Abstract
Post treatment voice quality is an important consideration in choosing the management option for laryngeal cancer. We assessed voice quality after radiotherapy in patients of early squamous cell carcinoma of glottis comprehensively using Videolaryngostroboscopy (VLS), Grade, Roughness, Breathiness, Asthenia and Strain (GRBAS) scores and Voice Handicap Index (VHI)-10. Fifty four consenting patients of early squamous cell carcinoma of glottis (Tis, T1 and T2) awaiting definitive radiotherapy were recruited consecutively. Voice was evaluated by VLS, GRBAS scores and VHI-10 before radiotherapy as well as 3 months and 12 months after radiotherapy. There were 52 males and 2 females in the study. Hoarseness of voice was the commonest presenting symptom. Mean duration of symptoms was 2.45 months (± 0.80), ranging from 1 to 4 months. 35 (64.82%) were T1 while 19 (35.18%) were T2 lesions. They received 60–70 Gy of radiotherapy in 28–35 fractions. There was only one recurrence on follow up for 12 months. On VLS at 12 months post-RT the periodicity, phase symmetry, mucosal waves and amplitude were normal in 74.07%, 70.37%, 56.67% and 78.7% cases respectively. Complete glottic closure was obtained in 72.22%. The voice was ‘acceptable’ (Grade 1 or 2 on VLS parameters) in more than 90% cases. Mean total GRBAS score was 3.39 (± 2.67). Mean total VHI-10 was 6.7 (± 1.75). All indices were significantly better than pre RT levels. Good quality of voice can be expected after radiotherapy for early glottic cancer in majority of patients.
Keywords: Laryngeal, Glottis, Voice quality, Radiotherapy, Hoarseness, Stroboscopy
Introduction
An impairment of voice not only interferes with daily life activities, but can also be emotionally devastating to the patient. Voice disorders, thus, have functional, emotional and psychosocial effect on an individual’s daily life. The impact of a disease process or its management on voice should not be underestimated [1, 2].
Laryngeal carcinoma is one of the most common carcinoma among Head and Neck malignancies and also the most important cause of change in voice quality. In India, the prevalence of laryngeal cancer is 3–6% of all cancers in men [3]. Histo-pathologically, glottic carcinomas are Squamous Cell Carcinomas in majority of cases. Smoking and alcohol are considered the main risk factors.
Hoarseness of voice is an early and the most common symptom of glottic cancer. Minimal change in vocal cord structure causes dramatic change in voice, hence these patients present early. Further, due to a paucity of lymphatics, nodal involvement is late. Both these factors result in very high success rate of treatment of Early Glottic Carcinoma which comprises Tis, T1 and T2 tumours without nodal or distant metastasis. These are treated with single modality of treatment which include surgery (open surgical procedures/CO2 laser assisted resection/radiofrequency assisted ablation i.e. coblation) and radiotherapy (RT). The cure rate in Early Glottic Carcinoma, as reported in the literature, is 90% and it is same for all treatment modalities [4], hence, voice quality after the treatment may be an important consideration for choosing the treatment modality in these cases.
Deterioration of voice quality after the treatment is a matter of concern for the clinician as well as the patient. Campos et al. [5] suggested that some degree of voice problem may persist in such cases for a long time after the treatment is completed. While the loco-regional control of the disease with various modalities of treatment for Early Glottic Carcinoma has been extensively studied, the issue of voice quality achieved after treatment with various treatment modalities is far from settled.
Studies involving comprehensive evaluation of voice pre- and post-RT are not many. Therefore, there is a need for a prospective study comparing the voice before and after RT in a comprehensive manner utilizing multiple and complimentary tools.
In this study, we have evaluated the voice of patients of Early Glottic Carcinoma pre-RT and compared it with post-RT voice at 3 months and also at 12 months after completion of therapy for long term evaluation of voice. Comprehensive analysis of voice has been carried out utilizing the tools which may be complimentary to each other, namely, instrument based structural and functional analysis of voice apparatus using Videolaryngostroboscopy (VLS), perceptual analysis of voice by Grade, Roughness, Breathiness, Asthenia and Strain (GRBAS) scale and patients’ own assessment of handicap due to voice using Voice Handicap Index (VHI)-10.
