Vocal Tract Discomfort and Dysphonia in Patients Undergoing Empiric Therapeutic Trial with Proton Pump Inhibitor for Suspected Laryngopharyngeal Reflux

Introductionthe aim of this study was to evaluate the correlation among dysphonic and vocal tract discomfort symptoms in patients who underwent empiric therapeutic trial with proton pump inhibitor (PPI) for a suspected laryngopharyngeal reflux (LPR).Materials and methodsA total of 34 patients with suspected LPR were enrolled in this study. All of them were evaluated using the reflux finding score, the reflux symptom Index (RSI), the vocal tract discomfort scale (VTDS), and the voice symptom scale (VoiSS) before and after the PPI treatment.ResultsA significant difference was found between pretreatment and posttreatment reflux finding score, RSI, VTDS, and VoiSS scores. Significant correlations among RSI, VTDS, and VoiSS before the PPI treatment were found.ConclusionPPI treatment determined a significant improvement of symptoms related to dysphonia and vocal tract discomfort in patients with suspected LPR, in addition, significant correlations among the RSI, VTDS, and VoiSS scores were demonstrated thus suggesting that LPR might influence the response of questionnaires not specifically developed in order to assess the complains in LPR patient.     

Perceptual and Acoustic Characteristics of Voice Changes in Reflux Laryngitis Patients

The aim of the study was to outline the multidimensional perceptual, subjective, and instrumental acoustic voice changes in the group of reflux laryngitis (RL) patients. Data of multidimensional voice assessment of 108 RL patients and 90 healthy persons of the control group were subjected to comparative analysis. A slight hoarseness according to the GRB (G-grade, R- rough, B-breathy) scale was prevailing in the RL patients group. Statistically significant difference (P < 0.001) between RL patients group and the control group was found of all voice parameters measured, with the patients having worse results--increased mean jitter, shimmer, normalized noise energy, voice handicap index (VHI), and decreased parameters of phonetogram. The results of the study demonstrated that multidimensional voice assessment documented deteriorated voice quality and restricted phonation capabilities in the tested group of RL patients.     

Acoustic Analysis Findings in Objective Laryngopharyngeal Reflux Patients

OBJECTIVE: The aim of this study was to identify the effects of objective laryngopharyngeal reflux (LPR) on the acoustic parameters of patients by comparing their voice samples with that of control subjects. STUDY DESIGN: Prospective study in two tertiary reference hospitals. METHODS: 48 consecutive patients with symptoms related to LPR and 64 control subjects were included in the study. Suspected LPR patients underwent a 24-hour ambulatory pH monitoring, and 25 (52%) of them were shown to have objective LPR. Acoustical evaluation results of objective LPR patients were compared with that of symptomatic LPR patients and control subjects. RESULTS: All frequency perturbation values obtained from objective and symptomatic LPR patients were higher than the control subjects (P<0.01). Mean fundamental frequency, amplitude perturbation measures, and noise-to-harmonics ratio were not significantly different between groups. CONCLUSION: LPR patients have significantly different frequency perturbation values than control subjects.     

An investigation of the Voice Handicap Index with Speakers of Portuguese: Preliminary data

Although the Voice Handicap Index (VHI) has been recognized as a useful tool for quantifying American English speakers' perceived consequences of voice disorder, it has not yet been widely applied in the clinic to study dysphonic patient populations, or tested with a normally speaking population. The purpose of this investigation was to obtain information about the VHI in a group of Portuguese speakers with voice complaints compared with an age- and gender-matched group of speakers without voice complaints. The results demonstrate that speakers with voice complaints have overall VHI total scores significantly higher than speakers without voice complaints (p < 0.001). This is also true for all VHI subscores in the emotional (p < 0.001), functional (p < 0.05), and physical (p < 0.001) domains. So, the assumption that a group with voice complaints has higher voice handicap impact than the matched control comparison group is justified for Portuguese speakers.     

