Injection laryngoplasty in the outpatient clinic under local anaesthetic: a case series of sixty-eight patients.

OBJECTIVES: We aimed to assess self-report and perceptual voice outcomes in patients undergoing local anaesthetic injection laryngoplasty in our outpatient clinic. DESIGN: Prospective case series. SETTING: Department of Otolaryngology-Head and Neck Surgery, Freeman Hospital, Newcastle-upon-Tyne, UK. PARTICIPANTS: Sixty-eight patients underwent local anaesthetic injection laryngoplasty in the outpatient clinic over the 2-year study period. MAIN OUTCOME MEASURE: Voice Performance Questionnaire (patient-rated), and perceptual voice analysis (observer-rated) Grade, Roughness, Breathiness, Aesthenia and Strain scores were recorded before and 2 weeks after injection laryngoplasty. RESULTS: Fifty-seven patients had sufficient pre- and post-procedure data to be included in the analysis. These included 32 men and 25 women, age range 26-97 years. Of the remaining patients, they were excluded due to failed procedure (n = 3), too unwell to proceed (n = 1), died before follow-up was complete (n = 3) and incomplete data (n = 4). The median Voice Performance Questionnaire score improved from 42 to 21; (P < 0.0001). Significant improvements were seen in all parameters of Grade, Roughness, Breathiness, Aesthenia, Strain. CONCLUSION: Injection laryngoplasty under local anaesthetic in the outpatient clinic generates improvements in subjective and perceptual voice outcomes similar to those obtained in the operating room under general anaesthetic or sedation. Complication rates between these procedures were also comparable. Injection laryngoplasty under local anaesthetic is timely, cost-effective and obviates need for general anaesthesia in patients, many of whom have comorbidities and diminished life expectancy.

Head and neck cancer and dysphagia; caring for carers.

OBJECTIVES: A diagnosis of head and neck cancer (HNC) is a profound event for patients and family members who play a crucial role in their care. Eating and drinking difficulties affect patients' quality of life (QOL), but the impact on the carers' QOL has not been explored. This preliminary mixed method study reports on carer QOL over time and investigates the relationship with dysphagia. METHODS: Two hundred and eight HNC patients referred for (chemo)radiotherapy were asked to identify a carer and complete a health-related QOL and a swallowing QOL questionnaire at pre-treatment, 3 and 12 months post-treatment. Carers were given the Caregiver QOL-Cancer (CQOL-C) questionnaire at the same time points. A purposive sample of patient and carer dyads was observed over mealtimes and interviewed. RESULTS: Seventy per cent of carers returned a questionnaire at least once. There was no change in CQOL-C scores between pre-treatment and 3 months, but a significant improvement was found between 3 and 12 months post-treatment (p = 0.012). Patient-reported outcomes accounted for 52% of variance in carer QOL measurements (R(2) = 0.52, p < 0.001). Four themes emerged from the qualitative data food provision, monitoring, motivation and changes to lifestyle. CONCLUSIONS: Findings suggest a relationship between carer and patient QOL. Elsewhere, these two characteristics have been associated such that the greater the patients' physical care needs, the poorer the carers' and patients' QOL. Living with someone with dysphagia not only involves managing the physical swallowing difficulties but is also likely to impact on social activities such as participation in shared meals, leading to permanent lifestyle changes.

Can we perceptually rate alaryngeal voice? Developing the Sunderland Tracheoesophageal Voice Perceptual Scale.

