OTPOL-119; No. of Pages 7 otolaryngologia polska xxx (2013) xxx–xxx

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Original research article/Artykuł oryginalny

Comparison of voice quality in patients with GERD-related dysphonia or chronic cough Porównanie jakości głosu pacjentów z dysfonią lub przewlekłym kaszlem o etiologii refluksowej Anna Domeracka-Kołodziej 1, Elżbieta M. Grabczak 2, Marta Dąbrowska 2, Magdalena Arcimowicz 1, Magdalena Lachowska 1,*, Ewa Osuch-Wójcikiewicz 1, Kazimierz Niemczyk 1 1 2

Department of Otolaryngology, Medical University of Warsaw, Poland Department of Internal Medicine, Pulmonology and Allergology, Medical University of Warsaw, Poland

article info

abstract

Article history:

Objective: The aim was to compare a voice quality in patients with GERD-related dysp-

Received: 16.09.2013

honia or chronic cough and to determine whether there is a relationship between the

Accepted: 02.10.2013

main symptom reported and voice quality. Material and methods: 249 consecutive

Available online: xxx

patients diagnosed with GERD-related chronic cough or dysphonia were involved in this retrospective study and were divided into two main groups of men and women, and

Keywords:  Gastroesophageal reflux disease  Voice assessment

furthermore into groups of chronic cough and dysphonia. Laryngeal lesions were evaluated with videolaryngostroboscopy using Reflux Finding Score. Voice quality was assessed using GRBAS scale, sonograms, and multidimensional voice program (MDVP). Results: All

 Acoustic voice analysis  Dysphonia

subjects were found to have vocal abnormalities both in subjective and objective voice

 Cough

analyzed groups depending on the reported symptom. In MDVP analysis, the group of

analysis. Perceptual assessment of voice (GRBAS) did not reveal any differences between women with cough as the main symptom demonstrated significantly less abnormalities

Słowa kluczowe:  choroba refluksowa (GERD)  refluks przełykowo-gardłowy

in VTI value. In men with cough as their main complaint, significantly less MDVP abnormalities were found in Jita, Jitt, RAP, PPQ, and sPPQ parameters. Conclusions: The comparison of voice perceptual assessment in patients with GERD-related dysphonia or chronic cough revealed no differences between analyzed groups. In objective voice analysis,

 analiza akustyczna głosu  ocean głosu

the latter group presented lower degree of hoarseness in Yanagihara's scale. In objective

 zaburzenia głosu  przewlekły kaszel

one of the noise related parameters in females and five frequency perturbation parame-

MDVP analysis, the chronic cough group presented lower degree of abnormalities only in ters in males. © 2013 Polish Otorhinolaryngology - Head and Neck Surgery Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

* Corresponding author at: Katedra i Klinika Otolaryngologii WUM, ul. Banacha 1a, 02-097 Warszawa, Poland. Tel.: +48 22 599 25 21/22 599 25 23. E-mail address: [email protected] (M. Lachowska). 0030-6657/$ – see front matter © 2013 Polish Otorhinolaryngology - Head and Neck Surgery Society. Published by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

http://dx.doi.org/10.1016/j.otpol.2013.10.003 Please cite this article in press as: Domeracka-Kołodziej A, et al. Comparison of voice quality in patients with GERD-related dysphonia or chronic cough. Otolaryngol Pol. (2013), http://dx.doi.org/10.1016/j.otpol.2013.10.003