Correlation of the Voice Handicap Index (VHI) and the Voice-Related Quality of Life Measure (V-RQOL)

The purpose of this study was to investigate the correlation between the Voice Handicap Index (VHI) and the Voice-Related Quality of Life Measure (V-RQOL), and to test conversion of scores between the two instruments. Understanding the relationship between instruments will facilitate comparison of voice outcome studies using different measures. A retrospective medical chart review of 140 consecutive patients with a chief complaint related to their voice presenting for speech pathology voice evaluation following laryngology evaluation and diagnosis was adopted. Each patient who filled out the VHI and V-RQOL within a 2-week period with no intervening treatment was included in the study. Correlation analysis for total scores was performed for the patients meeting inclusion criteria (n=132). Correlations were also performed as a function of diagnosis. Calculated VHI score based on measured V-RQOL score was compared to measured VHI score. Pearson correlation between scores on the VHI and V-RQOL was -0.82. There was no significant difference between the mean measured and mean calculated VHI scores. For individual scores, however, regression analysis did reveal a significant difference between calculated and measured VHI. The VHI and V-RQOL are highly correlated; however, this study suggests that the two instruments are not interchangeable for individuals.     

Voice-related Quality of Life in Laryngectomees: Assessment Using the VHI and V-RQOL Symptom Scales

The primary purpose of this study was to investigate the effect of the voice impairment across the physical, emotional, and functional domains in patients using valved speech following total laryngectomy with the help of two symptom specific scales. The study design used was a cross-sectional cohort. The setting was the Head and Neck Oncology Unit of a tertiary referral centre. Subjects were 54 patients who had undergone total laryngectomy. Two voice-specific questionnaires, the Voice-Related Quality of Life (V-RQOL-short form) Measure, and the Voice Handicap Index (VHI-long form) were used. The main outcome measure was patient perception of the voice following total laryngectomy in response to specific questions correlated with sociodemographic/treatment factors. Responses were received from 40 males and 14 females (response rate of 85.7%) with a median age of 63.4 years (range: 37-84). The V-RQOL overall analysis showed that 3 patients (5.6%) scored "excellent," 29 patients (53.7%) "fair to good," 14 patients (25.9%) "poor to fair," and 8 patients (14.8%) "poor." Analysis of the VHI revealed that 20 patients (37.0%) had a minimal handicap, 20 patients (37.0%) a moderate handicap, and 14 patients (25.9%) had a serious voice handicap. The individual domain or subscale scores for the VHI revealed a mean (SD) functional score of 15.8 (7.7), a physical score of 13.6 (7.2), and finally an emotional score of 11.6 (8.9). Functional aspects of the voice were significantly affected by age, radiotherapy, and chemotherapy (Spearman rho, P=0.01; Mann-Whitney, P=0.04 and P=0.01). The physical aspects of the voice were significantly affected by age and chemotherapy (Spearman rho, P=0.004; Mann-Whitney, P=0.04). Only age significantly affected the emotional aspects of the voice (Spearman rho, P=0.002). We found a strong correlation (Spearman rho, P<0.001) between the V-RQOL and VHI questionnaires. Our study revealed that the V-RQOL and VHI scores in our series of patients following voice restoration in laryngectomees were consistent with that reported in the literature. Only age, radiation, and chemotherapy were seen to influence the voice handicap scores. In addition, both symptom scales had good correlation between them and either one could be used with reliability in laryngectomees with a few modifications.     

Reliability of Speech-Language Pathologist and Otolaryngologist Ratings of Laryngeal Signs of Reflux in an Asymptomatic Population Using the Reflux Finding Score

OBJECTIVE: To determine inter- and intrajudge agreement in rating signs of laryngopharyngeal reflux (LPR) under "ideal" conditions: Experienced coworkers in a practice devoted to voice-disordered patients, raters trained in the items on a standardized scale, raters from both speech-language pathology (SLP) and otolaryngology, and raters of asymptomatic participants. STUDY DESIGN: Prospective study using a scale to rate videolaryngoscopic examinations. METHODS: Two SLPs and two otolaryngologists used the Reflux Finding Scale (RFS) to independently rate videotapes of endoscopic examinations for 30 participants asymptomatic of reflux. RESULTS: Thirteen (43%) were assigned a total score >7, indicative of LPR, by at least one rater. Intraclass correlation coefficients showed a significant lack of agreement in total scores provided by the otolaryngologists and by all raters combined. One otolaryngologist and the two SLPs demonstrated good interrater agreement in total scores. McNamar's statistic and Poisson regression modeling showed differences in rater agreement for many individual items. Repeated ratings of four participants showed no significant differences, indicating good intrarater reliability. CONCLUSIONS: Level of rater agreement regarding the presence and the severity of physical findings attributed to LPR within and between otolaryngologists and SLPs differed. Given the role each profession plays in the diagnosis and treatment of LPR and related voice disturbances, higher levels of interprofessional agreement are desired. Results support the need for greater consensus among professionals regarding the discreet features of physical findings associated with LPR, a fuller understanding of normal variants, and greater emphasis on interrater reliability when rating physical findings.     

