Otolaryngol Clin N Am

40 (2007) 991–1001

Strobovideolaryngoscopy
and Laboratory Voice Evaluation
Scott M. Kaszuba, MD, C. Gaelyn Garrett, MD*
Department of Otolaryngology, Vanderbilt Voice Center, Vanderbilt University,
7302 Medical Center East, South Tower, 1215 21st Avenue South, Nashville,
TN 37232-8783, USA

Although some laryngeal abnormalities affect the true vocal folds in

known manners, not all patients who have the same vocal pathology exhibit
the same subjective complaint, clinical finding, or physiologic impairment.
There is no single best method of laryngeal examination for all voice pa-
tients. One notable limitation of simple indirect laryngoscopy is that the ex-
amination does not yield a recordable and reproducible image of the larynx
and vocal tract. More importantly, the unaided human eye is unable to vi-
sualize the vibratory patterns of the true vocal folds during phonation. This
inadequacy may lead to inappropriate management decisions. Strobovideo-
laryngoscopy and laboratory vocal testing are most valuable to the voice
specialist in this clinical scenario [1,2].
Recognition of the advantages and disadvantages of current diagnostic
techniques allows for optimal appreciation and instrumentation selection
for supplemental diagnostic laryngeal testing. Although it is agreed that
there is no one gold standard algorithm for the diagnostic process of a pa-
tient who has a voice disorder, most practitioners would agree that some
additional laboratory testing is indicated in most patients. This article
discusses current diagnostic techniques available for physiologic vibratory
testing and anatomic and functional assessment of the vocal tract.

Strobovideolaryngoscopy
True vocal fold vibration is a complicated physiologic function, the ob-
servation of which far outreaches the visual capabilities of the human eye
with a normal light source. The human adducted vocal folds cyclically

* Corresponding author.
E-mail address: gaelyn.garrett@mcmail.vanderbilt.edu (C.G. Garrett).

0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2007.05.006 oto.theclinics.com
992 KASZUBA & GARRETT

open and close between 60 to 1500 times per second, depending on the pho-
natory pitch. Stroboscopic light visually makes the vocal fold vibrations ap-
pear to slow down so that the impression of vocal fold vibrations can be
observed and processed. Stroboscopy capitalizes on the inherent optic prop-
erties of our visual organ and exploits the limitations of observation of the
unaided eye. According to Talbot’s law, the human eye can perceive no
more than five distinct images per second. Each image therefore lingers
on the retina for approximately 0.2 seconds after exposure. Stroboscopic
flashes make the vocal folds appear to slow down by advancing the light
pulse through successive glottal cycles in percentage increments. Individual
still images are recorded at selected points from sequential vibratory cycles
and the human eye automatically fills in the missing pieces by fusing the im-
ages into what it sees as motion. This apparent motion is attributable to
a phenomenon called persistence of vision. Additional instrumentation
added to the stroboscopic light can facilitate the recording and documenta-
tion of the perceived vocal fold vibratory properties [2–4]. Strobovideolar-
yngoscopy as a whole allows the physician to observe important vocal
fold activities, which allows appropriate diagnostic decision making.
A brief historical overview allows full appreciation of the evolution of stro-
bovideolaryngoscopy. Indirect laryngoscopy was first described, but not yet
popularized, by Bozzini in 1806 when he constructed an angled speculum
with a mirror insert that was meant to examine various body cavities, includ-
ing the human larynx. It was not until 1854 that indirect laryngoscopy gained
wider acceptance when Manuel Garcia, a Spanish-born voice teacher who had
a limited gag reflex, first visualized his larynx with a small dental mirror using
sunlight as a light source. In 1895, Oertel followed suit and was credited with
creating the first laryngostroboscope. His device consisted of a variable-speed
perforated disc that was interspersed between a light source and the practi-
tioner’s head mirror [5,6]. Since that time, strobovideolaryngoscopy has
evolved into finely controlled, high-intensity light sources with fiberoptic endo-
scopes or distal camera scopes coupled with analog or digital recording
devices.
Strobovideolaryngoscopy in current clinical practice relies on a combi-
nation of several instruments: a stroboscopic light source, an endoscope,
a microphone, a video camera, a recording device, and a video monitor.
Stroboscopy is best performed in conjunction with video recording and ar-
chiving for complete clinical review and documentation. The examination
may be performed by transnasal flexible laryngoscopy with distal chip tech-
nology or perorally with a rigid angled telescope. Video cameras are now
available in single-chip and three-chip versions. A single-chip camera uses
a single array of light-sensing elements known as charge couple devices
(CCDs). Three-chip cameras use a dichroic prism, which divides the incom-
ing images into the three primary colors and offers more accurate color and
higher resolution. Analog or digital recording technologies are then used for
image capture, documentation, and reproduction [3,7].
 STROBOVIDEOLARYNGOSCOPY AND LABORATORY EVALUATION 993