OBJECTIVE: To investigate the inter and intra reliability of raters (in relation to both profession and expertise) when judging two alaryngeal voice parameters: 'Overall Grade' and 'Neoglottal Tonicity'. Reliable perceptual assessment is essential for surgical and therapeutic outcome measurement but has been minimally researched to date. DESIGN: Test of inter and intra rater agreement from audio recordings of 55 tracheoesophageal speakers. SETTING: Cancer Unit. PARTICIPANTS: Twelve speech and language therapists and ten Ear, Nose and Throat surgeons. MAIN OUTCOME MEASURES: Perceptual voice parameters of 'Overall Grade' rated with a 0-3 equally appearing interval scale and 'Neoglottal Tonicity' with an 11-point bipolar semantic scale. RESULTS: All raters achieved 'good' agreement for 'Overall Grade' with mean weighted kappa coefficients of 0.78 for intra and 0.70 for inter-rater agreement. All raters achieved 'good' intra-rater agreement for 'Neoglottal Tonicity' (0.64) but inter-rater agreement was only 'moderate' (0.40). However, the expert speech and language therapists sub-group attained 'good' inter-rater agreement with this parameter (0.63). The effect of 'Neoglottal Tonicity' on 'Overall Grade' was examined utilising only expert speech and language therapists data. Linear regression analysis resulted in an r-squared coefficient of 0.67. Analysis of the perceptual impression of hypotonicity and hypertonicity in relation to mean 'Overall Grade' score demonstrated neither tone was linked to a more favourable grade (P = 0.42). CONCLUSIONS: Expert speech and language therapist raters may be the optimal judges for tracheoesophageal voice assessment. Tonicity appears to be a good predictor of 'Overall Grade'. These scales have clinical applicability to investigate techniques that facilitate optotonic neoglottal voice quality.

Speech and voice outcomes in oropharyngeal cancer and evaluation of the University of Washington Quality of Life speech domain.

BACKGROUND: Radical treatment of oropharyngeal cancer can have significant impact on speech & voice outcomes. AIMS: (i) To assess the extent of speech & voice handicap in disease-free survivors of oropharyngeal squamous cell cancer. (ii) To assess the validity of the speech domain of UWQOL as a screening tool. (iii) To identify clinical characteristics associated with worse speech/voice outcome. DESIGN: Cross-sectional survey. SETTING: University Hospital Aintree, a university teaching hospital and tertiary referral centre. PATIENTS: All who were treated for oropharyngeal cancer between 1 January 1999 and 31 May 2005, were alive, disease free and willing to participate. INTERVENTIONS: Three patient-based questionnaires: University of Washington Quality of Life (UWQOL), voice handicap index (VHI) and voice related quality of life (VRQOL). Three expert-based assessments: GRBAS rating, speech intelligibility and dysarthria rating. RESULTS: Sixty-six per cent of patients participated. Median VHI score (29) & VRQOL score (15) imply mild to moderate voice impairment. 20% of patients had severe handicap (VHI score >60). Forty-eight per cent had normal voice ratings. Speech was normal in 26%, mildly impaired in 62% and significantly impaired in 12% patients (UWQOL). Correlation between UW-QOL speech domain with speech intelligibility rating was 0.52 (P < 0.001). There were clear demarcations between UW-QOL scores of 30, 70 and 100 on the voice questionnaires. Adverse speech and voice function were associated with tumour stage, radiotherapy (RT) & free-flap surgery. CONCLUSIONS: Voice & speech impairment is prevalent in >70% of oropharyngeal cancer patients. There is moderate correlation between UWQOL speech domain and speech intelligibility assessment & voice tools making it a quick and easy screening instrument. The main clinical correlates associated with adverse patient and observer rated speech and voice outcomes were tumour stage, RT and free-flap reconstruction.

Swallowing beyond six years post (chemo)radiotherapy for head and neck cancer; a cohort study.

OBJECTIVE: The objective of this prospective study is to report on long-term swallowing outcomes in a group of head and neck cancer patients following (chemo) radiotherapy treatment, assess for changes over time and identify any predictor variables of outcome. MATERIALS AND METHODS: 42 survivors were assessed on four swallowing measures and followed up from pre-treatment to six years post 3D (chemo) radiotherapy. Measures included a swallowing specific QOL questionnaire, penetration-aspiration scale, dietary restrictions and a timed water swallow test. RESULTS: At six years, 71% reported swallowing difficulties on the questionnaire. One fifth of patients had aspiration, with a raised risk of chest infection. Seven percent required a laryngectomy for a dysfunctional larynx. Despite this, half the group reported having a normal diet. There was variation in the pattern of change between one and six years. A significant deterioration was only observed in the timed water swallow test (p < 0.0001). Larger radiotherapy volume predicted this outcome. None of the variables tested predicted outcome for the other three swallow measures. CONCLUSION: Patients continue to report swallowing difficulties at six years, with a proportion having persistent aspiration. Further work on identifying the risk factors associated with aspiration tolerance, aspiration pneumonia, prevention and management is warranted. Long-term dysphagia remains a significant and serious concern following (chemo) radiotherapy for HNC and swallowing outcomes should continue to be monitored over time.