Voice Handicap Index in singers

The Voice Handicap Index (VHI) was developed to assess patients' perception of the severity of their voice disorder. The purpose of this study was to determine the degree of handicap expressed by professional and recreational presenters with a voice complaint. Singers (n = 106) and nonsingers (n = 369) with voice symptoms were studied. The results of the VHI for singers indicate that singers score significantly lower (less severe) on the VHI compared to nonsingers. Singers with vocal fold nodules had a lower mean VHI than singers with vocal fold cysts or polyps. Singers who perform classical music had the lowest mean VHI of all types of singers studied. A low VHI in singers may represent a significant handicap and should not be ignored when considering the severity of a singer's voice problem.     

Voice Change in Seasonal Allergic Rhinitis

Voice problems are seldom reported in pollen allergy, although the allergic reaction involves the entire airways. The objective of this study was to investigate voice dysfunction during the pollen season in patients with allergic rhinitis. Thirty patients with verified birch pollen allergy and 30 controls were investigated twice, during the pollen season and outside the pollen season. Both times they scored respiratory and voice symptoms, the latter with the validated questionnaire Voice Handicap Index (VHI), and performed standardized voice recordings. These recordings were analyzed in a controlled manner by a professional voice therapist. During the allergy season, patients reported more respiratory and voice symptoms compared with controls. Those with blinded scored voice dysfunction scored their voice quality during springtime as 31 mm (95% confidence interval [CI] 20-42 mm), compared with 13 mm (95% CI 6-21 mm for participants without voice dysfunction (P<0.01). Furthermore, the group with experienced voice dysfunction scored significantly higher on the VHI in the functional and physical domains and in the total VHI score. Although voice problems during the pollen season are rarely discussed, in allergic rhinitis the larynx may also be involved. These findings support that some patients experience voice change, an experience which can be objectively confirmed.     

Subjective and Objective Evaluation of Voice Quality in Patients With Asthma

OBJECTIVES: To evaluate the voice quality in patients with mild-to-moderate asthma by subjective and objective methods. STUDY DESIGN: Comparative, controlled, cross-sectional study. METHODS: Patients with mild-to-moderate asthma (n=40) and age- and sex-matched healthy controls (n=40) were included. Acoustic analyses were performed by the Multi-Dimensional Voice Program (MDVP; Kay Elemetrics Corporation, Lincoln Park, NJ) and the movements of the vocal cords were examined by videolaryngostroboscopy (VLS). In addition, the duration of illness, maximum phonation time, "s/z" values, and vital capacity were evaluated. Voice Handicap Index (VHI) and GRB scales were used for subjective evaluations. RESULTS: Maximum phonation time values were significantly shorter both in male and female asthma patients compared with controls (P<0.0001). Also, average shimmer values in MDVP were higher for both sexes in the patient group compared with controls (P=0.002 and P=0.04, respectively). There was a significant difference between female patients and sex-matched controls with regard to mean noise-to-harmonic ratio values (P=0.006). Female patients with asthma had higher average jitter values compared with sex-matched controls (P<0.0001). A significant difference was noted between asthma and control groups with regard to GRB scale (P<0.0001, P<0.001, and P<0.0001, respectively). The VHI score was above the normal limit in 16 (40%), and VLS findings were abnormal in 39 (97.5%) asthmatics. CONCLUSION: In asthmatic patients, maximum phonation time, frequency, and amplitude perturbation parameters were impaired, but the vital capacity and the duration of illness did not correlate with these findings.     

