Abstract
The aim of this study was to evaluate changes in voice after septoplasty in adults using the Dr.Speech assessment module in conjunction with subjective evaluation using Voice Handicap Index (VHI). A total of 50 consecutive patients with symptomatic Deviated Nasal Septum (DNS) undergoing septoplasty were included in the study. Patients fit for surgery underwent septoplasty by standard technique. Voice assessment was done by subjective voice evaluation and Acoustic voice analysis preoperatively, 1 week after surgery and 1 month after surgery. Mean values of both males and females for Fundamental frequency (F0) were within the normal range at all the three times of assessment. No- significant differences were obtained at all the three times of assessment in males and females respectively. Significant results were obtained while comparing the preoperative and postoperative SNR dB values. Mean VHI score at preoperative, 1 week postoperative and 1 month postoperative was 23.2, 22 and 21.5 respectively. No statistical difference was obtained while comparing the mean VHI score at different time intervals. The scores between 0 and 30 are in the mild category, i.e. minimal amount of handicap. The scores of all the patients were less than 30 at all times of assessment. To conclude, post-operative changes in the voice parameters were minimal and not significant, they were indicative of greater acoustical quality of voice and lesser nasalized speech, thus reflecting the positive outcome of surgery.
Keywords: Acoustic analysis, Septoplasty, Dr speech, Deviated nasal septum
Introduction
Nasal obstruction is one of the most common complaints of patients visiting Otorhinolaryngology clinic. One of the main reasons of nasal obstruction is Deviated Nasal Septum (DNS). Septal deviations affect the free aeration and cause nasal obstruction, blockage, allergic rhinitis and dryness of throat and hence influence the person’s quality of life. DNS can lead to sinusitis, affect the sinus drainage and also influence the resonance and voice characteristics of speech. It can have a significant impact on the quality of the nasal phenomes as well as on nasal airflow and also can result in hyponasality. As per the reports, males are affected more than females [1–3].
Voice occurs with the vibration of the vocal cords by the air passing through the glottis at the laryngeal level. The voice occurring here is shaped by the anatomical structures including the supraglottic larynx, oropharynx,nose, paranasalsinuses,tongue, lip and palate, following which it takes the form of speech [4].
Septoplasty is a well-known surgical procedure for the management of nasal septal deviation [5]. In this operation, much of the septal framework is retained. Only the most deviated parts are removed. This procedure is performed to widen the nasal passage, which in turn alters the resonance characteristics of vocal tract [6].
The goal of the surgical therapy in our study is to improve the permeability of the nasal cavities. Although, septoplasty is therapeutic for different chronic nasal obstructions, this procedure has the potential to affect nasal resonance and voice by altering the resonant characteristics of the vocal cord [7].
The present study aimed at evaluating the changes in the acoustic features of voice after septoplasty in adults using the Dr.Speech assessment module in conjunction with subjective evaluation by Voice Handicap Index.
Methodology
Approvalwas obtained from the Institutional Ethical Committee before conducting the study. All the patients with Deviated Nasal Septum (DNS) between the age range of 18–60 years, admitted for Septoplasty in the E.N.T department were included in this study. Patients who previously underwent septoplasty, patients with known dysphonia, history of speech and language disorder, hearing impairment, with any kind of nasal mass, with contraindications of surgery, with allergic rhinitis, craniofacial anomaly, neurological disease and laryngeal pathology were excluded from the study. Informed consent was obtained by all the subjects to participate in the study. A total of 50 consecutive patients with symptomatic DNS as diagnosed by Anterior Rhinoscopy and Nasal Endoscopy undergoing Septoplasty participated in the study. Patients fit for surgery underwent Septoplasty by standard technique. The complete voice evaluation was done in 3 conditions, two days before surgery (preoperatively), 1 week after surgery and 1 month after surgery (postoperatively).
Procedure
Subjective voice assessment was done using Voice Handicap Index (VHI) which is a self-administered questionnaire consisting of questions under physical, functional and emotional domains. The patients were instructed that these statements are how most people describe their voices and the effects of their voices on their lives.VHI is a 5-point rating scale where, 0 = Never, 1 = Almost Never, 2 = Sometimes, 3 = Almost Always, 4 = Always. Low score (0–30) indicate a minimal amount of handicap associated with the voice disorder, scores between 31 and 60 denotes a moderate amount of handicap due to voice problem and scores between 60 and 120 represent a significant and serious amount of handicap due to a voice problem.