Materials and Methods
This study was carried out at a tertiary care hospital from Mar 2016 to July 2019. Ethical clearance was obtained from the Institutional Ethics Committee and approval from the Scientific Review Committee of our Institute. Informed consent for RT as well as to participate in the study was obtained from all patients.
Considering the primary objective of the study i.e. pre- and post-RT voice quality (paired t test), for an α error (two-tailed) of 0.05, β error of 0.10, effect size of 0.5, standard deviation of change S(Δ) = 1.000; and keeping 10% allowance for loss to follow up, the sample size calculated was 47. However, we were able to study 54 cases which are presented here.
Inclusion Criteria
Patients of early stage laryngeal (glottic) carcinoma (Tis, T1, T2, without nodal or distant metastasis) who chose RT as definitive therapy.
Exclusion Criteria
Patients with recurrent carcinoma glottis.
Presence of any other Head and Neck primary tumour.
Any other co-existing disease affecting the larynx like Tuberculosis, thyroid disease.
Previous neck surgery, phono surgery or RT.
Patients who could not give up smoking before enrolment in the study.
Methodology
All patients reporting to our Out Patient Dept were screened as per the inclusion and exclusion criteria. History was elicited for various symptoms of vocal cord carcinoma, smoking and alcohol consumption. Complete general physical examination and systemic examination to rule out any local/distant metastasis or related co morbidities was carried out. Detailed ENT and Neck examination was done.
All patients underwent endoscopic examination of larynx using Hopkin’s telescope—70° and 90°—to determine extent of lesion and vocal cord mobility. CECT neck to determine extent of lesion, nodal status and presence of any secondary lesion was also done.
Patients underwent haematological and biochemical investigations, chest X-ray, electrocardiogram, ultrasound abdomen and pre-anaesthetic check-up. After getting fitness for surgery all the patients underwent Microlaryngoscopy, mapping of disease and biopsy from the lesion for histo-pathological examination. Staging of the disease was done after confirming the disease histo-pathologically.
All the patients were counseled regarding the advantages and disadvantages of the treatment options available. Treatment modality was chosen by mutual agreement between the patient and the clinician, after thorough discussion in the tumour board (attended by the patient), considering the pros and cons of each modality. Once, the patient consented to undergo RT, he/she was enrolled in the study.
In all enrolled patients, VLS was performed to assess the glottic closure, phase symmetry, periodicity, mucosal wave and amplitude before commencement of RT.The patient was seated in the examination chair at a comfortable height. The throat was sprayed with 4% lignocaine spray. A Karl Storz®70° rigid telescope (Tuttlingen, Germany) and Invisia Highlight Basic® (Padova, Italy) stroboscope were used. The examination was recorded and archived for future references. Two experienced Laryngologists scored the videotaped recordings. The findings were assessed according to a rating scale adapted from a study by Bless et al. [6] and noted as per the joint decision of the two Laryngologists.
In addition to VLS, the voice of the patient was graded by an expert using GRBAS scale [7], on a point Likert scale 0 (normal), 1 (slight), 2 (moderate), 3 (severe). For this, the participants read a phonetically balanced passage and produced a prolonged vowel sound in a sound proof room. The audio recordings were obtained and rated according to the GRBAS voice scale. The patients also completed voice-specific questionnaire i.e. VHI-10 [8] pre-RT.
The patients were referred to Department of Radiation Oncology for RT. While awaiting RT all of them were offered speech therapy in some form or the other. RT was given by Theratron-1000E, Cobalt 60 teletherapy machine (Siemens). Treatment plan was made on Radiotherapy Simulator Siemens 3000 for Intensity Modulated RT. Target volume encompassed the larynx, sparing the suprahyoid epiglottis.
All patients were followed up at 3 months and at 12 months after completion of RT. During the follow up, a complete ENT evaluation was done to rule out any residual/recurrent lesion. VLS findings, GRBAS score and VHI-10 scores were also recorded at each visit.
Statistical Analysis
Descriptive and demographic statistics have been presented as mean and standard deviation or proportions and percentage. Pre-and post-RT GRBAS scores and VHI-10 scores were compared using two tailed paired ‘t’ test, while Chi squared test was used to analyse VLS findings. Statistical analyses were performed using IBM© SPSS© Statistics for Windows, Version 22. A p value < 0.05 was considered significant.
