Otolaryngol Clin N Am 40 (2007) 991–1001

Strobovideolaryngoscopy and Laboratory Voice Evaluation
Scott M. Kaszuba, MD, C. Gaelyn Garrett, MD*
Department of Otolaryngology, Vanderbilt Voice Center, Vanderbilt University, 7302 Medical Center East, South Tower, 1215 21st Avenue South, Nashville, TN 37232-8783, USA

Although some laryngeal abnormalities affect the true vocal folds in known manners, not all patients who have the same vocal pathology exhibit the same subjective complaint, clinical finding, or physiologic impairment. There is no single best method of laryngeal examination for all voice patients. One notable limitation of simple indirect laryngoscopy is that the examination does not yield a recordable and reproducible image of the larynx and vocal tract. More importantly, the unaided human eye is unable to visualize the vibratory patterns of the true vocal folds during phonation. This inadequacy may lead to inappropriate management decisions. Strobovideolaryngoscopy and laboratory vocal testing are most valuable to the voice specialist in this clinical scenario [1,2]. Recognition of the advantages and disadvantages of current diagnostic techniques allows for optimal appreciation and instrumentation selection for supplemental diagnostic laryngeal testing. Although it is agreed that there is no one gold standard algorithm for the diagnostic process of a patient who has a voice disorder, most practitioners would agree that some additional laboratory testing is indicated in most patients. This article discusses current diagnostic techniques available for physiologic vibratory testing and anatomic and functional assessment of the vocal tract. Strobovideolaryngoscopy True vocal fold vibration is a complicated physiologic function, the observation of which far outreaches the visual capabilities of the human eye with a normal light source. The human adducted vocal folds cyclically

* Corresponding author. E-mail address: gaelyn.garrett@mcmail.vanderbilt.edu (C.G. Garrett). 0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2007.05.006




open and close between 60 to 1500 times per second, depending on the phonatory pitch. Stroboscopic light visually makes the vocal fold vibrations appear to slow down so that the impression of vocal fold vibrations can be observed and processed. Stroboscopy capitalizes on the inherent optic properties of our visual organ and exploits the limitations of observation of the unaided eye. According to Talbot’s law, the human eye can perceive no more than five distinct images per second. Each image therefore lingers on the retina for approximately 0.2 seconds after exposure. Stroboscopic flashes make the vocal folds appear to slow down by advancing the light pulse through successive glottal cycles in percentage increments. Individual still images are recorded at selected points from sequential vibratory cycles and the human eye automatically fills in the missing pieces by fusing the images into what it sees as motion. This apparent motion is attributable to a phenomenon called persistence of vision. Additional instrumentation added to the stroboscopic light can facilitate the recording and documentation of the perceived vocal fold vibratory properties [2–4]. Strobovideolaryngoscopy as a whole allows the physician to observe important vocal fold activities, which allows appropriate diagnostic decision making. A brief historical overview allows full appreciation of the evolution of strobovideolaryngoscopy. Indirect laryngoscopy was first described, but not yet popularized, by Bozzini in 1806 when he constructed an angled speculum with a mirror insert that was meant to examine various body cavities, including the human larynx. It was not until 1854 that indirect laryngoscopy gained wider acceptance when Manuel Garcia, a Spanish-born voice teacher who had a limited gag reflex, first visualized his larynx with a small dental mirror using sunlight as a light source. In 1895, Oertel followed suit and was credited with creating the first laryngostroboscope. His device consisted of a variable-speed perforated disc that was interspersed between a light source and the practitioner’s head mirror [5,6]. Since that time, strobovideolaryngoscopy has evolved into finely controlled, high-intensity light sources with fiberoptic endoscopes or distal camera scopes coupled with analog or digital recording devices. Strobovideolaryngoscopy in current clinical practice relies on a combination of several instruments: a stroboscopic light source, an endoscope, a microphone, a video camera, a recording device, and a video monitor. Stroboscopy is best performed in conjunction with video recording and archiving for complete clinical review and documentation. The examination may be performed by transnasal flexible laryngoscopy with distal chip technology or perorally with a rigid angled telescope. Video cameras are now available in single-chip and three-chip versions. A single-chip camera uses a single array of light-sensing elements known as charge couple devices (CCDs). Three-chip cameras use a dichroic prism, which divides the incoming images into the three primary colors and offers more accurate color and higher resolution. Analog or digital recording technologies are then used for image capture, documentation, and reproduction [3,7].



