Voice handicap index change following treatment of voice disorders

Outcome measurements of voice disorders is an important new area for both the evaluation of voice-disordered patients and evaluation of treatment efficacy. The Voice Handicap Index (VHI) measures the patient's perception of the impact of his or her voice-disorder. The VHI was used in this study to measure the changes of the patient's perception following treatment for four different voice disorders. The VHI showed a significant change following treatment for unilateral vocal fold paralysis, vocal cyst/polyp, and muscle tension dysphonia. Results of this paper indicate that the VHI is a useful instrument to monitor the treatment efficacy for voice disorders.     

Etiology, pathophysiology, treatment choices, and voice results for unilateral adductor vocal fold paralysis: A 3-year retrospective

Unilateral vocal fold paralysis is now considered a common disorder seen in the practice of otolaryngology and voice pathology. Concern first is for the accurate diagnosis of the associated etiology in an efficient and thorough fashion. When etiology has been determined the focus of treatment becomes the management of the presenting symptoms, which typically include dysphonia and dysphagia. A retrospective study was conducted reviewing the records of 117 patients with unilateral adductor vocal fold paralysis who presented to a large otolaryngology practice and clinical voice lab from 1995 to 1998. Demographic data reveal most patients to range in age from 16 to 91 with a dominant clustering for ages 50 to 70. Gender distribution reveals males slightly exceed females in this sample. Data regarding etiology type are collected in great detail, revealing that disease and surgery involving the chest contribute the greatest to the overall number in this study and that anterior approach to cervical spine surgery contributes as much as thyroid surgery. General outcomes of the patients are reviewed. A small group (n = 25) of patients who had pretreatment and posttreatment data available revealed statistically significant differences between voice outcomes for patients who were treated with medialization and for those treated with therapy. Patients receiving therapy had less severe symptoms pretreatment, while greater gains pretreatment to posttreatment were shown for those who had surgical medialization.     

Mechanical and dynamic aspects of voice production as related to voice therapy and phonosurgery

Laryngeal framework surgery can change the position and tensionof the vocal folds safely without direct surgical intervention in the vocal fold proper. Some 23 years of experience with phonosurgery have proved its usefulness in treating dysphonia related to unilateral vocal fold paralysis, vocal fold atrophy, and pitch-related dysphonias. Meanwhile, much information about the mechanism of voice production has been obtained through intraoperative findings of voice and fiberscopic examination of the larynx . Based on such knowledge together with information obtained through model experiments, the human vocal organ was reconsidered mainly from the mechanical view point, and the roles of voice therapy and singing pedagogy were discussed in relation to phonosurgery. The vocal organ may not be an ideal musical organ and is rather vulnerable, but its potential is enormous.     

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.     

Voice-Related Quality of Life (V-RQOL) following type I thyroplasty for unilateral vocal fold paralysis

Unilateral vocal fold paralysis is a common clinical problem which frequently causes severe dysphonia. Various treatment options exist for this condition, with the type I thyroplasty being one of the more commonly performed surgical procedures for vocal rehabilitation. The Voice-Related Quality of Life (V-RQOL) Measure is a validated outcomes instrument for voice disorders. This study measured the V-RQOL of patients with unilateral vocal fold paralysis who had undergone a type I thyroplasty and compared these scores to those of patients with untreated and uncompensated unilateral vocal fold paralysis and to normals. Treated patients had significantly higher domain and overall V-RQOL scores than untreated patients, but also scored lower than normals. These differences were true across gender and age. Patients who were more distant from surgery had lower V-RQOL scores than those who had more recently been treated. It is concluded that type I thyroplasty leads to a significantly higher V-RQOL for patients with unilateral vocal fold paralysis. This study also demonstrates further the utility of patient-oriented measures of treatment outcome.     

Vocal fold augmentation with injectable calcium hydroxylapatite: short-term results.

