Abstract
Emergence of “Voice specialty clinics” in ENT and Speech Language Pathologist (SLP) practice in India necessitates development of standard protocols for assessment and management of voice disorders. Based on recommendations from European Laryngological Society in Dejonckere (Eur Arch Otorhinolaryngol 258:77–82, 2001), a comprehensive voice assessment protocol was adapted for Indian population. This study aimed at verifying the face validity and feasibility of using the developed voice assessment protocol in a multi specialty tertiary care hospital. It included: history, clinical examination, visual analysis, perceptual analysis, aerodynamic measures, acoustic analysis and patients’ self assessment of voice. The developed protocol was administered on 200 patients with voice concerns and problems. Correlation of self assessment with the assessment by the professionals was done using Kendaul tau_b correlation test. The scores of self assessment did not correlate significantly with acoustic measures. Differences in lab findings and self percept of voice indicated that these two were complementary measures in the protocol. Further, diagnosis and management decisions were arrived through a consensus discussion involving the ENT surgeon, SLP and the patient. Vocal hygiene and voice conservation were advised to all patients. Recommendations for voice therapy and/or surgery were provided based on findings from the protocol. The study demonstrated feasibility of using a comprehensive protocol for effective documentation, comparisons, review, training and treatment planning.
Keywords: Voice protocol, Multi-parametric analysis, Self assessment, Clinical decisions
Introduction
Voice disorders are deviations in terms of ‘quality, pitch, loudness, or flexibility in voice’ from the voices of others of similar age, sex and cultural groups [1, 2]. They are classified as organic, functional or a combination of both [3]. According to a study in 2007 [4], around six percent of the general population in the world experiences voice problem. A survey in 2008, on professional voice users in India estimates an alarming 40–50% incidence of voice disorders among singers, teachers, politicians and vendors (hawkers) [5]. Although, voice disorders are not life threatening (other than malignancies), they impose a significant impact on day- to- day activities [6]. According to Smith et al., the estimate of the impact of voice disorders is found to be similar to impact of life threatening diseases such as cancer [7]. These have necessitated the concerned to reach voice clinics for help in recent years.
Voice function is multidimensional and complete analysis of all aspects of the voice problem such as structural and behavioral changes, functional impact of voice etc. is essential. So, a basic comprehensive protocol is needed and will be useful to assess organic and functional voice disorders (dysphonia). Such a protocol will also be useful in making comparisons with literature when presenting/publishing the results of voice analysis/treatments, and meta-analysis. In most voice clinics, the ENT surgeon makes diagnosis based on clinical and endoscopic examination of the larynx. The speech pathologist evaluates the voice for its function perceptually and acoustically (if available) after a referral from the ENT surgeon. Decision on management is made after these initial assessments by the professionals (independently/jointly).
In the recent years, voice facilities in India have been improving and professionals involved are increasingly dependent on each other to arrive at diagnostic and treatment decisions. This proposed comprehensive protocol will also facilitate communication of results among professionals (ENT surgeons, SLP, referring specialists, etc.) and including the patient while making decisions on management, hence leading to better patient care, and documentation.
The protocol is based on the framework proposed by the European Laryngological Society. The European Laryngological Society (ELS) guidelines primarily advocate a basic non-sophisticated multi parametric approach to voice assessment. The guidelines of the ELS include five components: perceptual evaluation, stroboscopy, acoustic analysis, aerodynamic measures, and self-evaluation. In the same line the following protocol was proposed considering economy of time, professionals involved and instrumentation to suit Indian needs, yet meet international standards.
Aim of the Study
The present study aimed (1) To develop a comprehensive protocol to assess organic and functional voice disorders (2) To check face validity and feasibility of using the comprehensive protocol in an interdisciplinary voice clinic of a tertiary care centre.
Method
Based on the recommendations made by ELS a comprehensive voice assessment protocol was developed. The protocol was given to four ENT surgeons and Speech Pathologists for content verification. The ENT surgeons and the Speech pathologists were asked to include and modify the protocol to meet the needs of the Indian scenario. The suggestions and modifications were incorporated for the final version of the voice assessment protocol. The developed protocol was administered on 200 patients who reported to the hospital with voice related concerns and problems. A data recording sheet was constructed to accommodate all components of voice assessment and the data was subjected to statistical analysis.
Analysis
Correlating the subjective self assessment and a multiparametric acoustic analysis using Kendaul tau_b correlation test.
