correlacion entre handicap y lab. de voz post fonocirugia

7/30/2019 Correlacion Entre Handicap y Lab. de Voz Post Fonocirugia.

1/7

ORIGINAL ARTICLE

Correlation between the VoiceHandicap Index and voice laboratorymeasurements after phonosurgeryJeffrey Cheng , M D; Peak W oo, MD, FACS

AbstractPhonosurgery is an effective treatment for s ome vocal o ldpathologies, and the Voice Handicap Index (VHI) surveyhas been shown to be a useful instrument for evaluatingtreatment effectiveness. We conducted a nonrand om-ized, prospective study of 21 patients who underwentphonosurgery for the treatment of non-neoplastic vocalfold lesions at our academic tertiary-care referral center.Our goals were to compare pre- and postoperative VHIscores (subjective assessments) and pre- and postopera-tive results of acoustic and aerodynamic tests (objectiveassessm ents). We sought to determine if there was an ycorrelation between the subjective and objective findings.We looked or differences between professional voice users(n = 10) and nonprofessional voice users (n = ll)in bothsubjective and objective measures. We found statisticallysignificant differences between pre- and postoperativevalues in three of four VHI param eters, but in only one of13 objective measures. There was no correlation betwee npreoperative VHI scores and preoperative acoustic andaerodynam ic test results. The professional voice usersexpressed greater postoperative improvem ent as reflectedby lower VHI scores than did the nonprofessional voiceusers, confirming that the former are more negativelyaffected by a vo ice disability.

IntroductionAnalyses of non-neop lastic voice disorders and quanti-fication of their effects on patients have been conduc tedfor quite some time, yet there is still much we do n ot

From the Eugen Grabscheid, M.D., Voice Center, Departmen t of O tolar-yngology, Mou nt Sinai Medical Center, New York City.Corresponding author: Jeffrey Cheng, M D, Departme nt of Otolaryngol-ogy, Mount Sinai Medical Center, O ne C ustave L. Levy Place, New

understand about the physiology and mechanisms ofthese disorders. In analyzing a patient's voice, clini-cians must consider subjective as well as objectivemeasurements. While objective assessments of voiceobtained by computer-assisted analyses are useful,they may not capture the global function of a patient'svoice. Subjective assessments, therefore, can be helpfulin attempting to overcome some of the limitations ofobjective testing .Subjective assessments are also useful in evaluating apatient's response to treatm ent. A patient's satisfaction

with a perceived improvement in voice following anintervention can have a positive effect on his or her emo-tional and functional status. Conversely, dissatisfactioncan have the opposite effect. Cohen et al conducted ameta-analysis of studies on the impact of non-neop lasticvoice disorders on patients' well-being and concludedthat the m anagement of patients with voice complaintsshould include a quahty-of-life assessment.'Jacobson and colleagues developed the Voice HandicapIndex (VHI) as a means of subjectively quantifying thepsychosocial effects of voice disorders.^ The VHI was

subsequently used in clinical research to measure voicechanges after therapy.^ However, there is no consensus inthe literature as to whe ther subjective VHI surveys andobjective data measurements should be used together.Therefore, we conducted a study ( 1 ) to compare pre- andpostoperative VHI scores and pre- and postoperativeobjective m easurements, (2) to determine if there was anycorrelation between VHI scores and objective m easures,and (3) to analyze differences between nonprofessionaland professional voice users.

Patientsand methodsThis nonrandomized, prospective study was under-


2/7

CHENG, WOO

Voice user c lass i f icat ion

Category 4:Professional voiceuser, s u c h a s a

t eache r , po l i t i c i an ,har r is ter

(n = 6; 29%)

Figure. Chart shows the breakdown ofvoice users by category. Patientsin categories 4 and 5 are classified as professional voice users.

measures in patients who unde rwen t phonosu rgery fornon-neoplastic vocal fold lesions. Institutional reviewboard approval was obtained prior to the init iation ofthe study protocol, and informed consent was obtainedprior to the enrollment of patients.