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Introduction Chronic cough and persistent dysphonia are the main complaints reported by patients with extra-esophageal manifestations of gastroesophageal reflux disease (GERD) [1–3]. Those patients are frequently referred to Departments of Otolaryngology. Typically, one of those manifestations is reported as the main symptom [4]. Prolonged cough, independently on reason, results in laryngeal irritation. GERD has been demonstrated to be one of the most common causes of chronic cough in adults [5, 6] and it is currently believed to be the third main cause of chronic cough after problems with nasal sinuses and asthma [7–9]. There are a lot of explanations for the mechanism in which GERD causes cough [10, 11], i.e. (a) esophageal receptor response involved in the esophagealtracheobronchial cough reflex; (b) variable response of the cough center in the central nervous system; (c) local neurotransmitter release; and (d) microaspiration. In addition, cough can trigger secondary gastroesophageal reflux (GER) episodes. The relationship between laryngeal diseases and GERD has been described since the 1960s [12–14]. The introduction of videolaryngoscopy (VLS) has been a breakthrough in recognizing laryngeal manifestations of GERD. This technique helps to identify patients who are very likely to suffer from laryngopharyngeal reflux (LPR) episodes. VLS helps to demonstrate that there is a large variety of laryngoscopic presentations in LPR [15, 16]. A number of patients' complaints, such as pain and a sensation of throat obstruction, accumulation of secretions in the lower throat, oropharyngeal phase dysphagia, pharyngeal globus, chronic or paroxysmal cough, the necessity to constantly clear the throat, as well as dysphonia, may be explained by laryngoscopic presentations that indicate GERD/LPR [17].

Aim

Laryngeal examinations and voice tests were performed by one of the authors in identical conditions, and with the use of the same equipment. History taking also included a patient self-administered Reflux Symptom Index (RSI) questionnaire regarding symptoms of laryngopharyngeal reflux (LPR) proposed by Belafsky [18]. According to Belafsky, the RSI score of 11 or more is considered abnormal. The larynx was carefully examined with the use of a STORZ 8020 videolaryngostroboscope with STORZ 8704 D rigid fiberoptics, a STORZ SL PAL 20212020 miniature camera and a Panasonic DMR – E85H DVD recorder for registering the images of the larynx on a DVD. Laryngeal lesions were evaluated using the Reflux Finding Score (RFS) for reflux-related laryngeal pathologies, proposed by Belafsky [19]. The RFS score of more than 7 is considered to suggest the LPR. The subjective voice analysis was assessed perceptually using GRBAS scale (Grade Roughness Breathiness Asthenia Strain). GRBAS scale has been recommended by the Japan Society of Logopedics and Phoniatrics [20]. An objective voice analysis of sustained vowel /a/ was conducted with the use of KAY Elemetrics System Model CSL 4300 with CSL 4305 and a multidimensional voice program (MDVP) software. Sonograms were evaluated with the use of Remackle's scale [21]. The severity of hoarseness was determined using sustained vowels /i/, /e/, and /a/ according to Yanagihara's classification [22]. Voice parameters were evaluated with MDVP and classified according to Van Lierde [23, 24]. Statistical analysis of data was performed using Statistica software (StatSoft, Inc. 2011, ver. 10) and OpenOffice.org Program Calc ver. 3.3.0. Data were tested for normality, parametric and nonparametric criteria (Student t and Mann– Whitney U test). A p value of 0.05

Significant difference (p < 0.05). Strong significant difference (p < 0.01).

**

Table IV – Degree of hoarseness in Yanagihara's scale for females and males with GERD accordingly to main symptom reported (dysphonia or chronic cough) Degree of hoarseness

Females 0 1 2 3 4 Males 0 1 2 3 4 * **

Dysphonia group

Chronic cough group

Statistical significance dysphonia vs. chronic cough

Number of patients

%

Number of patients

%

0 22 58 8 0

0.00 25.00 65.17 9.09 0.00

0 27 49 2 0

0.00 34.62 63.82 2.56 0.00

p < 0.05*

1 3 34 11 0

2.04 6.12 69.39 22.45 0.00

0 8 25 1 0

0 23.53 73.53 2.94 0.00

p < 0.01**

Significant difference (p < 0.05). Strong significant difference (p < 0.01).