Classification of voice disorders and management decision based on the findings from the protocol.
Results and Discussion
The results are presented in three sections:
-
I.
The protocol that was developed (Annexure 1)
-
II.
Correlation of patients’ self assessment of voice and acoustic analysis by the professional
-
III.
Categorization of voice disorders and management decisions
Development of the Protocol
A culture specific voice assessment protocol had been developed based on ELS protocol and it included:
Significant history
Clinical examination based on physical inspection and indirect laryngeal examination.
Visual analysis: It involved stroboscopic assessment of parameters such as glottal closure pattern [8], regularity, symmetry of the vocal fold vibration, mucosal wave, amplitude of vocal cord vibration, Non vibratory portion and hyperadduction of ventricular band.
Perceptual assessment: It included auditory perceptual assessment on a GRBAS scale [9] (G- Grade; R- Roughness; B- Breathiness; A- Asthenia and S- Strained) in ‘speaking voice’ (spontaneous speech/reading/counting numbers) and voice profile (pitch, loudness, quality, pitch breaks and voice breaks) in ‘phonated voice’ (sustained vowels) by the Speech pathologist.
Aerodynamic measures: It included simple aerodynamic measurements such as Maximum Phonation Time (MPT) and s/z ratio.
Acoustic analysis: It included frequency and intensity parameters, perturbation related measures, and Dysphonia Severity Index (DSI), a single weighted multiparametric measure [10].
Self evaluation by the patient: Voice Disorder Outcome Profile (V-DOP) developed by Mahalingam et al. [11] was administered for assessing individual’s percept of voice problems in domains such as physical, emotional and functional aspects for Indian population. [Annexure 2 (English version) and Annexure 3 (Tamil version)]
Reporting: The ENT surgeon made the preliminary medical diagnosis. The SLP evaluated vocal functions and behaviors. Final diagnosis and recommendation for treatment was decided by the ENT surgeon and the SLP.
Correlation of Patients’ Self Assessment of Voice and Acoustic Analysis by the Professional
Correlation between the physical, emotional, functional domains, total score and self perceived severity of V-DOP with the parameters of acoustic measures was evaluated using Kendaul tau_b correlation test. The results are tabulated in Table 1. The overall perceived severity of the voice disorder showed a negative correlation (r = −0.46; P < 0.05) with F0-high (Hz). This probably is due to association of the patient’s inability to sustain high pitches (restricted frequency range). There was a negative correlation (r = −0.3; P < 0.05) between physical domain and the MPT. Reduced MPT implied poor coordination between breathing and phonation or incapacity of the voice production mechanism. This reflected in elevated physical (discomfort) score and was statistically significant. However, the total V-DOP score did not correlate significantly with any of the parameters of acoustic analysis i.e. jitter %, I0-low dB (A), F0-high (Hz), maximum phonation time (sec) and DSI.
Table 1.
Kendall’s tau_b correlation between scores of V-DOP and parameters of the acoustic measures
| Jitter (%) | I0-low dB (A) | F0-high (Hz) | MPT (sec) | DSI | |
|---|---|---|---|---|---|
| Severity | −0.03 | −0.01 | −0.46* | 0.02 | −0.01 |
| Physical | 0.04 | −0.03 | −0.01 | −0.3* | 0.03 |
| Emotional | 0.00 | 0.04 | 0.06 | −0.01 | 0.17 |
| Functional | 0.02 | 0.06 | 0.05 | −0.14 | 0.04 |
| Total | 0.03 | 0.09 | 0.04 | −0.09 | 0.03 |
* Correlation is significant at 0.05 level
Categorization of Voice Disorders and Management Decisions
Based on the information from history, behavioral observation and visual analysis, clinical diagnosis was made as organic or functional voice disorder. The clinical diagnosis and treatment decisions of Organic and Functional voice disorders are given in Tables 2 and 3, respectively. All patients presented with changes in voice with varying degrees of severity. Acoustic and aerodynamic analysis allowed documentation of vocal function (allowing scope for comparisons during/after treatment). Self assessment provided scope to understand the impact of the voice change in the patient’s life. The table below summarizes the choice of management. All subjects were counseled on vocal hygiene and conservative voice use. Adequate hydration, dietary modification to reduce reflux disease and refraining from abusive vocal behaviors were recommended.
Table 2.