The illusion of apparent slow motion of the vibrating vocal folds during
strobovideolaryngoscopy evolves from the collection of several sequential
still images of the folds at selected time intervals during repeated glottal cy-
cles at a given vibratory frequency. This illusion is called the stroboscopic
glottal cycle and can be of any desirable duration. In addition, the strobo-
scopic flashes can be emitted either at the same frequency as phonation,
known as synchronization, or at a slight variation of the frequency, known
as asynchronization. This feature of stroboscopy is producible through tech-
nological communication between the microphone and the strobe light
source. By synchronizing the stroboscopic flashes to the fundamental fre-
quency of the vibrating vocal folds, a perceptual stopped image or standstill
of the vocal folds is produced. An asynchronized mode is generated by cal-
ibrating the stroboscopic flashes at a consistent frequency slightly different
than the produced phonatory fundamental frequency. This variation allows
successive light impulses to strike at different phases of the vibratory cycle
and produce a video image of one apparent cycle of vibration actually ob-
tained from different portions of several cycles. Another option, which al-
lows the examiner to manipulate the apparent glottal cycle by operation
of a rocking foot pedal, furthers the stop-action capability of the strobovideo-
laryngoscopy system. This feature is particularly useful when the exact loca-
tion of the vocal fold lesion is being determined in relation to movement of
the upper and lower lips during an approximation phase of the cycle [2,3,7].
The strobovideolaryngoscopic examination is most clinically useful to the
practitioner when a standard protocol is used for the acquisition of the data
and its interpretation. Phonatory tasks during the examination should be
performed at low, normal, and high pitches and in the range of the speaking
or singing problem area, if known. Once recorded, a standardized approach
to the interpretation of the examination allows consistency in diagnosing
and comparing laryngeal pathology. Once the initial examination is com-
pleted and recorded, additional repeat testing at predetermined time inter-
vals allows for evaluation of response to treatment. Although there is
arguably no one gold standard for the interpretation of a strobovideolar-
yngoscopic examination, several aspects of the examination are often rated.
The specific features of the vibratory pattern of the true vocal folds often
addressed include symmetry, periodicity, mucosal wave ratings, amplitude
of vibration, shape and contour of the glottal margin, and glottic closure.
Particular attention is also given to any adynamic segments and the presence
or absence of vertical phase difference [2,6,7]. Vocal fold symmetry remains
intact in the absence of abnormalities along the glottal margin. Periodicity
refers to the regularity of the vibratory cycles with the idea that normal vo-
cal folds should vibrate in mirror image to each other and vibrate the same
with successive cycles. Aperiodic vibrations may prohibit the synchroniza-
tion of the strobe light. The mucosal wave is generally described as the trav-
eling wave across the vocal fold superior surface from medial to lateral.
Abnormalities of the mucosal cover, including the epithelial layer or
994 KASZUBA & GARRETT