Acoustic voice analysis was performed using Dr. Speech Assessment Module by using Vocal Assessment, version 4-0:Voice assessment 3.0 of Tiger DRS.INC. Microphone used was Proton Boom 815, Super unidirectional electret condenser microphone and was kept at a distance of 15 cm from the oral cavity. The patients were asked to phonate sustained vowel /a/, which was recorded for 3 s and all the parameters were recorded for further analysis.
Statistical analysis:All the results were summarized and analyzed by SPSS software. Chi- square test and Mann Whitney test were used for assessment of level of significance. P- value of less than 0.05 was taken as significant.
Results
Maximum patients (42 subjects) included were in the age range of 18–30 years. Ten percent of the subjects (5 subjects) belonged to the age group of 31 to 40 years, 4 percent (2 subjects) and 2 percent (1 subject) belonged to the age group of 41 to 50 years and 51 to 60 years respectively. Forty four were males and six were females.
Mean VHI score at preoperative, 1 week postoperative and 1 month postoperative was 23.2, 22 and 21.5 respectively. No statistical difference was obtained (Table 1) while comparing the mean VHI score at different time intervals. As per the normative, the scores between 0 and 30 are in the mild category, i.e. minimal amount of handicap. The scores of all the patients were less than 30 at all times of assessment.
Table 1.
Descriptive statistics of F0 of males and females preoperatively, one week post-surgery and one month post-surgery
| Parameter | Preoperative | 1 week postoperative | 1 month postoperative | |||
|---|---|---|---|---|---|---|
| Males | Females | Males | Females | Males | Females | |
| Habitual Fo | 142.5 | 192.3 | 137.6 | 196.5 | 151.3 | 200.2 |
| Mean Fo | 139.4 | 193.6 | 140.5 | 198.2 | 146.6 | 201.3 |
| Maximum Fo | 141.8 | 199.1 | 142.8 | 199.4 | 148.6 | 205.7 |
| Minimum Fo | 137.7 | 195.6 | 138 | 197.5 | 141.8 | 196.8 |
Fundamental frequency (Fo) in males and females was assessed separately, the values of mean Fo, Habitual Fo, Minimum Fo and Maximum Fo are shown in Table 2. The values were in normal range and there is no significant difference preoperatively & postoperatively in both males and females. The details of jitter, shimmer, Fo tremor, Normalised Noise Energy (NNE), Harmonic to Noise Ratio (HNR) and Signal to Noise Ratio (SNR) are shown in Table 3. It can be seen that there is statistical significant seen in HNR and SNR when compared preoperatively, 1 week postoperative and 1 month postoperatively. No significant difference was seen in other voice parameters.
Table 2.
Comparison of Acoustic Voice parameters in patients preoperatively, one week post-surgery and one month post-surgery
| Acoustic voice parameter | Time interval | Mean | Std. deviation | p- value |
|---|---|---|---|---|
| Jitter (%) | Preoperative | 0.02 | 0.06 | 0.095 |
| Postoperative 1 week | 0.01 | 0.04 | ||
| Postoperative 1 month | 0.03 | 0.05 | ||
| Shimmer | Preoperative | 1.61 | 0.77 | 0.922 |
| Postoperative 1 week | 1.61 | 1.01 | ||
| postoperative1 month | 1.61 | 0.95 | ||
| F0 Tremor Hz | Preoperative | 9.10 | 36.33 | 0.525 |
| Postoperative 1 week | 8.85 | 33.51 | ||
| Postoperative1 month | 1.88 | 0.98 | ||
| NNE dB | Preoperative | – 12.22 | 24.59 | 0.441 |
| Postoperative 1 week | − 38.24 | 25.43 | ||
| Postoperative1 month | − 11.38 | 6.85 | ||
| SNR dB | Preoperative | 24.46 | 6.01 | 0.013* |
| Postoperative 1 week | 24.37 | 5.68 | ||
| Postoperative1 month | 24.28 | 4.68 | ||
| HNR dB | Preoperative | 26.43 | 3.86 | 0.001** |
| Postoperative 1 week | 26.12 | 4.49 | ||
| Postoperative 1 month | 25.39 | 4.51 | ||
| Amp Tremor Hz | Preoperative | 2.40 | 2.18 | 0.699 |
| Postoperative 1 week | 2.22 | 1.94 | ||
| Postoperative1 month | 2.15 | 1.93 | ||
| SZ Ratio | Preoperative | 1.4 | 4.56 | 0.98 |
| Postoperative 1 week | 1.39 | 3.02 | ||
| Postoperative1 month | 1.2 | 2.02 |
*Significance at the level of 0.05, **Significance at the level of 0.01
Table 3.