The illusion of apparent slow motion of the vibrating vocal folds during strobovideolaryngoscopy evolves from the collection of several sequential still images of the folds at selected time intervals during repeated glottal cycles at a given vibratory frequency. This illusion is called the stroboscopic glottal cycle and can be of any desirable duration. In addition, the stroboscopic flashes can be emitted either at the same frequency as phonation, known as synchronization, or at a slight variation of the frequency, known as asynchronization. This feature of stroboscopy is producible through technological communication between the microphone and the strobe light source. By synchronizing the stroboscopic flashes to the fundamental frequency of the vibrating vocal folds, a perceptual stopped image or standstill of the vocal folds is produced. An asynchronized mode is generated by calibrating the stroboscopic flashes at a consistent frequency slightly different than the produced phonatory fundamental frequency. This variation allows successive light impulses to strike at different phases of the vibratory cycle and produce a video image of one apparent cycle of vibration actually obtained from different portions of several cycles. Another option, which allows the examiner to manipulate the apparent glottal cycle by operation of a rocking foot pedal, furthers the stop-action capability of the strobovideolaryngoscopy system. This feature is particularly useful when the exact location of the vocal fold lesion is being determined in relation to movement of the upper and lower lips during an approximation phase of the cycle [2,3,7]. The strobovideolaryngoscopic examination is most clinically useful to the practitioner when a standard protocol is used for the acquisition of the data and its interpretation. Phonatory tasks during the examination should be performed at low, normal, and high pitches and in the range of the speaking or singing problem area, if known. Once recorded, a standardized approach to the interpretation of the examination allows consistency in diagnosing and comparing laryngeal pathology. Once the initial examination is completed and recorded, additional repeat testing at predetermined time intervals allows for evaluation of response to treatment. Although there is arguably no one gold standard for the interpretation of a strobovideolaryngoscopic examination, several aspects of the examination are often rated. The specific features of the vibratory pattern of the true vocal folds often addressed include symmetry, periodicity, mucosal wave ratings, amplitude of vibration, shape and contour of the glottal margin, and glottic closure. Particular attention is also given to any adynamic segments and the presence or absence of vertical phase difference [2,6,7]. Vocal fold symmetry remains intact in the absence of abnormalities along the glottal margin. Periodicity refers to the regularity of the vibratory cycles with the idea that normal vocal folds should vibrate in mirror image to each other and vibrate the same with successive cycles. Aperiodic vibrations may prohibit the synchronization of the strobe light. The mucosal wave is generally described as the traveling wave across the vocal fold superior surface from medial to lateral. Abnormalities of the mucosal cover, including the epithelial layer or



superficial lamina propria, are the most common causes of mucosal wave reduction. The mucosal wave should be differentiated from the vertical phase difference, which is created normally by the presence of an upper lip and lower lip at the medial vibratory vertical closing surface. Amplitude of vibration is a relative feature of the mucosal wave judged by the trained observer as reduced, normal, or excessive. Normal variations in amplitude occur with changes in vocal intensity. Glottal closure is described as complete; incomplete with anterior, mid, or posterior glottal chinks; and hourglass, usually secondary to mid-vocal fold lesions. From a clinical standpoint, strobovideolaryngoscopy has proved to be a valuable tool for the diagnosis of laryngeal pathology given the detailed physical examination it provides of the vocal tract and the vibratory margin of the vocal fold. Stroboscopic features of nodules, for example, often include symmetric but reduced amplitude of vibration, maintenance of periodicity, intact mucosal waves, and hourglass closure. Vocal fold polyps, which are frequently unilateral, have asymmetric vibration and variable periodicity depending on the size and shape of the polyp. Mucosal wave can be absent because of mass effect with large polyps or intact with broader-based polyps. The wave is generally intact on the contralateral side. Glottic closure is understandably asymmetric. Cysts within the vocal fold lamina propria can have the greatest adverse effect of the nonneoplastic lesions on the vibratory characteristics. Mucosal wave is frequently absent and aperiodic if present. A change in diagnosis and altered assessment of vocal pathology based on the strobovideolaryngoscopic findings can occur in 10% to 30% of cases [4,8]. Furthermore, abnormal findings have been reported in up to 58% of healthy, asymptomatic professional singers stressing the importance of screening examinations for certain populations of patients [9]. Strobovideolaryngoscopy is not a test to be done in the absence of other clinical data. It is only a valuable complement to a thorough vocal history and physical examination. The technique inherently suffers from the limitation of being a composite recording made from several glottal cycles, in contrast to high-speed photography or high-speed digital video, which records an entire vibratory cycle and provides detailed cycle-to-cycle variations. Even with this limitation, strobovideolaryngoscopy remains an invaluable tool in the diagnostic armamentarium of the voice specialist.

