Original Paper Folia Phoniatr Logop 2014;66:237–243 DOI: 10.1159/000369167
Published online: February 5, 2015
Early Voice Therapy in Patients with Unilateral Vocal Fold Paralysis Manal El-Banna Gamal Youssef Unit of Phoniatrics, Otorhinolaryngology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
Key Words Early voice therapy · Unilateral vocal fold paralysis · Dysphonia Severity Index · Voice Problem Self-Assessment Scale
the DSI. Conclusion: Early onset of voice therapy may enhance the reduction in glottal gap and improvement of voice quality by hindering the development of faulty hyperfunctional compensatory behaviors; early voice therapy may therefore enhance the patient’s quality of life. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 1021–7762/15/0666–0237$39.50/0 E-Mail [email protected] www.karger.com/fpl
Introduction
Unilateral vocal fold paralysis (UVFP) may alter phonation, airway protection, breathing and stabilization of the body core during physical activity. Weakness and change of voice quality and dysphagia are consequences of inadequate closure of the vocal folds. Dysphonia is the main symptom that causes a patient to seek a phoniatrician’s advice. The degree of voice complaints depends on the amount of glottal incompetence and on the type of compensatory behaviors the patient may employ to improve vocal intensity [1]. The voice may be breathy and rough, with restricted pitch and loudness variations as well as short phonation time. Diplophonia can occur as patients increase the effort to attain glottal closure [2]. Compensatory hyperfunctional behaviors, such as anterior-posterior or lateral compression of the false vocal Dr. Gamal Youssef ENT Department, Dubai Hospital ENT Voice Clinic, PO Box 7272 Dubai (UAE) E-Mail dr.gamal @ gmail.com
Downloaded by: Freie Universität Berlin 130.133.8.114 - 5/10/2015 6:08:55 PM
Abstract Objective: The purpose of this work was to study the efficacy of early voice therapy in the management of patients with unilateral vocal fold paralysis. Patients and Methods: Three groups of patients suffering from unilateral vocal fold paralysis were subjected to a protocol of voice evaluation including auditory-perceptual voice analysis, the Dysphonia Severity Index (DSI) and the 20-item Voice Problem Self-Assessment Scale (VPSS-20). Patients were also examined using video laryngostroboscopy. The early voice therapy group was enrolled in a voice therapy program for 16 sessions as soon as the patients were diagnosed; the second group of patients did not receive voice therapy during the course of their ailment. The late voice therapy group was enrolled in a voice therapy after a period of at least 6 months following the onset of vocal fold paralysis. All studied patients were reevaluated after a period of 2 months. Results: The early voice therapy group showed better outcomes regarding VPSS-20 scores, auditory-perceptual voice analysis as well as
Method Participants The study included 42 patients diagnosed as having UVFP and complaining of postoperative change of voice quality. The selection was restricted to patients with iatrogenic etiology to be able to determine the time of onset of the paralysis. Patients with preoperative thyroid nodules were followed up immediately after sur-
238
Folia Phoniatr Logop 2014;66:237–243 DOI: 10.1159/000369167
gery to select those with unilateral vocal fold immobility. The participants were 17 males and 25 females. The age range was 22–52 years (mean 35.38 years). The early voice therapy group included 22 patients (9 males and 13 females) with a mean age of 35 ± 7.17 years. The 15 patients (5 males and 7 females) who received no voice therapy had a mean age of 35 ± 5.97 years. The late voice therapy group consisted of 8 patients (3 males and 5 females) with a mean age of 37 ± 9.24 years. Vocal fold paralysis affected the right vocal fold in 19 patients and the left one in 33 patients. The duration of vocal fold paralysis at initial assessment ranged from 2 to 4 weeks, with a mean of 3.4 ± 1.6 weeks. In the late voice therapy group, the mean time between onset of vocal fold paralysis and onset of voice therapy ranged from 6 to 14 months, with a mean of 9.12 ± 2.6 months. Patients included in the study were only those candidates for voice therapy with a vocal fold in the paramedian position; patients with clinically significant aspiration were excluded from the study, as they had shown a large glottal gap, and other lines of intervention were suggested. The early voice therapy group participants