superficial lamina propria, are the most common causes of mucosal wave re-
duction. The mucosal wave should be differentiated from the vertical phase
difference, which is created normally by the presence of an upper lip and
lower lip at the medial vibratory vertical closing surface. Amplitude of vi-
bration is a relative feature of the mucosal wave judged by the trained ob-
server as reduced, normal, or excessive. Normal variations in amplitude
occur with changes in vocal intensity. Glottal closure is described as com-
plete; incomplete with anterior, mid, or posterior glottal chinks; and hour-
glass, usually secondary to mid-vocal fold lesions.
From a clinical standpoint, strobovideolaryngoscopy has proved to be
a valuable tool for the diagnosis of laryngeal pathology given the detailed
physical examination it provides of the vocal tract and the vibratory margin
of the vocal fold. Stroboscopic features of nodules, for example, often in-
clude symmetric but reduced amplitude of vibration, maintenance of period-
icity, intact mucosal waves, and hourglass closure. Vocal fold polyps, which
are frequently unilateral, have asymmetric vibration and variable periodicity
depending on the size and shape of the polyp. Mucosal wave can be absent
because of mass effect with large polyps or intact with broader-based polyps.
The wave is generally intact on the contralateral side. Glottic closure is un-
derstandably asymmetric. Cysts within the vocal fold lamina propria can
have the greatest adverse effect of the nonneoplastic lesions on the vibratory
characteristics. Mucosal wave is frequently absent and aperiodic if present.
A change in diagnosis and altered assessment of vocal pathology based on
the strobovideolaryngoscopic findings can occur in 10% to 30% of cases
[4,8]. Furthermore, abnormal findings have been reported in up to 58% of
healthy, asymptomatic professional singers stressing the importance of
screening examinations for certain populations of patients [9].
Strobovideolaryngoscopy is not a test to be done in the absence of other
clinical data. It is only a valuable complement to a thorough vocal history
and physical examination. The technique inherently suffers from the limita-
tion of being a composite recording made from several glottal cycles, in con-
trast to high-speed photography or high-speed digital video, which records
an entire vibratory cycle and provides detailed cycle-to-cycle variations.
Even with this limitation, strobovideolaryngoscopy remains an invaluable
tool in the diagnostic armamentarium of the voice specialist.

Glottography
Glottography is a general technique that monitors the vibration of the
vocal folds by the transmission of a probe signal from one side of the larynx
to the other. The probe signal itself can be directed in either a vertical plane
or horizontal plane. Current probing signals most commonly used in glot-
tography include electrical current flow, light transmission, and ultrasonic
waves. The time variation of the glottis combined with laryngeal tissues
 STROBOVIDEOLARYNGOSCOPY AND LABORATORY EVALUATION 995

that are in constant partial stages of contact during phonation modulates

the probe’s properties. This modulation is then detected and recorded sup-
plying immediate objective data in the form of graphic displays that can be
clinically interpreted. Glottography thus makes possible the physical mea-
surement of acoustic parameters, such as pitch, jitter (frequency perturba-
tions), shimmer (amplitude perturbations), or other perturbations. It also
provides a possible objective method that can be used to evaluate and detect
vocal fold pathology. Overall, glottography provides some clinical data
about vocal fold vibration. This technique fails to determine the vibration
capacity of an individual vocal fold or diagnose individual laryngeal lesions
without an additional visual examination [10,11].

Electroglottography
Electroglottography (EGG) is a technique based on the principle that hu-
man tissue can conduct an electrical current with laryngeal tissues being
a moderately good conductor of electricity. It is performed by placing two
electrodes above the thyroid laminae on the external neck and measuring
the impedance between them with a high-frequency, low-current signal.
Ohm’s law states that a current must flow through a system if its resistance
is to be measured. Based on this law, when the vocal folds are touching
a greater current flows through them compared with when they are open.
The electroglottographic signal represents the contact area between the
two vocal folds and can be used to determine when the vocal folds are closed
and how fast they are closing [10–13]. This characteristic contrasts with pho-
toglottography (PGG), which gives information about the separation of the
vocal folds and little information about the nature of vocal fold contact.
Various manufacturers provide instrumentation that produces, records,
and displays the electroglottographic signal. Several authors over the past
two decades have commented on the shape of the EGG waveform as it relates
to the underlying physiology of vocal fold vibration. Interpretation of EGG
waveforms remains controversial, however, especially as it relates to analyzing
vocal fold pathology. When used in conjunction with other laboratory tech-
niques, the interpretation of the EGG display becomes more reliable. For ex-
ample, synchronized strobovideolaryngoscopy and EGG have been shown to
be an effective tool for verifying information from the EGG waveform with
stroboscopic images [12,14]. Also, recent research is moving toward standard-
ization of normal EGG measurements with the goal of allowing this test to
serve as a reference for the diagnosis and follow-up of dysphonic patients [15].
There are limitations of EGG. The most obvious one for the voice specialist
is that it cannot be used with all dysphonic subjects. Patients who have a uni-
lateral vocal fold paralysis have a considerably diminished or absent signal
because of lack of good contact of the vocal folds. Obese or thick necks
may impede proper placement of the electrodes or hinder the electrical current
resulting in a poor EGG tracing. Finally, severe hoarseness may render
996 KASZUBA & GARRETT