Voice Therapy Outcome—A Randomized Clinical Trial Comparing Individual Voice Therapy,Therapy in Group,and Controls Without Therapy

ObjectiveA stumbling-block in voice therapy is how the patient will be able to apply the new voice technique in everyday life. Possibly this generalization process could be facilitated by giving voice therapy in group because of the natural forum for training voice-to-speech early in communication between the patients in a group setting. The aim of the study was to compare treatment results from individual voice therapy and voice therapy in group, at several time points and in comparison to patients with no voice therapy.MethodsA randomized treatment study was performed with 77 consecutive patients diagnosed with a functional voice disorder. Thirty-one patients were randomized to individual and group therapy, respectively, and 15 patients to no therapy. The assessments included standardized voice recording and registration of voice range profile (VRP), answering Voice handicap index (VHI) and visual analogue scales for self-hoarseness and self-vocal fatigue, and perceptual voice evaluation by speech-language pathologist. The assessments were performed before, direct after therapy, and three months later in all groups. The 2 therapy groups were also assessed 12 months after therapy.ResultsAll VHI scores as well as the self-ratings of hoarseness and vocal fatigue, and the perceptual evaluation of voice quality and maximum VRP improved significantly in both therapy groups 3 months after treatment and at 12 months follow-up. There were no significant changes in the control group, with the exception of decreased self-rated hoarseness and increased maximum VRP. Comparisons between treatment groups showed significant larger improvement after group therapy for VHI physical subscale at 12 months, as well as significant lower VHI total score at all measurement sessions and lower subscale scores at 12 months. There were no differences between treatment groups in self-hoarseness or self-vocal fatigue and no difference in perceptual voice quality or VRP. Comparison between controls and treatment groups showed significant larger change in treatment groups from baseline to three months in VHI total and to end of therapy in functional subscale. Treatment groups also showed significant lower scores than controls at each measurement session, for VHI total and physical subscale as well as lower degree of perceptual aberration of voice quality and vocal fatigue, at three months follow-up.ConclusionsThis study shows long-term improvement from behavioral voice therapy, particularly in a group setting. The results indicate the importance of early transfer-to-speech and late posttherapy test to capture whether the goal of voice therapy was fulfilled or not for the patients.     

Applying the Voice Handicap Index (VHI) to Dysphonic and Nondysphonic Hebrew Speakers

OBJECTIVE: To evaluate a translated version of the Voice Handicap Index (VHI) as a diagnostic tool for people with and without a laryngeal pathology, among Hebrew speakers. STUDY DESIGN: Parallel group design. METHODS: The VHI was translated and adapted to Hebrew. The translated version was, then, administered to a group of 182 patients with various laryngeal pathologies and a control group of 171 people with no laryngeal pathology. Based on the participants' responses to the VHI, statistical analyses were, initially, performed to assess validity and reliability, and then to evaluate group differences between the pathological and control groups and among the different pathological groups included in the study. RESULTS: Statistical analyses showed high reliability values of the Hebrew version of the VHI (overall Cronbach's alpha r = 0.976). Participants' scores were not affected by their age (P = 0.156) or gender (P = 0.261). The participants in the control group obtained significantly lower scores on the overall VHI score, as well as on all three subscale scores, in comparison with the pathological group (P < 0.001). In addition, within the pathological group, patients with neurogenic pathologies received higher scores than all other pathological groups, whereas patients with laryngeal inflammation received lower scores than all other pathological groups (P < 0.05). CONCLUSION: The VHI is a powerful tool for quantifying patients' perceptions of their voice handicaps, and it maintained its power across translation. The VHI was shown to be valuable for the assessment of speakers with, as well as without laryngeal pathologies.     

The Voice Handicap of Student-Teachers and Risk Factors Perceived to Have a Negative Influence on the Voice