The clinical features of functional dysphonia.

OBJECTIVE: This report aims to study the prevalence of features of laryngeal muscle tension in a population of patients with functional dysphonia (FD) and nondysphonic control subjects. STUDY DESIGN: Prospective control-blinded, cross-sectional study. METHODS: We reported on a prospective control-blinded, cross-sectional study of the prevalence of the six features described by Van Lawrence and the six features incorporated in the Morrison-Rammage classification. A senior laryngologist and senior speech pathologist independently rated sound-free, random-sequence video laryngoscopies of 51 patients with FD and 52 nondysphonic control subjects. Assessments were made of the presence or absence of the 12 laryngoscopic features of laryngeal dysfunction, and an overall rating made of the vocal technique as "normal" or "abnormal." RESULTS: More than 60% of the control population demonstrated 1 or more of the 12 features of hyperfunction. There was no significant difference in the prevalence of the six Van Lawrence features, the six Morrison-Rammage features, or the total number of abnormal features between patients with FD and control subjects. On overall assessment, both assessors noted a high prevalence (50% and 36%, respectively) of abnormal vocal technique in the control population. There was no statistical difference in the total number of abnormal features observed between patients with FD and control subjects. Positive predictive value calculations showed that the presence of a clinical feature, at best, presented a 75% chance of correctly identifying a patient with FD and, at worst, a 50% chance. CONCLUSION: The laryngoscopy features commonly associated with FD are frequently prevalent in the nondysphonic population and fail to distinguish patients with FD from normal subjects.

Tracheo-oesophageal puncture by retrograde passage of a gastroscope via mini-laparotomy and gastrotomy.

Secondary tracheo-oesophageal puncture is frequently used for voice restoration after laryngectomy. A method utilizing a flexible gastroscope passed via a mini-laparotomy and gastrotomy in a retrograde manner is described in a patient where extensive pharyngeal resection made it impossible to cannulate the upper aerodigestive tract. The patient suffered minimal morbidity and produced reasonable speech.

Thyroplasty for functional rehabilitation of the incompetent larynx.

Type I thyroplasty was performed in 12 patients with unilateral paralysis of the vocal fold. Subjective as well as objective improvement in vocal performance was reported in 11 patients. Aspiration was improved in six out of eight patients. Effort closure was evaluated by the ability of the patient to voluntarily raise his intra-abdominal pressure during Valsalva's manoeuvre. A comparison of pre- and post-thyroplasty measures, showed a statistically significant improvement in the efficacy of effort glottic closure (p < 0.05), indicating a better physical performance. We had one case of wound sepsis and another case of implant extrusion.

A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia.

Forty-five patients diagnosed as having nonorganic dysphonia were assigned in rotation to 1 of 3 groups. Patients in group 1 received no treatment and acted as a control group. Patients in groups 2 and 3 received a program of indirect therapy and direct with indirect therapy, respectively. A range of qualitative and quantitative measures were carried out on all patients before and after treatment to evaluate change in voice quality over time. Results revealed a significant difference between the 3 treatment groups in the amount of change for the voice severity, electrolaryngograph, and shimmer measurements and on ratings provided by a patient questionnaire (P<0.05). However, other measures failed to show significant differences between the 3 groups. Most of the patients (86%) in group 1 showed no significant change on any of the measures. Some patients in treatment group 2 (46%) showed significant change in voice quality. Fourteen out of 15 patients (93%) in treatment group showed significant changes in voice quality.

Formal perceptual evaluation of voice quality in the United Kingdom.

This document is a position statement on the formal perceptual evaluation of voice quality in the United Kingdom (UK). It addresses a number of clinical issues pertaining to the complexity of voice quality analysis. There is also a brief description of the three formal perceptual protocols most commonly used in the UK: The Vocal Profile Analysis (VPA), GRBAS and The Buffalo III Voice Profile. Potential clinical problems with perceptual voice quality evaluation are highlighted. Problems associated with the lack of defined terminology, limitless variety of voice quality, general lack of reliability data and difficulties in determining specificity and sensitivity are discussed. A practical guide for selecting an evaluation scheme is described. The conclusion is that the GRBAS scheme should be recommended as the absolute minimum standard for practising UK voice clinicians. However, there is a clear need to develop a more satisfactory perceptual rating scheme that is clinically realistic, theoretically sound, internationally acceptable and has proven reliability.