laryngeal tissue irritable and passing an electrical current through this envi-
ronment may produce an undesirable physiologic response [10,13].

Photoglottography
Photoglottography is a technique that estimates glottal area during pho-
nation. The principle of PGG is based on the concept that the glottis may
act like a shutter through which light can pass in proportion to the degree
of opening of the vocal folds. Light is usually directed transnasally from
above the glottis and is detected by an optoelectronic device over the skin
of the trachea immediately beneath the vocal folds. The external photosen-
sor then converts the light intensity absorbed into electric voltage, which can
be recorded and converted into a graphic display. The direction of the light
path during the study has no impact on the ability to record the PGG signal;
therefore the light source may be placed above or below the glottis or on the
external neck with the photosensor in the opposite complementary position.
Typically, for the best functional examination with the additional advantage
of simultaneous laryngeal observation, a transnasal flexible laryngoscope is
used as the light source with the photosensor placed externally on the neck.
PGG gives some clinical data during the open phase of phonation with
two common measurements routinely obtained. The speed quotient mea-
sures the symmetry of the opening and closing parts of the open phase,
and the open quotient is the time of the open phase of the vocal folds di-
vided by the total period of vibration. Some problems may exist with the
validity of the quantitative information obtained from this technique. These
are most often believed to be attributable to several extrinsic factors, includ-
ing inability to standardize the amount of light projected on the larynx,
changes in light-transmission characteristics of the glottis because of its ver-
tical movement during phonation, and volume changes of the hypopharynx
and supraglottis during different vowel productions. Overall, the PGG
waveform is considered complementary to the EGG signal [10,11,13].

Ultrasound glottography
Ultrasound glottography (UGG) is a technique in which ultrasonic waves
are constantly applied across the laryngeal area of the neck during phonation.
The border between the vocal fold surface and the glottal air is determined by
the difference in acoustic impedance between two media (air and soft tissue).
Like all ultrasound studies, it is based on the frequency shift produced when
a continuous ultrasonic beam is reflected back from or transmitted through
a tissue medium. In UGG, a narrow-beam ultrasound transducer is placed ex-
ternally on one side of the neck near the larynx with a receiver on the other
side. The ultrasonic signal is aimed at the air tissue interface of the glottis.
 STROBOVIDEOLARYNGOSCOPY AND LABORATORY EVALUATION 997

Air is an extremely poor ultrasound transmission medium and therefore when

the glottis is open the ultrasonic beam is not transmitted across it to the re-
ceiver on the opposite side of the neck. This continuous wave glottography
then displays an open–closed pattern that corresponds to the open and closed
phases of phonation. Unfortunately, the space resolution of ultrasound glot-
tograms is not very high and therefore few reports are available regarding
voice function. Nonetheless, it remains a noninvasive means of laryngeal
monitoring and combined with newer technological advances may hold
promise for future clinical voice research [10,11,13].

Videokymography
Videokymography is a laboratory technique that was developed as
a means of using television technology to visualize real-time vibratory acti-
vities of a small area of the glottis. This visualization is accomplished by us-
ing a line scan camera that is capable of limiting its entire field of view and
scanning of the endoscopic image to a rapid repetition of a single line. Each
new scan of the same line is stacked on top of the others from superior to
inferior so that a screen image is built up with time represented in the
vertical direction. The line scan camera therefore records a small area of
the vocal fold in a real-time fashion while it vibrates and allows for subtle
aperiodic irregularities or phase asymmetries to be observed and doc-
umented. A major shortcoming of this technique is that any movement
of either the larynx or endoscope during signal acquisition changes the locus
being observed. Also, the line image produced is not a complete image of the
larynx. Some training is also required for interpretation of the examination
results. Although still regarded as mainly an experimental technique for
laboratory voice testing, new generation digital videokymographic systems
are currently being developed in hopes of becoming an important tool for
routine clinical laryngeal examination [10,16,17].

