Hoarseness is a fact of life. Yelling too much at a football game, screaming at a concert, colds or the flu can all cause hoarseness. But when the culprit is vocal chord paralysis, reflux, or smoking, medical intervention is required. "Over the last 15 years or so, voice evaluation has gone from just kind of looking down there to now being able to videotape vocal chord movement, do slow motion studies, do pretty sophisticated computer-based analysis of voice for certain selected patients," says Richard W. Waguespack, MD, "and along with this has been improvement in the way we diagnose patients. "The rule of thumb for the most part is someone who's hoarse for more than a couple of weeks without an obvious explanation need to be seen by a doctor," he continues. "Now, they may well be seen by their regular medical doctor, but if things don't turn around very quickly and return to normal, then in general, someone needs to see an otolaryngologist." The first step is low-tech. "For most folks, it's a process of taking a pretty intensive history, because if one fails to identify other contributing factors — patient's potential misuse of voice, reflux, allergies, other health problems such as asthma and so forth — if you don't recognize those and try to place those into the context, you are obviously going to have a lot of trouble getting the patient improved." The next step involves visualization. In the past, a mirror exam was the way to go, but now a flexible scope exam offers additional benefits. "With the scope, it's a matter of anesthetizing and then passing a small scope, about 4 mm in diameter, through the nose and back around behind the palate to look at the vocal chords. The advantage of this is that it avoids the gag reflex in many patients. The flexible scope gets you around that in the majority of patients and it also lets you see patients in vocal activities while they speak or sing," says Waguespack. "In most cases, to do this in the voice lab setting, you're going to want to have a camera connected. There are new instruments which actually have the chip, the light sensitive chip in the tip of the scope, so instead of having the light come all the way through the fiber bundles to the camera at the end, which is the more traditional way, the chip itself is at the far end of the scope, and the signal comes back as opposed to the light coming back. One records this both in real time and the stroboscope device uses a microphone to monitor a patient's voice and to time-link a strobe effect. This, in effect, allows you to freeze vocal chord movement or to have it move very slowly. What this tries to reproduce is slow motion. So putting patients through these vocal exercises and activities usually allows you to really see how the vocal chords are vibrating. And that, in turn, drives your decision making as where to go from there," he explains. "There are other computer devices that allow you to do analysis on things such as air flow, the frequency of the voice and certain measurements of roughness and so forth. For some patients you want to capture that acoustical data to measure your progress as things go on. Waguespack points out that reflux is often the cause of voice and esophageal problems. Reflux symptoms often go beyond heartburn and belching. "For the usual reflux esophagitis symptoms, I'm sure physicians are already asking the right questions. Now, the flip side is the other symptoms, the throat symptoms…the chronic cough, the hoarseness that is there for no apparent reason. People will sometimes say 'I've got this lump in my throat. I wake up in the night and I feel like I'm choking.' The medical community needs to recognize that a lot of those folks, if not the majority, are probably refluxing. At least a trial of therapy is probably reasonable, and if not, then they need to be visualized by someone in my specialty."