Role of intensive nutrition support and prophylactic percutaneous endoscopic gastrostomy during concomitant chemoradiotherapy for oropharyngeal cancer.

BACKGROUND: Concomitant chemoradiotherapy (CCRT) produces severe mucositis and swallowing dysfunction, often resulting in malnutrition. Intensive nutrition support (INS) in addition to percutaneous endoscopic gastrostomy (PEG) is reported to decrease adverse effects during CCRT. PATIENTS AND METHODS: Fifty-eight patients with oropharyngeal cancer treated by CDDP-based CCRT were retrospectively analyzed. Twenty-nine patients treated with INS in addition to PEG were classified as INS group, and other 29 patients treated with PEG but without INS were classified as control group. RESULTS: INS in addition to PEG significantly increased calorie intake in the second half of CCRT and reduced adverse events including mucositis (p = 0.0019), leukopenia (p = 0.04), and renal function (p = 0.006). Moreover, 21 out of 29 patients had successfully administration of 200 mg/m2 or more of CDDP, while only 10 out of 29 patients had enough amount of CDDP in control group. CONCLUSIONS: These results suggest that INS in addition to prophylactic PEG not only decreases adverse effects but also may potentially improve oncological outcome of the patients with oropharyngeal cancer treated by CCRT.

The Minimal Important Difference of Acoustic Voice Quality Index in the Treatment of Voice Disorders.

OBJECTIVES: The acoustic voice quality index (AVQI) is a reliable tool that objectively assesses dysphonia levels using six acoustic parameters. Despite its high criterion-related concurrent validity, diagnostic accuracy, and minimal detectable change derived from test-retest reliability, the minimal important difference (MID) of the AVQI has not been tested before. This study aimed to estimate the MIDs of AVQI for improvement audibly perceived by clinicians and self-reported improvement by patients. METHODS: A retrospective study was conducted on 110 patients who received treatment for voice disorders. Patients completed AVQI and Voice Handicap Index-10 (VHI-10) questionnaires before and after the therapy. The MIDs of the AVQI were estimated using the anchor of either auditory-perceptual judgment of total dysphonia levels by clinicians or the VHI-10 questionnaire by patients. A distribution-based approach was also used to complement the results. RESULTS: First, using the auditory-perceptual anchor, a decrease of 0.95 in the AVQI was estimated as the MID for clinicians' perception, as a result of the receiver operating curve. Then, using the patient-reported anchor, an improvement of 1.36 in the AVQI was estimated as the MID for patients' voice-related disability. The distribution-based approach also ensured the anchor-based results of both the MIDs. CONCLUSIONS: The AVQI is a reliable and valid tool for evaluating voice quality, and a 0.95 decrease in the AVQI represents a meaningful improvement for clinicians' perception, whereas a 1.36 decrease in the AVQI influences patients' self-reported disability. This study contributes to understanding the minimal change necessary for clinicians to make informed decisions and ensure patient satisfaction. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2805-2811, 2024.

Vestibular function after simultaneous bilateral cochlear implantation in adults.

Introduction: Binaural hearing enhances speech intelligibility, source localization, and speech comprehension in noisy environments. Although bilateral cochlear implantation (CI) offers several benefits, concerns arise regarding the risk of bilateral postoperative vestibular dysfunction with simultaneous CI. This study aimed to longitudinally evaluate changes in vestibular function in adult patients who underwent simultaneous bilateral CI using minimally invasive electrodes and surgical techniques. Methods: A retrospective review was conducted on 10 patients who underwent simultaneous bilateral CI at our hospital. Vertigo symptoms and vestibular function test results were examined preoperatively, 1-6 months postoperatively, and 1 year postoperatively. Nystagmus tests, caloric reflex tests, vestibular evoked myogenic potentials (VEMP) measurements, and static stabilometry were performed as vestibular function tests. Results: Although an initial transient decline in vestibular function was observed, no significant long-term decline was observed in the caloric reflex test, ocular VEMP (oVEMP), or cervical VEMP (cVEMP). Moreover, regardless of the presence or absence of abnormalities in caloric reflex, oVEMP, or cVEMP, no significant deterioration was detected in the static stabilometer test. While two patients reported preoperative dizziness, all patients were symptom-free 1 year postoperatively. Discussion: The findings suggest that using current minimally invasive electrodes and surgical techniques in simultaneous bilateral CI leads to temporary vestibular function decline postoperatively. However, most patients experience a recovery in function over time, highlighting the potential safety and efficacy of the procedure. Simultaneous bilateral CI surgery is viable, depending on the patient's auditory needs and burden.