Results
All of the 54 consenting patients successfully completed their planned RT-33 (61.11%) patients received 63 Gy in 28 fractions while 20 (37.04%) received 70 Gy in 35 fractions and 1 (1.85%) received 60 Gy in 30 fractions. All patients were available for follow up at 3 and 12 months after completion of RT. Demographic and descriptive statistics are summarised in Table 1. None of the patients had a family history of Glottic Carcinoma. Forty (74.07%) were smokers (regular/occasional/reformed) while 14 (25.93%) never smoked. Thirty one patients (57.4%) gave history of alcohol consumption. Twenty one (38.89%) had positive history for both smoking as well as alcohol consumption. Most of the patients presented with hoarseness of voice. The mean duration of symptoms was 2.45 months (SD; 0.80), ranging from 1 to 4 months.
Table 1.
Demographic and descriptive statistics (n = 54)
| Variable/parameter | Number | % |
|---|---|---|
| Age group (years) | ||
| 41–50 | 01 | 01.85 |
| 51–60 | 20 | 37.04 |
| 61–70 | 28 | 51.85 |
| 71–80 | 05 | 09.26 |
| Gender | ||
| Male | 52 | 96.3 |
| Female | 02 | 03.7 |
| Main presenting symptom | ||
| Hoarseness of voice | 44 | 81.5 |
| Odynophagia | 4 | 7.4 |
| Chronic cough | 4 | 7.4 |
| Foreign body sensation in throat | 2 | 3.7 |
| Co-morbidities | ||
| Coronary artery disease | 08 | 14.8 |
| Hypertension | 14 | 25.9 |
| Chronic obstructive pulmonary disease | 05 | 10 |
| Diabetes mellitus type II | 05 | 10 |
| Gastro-esophageal reflux disease | 06 | 11.1 |
| Multiple diseases | 11 | 20.4 |
| No co-morbidity | 26 | 48.1 |
| T stage | ||
| T1a | 25 | 46.30 |
| T1b | 10 | 18.52 |
| T2 with normal cord mobility | 11 | 20.37 |
| T2 with restricted cord mobility | 08 | 14.81 |
| Laterality of diseased cord | ||
| One cord diseased (T1a plus 18 T2) | 43 | 79.63 |
| Both cords diseased (T1b plus 01 T2) | 11 | 20.37 |
Fifty two (96.3%) lesions were ulcero-proliferative clinically. Thirty five (64.82%) were T1 while 19 (35.18%) were T2. All of them were Squamous cell carcinoma, majority (33, 61.11%) of which was well differentiated.
At 03 months post-RT, no residual lesion was noted in any case, however, there was RT induced oedema of tissues in 05 (9.26%) patients.
At 12 months, 01 (1.85%) patient revealed recurrent growth over anterior half of both vocal cords, while remaining 53 (98.15%) had no abnormality. This patient had a T2 lesion pre-RT. The patient underwent salvage surgery later on.
On VLS at 12 months post-RT the periodicity and phase symmetry was normal (grade 1) in 74.07% and 70.37% cases respectively. Similarly, complete closure was obtained in 72.22% (Table 2). These figure are significantly better than pre-RT levels (p < 0.01).
Table 2.
Periodicity, phase symmetry and glottic closure on videolaryngostroboscopy
| Time of study Parameter studied |
Pre-RT No. (%) |
3 months post-RT No. (%) |
12 months post-RT No. (%) |
|---|---|---|---|
| Periodicity (n = 54) | |||
| Regular (Grade 1) | 13 (24.07) | 25 (46.3) | 40 (74.07) |
| Sometimes irregular (Grade 2) | 14 (25.93) | 21 (38.89) | 09 (16.67) |
| As usual irregular (grade 3) | 17 (31.48) | 6 (11.11) | 3 (5.56) |
| Irregular (Grade 4) | 10 (18.52) | 2 (3.7) | 2 (3.7) |
| Phase symmetry (n = 54) | |||
| Regular (Grade 1) | 6 (11.11) | 25 (46.3) | 38 (70.37) |
| Sometimes irregular (Grade 2) | 15 (27.78) | 22 (40.74) | 11 (20.37) |
| As usual irregular (grade 3) | 20 (7.04) | 04 (7.4) | 02 (3.7) |
| Irregular (Grade 4) | 13 (24.07) | 03 (5.56) | 03 (5.56) |
| Glottic closure (n = 54) | |||
| Complete | 19 (35.19) | 32 (59.26) | 39 (72.22) |
| Incomplete | 35 (64.81) | 22 (40.74) | 15 (27.18) |
Grading adapted from: Bless et al. [6]
Mucosal waves at 12 months post-RT were normal (grade 1) in 59 vocal cords (56.67%) while another 44 cords (40.74%) had small reduction (grade 2) in mucosal wave function. There was deterioration of mucosal wave grading in disease free (opposite) cords at 3 months post-RT in 11 (25.58%), but it improved in majority of these at 12 months post-RT (Table 3).