Voice change following thyroid and parathyroid surgery.

Voice complications following thyroid and parathyroid procedures have long been recognized in the literature. However, there is little clear data on the nature, severity, and duration of any changes. No single previous study has comprehensively addressed the multiple issues involved. Most studies have been retrospective, preventing control over extraneous variables, or are small prospective studies using limited assessment measures. Emphasis has been on damage (paralysis) to the recurrent laryngeal nerve (RLN). The effects of surgery on the more subtle (but equally important) aspects of voice disorders have received little attention. This prospective study of 67 participants used multidimensional voice outcomes measures to assess changes in voice following thyroid and parathyroid surgery. Strict exclusion criteria minimized the effects of extraneous variables. Participants were assessed preoperatively to establish a baseline and at least twice more postoperatively. Generally speaking, the patient vocal performance and expert perceptual rating data suggest an incidence of 0% for all operation types. Mild changes at the early postoperative stages had settled in all cases by the 3-month postoperative assessment. Videostroboscopic evaluation revealed an interesting picture of six patients who appeared to have improved vocal function postsurgery, 15 patients who showed signs of neurological damage at their first postoperative examination, and only five "permanent" RLN paralyses at 12 months postsurgery. The potential for improvement in voice quality postsurgery has not previously been reported in the literature as far as we are aware. Symptoms consistent with RLN and superior laryngeal nerve palsy were present both pre- and postoperatively. Apparent nerve damage did not necessarily result in dysphonia. The potential for undiagnosed nerve damage preoperatively has rarely been reported in the literature. These results may have medico-legal implications, in addition to influencing surgical risk management and informed patient consent.

Optimising outcome assessment of voice interventions, II: Sensitivity to change of self-reported and observer-rated measures.

OBJECTIVES: A wide range of well validated instruments is now available to assess voice quality and voice-related quality of life, but comparative studies of the responsiveness to change of these measures are lacking. The aim of this study was to assess the responsiveness to change of a range of different measures, following voice therapy and surgery. DESIGN: Longitudinal, cohort comparison study. SETTING: Two UK voice clinics. PARTICIPANTS: One hundred and forty-four patients referred for treatment of benign voice disorders, 90 undergoing voice therapy and 54 undergoing laryngeal microsurgery. MAIN OUTCOME MEASURES: Three measures of self-reported voice quality (the vocal performance questionnaire, the voice handicap index and the voice symptom scale), plus the short form 36 (SF 36) general health status measure and the hospital anxiety and depression score. Perceptual, observer-rated analysis of voice quality was performed using the grade-roughness-breathiness-asthenia-strain scale. We compared the effect sizes (i.e. responsiveness to change) of the principal subscales of all measures before and after voice therapy or phonosurgery. RESULTS: All three self-reported voice measures had large effect sizes following either voice therapy or surgery. Outcomes were similar in both treatment groups. The effect sizes for the observer-rated grade-roughness-breathiness-asthenia-strain scale scores were smaller, although still moderate. The roughness subscale in particular showed little change after therapy or surgery. Only small effects were observed in general health and mood measures. CONCLUSION: The results suggest that the use of a voice-specific questionnaire is essential for assessing the effectiveness of voice interventions. All three self-reported measures tested were capable of detecting change, and scores were highly correlated. On the basis of this evaluation of different measures' sensitivities to change, there is no strong evidence to favour either the vocal performance questionnaire, the voice handicap index or the voice symptom scale.

Comparing two models of voice care delivery.

Voice care is an important aspect in the successful treatment of patients with non-organic dysphonia. No previous study has examined the specific effect of voice care programmes or the comparative effectiveness of the delivery of these programmes across two healthcare professionals (speech and language therapists and ENT nurses). We describe a pilot study that provides preliminary data that suggests a short, easily deliverable voice care programme is (i) effective in reducing patients' perception of their dysphonia and (ii) equally effectively administered by an ENT nurse compared with a speech and language therapist. The study provides a firm base for continued research.