Clinical diagnosis and treatment decisions of organic voice disorders
| Voice disorder | No. of subjects | Diagnosis | Criteria for choice of management (information on visual analysis) | Treatment decisions |
|---|---|---|---|---|
| Vocal fold nodule (early) | 23 (7 M and 16 F) | Hyperfunctional voice disorder | Soft pliable nodules with mucosal waves present | Voice therapy—breathing and vocal function exercises |
| Vocal fold nodule (organized) | 2 (1 M and 1 F) | Hyperfunctional voice disorder | Organized nodule, stiff and waves absent at the site, tensed larynx (MTD grade I, II or III) | Trial Voice therapy for 1 month focusing on reduction of vocal hyperfunction, Re- assessment and microlaryngeal surgery (MLS) followed by voice therapy |
| Chronic laryngitis/vocal fold scarring | 16 (7 M and 9 F) | Hyperfunctional voice disorder | Inflammation and hypertrophied larynx, stiffness of cord increases; mucosal wave reduced or absent at site | Anti inflammatory medications, Voice therapy to unlearn hyperfunctional behaviors |
| Vocal fold polyp/polypoidal degeneration | 16 (11 M and 5 F) | Hyperfunctional voice disorder | Soft pliable polyp; increased mass; aperiodic and asymmetric movements; compensatory hyperfucntion. (MTD grade I, II or III) | Microlaryngeal surgery (MLS) followed by voice therapy |
| Vocal fold papilloma | 2 (2 M) | Hyperfunctional voice disorder | Multiple growth at glottis or subglottis; stiff and waves absent at the site | Microlaryngeal surgery (MLS) followed by voice therapy |
| Glottal web | 5 (5 M) | Hyperfunctional voice disorder | Reduced vibratory area | Excision of the web |
| LPR | 12 (8 M and 4 F) | Hyperfunctional voice disorder | Vocal fold edema, interaryntenoid band and arytenoid congestion | Proton pump inhibitors (PPI) and Prokinetics, lifestyle modification and follow up |
| Vocal fold edema | 14 (4 M and 10 F) | Hyperfunctional voice disorder | Increased mass and aperiodic and asymmetrical; compensatory hyperfucntion (MTD grade I, II or III) | Anti inflammatory medications and voice therapy |
| Unilateral vocal fold paralysis/paresis | 20 (12 M and 8 F) | Hypofunctional voice disorder | Bowing of vocal folds, level difference, compensatory hyperfunction (MTD grade I, II or III) | Voice therapy—effort closure exercises and vocal function exercises for 3 months, Re- assessment and medialization thyroplasty |
| Keratosis | 10 (5 M and 5 F) | Hyperfunctional voice disorder | Leukoplakia growth or plaque, stiff and waves absent at the site, tensed larynx (MTD grade I, II or III) | Microlaryngeal surgery (MLS) followed by voice therapy |
| Sulcus vocalis | 13 (10 M and 3 F) | Hypofunctional voice disorder | Decreased mass and increased stiffness, reduced/absent mucosal wave and amplitude; compensatory hyperfunction (MTD grade I, II or III) | Fat injection laryngoplasty followed by voice therapy |
| Contact ulcer | 1 (1 M) | Hyperfunctional voice disorder | Ulceration, inflammation, tensed larynx (MTD grade I, II or III) | Anti inflammatory medications and voice therapy |
| Hematoma | 2 (2 M) | Hyperfunctional voice disorder | Localized collection of blood, reduced mucosal wave, tensed larynx (MTD grade I, II or III) | Microlaryngeal surgery (MLS) followed by voice therapy |
| Intracordal cyst | 9 (3 M and 6 F) | Hyperfunctional voice disorder | Stiff, aperiodic, compensatory hyperfunction | Microlaryngeal surgery (MLS) followed by voice therapy |
| Ectasia | 1 (1 F) | Hyperfunctional voice disorder | Dilated blood vessel, aperiodic, reduced amplitude and mucosal wave | Voice rest |
| Adductor spasmodic dysphonia | 1 (1 F) | Hyperfunctional voice disorder | Quick adductory movements and tensed larynx | Neurological evaluation and voice therapy |
| Laryngeal tremor | 1(1 M) | Hyperfunctional voice disorder | Rhythmic movement, tensed larynx (MTD grade I, II or III) | Neurological evaluation and voice therapy |
| Presbylarynges | 2 (2 M) | Hypofunctional voice disorder | Atrophy and bowing of vocal fold, compensatory hyperfunction (MTD grade I, II or III) | Voice therapy |
Table 3.
