Effects and Changes on Voice After Rhinoplasty: A Long-Term Report

Abstract

Introduction:

Vocal changes after rhinoplasty have been poorly investigated, although this surgical procedure is nowadays one of the most requested. The production of voice largely depends on the anatomy and the size of the pyramid and the nasal cavity. The authors report 51 cases of both closed and open rhinoplasty and propose a 2-year report to analyze potential effective changes on voice.

Materials and Methods:

Fifty-one patients were enrolled and evaluated from September of 2012 to January of 2018. All patients were studied before and 2 years after surgery. Vocal changes were assessed with an objective and a subjective evaluation. The first one allowed to perform the measurement of the intensity and frequency of vowel sound (“a”) and nasal consonant sounds (“n” and “m”). For the subjective evaluation, our modified version of Voice Handicap Index Score allowed us to evaluate every single characteristic of the personal perception of voice.

Results:

The objective evaluation showed an increased frequency of production of the consonant sounds in 62% of cases and an increased frequency of production of the vowel sound in 68% of cases. The subjective evaluation allowed us to notice significant changes after surgery (P = .044). No significant differences were noticed between closed and open approach.

Conclusion:

Reduction rhinoplasty technique proved to induce several alterations on vocal pattern. The surgeon should always inform patients about the potential effects on the voice, particularly when such changes may produce influences on the working life.

Introduction

In 2017, the third most requested surgery in the United States was the rhinoplasty technique.¹ The effects of this kind of procedure have already been studied from many points of view; however, scientific production poorly focuses on the changes in voice after the surgery.^2-5 As it is well known, many characteristics of voice largely depend on the size and anatomy of the pyramid and the nasal cavity, the resonance box of the phonatory system.⁶ Primary rhinoplasty is the way to change the aesthetic outcome of the nose but also a good surgical technique that leads to the therapy of upper airway malformations and obstructions. Changes in the anatomy of pyramid and nasal cavity can lead to changes in voice. Human voice is an extraordinary mix of physical phenomena and personal characteristics. It is also one of the greatest ways to communicate our moods. Foroughian et al² investigated the effects of rhinoplasty in 27 Iranian patients with questionnaires, and the authors performed perceptual and acoustic analyses before and 5 months after the operation. Their results showed that reduction rhinoplasty technique has some effects on the voice, but these changes are problematic in general for most patients.^6-10 The aim of our longitudinal study was the analysis of the potential alterations on timbre, tones, and frequency of voice after closed and open rhinoplasty, with a subjective assessment and an objective analysis.

Materials and Methods

We conducted the study from September 2012 (first surgery) to January of 2018 (last evaluation). We enrolled 51 patients (32 females, 19 males, all Italian), aged between 19 and 59 (the average age was 29.8 years), who underwent a primary rhinoplasty with closed approach in 44 cases, with the open technique in 7 cases. We did not include patients affected by chronic respiratory diseases or allergies; secondary procedures were excluded, too. Of our patients, 27% used their voice professionally (14 patients in total, 8 female and 6 male): 7 were teachers, 4 singers, and 3 speakers. Patients’ medical history and preoperative physical evaluation was strongly taken into consideration. All patients were evaluated before surgery, after 6 months, again after 1 year, and finally after 2 years. An accurate clinical history and a written informed consent were obtained from all patients, all were operated on by the same surgeon. This study was approved by local ethical committee according to WMA’s Helsinki guidelines. Grafts were never used for the 51 patients of this study.

A septoplasty was performed on 24 patients who showed septum deviation at the moment of the preoperative evaluation. Nasal splints were removed after an average of 7 days. The postoperative evaluation was conducted after 6 months, 1 year, and 2 years post surgery, if the postoperative period did not show major complications. The evaluation of the voice was conducted with both subjective and objective methods. The subjective method was made up of a questionnaire, the objective one was supported by a spectrographic study through computerized recordings and a software analysis. The questionnaire is a modified version of the Voice Handicap Index Score (translated in Italian)^9,11 and allowed us to analyze the subjective effects. It covers 3 areas: the technical, structural, and perceptive areas with 25 total questions (Table 1). A higher score reflects a greater handicap. The first area (technical leg) is about impact of voice on work and everyday life. The second one (structural leg) consists of questions about detected physical disorders of voice. The third area (perceptive leg) is about the personal emotional perception of voice. The spectrographic analysis, instead, allows one to perform a measurement of the intensity and frequency of A vowel sound (“A”) and nasal consonants (“N” and “M”) before and after surgery and to analyze objective effects. It was conducted with a professional recording system and sounds were analyzed using the open-source PRAAT software (designed and realized by University of Amsterdam, the Netherlands—MAC OS X 10.6.8 version software package). The recordings were obtained in a totally quiet room, using the professional recording system at a constant distance from mouth (4.7 inches). Voices were analyzed in 4-second frames, and for every single sound we extracted a spectrogram and studied it with a spectrographic analysis (Figure 1). The Mann-Whitney U test allowed us to analyze data (expressed as ± standard deviation [SD]-mean) and to compare values before and after the intervention. All changes directly linked to surgery with a P value of .05 or less were statistically significant for the study.