Patien ts were eligible for this stu dy if ( 1 ) they demon-strated a voice impa irm ent that affected their daily life,(2) they agreed to undergo pho nosu rgery in an attem ptto improv e their voice, (3 ) they agreed to complete a VHIsurvey preoperatively and 6 weeks postoperatively, and(4) they agreed to undergo acoustic and aerodynamictesting preoperatively an d 6 weeks postoperatively. Pa-tients were recruited by the senior author (RW.) at theGrabscheid Voice Center of the Mount Sinai MedicalCenter in New York City from January 2007 throughJune 2008.

Initially, 23 patients m et the eligibility criteria and wereenrolled in the study. Two patien ts did not co mp lete thestudy, and th us our f inal study population was mad e u pof 21 patients12 m en and 9 women (mean age: 48.4 15.9 yr). All patients provided a medical history and un -derwen t a physical examination an d laryngo videostro-boscopy. Each patient's pa rticular vocal fold patho logywas diagnosed by the senior author. Seventeen patients(81.0%) were diagnosed with a vocal fold polyp and 1patie nt each (4.8%) was diagnos ed w ith a vocal fold cyst,

Patients were asked to rate their voice use on a scaleof 1 (low use) to 5 ("elite" use). A score of 1 indicatedthat a patient's voice use was no t a conc ern w ith respectto daily activities, while a score of 5 indicated that thepatient was a professional or an avocational voice user(e.g., a singer at religious services). Patients with a voiceuse rating of 1,2, or 3 were classified as nonprofessionalvoice users, and those with a rating of 4 or 5 w ere clas-sified as professionalvoice users. The me an score amon gthe 21 patients was 3.48 (1 .5 ); 10 patien ts qualified asprofessionalvoice users (figure).

Subjective assessments. The VHI is a self-administeredsurvey in which patients rate on a scale of 0 (never) to4 (always) the frequency with which they experiencevariou s negative situation s related to their voice impair-m ent ( e.g., "My voice makes it difficult for people to hearme."). Th e 30 survey items are evenly arrang ed in thre edom ains: functional, physical , and em otional. Possiblesubscale scores range from 0 (no perceived handicap)to 40 (worst possible handicap), and the overall scoreranges from 0 to 120. W ithin each do ma in, disabili ty wasclassified as mild (a score of


3/7

Table 1. Comp arisons of mean pre- and postoperative V HIscores inDomain

ail patients and by subgroupsPreop

AH patientsFunctionalPhysicalEmotionalTotar

12.2 7.220.8 8.714.0 9.347 22.0Nonprofessionat voice usersFunctionalPhysicalEmotionalTotar

9.8 6.515.8 7610.0 7 136 16Professional voice usersFunctionalPhysicalEmotionalTotar

14.9 7.326.3 6.418.5 9.860 2 0* Statistically significant, paired t test.t Total VH1 1

Postop

9.5 7211.0 8.17.5 7228 21.0

8.6 7.710.4 6.45.9 6.225 20

10.5 6.811.8 9.99.2 8 .232 2 4

whole num bers are rounded off.

Change

2.79.86.519

1.25.44.111

4.414.59.328

p Value

0.110.001*0.001*0.002*

0.610.130.05*0.12

0.100.002*0.01*

0.007*

V H D I =VH I total score / [ (observed jitter % / normalji t ter %) + (observed shimm er % / norm al shimm er %)+ (observed NHR / normal N HR) ]

Statistical analysis. Statistical analysis was performedwith VassarStats, an Internet-based statistical compu-tation program."* A correlated paired t test was used toanalyze the pre- and postoperative total and subscaleVHI scores, to compare pre- and postoperative voicelaboratory measurements, and to compare subjectiveand objective results in nonprofessional and professionalvoice users. We also used a Pearson r correlation analysisto determine if there was any correlation between pre-operative VHI scores and preoperative voice laboratorymeasurements . A p value of