High-speed photography and digital imaging

High-speed photography and digital imaging are laboratory techniques
that were developed to overcome the limitations of strobovideolaryngoscopy.
As previously discussed, stroboscopy is a technique that produces a virtual
slow-motion image of the larynx from the summation of images obtained
from several glottal cycles. The clinical use of this technique is based on vocal
tract pathology being periodic and stable at a given phonatory frequency.
Dysphonic patients suffering from aperiodic phonatory disorders may not
completely benefit from the examination, therefore. High-speed photography
and digital imaging overcome these limitations by providing real-time images
of successive glottal cycles of the larynx during phonation.
998 KASZUBA & GARRETT

High-speed photography requires several expensive pieces of equipment

that require technical expertise for proper operation. The main piece of
equipment is a camera capable of taking pictures at a rate of 3000 to
4000 frames per second. The recorded events are then viewed back and an-
alyzed in ultraslow motion. The technique itself requires that dysphonic pa-
tients be able to position themselves over a laryngeal mirror during the
camera recording, which is not always tolerated well. This technical diffi-
culty combined with increased cost and time expenditure necessary to com-
plete the examination have limited its clinical use. Nonetheless, high-speed
photography using a laryngeal mirror has provided valuable information
about vocal function when used in a clinical setting.
High-speed digital imaging has seen recent activity over the last several
years with the development of new camera image sensor systems with in-
creased image resolution combined with improved computer processing
speed and storage capacity. The technique uses standard rigid endoscopes
to record full images of the superior surface of the larynx at sampling rates
from 1000 to 8000 frames per second. The recorded images are typically in
black and white and can be played back in ultraslow motion for clinical
analysis. The current cost of the equipment has still limited its use as a rou-
tine clinical examination conducted by the voice specialist.
Limited availability of this equipment in the clinical setting has resulted in
few studies being performed regarding the application of this modality in di-
recting patient care. From a research standpoint, high-speed digital imaging
has been used to identify characteristics of normal and abnormal vocal fold
vibration. Digitization of the images enables accurate quantification of vocal
fold vibrating parameters not possible with strobovideolaryngoscopy. High-
speed digital imaging has also been used to examine the basic physiology of
different singing styles, in the assessment of vocal tremor, and in the differen-
tiation of spasmodic dysphonia from muscle tension dysphonia. Some re-
searchers have combined the technique with a laser calibration tool for
estimated measurements of glottal parameters, including scarring and other
elastic properties of the vocal folds [18,19]. Further development of this tech-
nology may lead to a better understanding of vocal fold elasticity measure-
ments and possibly direct the development of new laryngeal injection
materials. More widespread clinical use of high-speed digital imaging in the
future is expected as the cost of the instrumentation decreases.

Acoustic voice measurements

Phonatory tasks for normal and dysphonic patients may be obtained for
objective voice analysis. Speech samples obtained typically consist of sus-
tained vowel phonation, reading, and conversational speech. Measured pa-
rameters can include fundamental frequency, maximum phonation time,
vocal intensity, harmonics-to-noise ratio, jitter, and shimmer. These objec-
tive measurements have been used in numerous clinical settings to compare
 STROBOVIDEOLARYNGOSCOPY AND LABORATORY EVALUATION 999