Glottography Glottography is a general technique that monitors the vibration of the vocal folds by the transmission of a probe signal from one side of the larynx to the other. The probe signal itself can be directed in either a vertical plane or horizontal plane. Current probing signals most commonly used in glottography include electrical current flow, light transmission, and ultrasonic waves. The time variation of the glottis combined with laryngeal tissues



that are in constant partial stages of contact during phonation modulates the probe’s properties. This modulation is then detected and recorded supplying immediate objective data in the form of graphic displays that can be clinically interpreted. Glottography thus makes possible the physical measurement of acoustic parameters, such as pitch, jitter (frequency perturbations), shimmer (amplitude perturbations), or other perturbations. It also provides a possible objective method that can be used to evaluate and detect vocal fold pathology. Overall, glottography provides some clinical data about vocal fold vibration. This technique fails to determine the vibration capacity of an individual vocal fold or diagnose individual laryngeal lesions without an additional visual examination [10,11]. Electroglottography Electroglottography (EGG) is a technique based on the principle that human tissue can conduct an electrical current with laryngeal tissues being a moderately good conductor of electricity. It is performed by placing two electrodes above the thyroid laminae on the external neck and measuring the impedance between them with a high-frequency, low-current signal. Ohm’s law states that a current must flow through a system if its resistance is to be measured. Based on this law, when the vocal folds are touching a greater current flows through them compared with when they are open. The electroglottographic signal represents the contact area between the two vocal folds and can be used to determine when the vocal folds are closed and how fast they are closing [10–13]. This characteristic contrasts with photoglottography (PGG), which gives information about the separation of the vocal folds and little information about the nature of vocal fold contact. Various manufacturers provide instrumentation that produces, records, and displays the electroglottographic signal. Several authors over the past two decades have commented on the shape of the EGG waveform as it relates to the underlying physiology of vocal fold vibration. Interpretation of EGG waveforms remains controversial, however, especially as it relates to analyzing vocal fold pathology. When used in conjunction with other laboratory techniques, the interpretation of the EGG display becomes more reliable. For example, synchronized strobovideolaryngoscopy and EGG have been shown to be an effective tool for verifying information from the EGG waveform with stroboscopic images [12,14]. Also, recent research is moving toward standardization of normal EGG measurements with the goal of allowing this test to serve as a reference for the diagnosis and follow-up of dysphonic patients [15]. There are limitations of EGG. The most obvious one for the voice specialist is that it cannot be used with all dysphonic subjects. Patients who have a unilateral vocal fold paralysis have a considerably diminished or absent signal because of lack of good contact of the vocal folds. Obese or thick necks may impede proper placement of the electrodes or hinder the electrical current resulting in a poor EGG tracing. Finally, severe hoarseness may render



laryngeal tissue irritable and passing an electrical current through this environment may produce an undesirable physiologic response [10,13].

Photoglottography Photoglottography is a technique that estimates glottal area during phonation. The principle of PGG is based on the concept that the glottis may act like a shutter through which light can pass in proportion to the degree of opening of the vocal folds. Light is usually directed transnasally from above the glottis and is detected by an optoelectronic device over the skin of the trachea immediately beneath the vocal folds. The external photosensor then converts the light intensity absorbed into electric voltage, which can be recorded and converted into a graphic display. The direction of the light path during the study has no impact on the ability to record the PGG signal; therefore the light source may be placed above or below the glottis or on the external neck with the photosensor in the opposite complementary position. Typically, for the best functional examination with the additional advantage of simultaneous laryngeal observation, a transnasal flexible laryngoscope is used as the light source with the photosensor placed externally on the neck. PGG gives some clinical data during the open phase of phonation with two common measurements routinely obtained. The speed quotient measures the symmetry of the opening and closing parts of the open phase, and the open quotient is the time of the open phase of the vocal folds divided by the total period of vibration. Some problems may exist with the validity of the quantitative information obtained from this technique. These are most often believed to be attributable to several extrinsic factors, including inability to standardize the amount of light projected on the larynx, changes in light-transmission characteristics of the glottis because of its vertical movement during phonation, and volume changes of the hypopharynx and supraglottis during different vowel productions. Overall, the PGG waveform is considered complementary to the EGG signal [10,11,13].

