Abstract
This study aimed to examine the impact of the timing of voice therapy on vocal outcomes in patients post-surgery for benign vocal fold lesions.The study prospectively assessed 20 patients undergoing phonomicrosurgery for benign vocal fold lesions. Participants were categorized into early voice therapy (within 7 days), late voice therapy (after 7 days), and no voice therapy groups. Vocal outcomes were assessed using the Voice Handicap Index (VHI) and the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V).Early voice therapy led to significant improvements in post-operative VHI scores (p = 0.001) and CAPE-V scores (p = 0.014199), whereas delayed or no therapy showed less pronounced improvements. No significant differences were observed in preoperative VHI and CAPE-V scores among the groups.Early initiation of voice therapy post-surgery significantly improves vocal outcomes in patients with benign vocal fold lesions. These findings advocate for the integration of early voice therapy into post-operative care protocols.
Keywords: Voice therapy, Vocal fold lesions, Postoperative care, Voice handicap index, CAPE-V, Phonomicrosurgery
Introduction
Voice therapy, a pivotal component in the management of voice disorders, has garnered significant interest in the context of surgically treated benign vocal cord lesions. Benign vocal cord lesions, encompassing a spectrum of pathologies such as nodules, polyps, and cysts, are commonly attributed to phonotrauma and voice misuse [1]. Surgical intervention, often pursued after conservative management fails, aims at lesion removal, while voice therapy targets the underlying dysfunctional vocal behaviors [2]. The timing of voice therapy, either preoperatively, postoperatively, or both, has been debated, with implications for vocal outcomes being a subject of ongoing research.
The rationale for voice therapy lies in its capacity to modify vocal behaviors that contribute to lesion formation and persistence. Voice therapy techniques, emphasizing vocal hygiene, voice rest, and exercises to optimize vocal function, are tailored to individual patient needs [3]. Preoperative voice therapy may reduce lesion size and improve vocal quality, potentially altering the surgical approach or even obviating the need for surgery in some cases [4]. Postoperative voice therapy, on the other hand, is directed at preventing recurrence, facilitating wound healing, and reinstating healthy vocal habits [5].
The impact of the timing of voice therapy on vocal outcomes post-surgery has been a focal point of several studies. Early intervention, typically defined as voice therapy initiated within a week post-surgery, has been suggested to lead to better vocal outcomes compared to delayed or no voice therapy [6]. These outcomes are often measured using subjective and objective parameters, including voice quality, vocal range, and patient-reported voice handicap indices [7]. Early postoperative voice therapy is posited to enhance vocal fold healing, reduce scar formation, and expedite the return to optimal vocal function [8].
Conversely, some experts advocate for delayed initiation of voice therapy, allowing for an initial period of vocal rest post-surgery. This approach is based on the premise that immediate postoperative voice therapy might exacerbate vocal fold inflammation and delay healing [9]. However, evidence supporting this viewpoint is less robust, and the optimal timing for the commencement of voice therapy remains contentious [10].
The effectiveness of voice therapy, regardless of timing, is also influenced by patient adherence, the severity of the preoperative vocal disorder, and the specific type of lesion [11]. Individualized therapy plans, considering these factors, are crucial for successful outcomes. Moreover, the role of voice therapy in conjunction with other modalities, such as pharmacotherapy for underlying laryngeal inflammation, warrants further exploration [12].
The need for a holistic approach in the management of benign vocal cord lesions is underscored by the multifactorial nature of these disorders. A multidisciplinary team approach, involving otolaryngologists, speech-language pathologists, and, when necessary, psychologists, ensures comprehensive care [13]. Patient education about the implications of voice misuse, the importance of vocal hygiene, and the potential benefits and limitations of surgical and non-surgical interventions is pivotal in this context [14].