A cross-sectional questionnaire survey was performed. The objectives of the study were to assess the psychosocial impact of current voice complaints as perceived by student-teachers with voice complaints in comparison with student-teachers without voice complaints, and to observe the pattern of risk factors in relation to their voice handicap. Subjects in the general population without a voice-demanding profession were selected as a reference group for limited comparison with the total group of student-teachers (future professional voice users). The respondents to the questionnaires were anonymous. Among the student-teachers, 17.2% reported current voice complaints in comparison with 9.7% of the reference group, and the odds ratio was 1.94, which showed the relative risk. Student-teachers had significantly greater total Voice Handicap Index (VHI) scores than the reference group (P = 0.034). The VHI subscale scores were not significantly different (P > 0.05). Student-teachers who reported current voice complaints had a significantly higher total VHI and subscale scores than student teachers without voice complaints (P < 0.001). Of the student-teachers without voice complaints, 17.0% had VHI scores greater than the 75th percentile. These persons may be neglecting their voice handicap and probably represent the false-negative cases in the estimation of voice complaints. Logistic regression analysis of each of the given risk factors with the VHI as the independent variable showed that the perceived negative influence of the given risk factors on their voices was significantly greater with increasing VHI scores across the VHI range. A significant correlation was observed between the number of perceived risk factors and increasing VHI scores across the VHI range. An increased awareness of risk factors in relation to their voice handicap would serve to motivate student-teachers to change factors that contributed to their voice problem. Attention to all risk factors, which the subjects perceive to be a risk, would aid in effective management of their voice handicap.     

Vocal Improvement After Voice Therapy in Unilateral Vocal Fold Paralysis

Unilateral vocal fold paralysis (UVFP) is associated with changes in acoustic and aerodynamic voice measurements and can have a significant impact on a patient's quality of life. Few objective data regarding the efficacy of voice therapy for UVFP exist. The aim of this study was to retrospectively analyze voice modifications in a group of patients with UVFP before and after voice therapy. Forty patients with UVFP of different etiology were included in the study. Each subject had voice therapy with an experienced speech/language pathologist twice a week; the mean number of sessions was 12.6. A multidimensional assessment protocol was used; it included videoendoscopy, the maximum phonation time (MPT), the GIRBAS scale, spectrograms and a perturbation analysis, and the Voice Handicap Index (VHI). Pre- and posttreatment data were compared by means of the Wilcoxon and Student's t tests. A complete glottal closure was seen in 8 patients before voice therapy and in 14 afterward. Mean MPT increased significantly. In the perceptual assessment, the difference was significant for five out of six parameters. A significant improvement was found on spectrographic analysis; as for perturbation analysis, the differences in jitter, shimmer, and noise-to-harmonic ratio values were significant. VHI values showed a clear and significant improvement. A significant improvement of voice quality and quality of life after voice therapy is an often reached and reasonable goal in patients with UVFP.     

Japanese version of voice handicap index for subjective evaluation of voice disorder

Recently, the Voice Handicap Index (VHI), developed in the United States, has been highlighted as a means to assess a patient's perceptions of the severity of his or her voice disorder. The VHI is based on a self-administered questionnaire that quantifies the degree of a patient's disability related to his/her voice disorder. The questionnaire was translated into Japanese and applied to Japanese patients with various kinds of disordered voice or dysphonia. The results were analyzed and the usefulness discussed. In this study, 546 patients (281 males and 265 females) were included. Mean VHI scores were 36.2/120 in males and 44.1/120 in females. In the male patients, VHI scores were the highest among teens. However, VHI scores did not vary with age in the female patients. Patients with vocal fold paralysis, functional dysphonia, psychological dysphonia, and spasmodic dysphonia showed relatively high VHI scores, whereas those with laryngeal granuloma and laryngopharyngeal reflux disease showed low scores. In most diseases, functional and physiological scores were higher than emotional scores. In any treated patients, those with vocal nodule, vocal polyp, polypoid vocal fold, and recurrent laryngeal nerve paralysis, VHI scores decreased after therapeutic intervention. These findings suggest that the Japanese VHI is a useful tool for monitoring a patient's psychological status, choosing appropriate treatment, and assessing the therapeutic outcome.     

The Voice Handicap Index: Correlation Between Subjective Patient Response and Quantitative Assessment of Voice

The aim of this prospective study is to elucidate the relationship between the Voice Handicap Index (VHI) and several voice laboratory measurements in the network of the multidimensional voice assessment. Fifty-eight patients were included. Each patient replies to the questionnaire and performs a voice assessment during the same time. The following parameters were measured: minimum frequency, maximum frequency, range, minimum intensity, subglottic pressure, mean flow, maximum phonation time, jitter, and dysphonia severity index. Regarding the relationship with the scores of the VHI, poor correlations with the minimal frequency for all the scores except the emotional one (total and subscales) and with the range for only the physical one are found. Seventeen questions correlate with the voice laboratory measurements we performed, with a decreased distribution between physical, functional, and emotional subscales. We observe that acoustic parameter is correlated with the emotional subscale, the parameters of the profile range are more often involved in the emotional subscale, as is the minimal frequency, but never with the physical subscale, and all the subscales are interesting despite the smaller number of differences with the emotional one. The VHI and the laboratory measurements give independent informations in practice.     