4/7

CHENG, WOO

Table 2. Mean pre- and postoperative voice laboratory results inth e entire group(All) and in the nonprofessional (Non) and professional (Pro) voice user subgroups

Acoustic parametersFundamentalfrequency (F^) (Hz)Physiologic Frange of phonationLower pitchlimit (Hz)

Upper pitchlimit (Hz) :Jitter%

Shimmer %

Noise-harmonic ratio

% Voiceless

Aerodynamic parametersMaximum phonationtime (sec)Target flow (LVsec)

Efficiency

Resistance

Phonation thresholdpressure^Statistically significant, paired i

Ail

140.2741.8732.8710.396.3529.89

713.29281.172.172.925.589.950.160.106.45

19.9

15.58.310.260.11

50.9840.5950.5231.30

5.421.90t test.

PreoperativeNon

135.9641.9230.6710.16

100.0235.05

604.16277.012.993.918.0213.60.180.14

11.4127.12

13.547490.300.13

46.3138.2946.7936.40

5.121.66

Pro

145.0043.5435.2910.4392.3324.22

833.33244.651.270.472.910.800.130.020.99

1.89

17.659.020.230.08

56.1244.3054.6225.88

5.762.18

Aii

142.9838.2834.405.47971424.09

724.80234.241.541.093.242.290.140.062.84

6.01

15.566.630.230.10

108.34100.9663.8951.15

5.142.26

PostoperativeNo n

139.5231.0032.373.8697.2221.58

633.88158.451.561.103.422.190.120.032.42

4.41

15.577.010.230.08

110.77119.8062.8860.23

4.831.75

Pro

146.8046.4536.636.28970527.79

824.80269.851.541.133.052.490.150.083.30

763

15.556.560.220.13

105.6781.7865.0142.21

5.472.78

All

0.62

0.50

0.87

0.850.29

0.27

0.43

0.41

0.96

0.13

0.01*

0.08

0.61

p VaiueNon

0.71

0.55

0.77

0.750.18

0.25

0.23

0.28

0.06

0.03*

0.09

0.07

0.74

Pro

0.71

0.73

0.13

0.920.51

0.86

0.52

0.28

0.44

0.88

0.10

0.43

0.70

resenting an improvement in the physical domain frommoderate to mild disability. The changes were statisticallysignificant for the physical (p = 0.002) and emotional(p = 0.01) domains, but not for the functional domain(p = O.lO).

No significant difference was seen between any pre-and postoperative objective measure in the professional

VHDI. The professional voice users had a highermean VHDI ( 13.63 5.40) than did the nonprofessionalvoice users (7.22 6.26); the difference was statisticallysignificant {p = 0.02) (table 4). This indicates that theprofessional voice users perceived their preoperativevoice handicap to be more serious than did the non-professionals when normalized against their objective


5/7

CORREUTION BETWEEN THE VOICE HANDICAP INDEX AND VOICE LABORATORY MEASUREMENTS AFTER PHONOSURGERY

DiscussionWhen patients with voice com-plaints provide a history, theyoften use qualitative descriptionsand examples of how their voicedysfunction affects their everydayactivities that are difficult to quan-tify. The VHl has been validatedas a reliable means of quantifyingthe functional, physical, and emo-tional aspects of voice dysfunc-tion.^ An accurate assessment ofvoice complaints also depends onthe clinician's diagnostic acumenand ability to discern intricaciesand details in a patient's voice.Interobserver differences may eas-ily arise. Therefore, acoustic andaerodynamic testing is conductedto obtain an objective assessmentof vocal dysfunction.