were enrolled in voice therapy sessions as soon as they were referred and diagnosed postoperatively. The ‘no voice therapy’ group included patients who were unable or refused to attend regular voice therapy. The late voice therapy group included patients who were enrolled in voice therapy sessions after >6 months following the onset of the insult. They refused voice therapy sessions earlier, but were enrolled later when they were convinced about the importance of voice therapy as an intervention strategy. Voice Assessment All groups were initially assessed using a protocol of voice assessment, which included the following: • Auditory-perceptual voice analysis using the modified Grade, Roughness, Breathiness, Asthenia and Strain (GRBAS) scale [8] was performed by 3 expert phoniatricians. Their assessment of the voices was blinded, with no reference to the research group. • 20-Item VPSS (VPSS-20) [9] is a 4-point scale questionnaire with a total score of 80. The total score of the VPSS-20 summarizes the scores of 4 clusters which are the functional, physical, emotional and phonathenic clusters. The VPSS-20, like the 30item Voice Handicap Index (VHI-30), is a reliable and valid instrument that measures the impact of voice disorders on Egyptian patients. • The DSI was calculated using the following equation: DSI = 0.13 × MPT + 0.0053 × F0-high – 0.26 × I-low – 1.18 × jitter (%) + 12.4 [10]. The parameters used for the DSI are maximum phonation time (MPT, in seconds), the highest frequency (F0high, in Hz), the lowest intensity (I-low, in dB SPL), and jitter (in %). The measurements were collected using the Multidimensional Voice Profile and Visi-pitch. Participants were seated 30 cm from the microphone, and the ambient noise level was 30 dB in the room. Participants were asked to phonate /a/ as softly as possible at a comfortable pitch to obtain the fundamental frequency. The patients were asked to produce /a/ starting at a comfortable pitch going up to the highest and then down to the lowest pitch to obtain both F0-high and F0-low. To calculate jitter, the participants phonated /a/ three times at a comfortable pitch and loudness for approximately 3 s. Jitter was calculated on a sample of 1 s from each trial, starting half a second after voice onset. The lowest result of
El-Banna/Youssef
Downloaded by: Freie Universität Berlin 130.133.8.114 - 5/10/2015 6:08:55 PM
folds, can result in a rough, strained and low-pitched voice. Vocal fatigue, globus sensation and neck discomfort are other symptoms that may be associated with UVFP. This condition may have a negative impact on patients’ self-assessment of their voice problem [1, 2]. Management of UVFP includes surgical techniques such as Teflon, collagen, hydroxyapatite or autogenous micronized dermis, fat injection, type I thyroplasty, and nerve pedicle transfer [3], but voice therapy is strongly recommended for the management of UVFP with minimal glottal gap. The main goal of voice therapy is to improve glottal closure without causing supraglottic hyperfunction while developing abdominal support for breathing and improving the strength of intrinsic muscles [2]. The most commonly used voice therapy approaches involve hard glottal attack and pushing exercises, designed to narrow the glottis to permit the buildup of subglottal pressure which can then effectively vibrate the vocal folds for vowels production. These maneuvers should be avoided, however, as they may induce supraglottic hyperfunction; for this reason, glottal attack approaches have been recommended only as short-term therapies, at the outset of treatment [4, 5]. Modified pushing is an isometric exercise whereby sustaining vowels and gliding from the lowest to the highest note, and vice versa, is practiced. This approach encourages contraction of the thyroarytenoid muscle [4, 6]. The Smith accent method has also been suggested to improve auditory-perceptual and aerodynamic parameters of UVFP patients [7]. Data regarding the efficacy of early-onset voice therapy in patients with UVFP are scant. We hypothesized that patients in an early treatment group would exhibit a statistically significant improvement in the following vocal function measures: auditory-perceptual assessment of voice quality, Voice Problem Self-Assessment Scale (VPSS), Dysphonia Severity Index (DSI) and glottal gap size. The aim of this work is to study the efficacy of early voice therapy in improving voice quality in patients with unilateral vocal fold paralysis using both objective and subjective measures.
