The Larynx, Voice and Swallowing: Examination

The larynx, situated deep in the neck, is relatively inaccessible. Special techniques are therefore required to examine and evaluate its function.

Select a Diagnostic Study
Indirect Laryngoscopy
Flexible and Rigid Fiberoptic Laryngoscopy
Videostroboscopy
Electromyography (EMG)
Videofluoroscopic Swallowing Study/Modified Barium Swallow
Fiberoptic Endoscopic Evaluation of Swallowing (FEES)

Indirect Laryngoscopy

The simplest form of laryngeal examination involves the placement of a small, angled mirror at the back of the throat. This allows the examiner to view the major structures of the larynx. Many finer structures and their movements during normal speech, however, are difficult to discern. In patients with a strong gag reflex, the usefulness of this technique may be limited. Still, this method allows a quick, easy, and painless gross examination of the larynx.

View a normal stroboscopic exam (QuickTime format, file size approximately 1.2 MB). The rear of the larynx is at the top of the screen. The left vocal fold (the white, vibrating tissue at the midline) is on the right of the image, and vice-versa. The large flap-like structure at the bottom of the image is the epiglottis.


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Flexible and Rigid Fiberoptic Laryngoscopy

These types of examination use fiberoptic instruments to assist the examiner in visualizing the larynx. The instruments possess a small viewfinder in which the examiner views the image. Typically, the visual output from the instrument is fed via a camera into a digital recorder. This allows documentation of a patient's condition and allows for comparison with earlier examinations.

In an examination with a flexible scope, the patient's nasal passages are first decongested and lightly anesthetized. The flexible fiberoptic scope is then threaded through the nose and down the back of the throat into the pharynx. From this position, an image of the larynx and vocal folds (including their movement and position during respiration and speech) can be obtained.

An examination using a rigid scope involves placement of the tip of the instrument at the back of the tongue to provide a view of the throat. A prism at the tip allows visualization down into the larynx. This type of exam provides clear and highly magnified images of the vocal folds.


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Videostroboscopy

During speech, the vocal folds vibrate far too quickly (over 100 times per second) to be examined with the naked eye. In order to overcome this, a strobe light is used to illuminate the vocal folds in slow-motion. A strobe emits bright pulses of light at evenly spaced intervals. If the frequency of those pulses is the same as the fundamental vibration frequency of the vocal folds, then the folds will appear "frozen" in time. If, however, the frequency of the strobe is slightly less than that of the vocal folds, the folds will appear to move in slow-motion.

This type of exam is important because it allows the mucosa of the vocal folds to be examined during voice production. Many disorders of the larynx involve pathologic changes of this tissue which causes a change in the vibration of the vocal folds. During examination with a regular light source, these changes might go unnoticed. Stroboscopic examination allows easier visualization of any irregularities which might be present.


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Electromyography (EMG)

This type of exam differs from those discussed above in that the larynx is not directly observed. Instead, its function is assessed from the detection of the electrical potential changes which occur in the muscles of the larynx during contraction.

During electromyography, small needles are inserted through the skin into these muscles. Their electrical activity is then recorded on an oscilloscope at rest and during activity (speaking, breathing, and swallowing). The pattern, amplitude, and duration of the electrical discharge gives the examiner clues to the nature of a patient's disorder. For instance, if an electromyograph detects normal electrical activity in a patient with an immobile vocal fold, it would tend to rule out muscular paralysis in favor of some other cause (e.g. mechanical fixation or joint immobility).


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Videofluoroscopic Swallowing Study or a Modified Barium Swallow

Fluoroscopy is a radiographic technique, similar in principle to an ordinary X-ray, which is used to assess a patient's swallowing function if a swallowing problem is suspected. However, in contrast to the single exposure of a simple radiograph, videofluoroscopy provides a continuous video image. This is conducted with a radiologist and speech pathologist. In this exam, the patient  swallows barium of varying consistencies. As the swallow occurs, the examiner is able to follow the passage of material through the mouth and into the pharynx and esophagus.

A normal swallow includes precisely-timed sequence of events. Any departure from this sequence may indicate an injury or disease process. The study also allows for the identification of aspiration (food or liquid entering the lungs) as well as identifying the factors which may be causing it. Therapeutic strategies can be implemented to enhance the ease and safety of swallowing when a swallowing disorder is observed. These can then be used as the basis of a management or treatment plan. After the study is completed, the findings are usually shared with the individual and family or caregivers to provide better insight into the nature of the problem, as well as providing guidance for strategies to use while eating and drinking.

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Fiberoptic Endoscopic Evaluation of Swallowing (FEES)
As in Flexible Endoscopy, above, a FEES study uses a flexible scope to evaluate swallowing function. The nose is first decongested and anaesthetized and then the scope is gently inserted to the back of the nose in order to allow a view of the structures of the larynx and pharynx. With the scope in place, the individual is then asked to perform a variety of speech tasks which allow for the identification of any abnormalities in structure or function. Subsequently the exam then progresses to the presentation of some kind of stimulus for swallowing. In individuals who have a long history of aspiration and swallowing difficulties, stimulation may occur without food or liquid. In individuals who are currently eating and drinking, a variety of regular food and liquid consistencies are presented and intervention may only occur as and when problems occur. During the examination and any family/caregivers in the room are able to see the examination in real-time on a monitor. This allows for education regarding the nature of the problem, evaluation of various swallowing strategies, and biofeedback to teach swallowing maneuvers and exercises. These then can form the basis of swallowing treatment.

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