Table 1.

The Voice Handicap Index Score Used in our Study.^a

	Never	Almost Never	Sometimes	Almost Always	Always
Technical leg
I run out of air when I talk.
The sound of my voice varies throughout the day.
People ask, “What’s wrong with your voice?”
My voice sounds creaky and dry.
The clarity of my voice is unpredictable.
I try to change my voice to sound different.
I use a great deal of effort to speak.
My voice is worse in the evening.
Structural leg
My voice makes it difficult for people to hear me.
People have difficulty understanding me in a noisy room.
My family has difficulty hearing me when I call them throughout the house.
I use the phone less often than I would like.
I tend to avoid groups of people because of my voice.
I speak with friends, neighbors, or relatives less often because of my voice.
People ask me to repeat myself when speaking face-to-face.
My voice difficulties restrict my personal and social life.
Perceptive leg
I’m tense when talking with others because of my voice.
People seem irritated with my voice.
I find other people don’t understand my voice problem.
My voice problem upsets me.
My voice makes me feel handicapped.
I feel annoyed when people ask me to repeat.
I feel embarrassed when people ask me to repeat.
My voice makes me feel incompetent.
I’m ashamed of my voice problem.

^aPatients answered this questionnaire, translated in Italian.

Figure 1.

Example of a spectrographic analysis performed in our study.

Surgical Technique

We performed the closed approach for 44 surgical procedures and the open technique for 7 patients. All patients underwent general anesthesia supplemented with infiltration of a local anesthetic (xylocaine 1%) with vasoconstrictor (epinephrine 1:100 000). The closed procedure starts with intercartilaginous incision, performed with a #15 blade scalpel and a double hook retractor, with the following dissection of the vestibular skin. The surgeon dedicated his attention to the reduction in dorsum. The septum is separated bilaterally from the upper lateral cartilages, and later the cartilaginous dorsal septum is reduced with scissors. At this point, an Aufricht elevator allows to manage the bony dorsum reduction: a Joseph periosteal elevator is used to separate the periosteum. For many authors, the reduction is supported by a rasp, but we choose it only for secondary modifications, when required. We generally use a chisel with bilateral rails. The surgeon firmly holds the chisel and checks the correct progression of the instrument. An endonasal incision at the caudal level of piriform aperture allows to perform the lateral osteotomies: Before this step, a Joseph elevator lifts up the periosteum. The guarded osteotome is inserted into the incision, perpendicular to the rim of the maxilla process, for the beginning of a low-to-high osteotomy. Once the osteotome reaches the nasal bones near the medial canthus, it is moved forward to separate the nasal bone from the nasal process of the frontal bones. The bony nasal wall is then shifted with digital pressure. The lateral cartilages can now be treated, and the final step is the management of the nasal tip, performed with a delivery approach. An incision from the lateral to the medial crus, on both sides, allows to expose the lower lateral cartilages to open the way to a “hockey stick” excision. An interdomal suture closes this step. The surgeon checks the shape of the dorsum and provides an appropriate medication with nasal packings and a dorsal splint. The open approach is conducted with similar steps, with a midcolumellar inverted-V incision performed to start the dissection of the skin envelope.