Symptoms of unilateral vocal fold paralysis are improved significantly by augmenting the paralyzed vocal fold via vocal fold injection. In this trial, augmentation with a new calcium hydroxylapatite implant was evaluated. In addition, two different phonosurgical injection techniques were used, and these procedures were compared for accuracy and reliability. A total of 11 terminal patients with unilateral vocal fold paralysis underwent vocal fold injection with calcium hydroxylapatite. Efficacy of the implant was evaluated by comparing results from the Voice Handicap Index (VHI) and mean airflow measurements before and 6 months after injection. Surgeon evaluations determined the comparative benefits of either endoscopic direct vocal fold injection or percutaneous vocal fold injection. Six-month data were obtained for a cohort of five patients. VHI scores improved for all five patients available for full evaluation and four of the five achieved improvements in mean airflow rates. Of the remaining patients, one later had a medialization laryngoplasty, two died from their terminal diseases before the 6-month follow-up, and two of the remaining three reported satisfaction with the results via telephone follow-up. Vocal fold injection via endoscopic, direct laryngoscopy was found to be a more reliable procedure for vocal fold injection than percutaneous injection. Slight overinjection (10% to 15%) was found to provide optimum results. Vocal fold injection of calcium hydroxylapatite for unilateral vocal fold paralysis improved voice quality and reduced mean airflow rates in this patient group with short-term results. Long-term studies are needed to confirm the durability of these findings.     

Poor Voice Quality in Future Elite Vocal Performers and Professional Voice Users

The voice quality of 86 occupational voice users, i.e., students of a high school for audiovisual communication, was assessed by means of a multidimensional test battery containing: the GRBAS scale, videolaryngostroboscopy, maximum phonation time, jitter, lowest intensity, highest frequency, dysphonia severity index (DSI), and voice handicap index (VHI). In a questionnaire on daily habits the prevalence of smoking, eating habits, and vocal abuse were recorded. A comparison of the voice characteristics of the future occupational voice users with a control group revealed significant differences. The results of the VHI and the DSI of these students revealed significantly worse scores than the score of a control group characterized by no vocal complaints. Moreover, the questionnaire on daily habits showed that the future elite vocal performers and professional voice users take less precautions for the care of their voices. These findings support the importance of a good balanced vocal coaching.     

Psychogenic voice disorders and traumatic stress experience: a discussion paper with two case reports

Psychogenic dysphonia refers to loss of voice where there is insufficient structural or neurological pathology to account for the nature and severity of the dysphonia, and where loss of volitional control over phonation seems to be related to psychological processes such as anxiety, depression, conversion reaction, or personality disorder. Such dysphonias may often develop post-viral infection with laryngitis, and generally in close proximity to emotionally or psychologically taxing experiences, where "conflict over speaking out" is an issue. In more rare instances, severe and persistent psychogenic dysphonia may develop under innocuous or unrelated circumstances, but over time, it may be traced back to traumatic stress experiences that occurred many months or years prior to the onset of the voice disorder. In such cases, the qualitative nature of the traumatic experience may be reflected in the way the psychogenic voice disorder presents. The possible relationship between psychogenic dysphonia and earlier traumatic stress experience is discussed, and the reportedly low prevalence of conversion reaction (4% to 5%) as the basis for psychogenic dysphonia is challenged. Two cases are presented to illustrate the issues raised: the first, a young woman who was sexually assaulted and chose to "keep her secret," and the second, a 52-year-old woman who developed a psychogenic dysphonia following a second, modified thyroplasty for a unilateral vocal fold paresis.     

Voice and Laryngeal Configuration of Men With Unilateral Vocal Fold Paralysis Before and After Medialization

Aim

To describe the laryngeal configuration and the voice of male patients diagnosed with unilateral vocal fold paralysis (UVFP) before and after medialization.

Methods

A retrospective study involving the collection of data from medical records of 142 patients diagnosed with UVFP from January 2003 to April 2009, submitted to auditory-perceptual assessment of voices and visual perception of laryngeal images before and after medialization.

Results

The study included data from 24 male patients, with an average of 60.7 years, who underwent three surgical medialization techniques (injection of hyaluronic acid, type I thyroplasty, and injection of Teflon). Before treatment, the position of the paralyzed vocal fold was seen to have a significant influence to the passing of the healthy vocal fold beyond the midline and on the overall degree of dysphonia. After treatment, the complete glottic closure; the free margin of the linear vocal fold; paralyzed vocal fold in the median position, reduction of hoarseness, roughness and breathiness (more frequently mild), and asthenia (more frequently normal and mild); tension and instability (more frequency normal); and a decrease in the overall degree of dysphonia were found to be significant.

Conclusion

The position of the paralyzed vocal fold influences the position of the healthy vocal fold in relation to the midline and the overall degree of dysphonia. All three treatments improved the glottic configuration and the voice of patients with UVFP.     

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.     