Validation of Subharmonics Quantification Using Two-Stage Cepstral Analysis.

OBJECTIVES: Hoarseness is primarily perceived as breathiness or roughness. Despite the various tools that quantitatively assess hoarseness, roughness has been difficult to quantify because of its complex acoustic structure, such as subharmonics. The parameter obtained from the two-stage cepstral analysis is promising for evaluating roughness. Thus, this study aimed to improve the accuracy of the parameter using a customized pitch setting and investigate the relationship between roughness and subharmonics. STUDY DESIGN: The design is a retrospective study. METHODS: Two-stage cepstral analysis was used to analyze the voice recordings of 455 participants, speech impaired and normal controls, using the Analysis of Dysphonia in Speech and Voice and Praat software. For validation, the ground truth of subharmonics was visually quantified using a narrowband spectrogram. The reliability and validity of the two-stage cepstral analysis and subharmonics measures on spectrograms were evaluated. RESULTS: The two-stage cepstral analysis showed a very strong correlation (r = 0.963) between the two software programs. Intra- and inter-rater reliability of the subharmonics measures on spectrograms were also good. Two-stage cepstral analysis showed that even with customized pitch settings, the diagnostic systems and correlations for perceptual roughness and subharmonics were weak to moderate. The subharmonics measures on spectrograms showed a strong correlation with roughness and moderate diagnostic accuracy of subharmonics. CONCLUSIONS: The two-stage cepstral analysis showed some improvement in diagnostic accuracy and correlation with customized pitch settings, but it did not sufficiently detect subharmonics or roughness. The analysis using subharmonics measures on spectrograms proved the high correlation between subharmonics and roughness, indicating that developing acoustic analysis parameters that sufficiently detect subharmonics is necessary.

The Significant Influence of Hoarseness Levels in Connected Speech on the Voice-Related Disability Evaluated Using Voice Handicap Index-10.

OBJECTIVES: This retrospective study examines the influence of voice quality in connected speech (CS) and sustained vowels (SV) on the voice-related disability in patients' daily living documented by Voice Handicap Index-10 (VHI-10). METHODS: A total of 500 voice recordings of CS and SV samples from 338 patients with voice disturbances were included, along with the patients' age, diagnoses, maximum phonation time, and VHI-10. Dataset-1 comprised of 338 untreated patients, whereas Dataset-2 included 162 patients before and after phonosurgeries. As a preliminary study, the concurrent and diagnostic validities based on auditory-perceptual judgments were examined for cepstral peak prominence (CPP) and CPP smoothed (CPPS) for CS and SV tasks. Next, simple correlations and multivariate regression analyses (MRA) were performed to identify which of the acoustic measures for the CS or SV tasks significantly influenced the total score or improvement of VHI-10. RESULTS: The preliminary study confirmed high correlations with hoarseness levels as well as the excellent diagnostic accuracy of CPP and CPPS for both CS and SV tasks. In Dataset-1, the simple correlations and MRA results showed that cepstral measures in both tasks demonstrated moderate correlations with, and significant contribution to the total score of VHI-10, respectively. However, in Dataset-2, the changes of cepstral measures, as well as the median pitch after phonosurgeries in the CS tasks only, showed significant contributions to the improvement of VHI-10. CONCLUSION: The study demonstrated that the hoarseness levels in both the CS and SV tasks equivalently influenced the VHI-10 scores, and that the post-surgical change of voice quality only in the CS tasks influenced the improvement of voice-related disability in daily living.