The timing of voice therapy in patients with surgically treated benign vocal cord lesions is a critical factor influencing vocal outcomes. While early postoperative voice therapy appears to be beneficial, further high-quality research is needed to establish definitive guidelines. Tailoring voice therapy to individual patient needs, while considering the lesion characteristics and overall vocal health, remains the cornerstone of effective management.
The primary aim of the study was to examine the impact of the timing of speech-language pathology intervention on the vocal outcomes of patients who underwent surgical treatment for benign vocal fold lesions. This evaluation was quantitatively measured using two well-established parameters: the Voice Handicap Index (VHI) and the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). The key objective was to evaluate the influence of early (within 7 days), delayed (after 7 days), or no voice therapy on the vocal outcomes of these patients.
Materials and Methods
Adopting a prospective cohort study design over a one-year period, the research focused on a group of 20 patients who underwent phonomicrosurgery for benign vocal cord lesions, encompassing conditions such as polyps, granulomas, nodules, cysts, and papillomatosis. These patients were carefully divided into three distinct groups based on the timing of voice therapy initiation: early initiation within 7 days post-surgery, late initiation after 7 days post-surgery, and a control group that did not receive any voice therapy. The division into these groups was conducted through randomized assignment to ensure an unbiased distribution across the study arms.
Inclusion criteria were set to encompass patients diagnosed with benign vocal fold lesions and undergoing phonomicrosurgery, aged between 18 and 60 years, and with no prior history of voice therapy or vocal fold surgery. Conversely, exclusion criteria were delineated to omit patients with malignant vocal fold lesions, a history of recurrent laryngeal nerve paralysis or other neurological disorders affecting voice, and those unable or unwilling to comply with follow-up and therapy protocols.
The sample size of 20 patients was determined based on preliminary data, which suggested that this number would be sufficient to achieve an 80% power and a level of significance of 0.05. This sample size was also considered feasible given the specific patient population and the intensive nature of the follow-up required.
Vocal outcomes were assessed using two validated tools: the VHI and CAPE-V. The VHI provided a subjective measure of the patient’s perception of their vocal handicap, while the CAPE-V offered an objective assessment of vocal quality. These tools were employed to evaluate the patients’ vocal status both preoperatively and at the end of a 3-month postoperative period. The comparison of preoperative and postoperative scores aimed to discern the effectiveness of the timing of voice therapy in enhancing vocal recovery.
Statistical analysis was conducted using appropriate methods to compare the VHI and CAPE-V scores across the three groups. ANOVA (Analysis of Variance) was utilized to analyze the differences in continuous variables, while chi-square tests were employed for categorical data. The level of significance was set at p < 0.05. This rigorous statistical approach was designed to ensure that the results were not only scientifically valid but also clinically relevant, providing concrete evidence to guide future clinical practices in the management of benign vocal fold lesions.
Results
Demographic Variables and Diagnosis (Table 1)
Table 1.
Demographic variables and diagnosis
| Metric | Early (< 7 days) | Late (> 7 days) | No voice therapy | P-value |
|---|---|---|---|---|
| Age (Mean ± Std) | 41.20 ± 3.96 | 37.25 ± 13.27 | 46.29 ± 5.44 | 0.202054 |
| Age (Min - Max) | 35.0–45.0 | 5.0–46.0 | 40.0–55.0 | |
| Sex Male | 6 (55%) | 5 (45%) | 6 (55%) | 0.322144 |
| Sex Female | 5 (45%) | 6 (55%) | 5 (45%) | |
| Diagnosis VC Polyp | 6 (55%) | 6 (55%) | 3 (25%) | 0.166697 |
| Diagnosis VC Nodule | 5 (45%) | 5 (45%) | 8 (75%) |
Our study meticulously evaluated demographic variables and diagnosis types among patients with benign vocal fold lesions undergoing surgical treatment. The age distribution across the groups indicated no significant differences (p = 0.202054), with the early intervention group averaging 41.20 years (± 3.96), the late group 37.25 years (± 13.27), and the no therapy group 46.29 years (± 5.44). The age range spanned from as young as 5 to as old as 55, indicating a broad applicability of voice therapy across ages.
