance; 9 had no
change to the referring diagnosis; 8 had their
referring diagnosis changed by attendance. As a
result, of 20 patients assessed, 11 had their diagnosis
influenced by voice clinic input. In four patients,
vocal cord polyps or cysts were only recognized
after voice clinic attendance, whilst in three, nodules
were diagnosed in the ENT clinic where none
were present.
Referrals from ENT surgeons did not specify
whether direct or indirect laryngoscopy had been
performed in arriving at the diagnosis. However,
none of the patients had received VSL examination
before being seen in the voice clinic. All of the
referrals were from consultants, apart from one from
a specialist registrar (in which the diagnosis was
unchanged after voice clinic attendance).
The six patients whose notes were available but
who did not attend the voice clinic had the following
referral diagnoses: dysphonia ?cause (n /2), oedema
(n /2), muscle tension dysphonia (n /1), thickened
vocal cords (n /1). Referral and final diagnoses are
summarized in Tables I and II.
Discussion
Results show an over-diagnosis of nodules (three
patients), and a failure to recognize cysts and polyps
in the general ENT clinic (four patients). This
may reflect the fact that fibreoptic nasendoscopic
examination of the cords in a busy general ENT
clinic is not as reliable as VSL examination in a
specialist clinic, where more time is available, and
 92 P. S. Phillips et al.
Table I. Referral and final diagnoses.
Referral diagnosis
Diagnosis changed after voice clinic attendance
Mild phonatory gap
Thickened left cord
Erythematous cords,
previous dysplasia
Bilateral VC nodules
Oedematous cords
Early nodules, VC varices
Thickened VC
Bilateral VC nodules
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results as good as rigid laryngoscopic examination.
However, this is only when stroboscopic facilities are
Final diagnosis
available, and the flexible scope also suffers from a
reduction in size of image, optical distortion, and
Bilateral nodules lack of stability (6). It is only in smaller children that
Left vocal cord polyp rigid stroboscopy is rarely useful, as a good image
Normal cords is seldom obtainable (7); thus a flexible scope is
Large polypoidal cyst right VC
used (8).
Intracordal cyst There is limited evidence as to what the preva-
Prominent vessels but no lence of voice disorders should be. Estimates range
abnormality from 28
/121 per 100,000 in England (9,10),
Ulcerated area left VC
/ although this seems to be higher amongst the elderly
Squamous Cell Carcinoma
Bilateral cysts
population (from 12% (11) to 35% (12)). It has
been found that approximately 8% of patients

New diagnosis passing through a general ENT clinic have dyspho-

Dysphonia ?cause Normal cords nia problems, although by no means all of these will
Dysphonia ?cause Thickened vocal cords find their way to the specialist voice clinic (13).
Dysphonia ?cause Muscle Tension Dysphonia
Hyperfunctional voice disorders, which include
Diagnosis unchanged after voice clinic attendance nodules and polyps, constitute the largest group of
Vocal cord nodules Vocal cord nodules voice disorders amongst those referred to the voice
Right VC palsy Right VC palsy clinic, with nodules accounting for 15%
/22%, and
Early VC nodules Nodules/glottic chink polyps accounting for 5%
/20% (14). Although the
Mild VC oedema Mild VC oedema
Laryngitis/reflux Laryngitis/reflux
difference between these two pathologies seems to be
Muscle Tension Dysphonia Muscle Tension Dysphonia largely one of size (15), optimal treatment for each
Right VC polyp Right VC polyp still differs; polyps and cysts will require surgery for
For personal use only.

Nodules Nodules removal, whereas nodules, if soft, may be treated

Nodules Nodules effectively with voice therapy alone (16). Thus it is
VC/Vocal Cord. important to make the distinction between the two,
as this has implications for management.
where there is more than one observer. It may also The results indicate that referral to the specialist
suggest that general ENT surgeons are not aware voice clinic adds diagnostic value, as well as being
of the exact appearance of vocal cord cysts or polyps, the place where treatment can be initiated on a
and easily confuse them with the appearance of multidisciplinary basis. It is important to bear in
vocal cord nodules or thickened cords. This finding mind that the diagnosis arrived at in the voice clinic
is perhaps unsurprising, given the small amount with the aid of stroboscopic light is not a definitive
of training in voice pathology that most ENT one: findings during surgery may differ and the
surgeons receive. diagnosis may change (17).
The flexible nasendoscope can be used to effec-
tively diagnose voice problems (5) and can obtain Conclusion
With multidisciplinary input and superior diagnostic
Table II. Diagnostic categories. equipment, the voice clinic has been shown to
provide a useful diagnostic service, adding to the
Referring Final service available in general ENT clinics. General
diagnoses diagnoses ENT surgeons should be aware of the limits of
diagnosing voice pathology in general clinics, and
Vocal cord nodules 7 5
should have a low threshold for referral to specialist
Oedema of cords 2 1
Hoarseness/dysphonia ?cause 3 0 voice clinics.
Vocal cord polyp 1 2
Vocal cord cyst 0 3
Vocal cord palsy 1 1 References
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