Acid reflux and hoarseness

The aim of this study was to investigate the prevalence of acid reflux in patients complaining of hoarseness where no organic disease or functional dysphonia could be found. We also aimed to determine whether anti-reflux treatment improved their symptoms. Patients were not selected on the basis of symptoms of reflux. Fifty patients with hoarseness took part in a prospective study that sought to establish objectively whether acid reflux was present. All patients were given a 6-week course of ranitidine and Gaviscon. Patients were asked to score their voice quality before and after treatment. Although 72% of patients complained of heartburn more than once a week, only 40% proved to have acid reflux. Although subjective improvement after anti-reflux treatment was found in a larger proportion of those with than without proven reflux, the conclusions that can be drawn are limited as there were no satisfactory objective measurements of voice or controls.     

Assessing outcomes for dysphonic patients

This study was designed to evaluate a disease-specific outcome measure for patients with selected voice disorders and to relate this instrument to a standardized quality of life measurement. In addition, the study attempts to document the degree of handicap for dysphonia patients globally, between different vocal pathologies, and in comparison to other chronic diseases. In this prospective, observational study, 260 adult patients evaluated for alterations of voice completed a general quality of life measure (the Medical Outcomes Trust Short Form 36-Item[SF-36]) and a voice-specific instrument (Voice Handicap Index [VHI]) pretreatment.

The highest correlation was between the social functioning score of the SF-36and the total score of the VHI and the physical, emotional, and functional subscales (p < 0.001) of the VHI. Significant correlation was also obtained for the SF-36 domains mental health (p < 0.01), general health (p < 0.01), and role functioning emotional (p < 0.017) with the three VHI domains and the total VHI score. Patients had significantly lower scores than the general U.S. population in five of the eight domains of SF-36. Patients with vocal fold paralysis had the highest level of pretreatment disability as measured on both the VHI and SF-36 among voice patients. The patients with dysphonia had a lower level of physical functioning than the patients with chronic sinusitis (p < 0.01), reflecting a greater handicap. In addition, the dysphonia group had lower levels of social functioning than the angina (p < 0.01) and sciatica (p < 0.01) groups and a lower score for mental health than the angina group (p < 0.01).

The SF-36 correlates with the VHI in the domains of social functioning,mental health, and role functioning emotional. The baseline handicap for voice disorders represents a significant disability even in comparison to conditions such as angina pectoris, sciatica, and chronic sinusitis.     

Patient Versus Partner Perception of Voice Handicap

The primary purpose of this study was to compare patient's and communication partner's perceptions of handicap secondary to dysphonia. A secondary purpose was to compare patient health-related quality of life (HRQOL) to that of speakers with normal voice. Participants were 20 adults (mean age=69.15 years) with dysphonia and their communication partners. Patients completed the Voice Handicap Index (VHI), a questionnaire of self-perceived voice handicap, and the Short-Form 36 (SF-36), a general health questionnaire. Partners completed the Voice Handicap Index-Partner (VHI-P), a questionnaire derived from the VHI for this pilot study, to gauge partner perception of voice handicap. Patients in this study viewed themselves as only moderately handicapped by their dysphonia and their partners were in close agreement. Patients and their partners were also in close agreement on each of three VHI subscales (physical, functional, and emotional), and in all cases the physical domain was perceived by both patients and their partners to be most handicapped. Patients had lower SF-36 mean scores than those of persons with normal voice from the general U.S. population on scales assessing physical functioning, physical role, general health, vitality, social functioning, emotional role, and mental health. The results of this study are consistent with previous studies examining patient-partner agreement, which consider proxy ratings to be a useful alternative or collaborative source of patient's self-perception. Further research regarding the reliability of patient and partner agreement is necessary to most effectively assess and manage patients with dysphonia.