Table 3.
Mucosal waves on videolaryngostroboscopy
| Time of study Parameter studied |
Pre-RT No. (%) |
3 months post-RT No. (%) |
12 months post-RT No. (%) |
|---|---|---|---|
| Mucosal wave (diseased cord) in unilateral cases (n = 43) | |||
| Normal (Grade 1) | 0 | 14 (32.56) | 12 (27.91) |
| Small reduction (Grade 2) | 0 | 23 (53.49) | 29 (67.44) |
| Moderate reduction (Grade 3) | 4 (9.3) | 3 (6.98) | 01 (2.33) |
| Severe reduction/absent (Grade 4) | 39 (82 | 3 (6.98) | 01 (2.33) |
| Mucosal wave (disease free cord) in unilateral cases (n = 43) | |||
| Normal (Grade 1) | 43 (100) | 32 (74.42) | 35 (81.4) |
| Small reduction (Grade 2) | 0 | 11 (25.58) | 06 (13.95) |
| Moderate reduction (Grade 3) | 0 | 0 | 02 (4.66) |
| Severe reduction/absent (Grade 4) | 0 | 0 | 0 |
| Mucosal wave (right cord) in bilateral cases (n = 11) | |||
| Normal (Grade 1) | 00 | 02 (18.18) | 04 (36.36) |
| Small reduction (Grade 2) | 00 | 07 (63.64) | 07 (63.64) |
| Moderate reduction (Grade 3) | 00 | 02 (18.18) | 00 |
| Severe reduction/absent (Grade 4) | 11 (100) | 00 | 00 |
| Mucosal wave (left cord) in bilateral cases (n = 11) | |||
| Normal (Grade 1) | 2 (18.18) | 9 (75) | 8 (72.73) |
| Small reduction (Grade 2) | 0 | 2 (18.18) | 2 (18.18) |
| Moderate reduction (Grade 3) | 3 (27.27) | 0 | 1 (9.09) |
| Severe reduction/absent (Grade 4) | 6 (54.55) | 0 | 0 |
Grading adapted from: Bless et al. [6]
The amplitude of vocal cord motion at 12 months was normal (grade 1) in 85 vocal cords (78.70%) (Table 4).
Table 4.