Table 1. Mean and standard deviation of the auditory-perceptual assessment of voice quality at the initial and final assessment for the
three studied groups Quality of voice
Early voice therapy group
No voice therapy group
Late voice therapy group
IA
FA
IA
FA
IA
FA
Overall grade of dysphonia p value
2.00 ± 0.75 0.001
1.50 ± 0.67
2.00 ± 0.95 0.586
1.92 ± 0.99
2.00 ± 0.75 0.170
1.75 ± 0.71
Roughness p value
1.09 ± 0.68 0.030
0.82 ± 0.66
1.92 ± 0.90 0.339
1.00 ± 0.95
1.75 ± 0.46 0.351
1.62 ± 0.52
Breathiness p value
2.00±.75 0.001
1.50 ± 0.67
1.08±.90 0.220
1.58 ± 1.08
1.75±.46 0.351
1.62 ± 0.52
Asthenia p value
1.36 ± 0.49 0.104
1.18 ± 0.49
1.58 ± 0.79 0.191
1.33 ± 0.98
1.50 ± 0.53 –
1.50 ± 0.53
Strain p value
0.72 ± 0.83 0.016
0.41 ± 0.59
0.67 ± 0.89 0.339
1.08 ± 1.50
1.50 ± 1.07 0.011
0.87 ± 1.25
– = The correlation and t cannot be computed because the standard error of the difference is 0; IA = initial assessment; FA = followup assessment.
Voice Therapy Voice therapy was administered by one of the authors. It was individualized, based on the degree of glottal incompetence as well as on the type and degree of the compensatory behaviors used by the patient. The adopted voice therapy program included modified pushing exercises and the Smith accent method. The patients were asked to produce a hard glottal attack with the addition of stretching the vowel while gliding down to a lower pitch. They practiced modified hard glottal attack with vowels and words twice a day for 1 week. If progress was made, the patients incorporated isometric push to the exercise program. Progress was judged using the auditory-perceptual assessment, the patient’s subjective perception of improvement and endoscopic monitoring. If progress was not observed after the termination of voice therapy sessions, modified hard glottal attack was tried for another week, after which the accent method was started. Patient performance was monitored to guard against supraglottic hyperfunction using the auditory-perceptual voice analysis and endoscopic signs of supraglottic hyperfunction. The Smith accent method was applied as 20-min sessions twice weekly for 16 sessions [11].
Early Voice Therapy in UVFP
Follow-Up All groups were reassessed, using the same protocol as described above, after a period of 2 months to determine changes in vocal performance. Ethics The Institutional Review Board at the Faculty of Medicine, Alexandria University, Egypt, approved the protocol of this study, and written informed consent was obtained. Statistical Analysis The χ2 test was used to compare groups as regards qualitative variables, for example, gender. The Kruskal-Wallis H test was performed to compare the three studied groups, while paired t tests were used to assess differences between means obtained at the initial and follow-up assessment of the same group. All statistical analyses were performed using the SPSS software package version 13.0. p values
Published online: February 5, 2015
Early Voice Therapy in Patients with Unilateral Vocal Fold Paralysis Manal El-Banna Gamal Youssef Unit of Phoniatrics, Otorhinolaryngology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
Key Words Early voice therapy · Unilateral vocal fold paralysis · Dysphonia Severity Index · Voice Problem Self-Assessment Scale
the DSI. Conclusion: Early onset of voice therapy may enhance the reduction in glottal gap and improvement of voice quality by hindering the development of faulty hyperfunctional compensatory behaviors; early voice therapy may therefore enhance the patient’s quality of life. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 1021–7762/15/0666–0237$39.50/0 E-Mail [email protected] www.karger.com/fpl
Introduction
Unilateral vocal fold paralysis (UVFP) may alter phonation, airway protection, breathing and stabilization of the body core during physical activity. Weakness and change of voice quality and dysphagia are consequences of inadequate closure of the vocal folds. Dysphonia is the main symptom that causes a patient to seek a phoniatrician’s advice. The degree of voice complaints depends on the amount of glottal incompetence and on the type of compensatory behaviors the patient may employ to improve vocal intensity [1]. The voice may be breathy and rough, with restricted pitch and loudness variations as well as short phonation time. Diplophonia can occur as patients increase the effort to attain glottal closure [2]. Compensatory hyperfunctional behaviors, such as anterior-posterior or lateral compression of the false vocal Dr. Gamal Youssef ENT Department, Dubai Hospital ENT Voice Clinic, PO Box 7272 Dubai (UAE) E-Mail dr.gamal @ gmail.com