Ultrasound glottography Ultrasound glottography (UGG) is a technique in which ultrasonic waves are constantly applied across the laryngeal area of the neck during phonation. The border between the vocal fold surface and the glottal air is determined by the difference in acoustic impedance between two media (air and soft tissue). Like all ultrasound studies, it is based on the frequency shift produced when a continuous ultrasonic beam is reflected back from or transmitted through a tissue medium. In UGG, a narrow-beam ultrasound transducer is placed externally on one side of the neck near the larynx with a receiver on the other side. The ultrasonic signal is aimed at the air tissue interface of the glottis.



Air is an extremely poor ultrasound transmission medium and therefore when the glottis is open the ultrasonic beam is not transmitted across it to the receiver on the opposite side of the neck. This continuous wave glottography then displays an open–closed pattern that corresponds to the open and closed phases of phonation. Unfortunately, the space resolution of ultrasound glottograms is not very high and therefore few reports are available regarding voice function. Nonetheless, it remains a noninvasive means of laryngeal monitoring and combined with newer technological advances may hold promise for future clinical voice research [10,11,13].

Videokymography Videokymography is a laboratory technique that was developed as a means of using television technology to visualize real-time vibratory activities of a small area of the glottis. This visualization is accomplished by using a line scan camera that is capable of limiting its entire field of view and scanning of the endoscopic image to a rapid repetition of a single line. Each new scan of the same line is stacked on top of the others from superior to inferior so that a screen image is built up with time represented in the vertical direction. The line scan camera therefore records a small area of the vocal fold in a real-time fashion while it vibrates and allows for subtle aperiodic irregularities or phase asymmetries to be observed and documented. A major shortcoming of this technique is that any movement of either the larynx or endoscope during signal acquisition changes the locus being observed. Also, the line image produced is not a complete image of the larynx. Some training is also required for interpretation of the examination results. Although still regarded as mainly an experimental technique for laboratory voice testing, new generation digital videokymographic systems are currently being developed in hopes of becoming an important tool for routine clinical laryngeal examination [10,16,17].

High-speed photography and digital imaging High-speed photography and digital imaging are laboratory techniques that were developed to overcome the limitations of strobovideolaryngoscopy. As previously discussed, stroboscopy is a technique that produces a virtual slow-motion image of the larynx from the summation of images obtained from several glottal cycles. The clinical use of this technique is based on vocal tract pathology being periodic and stable at a given phonatory frequency. Dysphonic patients suffering from aperiodic phonatory disorders may not completely benefit from the examination, therefore. High-speed photography and digital imaging overcome these limitations by providing real-time images of successive glottal cycles of the larynx during phonation.



High-speed photography requires several expensive pieces of equipment that require technical expertise for proper operation. The main piece of equipment is a camera capable of taking pictures at a rate of 3000 to 4000 frames per second. The recorded events are then viewed back and analyzed in ultraslow motion. The technique itself requires that dysphonic patients be able to position themselves over a laryngeal mirror during the camera recording, which is not always tolerated well. This technical difficulty combined with increased cost and time expenditure necessary to complete the examination have limited its clinical use. Nonetheless, high-speed photography using a laryngeal mirror has provided valuable information about vocal function when used in a clinical setting. High-speed digital imaging has seen recent activity over the last several years with the development of new camera image sensor systems with increased image resolution combined with improved computer processing speed and storage capacity. The technique uses standard rigid endoscopes to record full images of the superior surface of the larynx at sampling rates from 1000 to 8000 frames per second. The recorded images are typically in black and white and can be played back in ultraslow motion for clinical analysis. The current cost of the equipment has still limited its use as a routine clinical examination conducted by the voice specialist. Limited availability of this equipment in the clinical setting has resulted in few studies being performed regarding the application of this modality in directing patient care. From a research standpoint, high-speed digital imaging has been used to identify characteristics of normal and abnormal vocal fold vibration. Digitization of the images enables accurate quantification of vocal fold vibrating parameters not possible with strobovideolaryngoscopy. Highspeed digital imaging has also been used to examine the basic physiology of different singing styles, in the assessment of vocal tremor, and in the differentiation of spasmodic dysphonia from muscle tension dysphonia. Some researchers have combined the technique with a laser calibration tool for estimated measurements of glottal parameters, including scarring and other elastic properties of the vocal folds [18,19]. Further development of this technology may lead to a better understanding of vocal fold elasticity measurements and possibly direct the development of new laryngeal injection materials. More widespread clinical use of high-speed digital imaging in the future is expected as the cost of the instrumentation decreases. Acoustic voice measurements Phonatory tasks for normal and dysphonic patients may be obtained for objective voice analysis. Speech samples obtained typically consist of sustained vowel phonation, reading, and conversational speech. Measured parameters can include fundamental frequency, maximum phonation time, vocal intensity, harmonics-to-noise ratio, jitter, and shimmer. These objective measurements have been used in numerous clinical settings to compare