In theory, a subjective measurement of a particularpatient's voice dysfunction should correlate with anobjective assessment. However, we found no correla-tion in our study. Indeed, as a profession, we do no t yetunderstand how physiologic acoustic analyses shouldcorrelate to VHl scores. This dissociation is one of thebarriers to developing a generalizable paradigm regard-ing how individual patients are differently affected byvoice disability.^V/heeler et al studied 50 patients and found that theresults of acoustic analyses were no t predictive of overallVHl scores and that the individual compo nents of theVHl survey did not consistently and significantly cor-relate with acousticfindings.*They surmised that thereason for this inconsistency was tha t there is a nonlinearrelationship between perceptions of handicap and indi-vidual patient circumstances, such as occupation, socialstatus, previous experiences with vocal dysfunction,overall personality, etc. Earlier,Hsiung et al undertook arelated investigation and came to a similar conclusion.'Using a Pearson r correlation analysis, they too found thatVH l overall and subscale scores were poorly associatedwith voice laboratory measurements. As a result, theywere unable to identify any definitive prognostic indica-tor in their c ohort of dysphonic p atients. V^oisard et alwere able to dem onstrate a fair correlation between totaland subscale VHl scores and the minim um frequencyas measured by voice laboratory measurements in 58patients; they also used a Pearson rcorrelation analysis.*

Table 3. Correlation of preoperative VHl subscaie and total scoreswith voice laboratory results (Pearson rcorrelation anaiysis)

FunctionaAcoustic parametersFundamental frequency {f jPhysiologic F^ range of phonationLower pitch limit (Hz)Upper pitch limit (Hz)Jitter %Shimmer %Noise-harmonic ratio% VoicelessAerodynamic parametersMaximum phonation time (sec)Target flow (L/sec)EfficiencyResistancePhonation thresho ld pressure^Statistically significant.

0.071.000.500.060.931.000.550.98

0.920.880.130.200.78

VHl domain1 Physical0.110.660.290.04*0.520.450.630.40

0.76. 0.820.070.960.25

Emot i ona i0.350.080.360.01*0.820.660.470.77

0.840.770.090.290.21

V H lto ta i0.100.360.080.01*0.850.910.760.82

0.940.930.05*0.390.99

They also found that vocal range was fairly correlatedwith the physical domain of the VHL Overall, however,they concluded that VHl scores were independent oflaboratory findings.We believe that voice specialists should not be dis-couraged by these negativefindingsand that we shouldcontinue to investigate ways to improve diagnosis andprognosis. Phonosurgery has been demonstrated to be aneffective treatm ent for benign vocal fold patho logies, andthe VHl has been shown to be useful in assessing trea t-ment efficacy. Patients with vocal fold cysts and polypsin particular seem to benefit from microlaryngoscopysurgery, and their postoperative VHl scores were shownby Rosen et al to refiect significant improvement.' Cohenet al were also able to show a statistically significantreduction in p ostoperative VHl scores among patientswith vocal fold polyps and cysts who underwen t surgeryand voice therapy.'" Our study results appear to echothose findings.Several circumstances might explain why our studyfound so little correlation between VHl scores andacoustic and aerodynamic test results. One possibleexplanation is the small num ber of patients in our study.Another might be the disparities in the voice qualitiesamong our patients. Yet another might be the fact thatacoustic parameters in patients with vocal fold polyps

and cysts (which accounted for >85% ofthe lesions inour study) are usually only slightly disordered , so anyacoustic improvement from surgery may no t be reflected


6/7

CHENG, w o o

Table 4. Comparison of the calculated VoiceHandicap D istress Index in the two subgroupsSubgroup

NonprofessionalProfessional

Mean score*

7.22 6.2613.63 5.40

95% Confidenceinterval3.00 to 11.429.77 to 17.49

^Statistically significant difference fp = 0.02).

in measurem ents of j i tter , shimm er, and N HR . Anotherfactor may be the timing of laboratory testing; inflam-mation, scarring, and healing take place over a periodof weeks to months after phonosurgical intervention,so early findings might not be reliable.Based on our experience, we believe that subjectiveand objective evaluations of voice dysfunction shou ldprobably be interpreted independently. Because voicequali ty is multidime nsional, i t might no t be prude nt torely on one instrument to evaluate voice dysfunctionand postoperative improvement. We believe the VHIshould be used as an addition to objective laboratorymeasurements. Also, we believe that larger studies areneeded to better elucidate the test-retest validity ofobjective measurements.