Blowing time ratio and high-resolution manometry to evaluate swallowing function of patients with oral and oropharyngeal cancer.

OBJECTIVE: The blowing time ratio, which is the ratio of the blowing time when the nostrils are open and closed, is significantly correlated with velopharyngeal pressure, not only during speech but also during swallowing. This study aimed to further evaluate the usefulness of the blowing time ratio as a screening tool to evaluate the swallowing pressure of patients treated for oral and oropharyngeal cancers using high-resolution manometery (HRM). METHODS: Ten patients treated for oral or oropharyngeal cancer were recruited for this study. Swallowing pressures at the velopharynx, oropharynx, and upper esophageal sphincter (UES) were measured using HRM. Their correlations with the blowing time ratio were analyzed. RESULTS: The blowing time ratio was significantly correlated with the swallowing pressures of the oropharynx (CC = 0.815, p = 0.004) and the velopharynx (CC = 0.657, p = 0.039), but not of the UES. CONCLUSIONS: The present results further support our previous finding that the blowing time ratio is a useful screening tool to evaluate velopharyngeal and oropharyngeal swallowing pressures in patients treated for oral and oropharyngeal cancer.

Two cases of glottic closure for refractory aspiration pneumonia after vertical partial laryngectomy.

Vertical partial laryngectomy is a well-established surgical procedure for early glottic cancers with acceptable functional and oncological outcomes. However, on a long-term basis, aspiration might be a serious problem with aging. Here we presented two cases of refractory aspiration pneumonia after vertical laryngectomy. Case 1: A 76-year old gentleman with a past history of malignant lymphoma treated by chemotherapy and radiotherapy had glottic cancer, which was treated by repeated vertical partial laryngectomies. Although glottic caner had been well controlled, he started to suffer from refractory aspiration pneumonia. Since his cervical skin was very thin and hard and his general condition was poor, we employed modified Kano's method for glottic closure. Case 2: A 87-year old Japanese male had a past history of glottic cancer treated by radiotherapy and vertical partial laryngectomy. He was repeatedly hospitalized for severe aspiration pneumonia. At the age of 87, he had second primary oropharyngeal cancer. Kano's method was simultaneously performed at the time of resection of oropharyngeal cancer. Postoperative courses were uneventful without sign of leakage in both cases. The patients started oral intake 2 weeks after the surgery. They have been alive without aspiration pneumonia and takes normal diet.

Prognostic factors after transoral resection of early hypopharyngeal cancer.

OBJECTIVE: This study aimed to investigate risk factors predictive of local recurrence and/or lymph node metastasis after transoral resection of early hypopharyngeal cancer. METHODS: Forty-nine consecutive patients who underwent transoral videolaryngoscopic surgery (TOVS) as an initial treatment for hypopharyngeal cancer were evaluated. On univariate and multivariate analysis, local recurrence rates were assessed respectively using log-rank test and cox regression analysis according to the following parameters: subsite, pT, mucosal margin, lymphatic invasion, vessel invasion, tumor thickness (> 4 mm vs ≤4 mm), history of esophageal cancer, and multiple Lugol-voiding lesions (LVLs) in the esophagus. Categorical variables were evaluated for their associations with lymph node metastasis using chi-squared test or Fisher's exact test. RESULT: The subsites of primary lesions were piriform sinus in 24 patients, posterior wall in 15 patients, and postcricoid in 10 patients. Thirty patients had esophageal cancer. Local recurrence occurred in 14 patients. Three patients had lymph node metastasis at the time of diagnosis and four patients developed lymph node metastasis after the initial treatment, resulting a total of seven patients having lymph node metastasis. While mucosal margin and LVLs showed significant associations with local recurrence on univariate analysis, only LVLs remained as a significant risk factor on multivariate analysis (P = .0395; hazard ratio = 8.897; 95% confidence interval, 1.113-71.15). Most cases of local recurrence were satisfactorily controlled by repeated TOVS. While multivariate analysis could not be performed due to the small number of the patients with lymph node metastases, venous invasion (P = .0166) and tumor thickness (P = .0092) were significantly associated with lymph node metastasis on univariate analysis. CONCLUSIONS: Local recurrence was more frequent in patients with LVLs, but most of them were salvaged by repeated TOVS. Patients with venous invasion and/or tumor thickness greater than 4 mm should be followed up with special attention to lymph node metastasis.Level of Evidence: 3.