Bioplastique injection laryngoplasty: voice performance outcome.

AIM: To compare voice performance following Bioplastique injection with that following Isshiki thyroplasty. MEASURES: A 12 item, self-reported voice performance questionnaire was completed and observer-rated perceptual voice analysis scores were also measured, before and after Bioplastique injection, for 14 patients. Results were compared with our previously reported outcomes for 28 thyroplasty patients. RESULTS: Only 14 of 30 patients had complete datasets. For these patients, the mean pre-operative voice performance questionnaire score improved significantly, from 40.3 to 18.9 (p=0.002, Wilcoxon test). All perceptual analysis parameters showed significant improvement. These results compare favourably with the thyroplasty cohort (mean voice performance questionnaire score: pre-operative 35; post-operative 18; p<0.001). One Bioplastique patient developed contralateral paresis, requiring partial removal of the material 18 months later. Two thyroplasty patients experienced complications and three required revision. CONCLUSIONS: Both Bioplastique injection and Isshiki thyroplasty resulted in a significant improvement in both subjective and perceptual voice performance. Our data suggest that the effect size of the two interventions is approximately similar (in nonrandomised cohorts of surviving patients). As in many similar studies, the incomplete follow-up data reflect severe comorbidity. Bioplastique injection is a quicker procedure associated with fewer complications, and thus appears superior to framework surgery in patients with limited life expectancy.

Optimising outcome assessment of voice interventions, I: Reliability and validity of three self-reported scales.

BACKGROUND: There is an increasing choice of voice outcome research tools, but good comparative data are lacking. OBJECTIVE: To evaluate the reliability and validity of three voice-specific, self-reported scales. DESIGN: Longitudinal, cohort comparison study. SETTING: Two UK voice clinics: the Freeman Hospital, Newcastle upon Tyne, and the Glasgow Royal Infirmary. PARTICIPANTS: One hundred and eighty-one patients presenting with dysphonia. MAIN OUTCOME MEASURES: All patients completed the vocal performance questionnaire, the voice handicap index and the voice symptom scale. For comparison, each patient's voice was recorded and assessed perceptually using the grade-roughness-breathiness-aesthenia-strain scale. The reliability and validity of the three self-reported vocal performance measures were assessed in all subjects, while 50 completed the questionnaires again to assess repeatability. RESULTS: The results of the 170 participants with completed data sets showed that all three questionnaires had high levels of internal consistency (Cronbach's alpha = 0.81-0.95) and repeatability (voice handicap index = 0.83; vocal performance questionnaire = 0.75; voice symptom scale = 0.63). Concurrent and criterion validity were also good, although, of the grade-roughness-breathiness-aesthenia-strain subscales, roughness was the least well correlated with the self-reported measures. CONCLUSION: The vocal performance questionnaire, the voice handicap index and the voice symptom scale are all reliable and valid instruments for measuring the patient-perceived impact of a voice disorder.

Exploring the relationship between severity of dysphonia and voice-related quality of life.

OBJECTIVES: To explore whether severity and/or consistency of dysphonia are linked to voice-related quality of life. DESIGN: Cross-sectional study. SETTING: Specialist voice clinics, University Teaching Hospital. PARTICIPANTS: Sixty adult patients attending with a primary complaint of dysphonia. Exclusion criteria were those below 16 years of age, transexual patients and those with a persistent dysphonia of >2 years. MAIN OUTCOME MEASURES: Voice-related quality of life as assessed by VoiSS. EXPLANATORY FACTORS: Severity of dysphonia as judged by perceptual ratings of voice (GRBAS); a visual analogue scale to judge best, worst and today's voice. RESULTS: There was a highly significant correlation between perceptual dysphonia severity as assessed by GRBAS and the total, impairment and emotional subsets of the VoiSS questionnaire (r from 0.48 to 0.64). There was a similar and highly significant correlation between best, worst and today's self-rated voice and the total, impairment and emotional subsets of the VoiSS questionnaire (r from -0.40 to -0.60). However, none of the self-rated parameters was demonstrably better at explaining the effect on quality of life. CONCLUSIONS: An increasingly negative effect on quality of life appears to be associated with an increase in the severity of dysphonia. Further research on the role of quality of life measures in the assessment and treatment of dysphonia would be of value.