To determ ine whether perceptions of voice handicap sare greater in professional voice users than in nonpro-fessional voice users, we created the V HD I. Our resultssuggest tha t all aspects of the VH I were more significantlyaffected in professiona l voice users. Their total and sub -scale perceptions of handic ap were significantly higher,bu t their perceived postop erative imp rove me nt was alsogreater (p = 0.02). Since the results of subjective tests ofvoice disability may not be consistent am ong differentpatient populations, we suggest that more refined andfocused measures be used for professional voice users.For examp le, the validated SingingVoice Handicap Indexhas been shown to be useful in mon itoring treatm ent-related changes in singers.'"

Our findings confirm those of other authors thatobjective me asu rem ents are less sensitive in identifyingvoice changes tha n are subjective mea sures. Also, even inou r small coho rt, the VHI survey was significantly mo resensitive in professional voice users than in nonp rofes-sional voice users. Such a disparity may affect othercomparisons of voice outcome measures based solelyon the VHI across different population groups.

In conclusion, our study showed tha t the VHI can beuseful in m onit orin g the efficacy of treatme nts for voice

me asurem ents did n ot signif icantly correlate with VH Iscores, and they were relatively less sensitive in m easu ringdifferences between pre - and postope rative status. Ourstud y serves as a further illus tratio n of how difficult it is(1) to integrate subjective and objective voice disabilitymea surem ents and (2) to make meaningful interpreta-tions of the multiple and varied aspects of voice with asingle instrument.AcknowledgmentsWe thank C handler Thom pson , MA, Linda Carroll , PhD,Ch and ra Ivey, M D, and Melissa Mo rtense n, M D, for theircontribu tions to the collection of patient data.

References1. Cohen SM, Dupont WD, Courey MS. Quality-of-life impact ofnon-neoplastic voice disorders: A meta-analysis. Ann O tol RhinolLaryngol 2006;l 15(2): 128-34.2. Jacobson BH, Johnson A, Grywalski C, et al. The voice handicapindex (VHJ): Development an d validation. Am J Speech Lang Pathol1997;6(3):66-70.3. Bogaardt H C, Hakkesteegt MM , Grolman W , Lindeboom R. Vali-dation of the voice handicap index using Rasch analysis. J Voice

2007;21(3):337-44.4. Lowry R. Concepts & Applications of Inferential Statistics 2008.http://facu lty.vassar .edu/low ry/we btext.htm l. Accessed Feb. 25,

2010.5. Deary IJ, Wilson JA, Carding PN, Mackenzie K. The dysphonicvoice heard by me, you and it: Differential associations with per-

sonality and psychological distress. Clin Otolaryngol Allied Sei2003;28(4):374-8.6. Wheeler KM, Collins SP, Sapienza CM. The relationship betweenVHI scores and specific acoustic measures of mildly disordered

voice produc tion. J Voice 2006;20(2):308 -17.7. Hsiung MW, PaiL, Wang HW. Correlation between voice handicap

index and voice laboratory m easurements in dysphonic patients.Eur Arch Otorhinolaryngol 2002;259(2):97-9.8. Woisard V, Bodin S,Yardeni E, Puech M. The voice handicap index:Correlation between subjective patient response and quantitativeassessment of voice. J Voice 2007;21(5):623 -31.9. Rosen CA, Mu rry T,Zinn A, et al. Voice handicap index change fol-lowing treatment of voice disorders. J Voice 2000;14 (4):619-23.

10. Cohe n SM, Witsell DL, Scearce L, et al. Treatme nt respon -siveness of the Singing Voice Handicap Index. Laryngoscope2008;118(9):1705-8.


7/7

Copyright of ENT: Ear, Nose & Throat Journal is the property of Vendome Group LLC and its content may not

be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written

permission. However, users may print, download, or email articles for individual use.

correlacion entre handicap y lab. de voz post fonocirugia

Documents