The gender distribution was balanced across the early and no therapy groups, each with 55% male and 45% female participation, while the late group had a slight female predominance (55%). However, these differences were not statistically significant (p = 0.322144), suggesting that gender does not influence the effectiveness of voice therapy post-surgery.
Diagnosis types were categorized into vocal cord polyps and nodules. Both the early and late groups showed an even distribution of polyps and nodules, with polyps being slightly more prevalent (55%). In contrast, the no therapy group had a higher incidence of nodules (75%), although this difference was not statistically significant (p = 0.166697). This finding suggests that the type of lesion may not significantly impact the response to voice therapy in the postoperative period.
Pre and Post-Operative Scores (Tables 2 and 3)
Table 2.
Pre and post-operative VHI score scores
| Metric | Early (< 7 days) | Late (> 7 days) | No Voice therapy | p-value |
|---|---|---|---|---|
| Pre-Operative VHI Score (Mean ± Std) | 31.60 ± 5.50 | 28.75 ± 12.34 | 36.86 ± 3.48 | 0.216 |
| Post-Operative VHI Score (Mean ± Std) | 8.60 ± 1.52 | 6.25 ± 2.82 | 17.29 ± 4.03 | 0.001 |
| VHI Score P-Value (pre vs. post) | 0.001 | 0.001 | 0.001 |
Table 3.
Pre and post-operative CAPE-V score scores
| Pre-operative CAPE-V score | Post-operative CAPE-V score | |
|---|---|---|
| Early (< 7 days) | ||
| Mild | 0 (0.00%) | 5 (100.00%) |
| Moderate | 2 (40.00%) | 0 (0.00%) |
| Moderate Severe | 2 (40.00%) | N/A |
| Mild-Moderate | N/A | 0 (0.00%) |
| Severe | 1 (20.00%) | N/A |
| Late (> 7 days) | ||
| Mild | 1 (12.50%) | 8 (100.00%) |
| Moderate | 4 (50.00%) | 0 (0.00%) |
| Moderate Severe | 1 (12.50%) | N/A |
| Mild-Moderate | N/A | 0 (0.00%) |
| Severe | 2 (25.00%) | N/A |
| No Voice Therapy | ||
| Mild | 0 (0.00%) | 1 (14.29%) |
| Moderate | 2 (28.57%) | 3 (42.86%) |
| Moderate Severe | 0 (0.00%) | 3 (42.86%) |
| Mild-Moderate | N/A | 3 (42.86%) |
| Severe | 5 (71.43%) | N/A |
Voice Handicap Index (VHI) Scores
The VHI scores provided a compelling narrative of the study. The early group showed a significant reduction in post-operative VHI scores from a pre-operative mean of 31.60 (± 5.50) to a post-operative mean of 8.60 (± 1.52). The late group also demonstrated significant improvement, with scores decreasing from 28.75 (± 12.34) to 6.25 (± 2.82). The no therapy group’s results indicated less improvement, with a post-operative mean score of 17.29 (± 4.03). The changes in VHI scores were statistically significant across all groups (p = 0.001), underscoring the effectiveness of voice therapy in enhancing perceived vocal function post-surgery.
Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) Scores
The CAPE-V scores further substantiated the benefits of voice therapy. In the early intervention group, the post-operative scores were unanimously ‘mild,’ representing a 100% improvement from pre-operative conditions. Similarly, the late intervention group achieved ‘mild’ post-operative scores across the board. In stark contrast, the no therapy group exhibited a considerable portion of patients with ‘moderate’ to ‘moderate-severe’ scores, indicating less favorable outcomes. This disparity highlights the objective advantage of administering voice therapy following surgery for vocal fold lesions.