MDVP analysis In all patients, all parameters of MDVP were abnormal. The females who reported dysphonia or cough as their main symptom were found to differ significantly only in mean VTI values (p = 0.016). The men who reported dysphonia or chronic cough were found to differ significantly in following mean frequency perturbation parameters: Jita (p = 0.005), Jitt ( p = 0.011), RAP ( p = 0.010), PPQ ( p = 0.009), and sPPQ ( p = 0.011) values. Mean value of MDVP parameters are presented in Table V.

Discussion In this study, in 249 analyzed patients with the clinical presentation of posterior laryngitis and confirmed GERD it was found that the most commonly reported symptoms

were dysphonia and cough. Only 9 patients (8.03%) from the group with chronic cough had no history of dysphonia. Such high prevalence of dysphonia among patients with cough may suggest that the cough reflex might be responsible for the intense muscle contraction at the glottic and vestibular level of the larynx as well as aryepiglottic folds. Most probably, it is associated with repeated injuries of the glottis, especially in the region of vocal processes. Moreover, recurrent cough or frequent throat clearing during vocal activity might result in the development and consolidation of a hyperfunctional phonation mechanism. Therefore, dysphonia might be a result of both functional and organic pathologies. Hyperfunctional behavior of the larynx is a natural defense mechanism protecting lower respiratory tract from reflux content [25, 26]. From our experience, patients with chronic cough are usually referred for initial internal disease diagnostics, often followed by a pulmonological or allergological consultation. After lung cancer, asthma and tuberculosis have been excluded, and cough sufferers are treated with

Please cite this article in press as: Domeracka-Kołodziej A, et al. Comparison of voice quality in patients with GERD-related dysphonia or chronic cough. Otolaryngol Pol. (2013), http://dx.doi.org/10.1016/j.otpol.2013.10.003

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Table V – Mean values of MDVP results comparing patients with dysphonia and chronic cough Analyzed MDVP parameter

Female N = 166 Dysphonia group

Chronic cough group

Male N = 83 Student t test results t

Fundamental frequency parameters 196.29 Fo 213.99 Fhi Flo 180.12 4.61 STD 4.03 PFR Frequency perturbation parameters 106.72 Jita Jitt 1.89 RAP 1.15 PPQ 1.05 sPPQ 1.32 vFo 2.45 Amplitude parameters 0.42 ShdB 4.66 Shim 3.18 APQ 5.00 sAPQ 12.70 vAm Voice irregularity parameters 2.33 DUV NUV 2.06 Tremor analysis parameters 4.14 Fftr 4.18 Fatr 0.90 FTRI 5.39 ATRI Voice break related parameters 0.11 DVB NVB 0.05 Subharmonic analysis parameters 2.38 DSH NSH 1.77 Noise related parameters 0.14 NHR 0.04 VTI SPI 18.94