pretreatment to posttreatment phonatory characteristics after a specific sur-

gical or nonsurgical intervention has been performed by the voice specialist.
Several commercially available pitch meters/analyzers are available to the
voice specialist, including the VisiPitch (Kay Elemetrics Corporation) in-
strument. This equipment is most useful for obtaining fundamental frequency
and vocal intensity and can provide other measures of speech parameters also.
In addition, numerous computer programs, some used in conjunction with
strobovideolaryngoscopy, also exist. Computerized Speech Lab (CSL, Kay
Elemetrics Corporation, Lincoln Park, New Jersey), CSpeech, and Dr. Speech
Science (Tiger Electronics, Seattle, Washington) run on PC-compatible com-
puters. MacSpeech Lab is available for the Macintosh computer. These pro-
grams provide a multidimensional voice analysis of the above-mentioned
parameters and are relatively simple to use. Research suggests that although
these systems are not necessarily comparable in absolute figures, their judg-
ment against normative data is typically similar. Ambulatory monitoring of
the dysphonic patient in the form of miniature accelerometers placed on the
anterior neck has also been reported and may show future promise in the clin-
ical assessment and management of voice disorders [13,20,21].
Speech spectrograms represent a measure of the vibratory characteristics of
the vocal folds and the vocal tract. They are useful for analyzing and display-
ing changes in the spectral characteristics of vocal fold sound. Care must be
taken to use the same vowel while comparing spectrograms of a patient to
eliminate the vocal tract as a variable and therefore allow independent analy-
sis of the vocal folds. The most useful measure from a speech spectrogram is
the harmonics-to-noise ratio (signal-to-noise ratio). It represents a ratio of the
energy in the harmonics of the vocal signal against the noise energy in the sig-
nal. Dysphonic voices exhibit a greater noise signal and therefore the ratio is
decreased when compared with normative data. The computer software pro-
grams previously mentioned produce good-quality speech spectrograms. Ad-
ditional instrumentation may obtained by the voice specialist to produce
higher-quality spectrograms at a greater expense [13].
Perturbation measures rely on the inherent ability to determine an accurate
fundamental frequency and are usually measured using sustained vowel frag-
ments. Dysphonic voice samples are often only marginally periodic at best and
are often difficult to obtain. Furthermore, most dysphonias are multifactorial
in nature and often times show variability at different points in a patient’s vo-
cal range. Connected speech may overcome some of these obstacles and there-
fore be a more appropriate stimulus for the dysphonic patient because it is
more representative of functional vocal productions over a broader vocal
range. An inherent difficulty with the analysis of connected speech by typical
perturbation methods as previously mentioned is that these measures are
influenced by intonation and other modulation effects. Long-term average
speech spectrum (eg, spectral tilt) and derivations of the spectrum such as
cepstral peak prominence overcome these difficulties. These measures do
not rely on determination of fundamental frequency and are not confounded
1000 KASZUBA & GARRETT

by variables such as recording technique and recording volume. Several au-

thors have noted that measures of the cepstrum, a Fourier transformation
of the spectrum of the signal, better correlate with perceptual measures of
overall dysphonia compared with more traditional measures of periodicity
or perturbation [22]. Special software is needed to complete these measures
and currently is not available in any commercial software program [23,24].

Vocal quality-of-life measures

The degree to which a dysphonia impacts a patient’s day-to-day activities is
often difficult to measure. Factors such as the severity of the voice disorder
and the vocal needs of the patient are central to the determination of how
the dysphonia alters his or her physical, social, and emotional well-being.
Two well-known instruments that quantify the psychosocial consequences
of voice disorders are the Voice-Related Quality of Life Measure and the
Voice Handicap Index. Both instruments have been shown to be valid and
reliable as a vocal quality-of-life measure [25,26]. They allow for subjective
perceptual analysis of a given clinical intervention by the voice specialist
and are a low burden in a population of patients who have a diverse group
of voice disorders [27]. One drawback of all outcome instruments for
dysphonia is the large number of questions that need to be answered to receive
a complete score. Recently, the development and validation of the Voice
Handicap Index-10 has been introduced as one instrument that may decrease
this burden [28]. Overall, outcome instruments for vocal quality of life are
important indices of patient functional capacity that enhance the voice
specialist’s ability to successfully treat patients who have voice disorders.

Summary
Laboratory and strobovideolaryngoscopy voice evaluation are important
parts of the clinical work-up of the dysphonic patient. When selected appro-
priately with appreciation of their limitations, the techniques discussed
afford the voice specialist the opportunity to make informed diagnostic
decisions and improve the overall quality of care delivered.

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