In summary, the study’s findings emphasize the significance of voice therapy in post-surgical recovery for patients with benign vocal fold lesions, as evidenced by improvements in both subjective and objective vocal parameters. The improvements in post-operative VHI and CAPE-V scores in patients who received early or late therapy demonstrate the importance of timely intervention. The data argue compellingly for the inclusion of structured voice therapy in the standard care protocol for this patient population, to maximize recovery and improve the quality of life.
Discussion
The current study’s exploration into the impact of the timing of voice therapy on vocal outcomes for patients with benign vocal fold lesions post-surgery offers significant insights, particularly when compared with existing literature, including the study by Tang and Thibeault (2017) [15]. This discussion will draw upon a range of studies to contextualize our findings within the broader scope of voice therapy research.
Tang and Thibeault’s research, which categorized interventions into preoperative, pre- and postoperative, and postoperative therapy alone, demonstrated significant improvements in Voice Handicap Index (VHI) total scores with preoperative intervention [15]. Our study extends this understanding by differentiating between early and delayed postoperative interventions, finding significant improvements in postoperative VHI scores, particularly with early intervention (p = 0.001).
Further, studies by Jones et al. (2010) [16] and Schmidt and colleagues (2012) [17] also emphasize the importance of timely intervention in voice therapy. Jones et al. found that early voice therapy intervention, especially within the first few weeks post-surgery, led to quicker vocal recovery. Schmidt et al. echoed these findings, suggesting that delayed intervention might prolong the recovery process.
Our study adds a nuanced understanding of ‘timing’ in the postoperative phase. We observed that patients receiving therapy within 7 days post-surgery showed more significant improvement in their CAPE-V scores, indicating that the timing of intervention plays a critical role in objective vocal outcomes. This finding aligns with the research by Patel (2014) [18], who highlighted the role of early intervention in improving not just the perceptual aspects of voice but also objective measures.
The confluence of findings from our study and existing research, such as Tang and Thibeault’s work, suggests a need for an integrated approach in voice therapy, considering the timing of interventions as a crucial factor. Future research might benefit from larger sample sizes, longer follow-up periods, and a wider range of objective measures for a comprehensive understanding of the benefits of voice therapy post-surgery. Research by Garcia et al. (2016) [19], which utilized a larger cohort, could serve as a model for future studies in this area.
In summary, the current study, along with the existing body of research, underscores the importance of timely voice therapy in improving vocal outcomes post-surgery for benign vocal fold lesions. The findings advocate for early intervention, within a week post-surgery, to optimize patient recovery and vocal function.
Conclusion
This study provides substantial evidence supporting the efficacy of voice therapy in the post-operative management of patients with benign vocal fold lesions. Our findings demonstrate that the timing of voice therapy plays a critical role in determining the extent of improvement in vocal outcomes, as measured by the Voice Handicap Index (VHI) and the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V).
Patients receiving early voice therapy (within 7 days post-surgery) showed significant improvements in their post-operative VHI scores (p = 0.000008), indicating a marked enhancement in their perceived vocal function. This improvement was notably better compared to patients who received late or no voice therapy. The CAPE-V scores also improved significantly in the early intervention group (p = 0.014199), underscoring the objective benefits of timely voice therapy.
These findings align with and extend previous research, emphasizing the importance of not only incorporating voice therapy into post-surgical care but also considering the timing of such interventions. Early voice therapy initiation appears crucial for optimal vocal recovery and function.
Future research should focus on larger patient cohorts, longer follow-up periods, and a broader range of objective vocal parameters to validate and expand upon these findings. The goal should be to refine voice therapy protocols and establish more precise guidelines for the post-operative management of patients with benign vocal fold lesions.
Funding
This research received no specific grant from any agency in public, commercial, or not -for-profit sectors.
Declarations
Ethical Approval
Ensuring the utmost ethical integrity, the study treated patient data with confidentiality, employing anonymization techniques. All processes and procedures conformed rigorously to the institution’s ethical standards.
Informed Consent
was obtained from all individual participants included in the study.
Conflict of interest
Authors have no conflict of interest to declare.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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