pretreatment to posttreatment phonatory characteristics after a specific surgical or nonsurgical intervention has been performed by the voice specialist. Several commercially available pitch meters/analyzers are available to the voice specialist, including the VisiPitch (Kay Elemetrics Corporation) instrument. This equipment is most useful for obtaining fundamental frequency and vocal intensity and can provide other measures of speech parameters also. In addition, numerous computer programs, some used in conjunction with strobovideolaryngoscopy, also exist. Computerized Speech Lab (CSL, Kay Elemetrics Corporation, Lincoln Park, New Jersey), CSpeech, and Dr. Speech Science (Tiger Electronics, Seattle, Washington) run on PC-compatible computers. MacSpeech Lab is available for the Macintosh computer. These programs provide a multidimensional voice analysis of the above-mentioned parameters and are relatively simple to use. Research suggests that although these systems are not necessarily comparable in absolute figures, their judgment against normative data is typically similar. Ambulatory monitoring of the dysphonic patient in the form of miniature accelerometers placed on the anterior neck has also been reported and may show future promise in the clinical assessment and management of voice disorders [13,20,21]. Speech spectrograms represent a measure of the vibratory characteristics of the vocal folds and the vocal tract. They are useful for analyzing and displaying changes in the spectral characteristics of vocal fold sound. Care must be taken to use the same vowel while comparing spectrograms of a patient to eliminate the vocal tract as a variable and therefore allow independent analysis of the vocal folds. The most useful measure from a speech spectrogram is the harmonics-to-noise ratio (signal-to-noise ratio). It represents a ratio of the energy in the harmonics of the vocal signal against the noise energy in the signal. Dysphonic voices exhibit a greater noise signal and therefore the ratio is decreased when compared with normative data. The computer software programs previously mentioned produce good-quality speech spectrograms. Additional instrumentation may obtained by the voice specialist to produce higher-quality spectrograms at a greater expense [13]. Perturbation measures rely on the inherent ability to determine an accurate fundamental frequency and are usually measured using sustained vowel fragments. Dysphonic voice samples are often only marginally periodic at best and are often difficult to obtain. Furthermore, most dysphonias are multifactorial in nature and often times show variability at different points in a patient’s vocal range. Connected speech may overcome some of these obstacles and therefore be a more appropriate stimulus for the dysphonic patient because it is more representative of functional vocal productions over a broader vocal range. An inherent difficulty with the analysis of connected speech by typical perturbation methods as previously mentioned is that these measures are influenced by intonation and other modulation effects. Long-term average speech spectrum (eg, spectral tilt) and derivations of the spectrum such as cepstral peak prominence overcome these difficulties. These measures do not rely on determination of fundamental frequency and are not confounded



by variables such as recording technique and recording volume. Several authors have noted that measures of the cepstrum, a Fourier transformation of the spectrum of the signal, better correlate with perceptual measures of overall dysphonia compared with more traditional measures of periodicity or perturbation [22]. Special software is needed to complete these measures and currently is not available in any commercial software program [23,24]. Vocal quality-of-life measures The degree to which a dysphonia impacts a patient’s day-to-day activities is often difficult to measure. Factors such as the severity of the voice disorder and the vocal needs of the patient are central to the determination of how the dysphonia alters his or her physical, social, and emotional well-being. Two well-known instruments that quantify the psychosocial consequences of voice disorders are the Voice-Related Quality of Life Measure and the Voice Handicap Index. Both instruments have been shown to be valid and reliable as a vocal quality-of-life measure [25,26]. They allow for subjective perceptual analysis of a given clinical intervention by the voice specialist and are a low burden in a population of patients who have a diverse group of voice disorders [27]. One drawback of all outcome instruments for dysphonia is the large number of questions that need to be answered to receive a complete score. Recently, the development and validation of the Voice Handicap Index-10 has been introduced as one instrument that may decrease this burden [28]. Overall, outcome instruments for vocal quality of life are important indices of patient functional capacity that enhance the voice specialist’s ability to successfully treat patients who have voice disorders. Summary Laboratory and strobovideolaryngoscopy voice evaluation are important parts of the clinical work-up of the dysphonic patient. When selected appropriately with appreciation of their limitations, the techniques discussed afford the voice specialist the opportunity to make informed diagnostic decisions and improve the overall quality of care delivered.

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