Intertext Variability of Smoothed Cepstral Peak Prominence, Methods to Control It, and Its Diagnostic Properties.

OBJECTIVES: This study aimed to estimate the intertext variability of smoothed cepstral peak prominence (CPPS), examine whether sound-processing techniques improved its variability and diagnostic capability, and evaluate the degree of intertext variability in detail with reference to the CPPS variabilities in sustained vowels. STUDY DESIGN: This was a retrospective study. METHODS: Text readings of 58 Japanese syllables were recorded from 210 speakers with different diagnoses and varying degrees of dysphonia, and were divided into six passages. Applying the sound-processing techniques to those passages, we prepared three sample types: (1) nonprocessed, (2) only-loud, and (3) only-voiced samples. The intertext CPPS variability and diagnostic properties were compared across the passages and sample types. For detailed analysis, we subsequently extracted 63 normophonic speakers who maintained constant quality in their vowel utterances to evaluate the degree of intertext CPPS variability in relation to the variabilities between repeated identical vowels and across different vowels. RESULTS: Although several combinations of passages showed moderate-to-large CPPS variabilities, those variabilities were decreased by either technique, especially the deletion of silent segments, which resulted in the best diagnostic accuracy. The degree of intertext CPPS variability for the only-voiced samples was comparable to that of the CPPS variabilities in sustained vowels. CONCLUSIONS: The sound-processing technique removing silent segments should be applied to enhance the diagnostic properties of CPPS. The additional technique of deleting unvoiced segments is worth adopting if clinicians and researchers seek to attenuate the influence of text differences in calculating CPPS values.

Oncologic and functional outcomes of transoral CO2 laser cordectomy for early glottic cancer.

OBJECTIVE: To investigate the oncological and functional outcomes of the patients treated with transoral CO2 laser cordectomy for early glottic cancer. PATIENTS AND METHODS: Fifty-five consecutive patients who underwent CO2 laser cordectomy for early glottic cancer were retrospectively reviewed. RESULTS: Overall survival, larynx preservation, and relapse free local control rates were 96%, 100%, and 91%, respectively. Five patients with local recurrences were salvaged with re-cordectomy and/or radiotherapy. In type I cordectomy, VHI-10 consistently improved during postoperative course and VHI-10 at postoperative 12months was significantly better than preoperative value (2.3 vs. 9.4, p=0.02). Perceptual grading, MPT, MFR and AC/DC also improved and were better than preoperative values. In type III cordectomy, shimmer at 12months after cordectomy was significantly better than preoperative value (14.7 vs. 9.3, p=0.007). CONCLUSIONS: These results further support the rationale of CO2 cordectomy as initial and salvage surgery for early glottic cancer.

The Acoustic Voice Quality Index Version 03.01 for the Japanese-speaking Population.