Amplitude of vocal cord motion on videolaryngostroboscopy
| Time of study Parameter studied |
Pre-RT No.(%) |
3 months post-RT No. (%) |
12 months post-RT No. (%) |
|---|---|---|---|
| Amplitude (diseased cord) in unilateral cases (n = 43) | |||
| Normal (Grade 1) | 16 (37.21) | 21 (48.84) | 31 (72.9) |
| Small reduction (Grade 2) | 13 (30.23) | 20 (46.51) | 10 (23.26 |
| Moderate reduction (Grade 3) | 13 (30.23) | 02 (4.65) | 02 (4.65) |
| Severe reduction (Grade 4) | 01 (2.33) | 0 | 0 |
| No movement (Grade 5) | 0 | 0 | 0 |
| Amplitude (disease free cord) in unilateral cases (n = 43) | |||
| Normal (Grade 1) | 43 (100) | 32 (74.42) | 36 (83.72) |
| Small reduction (Grade 2) | 0 | 8 (18.6) | 05 (11.63) |
| Moderate reduction (Grade 3) | 0 | 03 (6.98) | 02 (4.65) |
| Severe reduction (Grade 4) | 0 | 0 | 0 |
| No movement (Grade 5) | 0 | 0 | 0 |
| Amplitude (right cord) in bilateral cases (n = 11) | |||
| Normal (Grade 1) | 4 (36.36) | 7 (63.64) | 8 (72.72) |
| Small reduction (Grade 2) | 6 (54.55) | 3 (27.27) | 2 (18.18) |
| Moderate reduction (Grade 3) | 1 (9.09) | 01 (9.09) | 01 (9.09) |
| Severe reduction (Grade 4) | 0 | 0 | 0 |
| No movement (Grade 5) | 0 | 0 | 0 |
| Amplitude (left cord) in bilateral cases (n = 11) | |||
| Normal (Grade 1) | 3 (27.27) | 6 (54.55) | 10 (90.9) |
| Small reduction (Grade 2) | 8 (72.72) | 5 (45.45) | 0 |
| Moderate reduction (Grade 3) | 0 | 0 | 01 (9.09) |
| Severe reduction (Grade 4) | 0 | 0 | 0 |
| No movement (Grade 5) | 0 | 0 | 0 |
Grading adapted from: Bless et al. [6]
We have further analysed the VLS parameters from their practical and clinical point of view by pairing them into ‘acceptable’ (normal or minimal deterioration encompassing grade 1 and 2) and ‘not acceptable’(moderate or severe deterioration encompassing grade 3,4 and 5) as shown in Table 5. This analysis revealed that at 12 months post-RT, the voice was in ‘acceptable’ category in 49 (90.74%) patients in periodicity and phase symmetry, in 103 (95.37%) vocal cords in mucosal waves and in 102 (94.44%) vocal cords in amplitude. Glottic closure was complete in 39 (72.77%) patients. All these figures were significantly better than pre-RT levels.
Table 5.
Summary of videolaryngostroboscopy results
| Time parameter | Pre-RT No. (%) |
3 months post-RT No. (%) |
12 months post-RT No (%) |
p value (Chi squared test) |
|---|---|---|---|---|
| Periodicity (n = 54) | ||||
| Acceptable function (Grade 1 and 2) | 27 (50) | 46 (85.19) | 49 (90.74) | < 0.01 |
| Not acceptable function (Grade 3 and 4) | 27 (50) | 8 (14.81) | 5 (9.26) | |
| Phase symmetry (n = 54) | ||||
| Acceptable function (Grade 1 and 2) | 21 (38.89) | 47 (87.04) | 49 (90.74) | < 0.01 |
| Not acceptable function (Grade 3 and 4) | 33 (61.11) | 7 (12.96) | 5 (9.26) | |
| Glottic closure (n = 54) | ||||
| Complete | 19 (35.19) | 32 (59.26) | 39 (72.22) | < 0.01 |
| Incomplete | 35 (64.81) | 22 (40.74) | 15 (27.18) | |
| Mucosal waves (n = 108) | ||||
| Acceptable function (Grade 1 and 2) | 45 (41.67) | 100 (92.59) | 103 (95.37) | < 0.01 |
| Not acceptable function (Grade 3 and 4) | 63 (58.33) | 8 (7.41) | 5 (4.63) | |
| Amplitude of cord motion (n = 108) | ||||
| Acceptable function (Grade 1 and 2) | 93 (86.11) | 102 (94.44) | 102 (94.44) | 0.04 |
| Not acceptable function (Grade 3, 4, 5) | 15 (13.89) | 6 (5.56) | 6 (5.56) | |
Grading adapted from: Bless et al. [6]
GRBAS scores also significantly reduced (indicating improvement in voice) at 3 months post-RT and 12 months post-RT on all accounts i.e. G, R, B, A and S (Table 6). Similarly, there was a significant reduction in VHI-10 scores from pre-RT to 3 months post-RT in all the 3 domains (Functional, Physical and Emotional); as well as total score (Table 7). Between 3 and 12 months post-RT, significant reduction was seen only in the emotional domain and total score of VHI-10 (p < 0.00001 and 0.00009 respectively) but not in functional and physical domains (p = 0.32 for both measurements).
Table 6.
