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“Dropping Acid” Blog


The success of treating patients with voice disorders depends to a great extent upon accurate diagnosis. To get successful outcomes, it is necessary to diagnose and treat each of the underlying problems. All of the testing done at the Voice Institute of New York is state of the art. Furthermore, we have extensive experience with most of the important testing methods.


Videostroboscopy is a quick and painless examination of the larynx and throat. It is performed by the doctor spraying the nose with a numbing medicine and then placing a small soft, flexible optical instrument through the nose to view the throat. This procedure allows for a magnified view of the vocal folds for assessment of vocal fold vibrations, for a subsequent video-analysis, and for photography. At the Voice Institute of New York, all videostroboscopy examinations are digitally archived.

Laryngeal Electromyography

Laryngeal electromyography (LEMG) is a term that almost defines itself. The larynx is the voice box, electro means electrical, myo means muscle, and ography means measurement. Thus, this test is performed by inserting a fine needle like an acupuncture needle into the voice box and measuring the electrical potentials of the muscles. While this test can be uncomfortable, it lasts only about a few minutes and it is not associated with any complications.

LEMG provides essential information about the neuromuscular status of the larynx that no other test can provide. Dr. Jamie Koufman, the Institute’s director, has been performing LEMG on a daily basis since 1987, “I make more clinical decisions based upon laryngeal electromyography than almost any other test.”

Short technical article on indications, technique, and interpretation of laryngeal electromyography (LEMG)

Laryngeal electromyography (Conprehensive article that also presents a large series of cases)

The cricothyroid muscle does not influence vocal fold position in vocal fold paralysis (EMG findings)

Acid Reflux Testing

Acid reflux refers to the back flow of gastric (stomach) contents into the esophagus or throat. Laryngopharyngeal reflux (LPR) is very common in voice disorder patients and it can be “silent”, that is, it can occur without heartburn or digestive symptoms. Acid reflux testing actually has several elements: esophageal manometry, ambulatory 24-hour pH testing, and transnasal esophagoscopy.

Reflux Testing Information and Instructions


Manometry is a way of measuring swallowing pressures and effectiveness of the entire swallow mechanism, including the upper and lower esophageal sphincters. (The upper esophageal sphincter is supposed to prevent reflux into the larynx and pharynx; whereas, the lower esophageal sphincter is supposed to prevent reflux into the esophagus.) In actuality, everyone has some reflux some of the time. This test determines whether or not the valves and the swallowing mechanism itself are healthy or defective.

Ambulatory 24-Hour Double-Probe pH Monitoring: The Importance of Manometry

pH Monitoring

pH monitoring is a method of testing in the esophagus and throat for acid reflux. This test is performed overnight. A small flexible tube in placed in the nose and enters the throat and esophagus where it measures acidity and backflow in both the esophagus and the laryngeal areas. This test is the state-of-the-art and it is profoundly important in many voice disorder patients.

Transnasal Esophagoscopy

We are able to evaluate the esophagus in the office without any intravenous sedation or anesthesia. The small flexible instrument that is used to examine the larynx can be inserted into the esophagus just behind the voice box and provide a spectacular quick and comfortable examination. This technique obviates more complex time-consuming, expensive, and unpleasant procedures. See also www.transnasalesophagosocpy.com.

Transnasal esophagoscopy: A position statement from the American Bronchoesophagological Association (ABEA): This landmark article authored by the prestigious ABEA states that transnasal esophagoscopy (TNE) is an excellent endoscopy (endoscopic method) for examining the esophagus (esophagoscopy) and the stomach. The quality of the TNE examination is comparable to traditional endoscopy performed in an endoscopy suite under anesthesia; however, TNE has many fewer complications; it is well-tolerated — patients are awake and alert — and it is far less expensive.   Consequently, TNE is the preferred technique for screening for esophageal cancer and Barrett’s esophagus (esophageal pre-cancer).

Transnasal Esophagoscopy: Revisited (over 700 Consecutive Cases): This article reviews some of the experience of  Dr. Koufman and her team at Wake Forest University. This is the largest series reported in the literature.