Dysphonia group

Chronic cough group

p

Student t test results t

p

194.93 213.08 177.32 5.21 4.48

0.21 0.13 0.44 0.63 0.87

0.830 0.898 0.662 0.532 0.383

124.74 143.56 114.96 4.14 4.20

125.12 132.65 118.15 2.15 2.83

0.07 0.77 0.59 1.35 1.61

0.945 0.441 0.557 0.179 0.112

85.60 1.59 0.96 0.92 1.27 2.92

1.09 1.09 1.07 1.01 0.24 0.78

0.276 0.276 0.285 0.316 0.814 0.437

139.18 1.65 0.98 0.98 1.46 3.12

84.79 1.06 0.63 0.61 0.90 1.70

2.86 2.62 2.62 2.68 2.62 1.45

0.005** 0.011* 0.010* 0.009** 0.011* 0.152

0.42 4.67 3.29 5.17 14.08

0.08 0.02 0.37 0.44 1.19

0.934 0.983 0.712 0.664 0.237

0.44 5.01 3.80 5.32 11.36

0.37 4.03 3.19 4.95 11.56

1.10 1.31 1.23 0.58 0.11

0.275 0.193 0.222 0.561 0.915

1.25 0.70

1.03 1.53

0.303 0.128

6.36 6.23

1.30 0.67

1.79 1.73

0.077 0.087

4.50 4.39 0.75 5.81

0.97 0.46 0.75 0.45

0.333 0.644 0.453 0.656

4.36 4.87 0.62 4.39

4.43 4.15 0.64 4.58

0.12 1.24 0.13 0.26

0.905 0.221 0.899 0.797

0.21 0.01

0.53 1.21

0.597 0.228

0.89 0.09

0.00 0.00

1.08 1.29

0.283 0.200

3.54 2.16

1.17 0.60

0.244 0.551

0.25 0.57

0.34 2.08

0.25 0.85

0.806 0.399

0.14 0.06 15.61

0.11 2.44 1.77

0.912 0.016* 0.078

0.15 0.07 21.55

0.15 0.05 17.79

0.08 0.82 1.45

0.935 0.417 0.150

MDVP = multidimensional voice program; F0 = the fundamental frequency; Fhi = the lowest fundamental frequency; Flo = the highest fundamental frequency; STD = standard deviation of the fundamental frequency; PFR = phonatory fundamental frequency range; Jita = absolute jitter; Jitt = jitter percent; RAP = relative average perturbation; PPQ = pitch period perturbation quotient; sPPQ = smoothed pitch period perturbation quotient; vF0 = fundamental frequency variation; ShdB = shimmer in dB; Shim = shimmer percent; APQ = amplitude perturbation quotient; sAPQ = smoothed amplitude perturbation quotient; vAm = peak amplitude variation; DUV = degree of voiceless; NUV = number of unvoiced segments; Fftr = F0-tremor frequency; Fatr = amplitude-tremor frequency; FTRI = F0 tremor intensity index; ATRI = amplitude tremor intensity index; DVB = degree of voice breaks; NVB = number of voice breaks; DSH = degree of sub-harmonic components; NSH = number of subharmonic segments; NHR = the noise-to-harmonics ratio; VTI = voice turbulence index; SPI = spectrum soft phonation index. * Significant difference (p < 0.05). ** Strong significant difference (p < 0.01).

a long-term symptomatic treatment. A wide range of cough incidences among patients with the LPR is reported in the world literature [3, 10, 27]. Mujica et al. reported the incidence of cough in 10% of patients with LPR [27]. Šiupšiuskienê found that 71.7% of patients with LPR suffered from cough [3]. Grabczak described GERD as the most common cause of cough, presented by 74% patients [10]. Patients with dysphonia usually seek help of otolaryngologist quicker than the ones with cough do. The most probable reason is that

hoarseness raises fear of laryngeal cancer, especially in smokers, who are predominantly males. RSI is widely used test to analyze patients' symptoms of possible LPR [28–32]. Patients with cough usually present higher RSI values. This is probably associated with the symptom duration, which is described as longer in the group of patients with chronic cough [18]. In our study, a significant correlation between the main symptom reported by the patients and the severity of morphological

Please cite this article in press as: Domeracka-Kołodziej A, et al. Comparison of voice quality in patients with GERD-related dysphonia or chronic cough. Otolaryngol Pol. (2013), http://dx.doi.org/10.1016/j.otpol.2013.10.003