Prevalence and Relative Risk of Dysphonia in Rheumatoid Arthritis

SUMMARY: Laryngeal involvement in rheumatoid arthritis is not uncommon and may include cricoarytenoid arthritis or vocal fold lesions such as vocal fold rheumatoid nodules or bamboo nodes. Dysphonia or voicing problems can be the result of such laryngeal involvement. This cohort study investigates the prevalence and the relative risk of dysphonia when suffering from rheumatoid arthritis compared to that of healthy subjects. One hundred and sixty-six subjects with rheumatic arthritis and 148 healthy control subjects completed two quality-of-life questionnaires: the Voice Handicap Index and a three-item outcome scale. Both instruments measure the quality of the voice itself and the extent of impairment resulting from dysphonia as experienced by the patient in social and occupational settings. Patients proved to have statistically significant higher prevalence and relative risk of dysphonia. Depending on the questionnaire being used, prevalence data of dysphonia in patients varied between 12% and 27%, whereas the healthy subjects showed prevalence data varying from about 3% to 8%. A patient's relative risk varied from about 3 to 4 when compared to healthy subjects. Patients suffering from rheumatoid arthritis have a clearly higher risk of dysphonia compared to healthy subjects.     

Functional reinnervation of vocal folds after selective laryngeal adductor denervation-reinnervation surgery for spasmodic dysphonia

Selective laryngeal adductor denervation-reinnervation surgery (SLAD-R) offers a viable surgical alternative for patients with adductor spasmodic dysphonia refractory to botulinum toxin injections. SLAD-R selectively denervates the symptomatic thyroarytenoid muscle by dividing the distal adductor branch of the recurrent laryngeal nerve (RLN), and preventing reinnervation, by the proximal RLN and maintaining vocal fold bulk and tone by reinnervating the distal RLN with the ansa cervicalis. We present a patient who had previously undergone successful SLAD-R but presented 10 years postoperatively with a new regional dystonia involving his strap muscles translocated to his reinnervated larynx by his previous ansa-RLN neurorraphy. The patient's symptomatic vocal fold adduction resolved completely on division of the ansa-RLN neurorraphy confirming successful selective functional reinnervation of vocal fold adductors by the ansa cervicalis.     

The Frequency of Perceived Stress, Anxiety, and Depression in Patients with Common Pathologies Affecting Voice

The study's objectives were to investigate (1) the frequency of perceived stress, anxiety, and depression for patients with common voice disorders, (2) the distribution of these variables by diagnosis, and (3) the distribution of the variables by gender. Retrospective data were derived from self-report questionnaires assessing recent stress (Perceived Stress Scale-10), anxiety, and depression (Hospital Anxiety and Depression Scale) in a cohort of new patients presenting to a voice clinic. Data are presented on 160 patients with muscle tension dysphonia (MTD), benign vocal fold lesions, paradoxical vocal fold movement disorder (PVFMD), or glottal insufficiency. Pooled data indicated that average stress, anxiety, and depression scores were similar to those found for the healthy population. However, 25.0%, 36.9%, and 31.2% of patients showed elevated stress, anxiety, and depression scores, respectively, compared to norms. Patients with PVFMD had the most frequent occurrence-and patients with glottal insufficiency had the least frequent occurrence of elevated stress, anxiety, and depression. Stress and depression were more common with MTD than with lesions, whereas reverse results were obtained for anxiety. More females than males had elevated stress, anxiety, and depression scores. The data are consistent with suggestions that stress, anxiety, and depression may be common among some patients with PVFMD, MTD, and vocal fold lesions and more common for women than men. However, individual variability in the data set was large. Further studies should evaluate the specific role of these conditions for selected categories of voice disorders in susceptible individuals.     

The Relationship Between Perceptual Evaluation and Objective Multiparametric Evaluation of Dysphonia Severity

SUMMARY: The purpose of this study was to investigate the usefulness of the Dysphonia Severity Index (DSI) as an objective multiparametric measurement in assessing dysphonia. The DSI was compared with the score on Grade of the GRBAS scale. Investigated was also whether the DSI is related to severity of dysphonia, which was represented by different diagnosis groups. Furthermore, it was investigated whether the DSI can differentiate between a group of patients and a control group. A total of 294 patients with different voice pathologies were included. A control group consisted of 118 volunteers without any voice complaints. The voices of all participants were perceptually evaluated on Grade, and the DSI was measured. The groups of patients with voice complaints have a lower DSI and higher scores on Grade than the control group. The DSI was significantly lower when the score on Grade was higher. The DSI discriminates between patients with nonorganic voice disorders, vocal fold mass lesions, and vocal fold paresis/paralysis. To determine whether the DSI discriminates between patients and controls, the sensitivity and specificity for different DSI cutoff points were calculated. With a DSI cutoff of 3.0, maximum sensitivity (0.72) and specificity (0.75) were found. We conclude that the DSI is a useful instrument to objectively measure the severity of dysphonia.     