Results

All our 51 patients were studied before, 6 months, 1 year, and 2 years after surgery with reduction rhinoplasty technique. We performed a statistic analysis, using the Mann-Whitney U test, for the 2 evaluation systems. All data were expressed as ± SD (mean). The modified version of Voice Handicap Index Score allowed us to study every single property of the personal perception of voice. We found a significant difference after surgery not only for the total score (P = .044) but also for the separate areas of study (P = .045 for the technical leg, P = .043 for the structural leg, and P = .045 for the perceptive leg). These results are shown in Table 2. The increased score suggests that vocal features change after this kind of surgery, indicating a worsening of voice quality. The spectrographic analysis was performed separately for the 3 single sounds (“A” vowel, “N” and “M” consonants), before, 6 months, 1 year, and 2 years after surgery. For each spectrogram, we studied frequency (data expressed in Hertz), intensity (data expressed in dB), and sound pressure level (data expressed in dB/Hz; Figure 2). We detected an increased frequency of production of consonant sounds in 62% of cases, while in 68% of cases the same phenomenon was noticed for vowel sounds. The difference of mean values of frequencies was significant after surgery (P = .0018 for “A” vowel, P = .040 for “N” consonant, and P = .024 for “M” consonant; Table 3). The role of septoplasty does not appear crucial for the 24 patients who underwent this additional procedure. Both the objective and the subjective analyses showed data in keeping with the other results. The results of these analyses are shown in Tables 4 and 5. In the immediate postoperative period (2 weeks) we did not detect major complications, although 4 cases of ecchymosis and 2 cases of minor skin inflammatory reaction were reported.

Table 2.

Results of Subjective Evaluation.

Voice Handicap Index Score Area	Before Surgery	6 Months After Surgery	1 Year After Surgery	2 Years After Surgery	P Value
Technical leg	1.8 ± 2.1	3.1 ± 3.5	3.7 ± 3.9	3.9 ± 4	.045
Structural leg	2 ± 3.9	4.2 ± 4.4	4.7 ± 4.9	4.9 ± 4.6	.043
Perceptive leg	0.1 ± 0.2	0.1 ± 0.3	0.3 ± 0.4	0.4 ± 0.6	.045
Total	3.1 ± 4.2	5.6 ± 7.8	9.9 ± 12.2	9.7 ± 13.5	.044

Figure 2.

Comparison of spectrographic analyses of a patient before and after surgery.

Table 3.

Results of Objective Evaluation.

Analyzed Sound Parameter	Before Surgery	6 Months After Surgery	1 Year After Surgery	2 Years After Surgery	P Value
“A” Vowel Frequency (Hz)	717 ± 69	755 ± 71	784 ± 73	796 ± 75	.0018
“N” Consonant Frequency (Hz)	269 ± 18	282 ± 34	288 ± 39	290 ± 39	.040
“M” Consonant Frequency (Hz)	168 ± 24	189 ± 23	212 ± 21	214 ± 22	.024

Table 4.

Results of Subjective Evaluation of 24 Patients Who Also Underwent Septoplasty.

Voice Handicap Index Score Area	Before Surgery	6 Months After Surgery	1 Year After Surgery	2 Years After Surgery	P Value
Technical leg	2.1 ± 3.3	4.1 ± 3.7	4.4 ± 3.9	4.5 ± 3.9	.047
Structural leg	2.2 ± 4.1	4.5 ± 4.2	4.6 ± 4.1	4.9 ± 4.3	.049
Perceptive leg	0.9 ± 0.5	0.7 ± 0.8	0.6 ± 0.9	0.7 ± 0.9	.040
Total	3.8 ± 5.3	5.4 ± 7.8	9.6 ± 11.2	9.8 ± 11.7	.049

Table 5.

Results of Objective Evaluation of 24 Patients Who Also Underwent Septoplasty.

Analyzed Sound Parameter	Before Surgery	6 Months After Surgery	1 Year After Surgery	2 Years After Surgery	P Value
“A” Vowel Frequency (Hz)	720 ± 27	728 ± 29	733 ± 31	748 ± 32	.0069
“N” Consonant Frequency (Hz)	282 ± 19	278 ± 14	291 ± 11	293 ± 13	.045
“M” Consonant Frequency (Hz)	191 ± 24	199 ± 28	205 ± 28	209 ± 29	.044

Discussion

Our long-term study focused on the effects and changes in voice after a reduction rhinoplasty technique, one of the most requested aesthetic surgeries today, and provided some statistically significant measures about changes in several features of voice. We started from the idea that the narrowing of nasal cavity, the resonance box of the phonatory system, could lead to significant changes in frequency and personal perception of vocal pattern. The resistance that the nasal cavity offers basically depends on the anatomy and size of the cavity itself. Every anterior obstruction leads to an increased resistance of nasal airflow by shortening the airway patency. Past scientific production has shown how surgery can change the personal perception of voice,^12-15 but literature poorly focused on the analysis of effective and significant effects on voice after rhinoplasty.^11,16-21 The impact of this kind of surgery has received little attention, although its role about nasal resonance is well known. As recently underlined by Yeung et al,²² the anatomy of the nasal airway seems to be crucial since the introduction of the term nasal valve in 1920²¹; following this way, physicians have considered 2 components of the nasal valve: the external nasal valve and the internal nasal valve. Plastic surgeons must face the question brought by the lack of cartilage support in the area between the external and the internal nasal valves. Many prefer the open approach and the consequent use of grafts.²³ Nasal narrowing brought by lateral osteotomies may be considered significant in the development of a “new” voice after surgery (Figure 3). We tried to fill this empty space, so we conducted a study with 51 patients who underwent a primary rhinoplasty. A subjective and an objective analysis supported this evaluation, the first one coadiuvated by a modified version of the “Voice Handicap Index Score” questionnaire (it was translated in Italian⁷) and the second one by a spectrographic comparison of 3 sounds frequencies (“A” vowel and “N”/”M” consonants, recorded with a professional software and expressed in Hertz) before and after surgery.