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changes within the larynx was not found. Rolla et al. [33] observed that patients with chronic cough have a higher RFS, decreased LES and UES pressure, increased duration of acid contact with the esophagus, and prolonged esophageal clearance in comparison to those parameters in GERD patients without cough. In this study, in the perceptual voice assessment there were no cases of normal voice. Furthermore, no statistically significant difference in subjectively assessed voice features between patients groups was found. Remackle's type III sonograms were prevalent in both female and male groups. This means a constant presence of the fundamental frequency (F0) accompanied by harmonic as well as noise components in the most sonograms. Females demonstrated a statistically significant correlation between the sonogram type and the main symptom reported. In the group with dysphonia, more sonograms showed the presence of noise components. In the male group, there was no statistically significant correlation between the sonogram type and the main symptom reported. Both in the female and male groups, 1/3 patients showed inability to maintain the F0 at the same level and additionally F0 was accompanied by diplophonia. It might suggest hyperfunctional mechanism of phonation with vestibular fold involvement (analysis revealed no significant differences between the study groups). Both in the male and female groups the prevalent sonographic pattern was IInd degree of hoarseness according to Yanagihara's classification [22] with statistically significant correlation to the main symptom, i.e. less severe hoarseness was found in patients with cough, both men and women. The mean F0 value was within normal limits in both male groups. In the female patients, F0 value was found to be decreased to 195.61 Hz in comparison to the generally established norm that is 256 Hz, but with no significant difference between the groups. Van Lierde et al. [23, 24] reported that usefulness of an MDVP acoustic analysis was undeniable and this technique should be utilized in clinical diagnostics in every patient with dysphonia. Parameters such as F0, jitter, shimmer, HNR constitute the fundamental elements of voice quality. Roughness can be evaluated based on the values of jitter and HNR [34, 35]. Breathiness is reflected in the shimmer value [36]. Hoarseness results in increased jitter, shimmer, and HNR [28, 29]. Elevated levels of jitter and shimmer might be a result of reduced control of laryngeal phonation and degenerative tissue changes [36, 37]. Aperiodic components of the speech signal (noise) result from irregular vocal folds vibrations [34, 36]. Abnormalities of the parameters reflecting frequency disturbances (Jita, Jitt, vF0) confirm the presence of hoarseness which is documented by abnormal values related to vocal tremor (FTRI, ATRI, Fftr, Fatr), voice irregularities (DUV, NUV), breaks in phonation (DVB, NVB), and a relative measure of noise (HNR, VTI, SPI). Nonconstant character of F0 observed in sonograms is confirmed by abnormal values of parameters of voice frequency and volume (ShdB, Shim, vAm). The presence of diplophonia in the speech signal is reflected by abnormal values of subharmonic parameters (DSH, NSH). In our study, the values of VTI were found to be significantly higher in the group of females reporting dysphonia as a main symptom.

In men, the relevant parameters were Jita, Jitt, RAP, PPQ, and sPPQ.

Conclusions In comparison to patients with laryngitis posterior caused by GERD and with dysphonia as the main symptom, patients with chronic cough did not differ in perceptual assessment of voice. In objective voice analysis, however, the chronic cough group presented abnormalities in less degree. Contrary to our expectation that voice disorders might be more severe in patients with chronic cough due to the chemical or mechanical irritation, the results of this study did not confirm this. Both dysphonia and chronic cough in GERD caused large voice disorders.

Authors' contributions/Wkład autorów AD-K – study design, data collection and interpretation, acceptance of final manuscript version, literature search. EMG, MD, MA – data collection. ML – statistical analysis, preparation of the manuscript. EO-W, KN – acceptance of final manuscript version.

Conflict of interest/Konflikt interesu None declared.

Financial support/Finansowanie None declared.

Ethics/Etyka The work described in this article has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans; EU Directive 2010/63/EU for animal experiments; Uniform Requirements for manuscripts submitted to Biomedical journals. The Ethics Committee Review Board at the Medical University of Warsaw approved the project.

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Please cite this article in press as: Domeracka-Kołodziej A, et al. Comparison of voice quality in patients with GERD-related dysphonia or chronic cough. Otolaryngol Pol. (2013), http://dx.doi.org/10.1016/j.otpol.2013.10.003

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Comparison of voice quality in patients with GERD-related dysphonia or chronic cough.

The aim was to compare a voice quality in patients with GERD-related dysphonia or chronic cough and to determine whether there is a relationship betwe...
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