Downloaded by: Freie Universität Berlin 130.133.8.114 - 5/10/2015 6:08:55 PM
Abstract Objective: The purpose of this work was to study the efficacy of early voice therapy in the management of patients with unilateral vocal fold paralysis. Patients and Methods: Three groups of patients suffering from unilateral vocal fold paralysis were subjected to a protocol of voice evaluation including auditory-perceptual voice analysis, the Dysphonia Severity Index (DSI) and the 20-item Voice Problem Self-Assessment Scale (VPSS-20). Patients were also examined using video laryngostroboscopy. The early voice therapy group was enrolled in a voice therapy program for 16 sessions as soon as the patients were diagnosed; the second group of patients did not receive voice therapy during the course of their ailment. The late voice therapy group was enrolled in a voice therapy after a period of at least 6 months following the onset of vocal fold paralysis. All studied patients were reevaluated after a period of 2 months. Results: The early voice therapy group showed better outcomes regarding VPSS-20 scores, auditory-perceptual voice analysis as well as
Method Participants The study included 42 patients diagnosed as having UVFP and complaining of postoperative change of voice quality. The selection was restricted to patients with iatrogenic etiology to be able to determine the time of onset of the paralysis. Patients with preoperative thyroid nodules were followed up immediately after sur-
238
Folia Phoniatr Logop 2014;66:237–243 DOI: 10.1159/000369167
gery to select those with unilateral vocal fold immobility. The participants were 17 males and 25 females. The age range was 22–52 years (mean 35.38 years). The early voice therapy group included 22 patients (9 males and 13 females) with a mean age of 35 ± 7.17 years. The 15 patients (5 males and 7 females) who received no voice therapy had a mean age of 35 ± 5.97 years. The late voice therapy group consisted of 8 patients (3 males and 5 females) with a mean age of 37 ± 9.24 years. Vocal fold paralysis affected the right vocal fold in 19 patients and the left one in 33 patients. The duration of vocal fold paralysis at initial assessment ranged from 2 to 4 weeks, with a mean of 3.4 ± 1.6 weeks. In the late voice therapy group, the mean time between onset of vocal fold paralysis and onset of voice therapy ranged from 6 to 14 months, with a mean of 9.12 ± 2.6 months. Patients included in the study were only those candidates for voice therapy with a vocal fold in the paramedian position; patients with clinically significant aspiration were excluded from the study, as they had shown a large glottal gap, and other lines of intervention were suggested. The early voice therapy group participants were enrolled in voice therapy sessions as soon as they were referred and diagnosed postoperatively. The ‘no voice therapy’ group included patients who were unable or refused to attend regular voice therapy. The late voice therapy group included patients who were enrolled in voice therapy sessions after >6 months following the onset of the insult. They refused voice therapy sessions earlier, but were enrolled later when they were convinced about the importance of voice therapy as an intervention strategy. Voice Assessment All groups were initially assessed using a protocol of voice assessment, which included the following: • Auditory-perceptual voice analysis using the modified Grade, Roughness, Breathiness, Asthenia and Strain (GRBAS) scale [8] was performed by 3 expert phoniatricians. Their assessment of the voices was blinded, with no reference to the research group. • 20-Item VPSS (VPSS-20) [9] is a 4-point scale questionnaire with a total score of 80. The total score of the VPSS-20 summarizes the scores of 4 clusters which are