OBJECTIVES: We aimed to determine the most appropriate syllable number for analyzing the Acoustic Voice Quality Index for the Japanese-speaking population (AVQIv3-JP) and to validate AVQIv3-JP using the determined syllable number. METHODS: First, we counted how many syllables should be included in each continuous speech (CS) sample to achieve time-balanced analysis between CS and sustained vowel samples using our previous dataset including 336 CS samples with 58 syllables. From the descriptive statistics of the counted syllable numbers, the most appropriate syllable number was identified. Subsequently, we performed validation procedures of AVQIv3-JP using our latest dataset including 455 recordings. RESULTS: Thirty Japanese syllables were judged to be the most appropriate syllable number. The concurrent validity of the AVQIv3-JP using 30 syllables was confirmed by Spearman's rho of 0.873. Subsequently, the receiver operating characteristic analysis demonstrated the excellent discriminative capability of AVQIv3-JP, showing the area under the curve of 0.915. The AVQIv3's original threshold of 2.43 in the Dutch language corresponded to sensitivity and specificity of 64.6% and 97.3%, respectively. In the present study, a threshold of 1.41 achieved the best accuracy with balanced sensitivity and specificity of 84.4% and 85.6%, respectively. Furthermore, the 95th percentile of the control participants exhibited a threshold of 2.06, showing sensitivity and specificity of 72.1% and 93.8%, respectively, as well as reasonable positive and negative likelihood ratios of 11.7 and 0.298, respectively. CONCLUSION: The AVQIv3 using 30 Japanese syllables is a reliable measurement tool for estimating the severity of voice quality and detecting abnormal voices.

Acoustic Breathiness Index for the Japanese-Speaking Population: Validation Study and Exploration of Affecting Factors.

Objectives The purposes of this study were to validate the Acoustic Breathiness Index (ABI) for the Japanese-speaking population and to determine whether it is independent of factors such as sex, age, and perceptual ratings of roughness. Method First, the concurrent validity of the ABI for perceptual breathiness was evaluated on the concatenations of continuous speech and sustained vowels from 288 patients with varying degrees of dysphonia. The diagnostic accuracy was examined on 343 samples with 55 additional normophonic speakers. Second, the validity related to responsiveness-to-change was estimated on 222 samples obtained before and after interventions for 111 voice-disordered patients. Third, the relationships between the ABI and other variables (i.e., perceptual hoarseness/breathiness/roughness, sex, and age) were explored using bivariate and multivariate analyses for the 288 patients. Results First, the concurrent validity and the responsiveness-to-change validity were confirmed by strong correlation coefficients of .890 and .878, respectively. Second, the receiver operating characteristic analysis showed the area under the curve to be 0.939, indicating excellent accuracy. The ABI of 3.44 exhibited a sensitivity of 76.3% and a specificity of 94.1%. Third, although bivariate analyses revealed a weak relationship between ABI and roughness and an ABI difference by age, multiple regression analyses showed a strong relation between only ABI and breathiness, without a meaningful contribution from roughness, sex, and age factors. Conclusion The study confirmed that the ABI is an accurate and specific tool to estimate breathiness levels in the Japanese-speaking population and neither roughness, sex, nor age significantly affects the ABI.

Validation of the Acoustic Voice Quality Index in the Japanese Language.

OBJECTIVES: The Acoustic Voice Quality Index (AVQI) is a multivariate construct for quantification of overall voice quality based on the analysis of continuous speech and sustained vowel. The stability and validity of the AVQI is well established in several language families. However, the Japanese language has distinct characteristics with respect to several parameters of articulatory and phonatory physiology. The aim of the study was to confirm the criterion-related concurrent validity of AVQI, as well as its responsiveness to change and diagnostic accuracy for voice assessment in the Japanese-speaking population. STUDY DESIGN: This is a retrospective study. METHODS: A total of 336 voice recordings, which included 69 pairs of voice recordings (before and after therapeutic interventions), were eligible for the study. The auditory-perceptual judgment of overall voice quality was evaluated by five experienced raters. The concurrent validity, responsiveness to change, and diagnostic accuracy of the AVQI were estimated. RESULTS: The concurrent validity and responsiveness to change based on the overall voice quality was indicated by high correlation coefficients 0.828 and 0.767, respectively. Receiver operating characteristic analysis revealed an excellent diagnostic accuracy for discrimination between dysphonic and normophonic voices (area under the curve: 0.905). The best threshold level for the AVQI of 3.15 corresponded with a sensitivity of 72.5% and specificity of 95.2%, with the positive and negative likelihood ratios of 15.1 and 0.29, respectively. CONCLUSIONS: We demonstrated the validity of the AVQI as a tool for assessment of overall voice quality and that of voice therapy outcomes in the Japanese-speaking population.