Clinical diagnosis and treatment decisions of Functional voice disorders
| Voice disorder | No. of subjects | Diagnosis | Criteria for choice of management (information on visual analysis) | Treatment decisions |
|---|---|---|---|---|
| Dysphonia | 21 (9 M and 12 F) | Hyperfunctional voice disorder | Tensed larynx | Voice therapy—breathing and vocal function exercises |
| Plica ventricularis | 2 (2 M) | Hyperfunctional voice disorder | Ventricular band hyperadduction and strain | Voice therapy—vocal function exercises |
| Muscle tension dysphonia (grades I, II, and III) | 7 (4 M and 3 F) | Hyperfunctional voice disorder | Excessive muscle tension, normal structures, tensed larynx | Voice therapy—laryngeal massage, breathing and vocal function exercises |
| Functional aphonia | 1 (1 F) | Hypofunctional voice disorder | Unable to adduct during phonation, but adducts during cough and laugh | Voice therapy |
| Puberphonia | 19 (19 M) | Hyperfunctional voice disorder | Normal structures, stiff vocal folds, posterior glottic chink (in many), tensed larynx | Pitch alteration and vocal function exercises |
Discussing specifics of every patient is beyond the scope of this article, and so most observable signs are documented in the above table
Conclusions
The study highlighted the feasibility of using a culturally adapted comprehensive protocol for inter-disciplinary approach to voice diagnostics and management. Differences in lab findings and self percept of voice indicated that these two are complementary measures for comprehensive voice analysis and treatment. Such information would be helpful in clinical decisions such as prioritizing patient selection for treatment. Addressing this difference through client education becomes crucial in management. Visualization of laryngeal function helped patients and family members to understand the mechanism of vocal function and hence aided in counseling to improve compliance in the treatment. The protocol also serves as an excellent tool for teaching juniors and residents in training.
References
- 1.Dejonckere P, Bradeley P, Clemente P, Cornut G, Buchman LC, Friedrich G, Van De Heyning P, Remacle M, Woisard V. A basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques. Eur Arch Otorhinolaryngol. 2001;258:77–82. doi: 10.1007/s004050000299. [DOI] [PubMed] [Google Scholar]
- 2.Aronson AE. Clinical voice disorders: an interdisciplinary approach. 3. New York: Thieme; 1990. [Google Scholar]
- 3.Boone DR, McFarlane SC, Von Berg SL. The voice and voice therapy. 7. Boston: Pearson Education; 2005. [Google Scholar]
- 4.Estella P, Edwin M. Application of the ICF in voice disorders. Semi Sp Lang. 2007;28(4):343–350. doi: 10.1055/s-2007-986531. [DOI] [PubMed] [Google Scholar]
- 5.Boominathan P, Rajendran A, Nagarajan R, Jayashree S, Muthukumaran G. Vocal abuse and vocal hygiene practices among different level professional voice users in India—a survey. Asia Pac J Sp Lang Hear. 2008;11(1):47–53. doi: 10.1179/136132808805297322. [DOI] [Google Scholar]
- 6.Boominathan P, Shekar DC, Nagarajan R, Zainab M, Rajan A. Vocal hygiene awareness program for professional voice users (teachers)—an evaluative study from Chennai. Asia Pac J Sp Lang Hear. 2008;11(1):39–45. doi: 10.1179/136132808805297377. [DOI] [Google Scholar]
- 7.Smith E, Verdolini K, Gray S. Effect of voice disorders on quality of life. J Med Sp Lang Path. 1996;4(4):223–244. [Google Scholar]
- 8.Hirano M, Bless DM. Videostroboscopic examination of the larynx. San Diego: Singilar Publishing; 1993. [Google Scholar]
- 9.Hirano M. Objective evaluation of the human voice: clinical aspects. Folia Phoniatr. 1989;41:89–144. doi: 10.1159/000265950. [DOI] [PubMed] [Google Scholar]
- 10.Wuyts FL, De Bodt MS, Molenberghs G, et al. The dysphonia severity index: an objective measure of vocal quality based on a multiparametric approach. J Speech Lang Hear Res. 2001;43:796–809. doi: 10.1044/jslhr.4303.796. [DOI] [PubMed] [Google Scholar]
- 11.Mahalingam S, Boominathan P, Balasubramaniyan B (2010) Correlation of dysphonia severity index (DSI) and voice disorder outcome profile (V-DOP). In: Paper presented at the 4th World voice congress; 2010 Sep 6–9. Seoul, South Korea