Figure 3.

Nasal narrowing produced by lateral osteotomies.

The subjective evaluation helped us to notice a significant difference in the perception of voice after surgery (P = .044). Behlau et al¹² investigated a population of 975 patients who answered a questionnaire consisting of 10 questions from 2 areas, physical functioning and social–emotional functioning: They found that the relationship between self-assessment of voice quality and questionnaire scores was very clear and statistically significant, especially when considering the group with a known voice disorder. In our study, the total subjective analysis showed a significant difference in the perception of voice after surgery (P = .044). We also considered every single area of the questionnaire: every single leg showed, separately, a significant difference (P = .045 for the technical leg, P = .043 for the structural leg, and P = .045 for the perceptive leg). This result reflects the impact on the real quality of life, but the type of instrument used and the variables regarding age, gender, comorbidities, and work can influence the results of modified Voice Handicap Index Score among patients, as Martinello et al detected for teachers¹³ and by Swapna et al¹⁴ for geriatric patients.

We think that these changes could originate from lateral osteotomies performed during the rhinoplasty: Although this kind of surgery is therapeutic for several chronic respiratory diseases, the procedure in examination has the potential to affect in this way nasal resonance and voice by changing the resonant characteristics of the phonatory system.

The objective evaluation, supported by a professional technology (the open-source software “PRAAT” and a professional recording system), allowed us to find effective changes in frequency, amplitude, and intensity of voice after surgery. This evaluation was repeated after 1 year and 2 years. All data extracted from the spectrograms were expressed as mean ± SD and analyzed with the Mann-Whitney U test. A spectrogram is a graphic spectrotemporal representation of a sound. The horizontal direction represents the time, the vertical direction reports frequency values. Results of spectrographic analysis showed a significant increase in the frequency production for the “A” vowel and the “N”/“M” consonants (P = .0018 for “A” vowel, P = .040 for “N” consonant, and P = .024 for “M” consonant).

This is the first and the longest reported study on rhinoplasty conducted with this method. We also believe that this evaluation has several limits, for 2 reasons. First, the aim of our study was the evaluation of changes on voice after a single and standardized surgical procedure. This also explains why we never used grafts or additional procedures for the 51 patients of our study. Second, at the time of the final evaluation (after 2 years), we did not study a sufficient and homogeneous number of patients who underwent open rhinoplasty (7 patients underwent open rhinoplasty). For the same reason, we did not include additional procedures, which are largely performed today. Our aim was the evaluation after a simple and widely performed technique, without additional changes on the airway.

We supposed that these effects could originate from anatomic changes brought by lateral osteotomies during the surgical procedure. This theory is supported by 2 statements: First, the objective and subjective analyses performed on the 24 patients who also underwent septoplasty showed results in line with the total group. Second, the procedure we performed for all 51 patients did not include turbinectomy or the use of grafts. The procedure leads to an increased resistance to the airflow passing through the nasal cavity, which remains constant 2 years after surgery. Our longitudinal study shows effective and statistically significant effects on voice from several points of view. We will, however, continue the study with more patients (supported by a stronger comparison with the open approach procedure) in order to confirm the results we found during this period of evaluation.

Conclusion

From our 2-year evaluation, we found that reduction rhinoplasty technique can have statistically significant effects on voice characteristics. The subjective analysis reveals how patients who work with voice can feel the changes after surgery. The objective evaluation shows significant differences in sound amplitude and frequency after this surgical approach. Many patients who undergo rhinoplasty think that the surgical procedure only leads to anatomical changes and improvement in respiratory function. As this study reveals, such changes may have influence on the working life of the patients, although further studies, linked with evaluations on nasal airway resistance, are indicated to confirm this theory. The surgeon should instead accurately inform patients about the potential effects on their voice, particularly in cases where such changes may have influences on the working life of the patients. In these cases, patients might not like a new personal perception of vocal pattern.