Role of immediate recurrent laryngeal nerve reconstruction in surgery for thyroid cancers with fixed vocal cords.

BACKGROUND: Quality of voice after immediate recurrent laryngeal nerve (RLN) reconstruction in thyroid cancers has not been thoroughly studied. METHODS: Thirteen patients with fixed vocal cords (fixed vocal cord group) and 8 patients with intact or impaired mobile vocal cords (mobile vocal cord group) who had immediate RLN reconstruction simultaneously with total thyroidectomy, and patients who had arytenoid adduction and thyroplasty for vocal cord paralysis caused by previous surgery (arytenoid adduction thyroplasty group) were enrolled in this study. RESULTS: Preoperative phonation efficiency index was significantly lower (p = .008) in the fixed vocal cord group than in the mobile vocal cord group. One year after surgery, all voice parameters of the patients in the fixed vocal cord group had improved, compared with their preoperative data. The fixed vocal cord group had attained satisfactory voice qualities equivalent to those of the mobile vocal cord group in terms of various voice parameters. CONCLUSION: The present results support the idea that immediate RLN reconstruction at the time of surgery for thyroid cancers may spare the need for subsequent arytenoid adduction thyroplasty even in the patients with preoperatively fixed vocal cords. © 2016 Wiley Periodicals, Inc. Head Neck 39: 427-431, 2017.

Voice quality after surgical treatment for thyroid cancer.

BACKGROUND: Thyroidectomy is a standard treatment for thyroid cancers. Hoarseness due to the paralysis of the recurrent laryngeal nerve is one of the most common postoperative complications, and has been studied by many investigators. However, voice quality after thyroidectomy in patients in whom recurrent laryngeal nerves were preserved and vocal cord morbidity was endoscopically normal has not been well studied. To understand voice quality after thyroidectomy further, we conducted a time-course analysis of voice quality in patients who had thyroidectomy with normal cord morbidity by various measures. METHODS: We evaluated voice parameters including the Voice Handicap Index-10 (VHI-10), the vocal efficacy index, the fundamental frequency (F0), the maximum phonation time (MPT), the mean air flow rate (MFR), jitter, shimmer, and the noise-to-harmonics ratio (NHR) before and after total thyroidectomy (TT) or lobectomy (LO) for thyroid cancers in 110 patients in whom the recurrent laryngeal nerves were preserved without apparent injury and normal vocal cord mobility was confirmed by endoscopic examination. Thirteen patients who underwent parotidectomy were enrolled as controls. RESULTS: Immediately after surgery, significant decreases in MPT (p=0.003) and significant increases in jitters, shimmers, and NHR (p=0.0002, 0.02, and 0.03, respectively) were observed in the patients who underwent TT. In comparison with the controls, jitters and NHR were significantly higher in the patients who had a TT (p=0.03, 0.04). MFR was significantly higher in the patients who had an LO than in the controls (p=0.02). As compared with the patients who had an LO, MPT was significantly shorter (p=0.0004) and MFR and NHR were significantly higher (p=0.004, 0.03) in the patients with a TT. In the patients who had a TT, the MPT immediately after the surgery was significantly longer in the patients who had simultaneously neck dissection (ND) in comparison with the patients who did not have ND. However, all these differences gradually decreased and were not significant at one month after surgery. CONCLUSIONS: Our results suggest that TT and ND have a distinct impact on voice quality after surgical treatment for thyroid cancer, probably due to slight and transient nerve conduction disorders induced by the manipulation around recurrent laryngeal nerves and/or laryngeal edema induced by the disturbance of venous and lymphatic drainages. However, these changes appear to be temporary, lasting only a few weeks.