Mean GRBAS scoresa Pre- and post-RT
| Time of evaluation | Grade (0–3) | Roughness (0–3) | Breathiness (0–3) | Asthenia (0–3) | Strain (0–3) | Total (0–15) |
|---|---|---|---|---|---|---|
| Pre-RT mean | 2.24 | 2.22 | 2.17 | 2.09 | 2.22 | 10.9 |
| SD | 0.55 | 0.57 | 0.64 | 0.71 | 0.5 | 2.41 |
| 3 months post-Rt mean | 1.53 | 1.3 | 1.17 | 1.37 | 1.43 | 6.78 |
| SD | 0.61 | 0.63 | 0.61 | 0.68 | 0.69 | 2.62 |
| p valuea1 | < 0.00001 | < 0.00001 | < 0.00001 | < 0.00001 | < 0.00001 | < 0.00001 |
| 12 months post RT mean | 0.87 | 0.72 | 0.5 | 0.67 | 0.63 | 3.39 |
| SD | 0.62 | 0.6 | 0.54 | 0.67 | 0.59 | 2.67 |
| p valuea2 | < 0.00001 | < 0.00001 | < 0.00001 | < 0.00001 | < 0.00001 | < 0.00001 |
a1Two tailed paired t test comparing pre-RT with 3 months post-RT
a2Two tailed paired t test comparing 3 months post-RT with 12 months post-RT
aHirano [7]
Table 7.
Voice handicap index-10a pre- and post-RT
| Time of evaluation | Functional (0–20) | Physical (0–12) | Emotional (0–8) | Total (0–40) |
|---|---|---|---|---|
| Pre-RT mean | 4.6 | 3.6 | 3.2 | 11.5 |
| SD | 1 | 0.85 | 0.94 | 2.45 |
| 3 months post-RT mean | 3.24 | 2.44 | 1.51 | 7.20 |
| SD | 0.72 | 0.57 | 0.6 | 1.42 |
| p valuea1 | < 0.00001 | < 0.00001 | < 0.00001 | < 0.00001 |
| 12 months post RT mean | 3.28 | 2.48 | 0.94 | 6.70 |
| SD | 0.85 | 0.66 | 0.72 | 1.75 |
| p valuea2 | 0.32 | 0.32 | 0.00008 | 0.00009 |
a1Two tailed paired t test comparing pre-RT with 3 months post-RT
a2Two tailed paired t test comparing 3 months post-RT with 12 months post-RT
aRosen et al. [8]
Only minor, self-limited complications of RT occurred in our study. These included mucositis in 20 (37.04%), Odynophagia in 06 (11.11%), dysphagia in 04 (7.41%), skin blistering in 03 (5.56%) and skin erythema in 05 (9.26%) patients. No major complications occurred in this study.
Discussion
Age distribution of our patients was similar to other studies (i.e. mean age of 67.72 years; with maximum patients falling in 61 to 70 years group and no patient below 40 years). Like other studies, predominantly males were affected [9, 10].
Observation of smoking and alcohol consumption by majority of the affected patients has also been reflected in earlier studies, as has been the existence of co-morbidties in many cases [11, 12]. Hoarseness of voice as the early and the most common presenting symptom seen in our study was also reported by Lee et al. in a meta analysis performed by them on early glottis carcinoma [13].
Although gastro-oesophageal reflux has been reported to be an independent risk factor for laryngo-pharyngeal cancer [14], it was seen in only 6 (11.11%) patients in our study. The difference may be due to the difference in susceptibility and life style of different populations.
RT causes dissolution of the lesion from the vocal cord leading to improved mucosal wave and amplitude, however, it also causes damage and fibrosis of the tissues of normal cord leading to deterioration in mucosal wave. This may explain why some of the disease free cords showed deteriorated mucosal wave function post-RT, while diseased cords showed improvement in their function. This deterioration improved to great extent at 12 months post-RT compared to 3 months post-RT. At 12 months post RT much less percentage of cords achieved normal grade in mucosal waves compared to amplitude, periodicity, phase symmetry and glottic closure. This shows that mucosal waves get affected with even minimal structural damage to cords, hence, mucosal wave function may be the most sensitive VLS parameter for structural and functional integrity of vocal cords.