Comparison of VHI score in patients preoperatively, one week post-surgery and one month post-surgery
| Parameter | Pre-treatment | Post-treatment 1 week | Post-treatment 1 month | p- value |
|---|---|---|---|---|
| Mean VHI score | 23.2 | 22 | 21.5 | 0.40 |
Discussion
In the present study eighty four percent patients were in between the age group of 18 to 30 years. Our results were in correlation with the results obtained by Yeğin Y et al. and OzbalKoc EA et al. who observed similar findings in their study. Mean age of the patients in the study conducted by Yegin Y et al. and OzbalKoc EA et al. was 32.13 years and 28 years respectively [8, 9].It is also seen DNS is more prevalent in males as reported in the literature [4, 10].
Mean VHI score at preoperative, 1 week postoperative and 1 month postoperative was 23.2, 22 and 21.5 respectively. No statistical significant difference was obtained while comparing the mean VHI score at different time intervals. The scores between 0 and 30 are in the mild category, i.e. minimal amount of handicap. The scores of all the patients were less than 30 at all times of assessment showing minimum effect on voice. Atan D et al. in their study analyzed the effect of septoplasty, performed in 2 groups with different grades of nasal septal deviation (NSD), on voice performance. They concluded that septoplasty performed for severe nasal septal deviation obstructing nasal lumen totally or near totally, results in significant improvements in the voice performance [11].
In the present study, mean habitual Fo parameter was obtained in males and females in three different time intervals. At preoperative time, Fo for males was 142.5 Hz and for females was 192.3 while at postoperative 1 week value was 137.6 for males and 196.5 for females & at postoperative 1 month value for males was 151.3 and for females 200.2. All the values lie in the normative range of 85–196 Hz for males & 155–334 Hz for females. However; the change was found to be statistically non- significant. The Fo is indicative of the vocal fold vibratory rate and reflects resonance characteristics of the supra-laryngeal vocal tract. Our results were in concordance with the results obtained by Yegin Y et al., who didn’t observe any significant difference in Fo values at different time intervals after septoplasty [1, 8, 9]. In the study conducted by Subramaniam et al. on 45 patients, they reported no significant change in the Fo values in the post-operative period. The present finding is consistent with other studies, which say that septoplasty does not affect the vocal fold vibration and therefore, should not influence vocal Fo [1, 8, 9, 12].
Mean Jitter(%) value in the present study preoperatively was 0.02, while post operatively 1 week and 1 month were found to be 0.01 and 0.02 respectively, which are in normal range. No significant results were obtained while comparing the mean Jitter in the study group at different time intervals. Our results were in concordance with the results obtained by Yegin Y et al. who didn’t observe any significant difference in Jitter values at different time intervals. Similarly in the study conducted by Subramaniam et al., on 45 patients, they reported no significant change in Jitter values in the postoperative period [8, 9, 12]. Mean Shimmer value in all the three Groups were found to be 1.61 respectively. No statistical significant difference was seen in Shimmer values in all the three time intervals. The results are in concordance with previous studies [8, 9, 12]. It was reported by a researcher that the shimmer values in patients with DNS were significantly higher as compared to controls and the shimmer values decrease after surgery with improvisation in patients [12].
The Harmonic to noise ratio (HNR) which is an indication of the overall periodicity of the voice signal by quantifying the ratio between the periodic (harmonic part) and aperiodic (noise) components, shows statistically significant results. The HNR shows value of 25.39 dB in the preoperative time while increase in the values post operatively in the 1 week and 1 month postoperative from 26.12 to 26.43 respectively. Signal to noise ratio has shown a decreasing trend and is statistically significant. The results show that there is a manifestation on voice with the pathology followed with Septoplasty. The similar results were obtained by previous researchers as well [8].The acoustic parameter Amplitude tremor shows values of 2.40 in the preoperative week, then 2.22 and 2.15 Hz in the next postoperative 1 week and 1 month respectively. There is no statistical significant result seen. The acoustic parameter /S/ &/Z/ ratio, which is the ratio of time of sustained production of [S] & [Z] consonants, has the normative value of 1–1.4. Increase in the value represents potential difficulty in phonation. In the present study it shows values of 1.4 pre operatively and 1.39 and 1.2 post operatively 1 week and 1 month after surgery.There is no statistically significant result seen but the values indicate that voice was settled 1 month after surgery.
