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BVI’S
integrative diagnostic model/method for voice disorders
In an attempt to utilize only what is necessary and
sufficient from the remarkable list of options available for
evaluation, Dr. Bastian developed and refined an unusually
accurate and efficient process for diagnosing voice disorders.
In many other clinics, voice specialists
diagnosing voice disorders continue to rely on the patient
history followed directly by an examination of the larynx.
The history, as told by the patient and family, is the “story
line” of the problem. The examination is performed either
with the time-honored mirror or a fiberscope. BVI does use
this approach – which we have dubbed the traditional
model – but only for obvious and acute circumstances.
For many more chronic or elusive disorders, we have found
that this traditional model does not provide enough information
to make a complete diagnosis.
The response to the inadequacy of the traditional
model in some other clinics has been to dramatically expand
the diagnostic process, and to divide a large number of diagnostic
tasks among two or more clinicians. That is, different individuals
may take one or more histories; then assess basic characteristics
of the voice using what is called auditory perception; then
make acoustical, aerodynamic, electroglottographic, and even
electromyographic machine measures of the acoustic, airflow,
and neurophysiological output of the larynx; and finally examine
the vocal folds using a state-of-the-art technique called
laryngeal videostroboscopy. At BVI, we call this the technology-driven
or reductionistic model. Although we have available these
methods of measurement, we believe that some of them are superfluous
for evaluation – and only encumber the process. Even
when this approach arrives at an accurate diagnosis, it may
have done so with much more complexity, time, and expense
than necessary. Furthermore, unless machine measures are collected
with extremes of vocal capability in mind and these various
kinds of data are then skillfully integrated, the diagnosis
may still be missed.
At BVI, we believe that simplicity is a
virtue; hence, we utilize a third approach, which we have
dubbed the integrative diagnostic model. Based on his extensive
review of all of the diagnostic modalities available for the
voice and his 20 years of experience as a laryngologist, Dr.
Bastian has “swum against the current” in resisting,
for purposes of diagnosis, methodologies that can be shown
to contribute little to the diagnostic process. Instead, he
has developed and taught his integrative diagnostic model
to residents, fellows, and colleagues, both nationally and
internationally.
How BVI’s
integrative diagnostic model works
- In the first step, the patient’s
history (story line of the problem) is mined for crucial,
insight-giving information. It is not the quantity but the
relevance of historical details that makes the difference.
At Bastian Voice Institute, we have refined a focused, voice-relevant
history that attempts to go directly to crucial information
and organize it in a coherent fashion. We believe that by
the time the history has been completed, the physician should
routinely have generated a list of the two or three most
likely diagnoses and be ready to move into the second step
of the diagnostic process.
- In the second step, the voice itself
is assessed via what we call a vocal capability battery.
The idea here is to ask each voice to accomplish various
tasks, each of which helps the physician assess one or another
extreme of a particular vocal capability. We are interested,
more than anything else, in the extremes of capability because
that is where the “abnormal phenomenology” of
each particular voice disorder is typically most clearly
revealed. The vocal phenomenology that one hears during
the vocal capability battery tends to support one or another
of the preliminary diagnoses that came to mind during the
history. At this point, the clinician is often already focusing
in on the single most likely diagnosis, and rarely two or
more remain in play.
- In the third step, the larynx itself
is subjected to intense visual imaging. Most often this
includes video-endoscopic or videostroboscopic pictures
of the larynx, subglottis, and trachea. We use the latest
scopes available, and, often, topical anesthesia to permit
a very close-up and precise view of the larynx – in
effect coaxing it to give up its secrets. Often, examination
is performed during the patient’s performance of the
same extremes of vocal capability where abnormal vocal phenomenology
was heard.
- After the historical, vocal phenomenology,
and laryngeal image information is collected from steps
1, 2, and 3, the physician must integrate and synthesize
a diagnosis which assures that the information gleaned from
each part of the model fits with the type of information
extracted from the other parts of the model. Infrequently,
the physician will need to keep two potential diagnoses
open, though one is usually favored over the other. In such
a case, the patient is asked to see the speech pathologist
who, through an extended interaction with the patient’s
voice and vocal phenomenology, can add additional insight.
Almost always, however, a firm diagnosis is reached at the
conclusion of the initial consultation and is shared with
patient and family, along with the proposed treatment plan
– medical and/or behaviorial (speech therapy) and/or
surgery.
In an ideal world, key features of the
model are as follows:
- All parts of the model preferably
should be mastered by a single individual, rather than spreading
it between two or three individuals who see the patient
separately or “as a committee.”
- Each step of the three-part model should
be applied in a codified sequence within the same consultation
to make the necessary integration and synthesis of the diagnosis
as efficient as possible.
- The diagnostic model chooses from the
long list of potential evaluations and examinations/measurements
only those items that are both necessary and sufficient
to accomplish a robust diagnosis.
- Measurements or evaluations that do
not fit the requirements of (3) may be utilized, but primarily
for research purposes or for therapy rather than as part
of the diagnostic process itself.
- The individual who masters the diagnostic
model in any particular site is the one who should take
primary responsibility for diagnosis, whether that individual
is a physician (as is the case at BVI) or speech pathologist.
(In the latter case, there must of course be physician oversight,
especially for medical and structural abnormalities.)
BVI clinician roles
At BVI, Drs. Bastian and Richardson take primary responsibility
for diagnosis. Lori Sonnenberg, speech pathologist, additionally
evaluates functional disorders. She also serves as a teacher,
verifying the patient’s understanding of the diagnosis.
She may make various measures of vocal output for documentation
and instructional purposes. She may also teach voice care
in general and in particular, targeting it to the disorder
experienced by the individual patient. She may be involved
in helping the patient adapt his or her workplace to the voice
disorder. Finally, and in some ways most importantly, she
works with the patient on voice production. This serves to
improve the voice’s clarity, resonance, ease, and efficiency
to reduce unnecessary “wear and tear” and in some
cases to “build” the impaired voice’s strength
and capabilities. When the patient is a singer, his or her
voice teacher is brought into the process, as appropriate.
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