Vocal limitations

Vocal limitations are expected capabilities that the individual has lost. Via elicitation, the examiner seeks to answer the question: “What can’t this voice do that it should be able to do?” In other words, vocal limitations are the set of incapacities of an individual voice, as compared with what would be expected, if that voice were entirely normal for age and sex.

Vocal limitations may not be understood by clinicians who: (1) do not have a complete understanding of normal capabilities, often derived from thorough knowledge of singing voice capabilities; (2) can’t or don’t elicit a complete vocal capability battery, with necessary modeling of various vocal tasks, particularly at the extremes of vocal capability.

Vocal capabilities

Vocal capabilities refer to the full extent of the voice’s abilities in terms of loudness, range, steadiness and control, rapid repetitive sound-making, high soft singing, and so forth. Understanding of any voice’s capabilities (and limitations) requires much elicitation by the examiner. Also required is an understanding of expected capabilities for sex and age, so that an individual’s capabilities can be compared with what is expected.

Traditional diagnostic model (for voice disorders)

The traditional diagnostic model (for voice disorders) is the method of diagnosis used up to recent decades, and still by far the most prevalent model worldwide. Here, the clinician collects a patient history and then proceeds directly to mirror examination, or possibly one using the fiberscope. Unfortunately, many diagnoses may be missed due to missing information. See also: the integrative diagnostic model for voice disorders.

Technology-driven diagnostic model

A term used somewhat interchangeably with the reductionistic diagnostic model. The idea of a technology-driven diagnostic model is that technology is generally the answer to difficult diagnostic dilemmas. The hope is also looking to make voice diagnosis more “scientific” or “objective.” Inherent to the technology-driven model is the idea that the disorder will be better understood if only we can make enough measures of various sorts. By extension, if we don’t understand a voice disorder completely by the end of a large battery of measurements, we need more measures. While the clinicians at our practice make use of state-of-the-art technology, the integrative diagnostic model is preferred.


The cycle-to-cycle variability of the period amplitude of vocal cord vibration. Shimmer is used as one of the measures for the micro-instability of vocal cord vibrations. Given that shimmer may vary dramatically with changes of voice production within the same voice, and also that a given shimmer measurement is non-specific to any particular voice disorder, this measure is considered superfluous to the integrative diagnostic model. Shimmer is therefore not used routinely at our practice.


Sedation is a state of reduced excitement or anxiety induced by the administration of sedative agents such as lorazepam (Ativan) and diazepam (Valium). At our practice, we occasionally administer lorazepam, given orally a couple of hours before a procedure, to allay anxiety.

Secondary gain

Advantage gained from holding on longer than necessary to an illness—be it organic or nonorganic. At our practice, the phenomenon of secondary gain is most commonly seen in nonorganic voice and breathing (tracheal or laryngeal) disorders. An example might be that a person consciously or subconsciously maintains “laryngitis” after the initial organic infection has resolved, for the secondary gain of being excused from school or work. In this case the loss of voice is “worth it” as compared with the “gain” achieved. The secondary gain may have to do with attention, avoiding a responsibility, punishing or controlling another person, or possibly other issues.