BVI’s integrative diagnostic model

In an attempt to use 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 use 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

  1. 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.
  2. 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.
  3. 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.
  4. 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:

  1. 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.”
  2. 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.
  3. 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.
  4. Measurements or evaluations that do not fit the requirements of (3) may be used, but primarily for research purposes or for therapy rather than as part of the diagnostic process itself.
  5. 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. Our speech pathologist additionally evaluates functional disorders. He also serves as a teacher, verifying the patient’s understanding of the diagnosis. He may make various measures of vocal output for documentation and instructional purposes. He may also teach voice care in general and in particular, targeting it to the disorder experienced by the individual patient. He may be involved in helping the patient adapt his or her workplace to the voice disorder. Finally, and in some ways most importantly, he 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.