Many of us are familiar from our former geometry lessons that, “Not all rectangles are squares, but all squares are rectangles.” This article is going to give you a crash course on how laryngologists are like the squares in this analogy, while otolaryngologists (also called Ear Nose and Throat physicians—ENTs) are like the rectangles, and why it’s important to seek out a laryngologist to evaluate your voice.
An otolaryngologist/ENT is a doctor who undergoes medical training and residency to specialize in areas of the head and neck. Some doctors stick with a more generalized course and have a well-rounded knowledge of matters of the ears and vestibular system, nose and sinuses, and throat and larynx (“voice box”). Other doctors have several years of extra training called a Fellowship. During this time they receive additional education and experience that is specific to one of the various subgroups of otolaryngology, and thus will earn a more distinctive title.
A laryngologist is a specialist of the voice. In reference to the aforementioned square-rectangle analogy, think of it this way: all laryngologists are otolaryngologists, but not all otolaryngologists have the specialized knowledge and nuanced experience in matters specific to the larynx that is required of a fellowship-trained laryngologist. This doesn’t mean that if you are having voice troubles and can only see a general ENT that it won’t be beneficial. They can still assess the structural integrity of your larynx and note anything that may be time-sensitive or serious. However, they may not have the tools and skills to fully evaluate your vocal function, and may end up referring you to a colleague in the end.
Let’s briefly talk about what to expect from your appointment with a laryngologist. Your physician may or may not have a co-clinic with a speech-language pathologist (SLP). If they do, the SLP may perform key parts of the evaluation, such as case history intake and/or the laryngoscopy procedure where they visualize the larynx. Like any physician appointment, you will talk with the provider about your symptoms, answer questions, and undergo a typical health assessment. Next comes the fun part—the laryngoscopy! Gulp.
Joking aside, fear not. While the instrumentation may appear mildly alarming at first glance, the procedure itself is rather quick and not as scary as you may think. So what can you expect from a laryngoscopy? First we need to establish that there are many different kinds of laryngoscopy. Which one(s) you will experience largely depends on the available instruments at your physician’s office, and oftentimes whether you are seeing a laryngologist versus an otolaryngologist. Now I will make a disclaimer: I have seen the gamut of laryngeal evaluation methods, including having experienced the old-school method of the “mirror in the throat” technique that is rare these days, and not quite the standard of care for a specialized voice examination. So for our purposes, I will go over the more common, hi-tech varieties. Be sure to check out my blog post How to Prepare for Your ENT Voice Evaluation for helpful tips for a smooth and stress-free laryngoscopy.
Flexible laryngoscopy: This "snake-like" tool is a long, thin, flexible camera that is threaded through your nasal passageway and hangs over the back of the throat. While you may feel slight pressure in the nose, it is rarely painful. To help things out, many ENTs will offer a spray of lidocaine mixed with Afrin to both numb and open up the nose. The benefit of this camera is that because you are hovering above the larynx in the throat, you can get a full picture of the airway and the movement of the larynx. This means not only can the doctor tell if something looks problematic, but the patient can easily talk, sing, and perform other vocalizations. This is incredibly beneficial to assess that everything is moving fully or detect any functional problems like muscle tension. The flexible scope may or may not have a strobe light on the end of it (more information on this below!).
Rigid laryngoscopy: This is quite the opposite of the flexible scope; it is a long, cylindrical camera—that we often liken to a metal tongue depressor of sorts—that enters through your mouth and hovers in the back of the throat. Now I know what you’re thinking...this sounds rather unpleasant. While a numbing spray is typically offered to help stunt your gag reflex, you can also use strategies (like those mentioned in my blog post!) that will help prepare you. This scope offers an incredibly detailed, magnified view of the larynx with a strobe light on the end to assess the vocal cords in action. You will most likely undergo a rigid stroboscopy if you see a laryngologist, who will often use both flexible and rigid scopes at the time of your appointment. This exam provides necessary information of the vibratory properties of the vocal cords and any subtleties of the structures missed with the flexible scope. It can be a slightly more awkward procedure, as positioning requires the patient to lean slightly forward with the tongue out of the mouth, but it is well worth the process!
Stroboscopy: Many of you may be familiar with a strobe light from dance floors to halloween effects. In our case, this special, fast-blinking light is located at the tip of the flexible or rigid scope. The light breaks up the image of the vocal cords into “split-second” frames, giving us the illusion that we are seeing all the phases of vocal cord movement. We call this type of laryngoscopy a “stroboscopy.” The stroboscopy is a crucial aspect of assessing the vocal cords because it shows us how they open and close, draw attention to stiffness or swelling, and reveal details of any possible vocal cord pathology. Therefore, the stroboscopy is truly necessary to help us understand the cause of the voice problem. A laryngologist should have flexible and/or rigid stroboscopy available. For the curious folks, watch this flexible stroboscopy demonstration to see it for yourself.
Videostroboscopy: Lastly, my personal favorite, is the videostroboscopy, which with your newfound knowledge is exactly what it sounds like: a stroboscopy captured in real time and displayed on a screen. The video gives the physician the ability to record and save your laryngeal evaluation. This way the ENT can visually compare progress with each follow-up, and what’s more is the patient can really benefit from reviewing the examination with the doctor. Video strobe can also be an excellent aid in voice therapy as needed. The alternative to video is a scope that attaches to an eyepiece that only the physician looks into. Which one you experience is solely dependent on what is available at your physician’s office.
Now that you are well-versed in the instrumentation used during a typical laryngoscopy, let’s discuss the process. Your physician will guide you in performing actions and vocalizations that will offer different bits of information when evaluating your voice. A laryngologist will likely have a more in-depth approach to their process—from whistling to whispering to “ees,” “ahs” and glides; sniffs and gasps; counting; or even a Happy Birthday. A general otolaryngologist may or may not understand or require the value of all of these sounds, and may have a more basic approach to assess the larynx. The laryngoscopy procedure typically lasts several minutes and is over before you know it!
To conclude, an appointment with a laryngologist will be ideal in matters specific to the voice, including evaluation, treatment, and any surgical intervention as needed. They not only should have the tools and appropriate laryngoscopy equipment available, but they have the specialized fellowship training to be most knowledgeable and up-to-date on best practices for voice-related symptoms and diagnoses. Singers may value establishing care with a laryngologist, even at a healthy baseline voice. Please remember, both squares and rectangles are valuable shapes! Seeing an otolaryngologist in a timely manner is still beneficial to start; they can help you in matters of the throat. A referral or second opinion can always be scheduled if a laryngologist is required.
Jessica Schwartz Smith, MS, CCC-SLP is a licensed and certified speech-language pathologist in Pennsylvania and North Carolina. She is the owner of Resonate Voice and Speech Services, a speech therapy practice based in Philadelphia that specializes in voice disorders, chronic cough, VCD/PVFM, gender affirming voice therapy, and adult dysphagia.