Overall, excellent voice outcomes were achieved after RT in our study with most of the patients showing improvement at 3 months as well as 12 months post-RT on assessment with all the three tools—VLS showed acceptable structural and functional parameters, GRBAS showed good perceptual quality of voice and VHI-10 showed low handicap—in majority of the patients. The only patient who showed worsening of voice had recurrence of lesion within 1 year.
Our findings are in line with the study of Watson et al. [15] who reported improvement in voice outcomes at 1 year post radiotherapy; which was maintained for long term. Additionally, high level of Voice Related Quality of Life (VRQOL) score was maintained many years after curative radiotherapy in their study.
In a study by Tripathi et al. [16], the authors concluded that voice quality improves following radiotherapy but not all the patients regain normal voice. In our study also many patients did not achieve normal standards of voice, although they had improvement in their voice compared to pre-RT level.
Wedman et al. [17] utilizing VLS demonstrated that there was no significant difference in mucosal wave form, symmetry or glottic closure between the patients of T1a laryngeal cancer treated with RT and those treated with laser surgery.
Many studies utilizing patient’s own perception of handicap due to voice (VHI) also have revealed superior voice outcomes after RT than post laser surgery and significantly lower VHI have been reported in these studies [18–20]. These studies support our results of good voice outcomes post RT in these cases, though we had no comparative arm with any other modality of therapy to compare.
Results of various studies performing sub analysis in various domains of VHI have been conflicting especially in the functional and emotional domains. Better scores in emotional domain were achieved by patients receiving laser surgery in the study by Goor et al. [19], whereas Nunez Batalla et al. [20] and Dinapoli et al. [21] reported better emotional scores in patients receiving RT. On the other hand, functional domain scores were better in patients receiving RT in the study by Nunez Batalla et al. [20] while Goor et al. [19] and Dinapoli et al. [21] found no difference between the two groups.
In our study, all domains of VHI-10 showed significant improvement from pre-RT to 3 months post-RT, but from 3 months post-RT to 12 months post-RT only emotional domain showed significant improvement while functional and physical domains did not show significant change. This may occur due to patients’ acceptance of their voice, while physical and functional aspect of voice may remain same.
In a randomized trial comparing RT with laser surgery Aaltonen et al. found overall voice quality between the groups to be similar, but in the laser surgery group, the voice was more breathy and the glottic gap was wider [22].
In contrast to above studies, many other studies have reported poorer results in voice outcomes after RT [23]. Ma et al. [24] reported significantly better voice results with laser surgery than RT in GRBAS score and objective voice analysis but not in VHI-10.
It is also important to note that voice results after laser surgery will also depend on the type of cordectomy [25], hence comparison of voice quality after surgery and after RT may be difficult.
Limitations
VLS and GRBAS are subjective tools and are likely to have inter-observer bias. Similarly, VHI-10 is also dependent on the patient’s perception. Hence, the results of our study may vary from other researchers.
Speech Therapy was provided to all the patients while they were awaiting RT. This could have also affected voice quality post therapy.
Conclusions
Good quality of voice can be expected after RT for early glottic cancer. Majority of the patients are likely to have acceptable voice quality. These findings can serve as valuable input for making an informed decision while choosing the treatment option.
Author Contribution
AKM: Study Supervision, Data analysis, Drafting manuscript, Approval of final version. VRS: Study concept, Data acquisition, manuscript revision, Approval of final version. VS: Study design, Data acquisition, Drafting manuscript, Approval of final version. AN: Study Concept, Data Analysis, Manuscript revision, Approval of final version.
Funding
We are grateful to the Director General, Armed Forces Medical Services, India for providing financial aid for this study through Armed Forces Medical Research Committee Project No 4650/2015.
Compliance with Ethical Standards
Conflict of interest
All authors declare that there is no conflict of interest.
Ethics Approval
All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration (as amended). The study was approved by the Institutional Ethics Committee of Army Hospital (R&R) Delhi Cantt. Informed consent was taken from all participants to participate and for publication.
Footnotes
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Contributor Information
Awadhesh Kumar Mishra, Email: buddhiprakash@rediffmail.com.
Vivek Raj Sinha, Email: sinha_vrs@yahoo.com.
Virender Suhag, Email: virendersuhag@gmail.com.
Ajith Nilakantan, Email: ajith.nil@gmail.com.
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