Since there is paucity of data in the literature in relation to effect of Septoplasty on different acoustic voice parameters, further studies are recommended for better exploration of this field in both nasal and non-nasal sounds. Limitation of our study is that there was no control group to compare with and nasal sounds were not analyzed.
Conclusion
Post-operative changes in the voice parameters other than SNR and HNR were minimal and not significant. The effect can be seen on the nasalized sounds, which is a future recommendation. Therefore, it can be concluded that a widened nasal cavity has no effect on overall voice quality in context to non-nasal sounds and procedures like septoplasty could be performed safely.
Acknowledgements
We would like to thank the Staff and Students of ENT department for helping us in successful completion of the study.
Funding
No funding received.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
Human and Animals Rights
Yes and the research was approved by the Research Ethics Committee of Guru Gobind Singh Medical College, Faridkot. The study was in compliance with the ethical standards.
Informed Consent
The participants were informed regarding the aim and procedure of the study and they signed the consent forms prior to testing.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Thejaswi D, Alfred R, D'Souza FP. Effect of septoplasty on cepstral analysis of voice. Indian J Otolaryngol Head Neck Surg. 2016;68(3):289–293. doi: 10.1007/s12070-015-0862-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Mora R, Jankowska B, Dellepiane M, Mora F, Crippa B, Salami A. Acoustic features of voice after septoplasty. Med Sci Monit. 2009;15(6):269–273. [PubMed] [Google Scholar]
- 3.Brain D. The nasal septum. In: Scott-Brown WG, Stephens D, Kerr AG, editors. Scott–Brown’s otolaryngology. 6. Oxford: Butterworth-Heinemann; 1997. pp. 1–27. [Google Scholar]
- 4.Browning GG, Robinson K, Gatehouse S. Measuring patient benefit from otorhinolaryngological surgery and therapy. Ann Otol Rhinol Laryngol. 1996;105:415–422. doi: 10.1177/000348949610500601. [DOI] [PubMed] [Google Scholar]
- 5.Mora R, Jankowska B, Mora F, Crippa B, Dellepiane M, Salami A. Effects of tonsillectomy on speech and voice. J Voice. 2009;23(5):614–618. doi: 10.1016/j.jvoice.2008.01.008. [DOI] [PubMed] [Google Scholar]
- 6.Celik O, Boyaci Z, Yelken K, Atespare A, Celebi S, Koca O. Septorhinoplasty with spreader grafts enhances perceived voice quality without affecting acoustic characteristics. J Voice. 2012;26(4):493–495. doi: 10.1016/j.jvoice.2011.03.005. [DOI] [PubMed] [Google Scholar]
- 7.Hong KH, Kwon SH, Jung SS. The assessment of nasality with a nasometer and sound spectrography in patients with nasal polyposis. Otolaryngol Head Neck Surg. 1997;117:343–348. doi: 10.1016/S0194-5998(97)70124-4. [DOI] [PubMed] [Google Scholar]
- 8.Yegin Y, Celik M, SImsek BM, Akidil AO, Olgun B, Altıntas A, et al. Assessment of effects of septoplasty on acoustic parameters of voice: a prospective clinical study. Turk Arch Otorhinolaryngol. 2016;54(4):146–149. doi: 10.5152/tao.2016.1915. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Koc EA, Koc B, Ercan I, Kocak I, Tadihan E, Turgut S. Effects of septoplasty on speech and voice. J Voice. 2014;28(3):393–311. doi: 10.1016/j.jvoice.2013.09.008. [DOI] [PubMed] [Google Scholar]
- 10.Oliveira AKP, Junior EE, Santos LV, Bettega SG, Mocellin M. Prevalence of deviated nasal septum in curitiba. Brazil Int Arch Otorhinolaryngol. 2005;9(4):288–292. [Google Scholar]
- 11.Atan D, Ozcan KM, Gurbuz AB, Dere H. The effect of septoplasty on voice performance in patients with severe and mild nasal septal deviation. J Craniofacial Surg. 2016;27(5):1162–1164. doi: 10.1097/SCS.0000000000002794. [DOI] [PubMed] [Google Scholar]
- 12.Subramaniam V, Yoonus R, Narra M. Effects of septoplasty on the acoustic parameters of voice. Egypt J Ear Nose Throat Allied Sci. 2015;16(3):259–263. doi: 10.1016/j.ejenta.2015.08.006. [DOI] [Google Scholar]