Nonlinear dynamics of the voice: Signal analysis and biomechanical modeling

Irregularities in voiced speech are often observed as a consequence of vocal fold lesions, paralyses, and other pathological conditions. Many of these instabilities are related to the intrinsic nonlinearities in the vibrations of the vocal folds. In this paper, bifurcations in voice signals are analyzed using narrow-band spectrograms. We study sustained phonation of patients with laryngeal paralysis and data from an excised larynx experiment. These spectrograms are compared with computer simulations of an asymmetric 2-mass model of the vocal folds. (c) 1995 American Institute of Physics.     

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.     

Acoustic analysis of voice in multiple sclerosis patients

The objective is to investigate the presence of dysphonic symptoms in multiple sclerosis (MS) patients and to compare quantitative acoustic parameters in multiple sclerosis patients and normal individuals. The method of study was an 8-month controlled cross-sectional that was carried out with 106 individuals (30 MS, 76 controls). Both groups included males and females from 20 to 55 years. Exclusion criteria were prior vocal disorder, laryngeal microsurgery, recent endotracheal intubation, tumors, laryngeal, lung or mediastinal metastases, respiratory disease, and other associated neurological diagnoses. For dysphonic symptoms (qualitative variables), associations were assessed using Mantel-Haenszel's chi2 test, with Yates correction or the Fisher exact test when necessary. Statistical significance was set at p< or =0.05. Dysphonia was observed in 70% of MS individuals versus 33% of controls (p=0.01). Association was found between MS and dysphonia (OR: 2.2, CI 95%: 1.13-4.25). Fundamental frequency was higher among MS patients (p=0.01). Fundamental frequency deviation was significantly higher in MS women (but not men) than controls (p=0.00). Jitter was higher in MS men than in all other groups (p=0.00). Results suggest that evaluation and treatment of MS patients should be revised, evaluating voice alterations in relation to other signs. MS seems to intensify gender effect on fundamental frequency deviation, noise, and jitter, with MS women presenting fewer voice variations than men.     

Acoustic analysis of the speaking voice after thyroidectomy

Voices of 47 female patients were analyzed before and after thyroidectomy, with preservation of the recurrent and superior laryngeal nerves and normal vocal fold motility during the observation period. A mean decrease of the speaking fundamental frequency (SFF) of 12 Hz was found on day 4; in 8 patients the postoperative vocal pitch was more than 2 semitones lower. The distance between the highest and lowest F₀ during speaking was diminished (speech was more monotone) and the vocal jitter was elevated. In the frequency spectrum, there was a diminished prominence of the harmonics. The other spectral parameters (as the slope of the spectrum and the H1/H2 ratio) were unchanged. All changes had disappeared the fifteenth day, except for a lower SFF (>2 semitones) in 2 cases. It is concluded that after normal dissection of the laryngeal nerves, and in the absence of vocal fold paresis, other reasons for voice changes immediately after thyroidectomy remain: alterations in the neck muscles, in the laryngeal mucosa, and in the patient's general condition. Although the effects seem limited and of short duration, knowledge of them is helpful when informing the patient before thyroid surgery.     

Combined-modality treatment of adductor spasmodic dysphonia with botulinum toxin and voice therapy

A combined-modality treatment program consisting of botulinum toxin injection (Botox) and voice therapy was used to treat 17 subjects diagnosed with adductor spasmodic dysphonia (ADD SD). Ten subjects with ADD SD served as the control and were given Botox only. Voice therapy after Botox injection was directed toward reducing the hyperfunctional vocal behaviors, primarily glottal overpressure at voice onset and anterior-posterior squeezing. The results indicated that subjects who underwent combined-modality treatment maintained significantly higher mean airflow rates for significantly longer periods. Moreover, there was a carryover effect in these patients when they received Botox only. Adductor spasmodic dysphonia is treated most effectively when intrinsic laryngeal muscle spasms are reduced or eliminated by Botox injection and extrinsic hyperfunctional vocal behaviors are treated with voice therapy