the functional, physical, emotional and phonathenic clusters. The VPSS-20, like the 30item Voice Handicap Index (VHI-30), is a reliable and valid instrument that measures the impact of voice disorders on Egyptian patients. • The DSI was calculated using the following equation: DSI = 0.13 × MPT + 0.0053 × F0-high – 0.26 × I-low – 1.18 × jitter (%) + 12.4 [10]. The parameters used for the DSI are maximum phonation time (MPT, in seconds), the highest frequency (F0high, in Hz), the lowest intensity (I-low, in dB SPL), and jitter (in %). The measurements were collected using the Multidimensional Voice Profile and Visi-pitch. Participants were seated 30 cm from the microphone, and the ambient noise level was 30 dB in the room. Participants were asked to phonate /a/ as softly as possible at a comfortable pitch to obtain the fundamental frequency. The patients were asked to produce /a/ starting at a comfortable pitch going up to the highest and then down to the lowest pitch to obtain both F0-high and F0-low. To calculate jitter, the participants phonated /a/ three times at a comfortable pitch and loudness for approximately 3 s. Jitter was calculated on a sample of 1 s from each trial, starting half a second after voice onset. The lowest result of
El-Banna/Youssef
Downloaded by: Freie Universität Berlin 130.133.8.114 - 5/10/2015 6:08:55 PM
folds, can result in a rough, strained and low-pitched voice. Vocal fatigue, globus sensation and neck discomfort are other symptoms that may be associated with UVFP. This condition may have a negative impact on patients’ self-assessment of their voice problem [1, 2]. Management of UVFP includes surgical techniques such as Teflon, collagen, hydroxyapatite or autogenous micronized dermis, fat injection, type I thyroplasty, and nerve pedicle transfer [3], but voice therapy is strongly recommended for the management of UVFP with minimal glottal gap. The main goal of voice therapy is to improve glottal closure without causing supraglottic hyperfunction while developing abdominal support for breathing and improving the strength of intrinsic muscles [2]. The most commonly used voice therapy approaches involve hard glottal attack and pushing exercises, designed to narrow the glottis to permit the buildup of subglottal pressure which can then effectively vibrate the vocal folds for vowels production. These maneuvers should be avoided, however, as they may induce supraglottic hyperfunction; for this reason, glottal attack approaches have been recommended only as short-term therapies, at the outset of treatment [4, 5]. Modified pushing is an isometric exercise whereby sustaining vowels and gliding from the lowest to the highest note, and vice versa, is practiced. This approach encourages contraction of the thyroarytenoid muscle [4, 6]. The Smith accent method has also been suggested to improve auditory-perceptual and aerodynamic parameters of UVFP patients [7]. Data regarding the efficacy of early-onset voice therapy in patients with UVFP are scant. We hypothesized that patients in an early treatment group would exhibit a statistically significant improvement in the following vocal function measures: auditory-perceptual assessment of voice quality, Voice Problem Self-Assessment Scale (VPSS), Dysphonia Severity Index (DSI) and glottal gap size. The aim of this work is to study the efficacy of early voice therapy in improving voice quality in patients with unilateral vocal fold paralysis using both objective and subjective measures.
Table 1. Mean and standard deviation of the auditory-perceptual assessment of voice quality at the initial and final assessment for the
three studied groups Quality of voice
Early voice therapy group
No voice therapy group
Late voice therapy group
IA
FA
IA
FA
IA
FA
Overall grade of dysphonia p value
2.00 ± 0.75 0.001
1.50 ± 0.67
2.00 ± 0.95 0.586
1.92 ± 0.99
2.00 ± 0.75 0.170
1.75 ± 0.71
Roughness p value
1.09 ± 0.68 0.030
0.82 ± 0.66
1.92 ± 0.90 0.339
1.00 ± 0.95
1.75 ± 0.46 0.351
1.62 ± 0.52
Breathiness p value
2.00±.75 0.001
1.50 ± 0.67
1.08±.90 0.220
1.58 ± 1.08
1.75±.46 0.351
1.62 ± 0.52
Asthenia p value
1.36 ± 0.49 0.104
1.18 ± 0.49
1.58 ± 0.79 0.191
1.33 ± 0.98
1.50 ± 0.53 –
1.50 ± 0.53
Strain p value
0.72 ± 0.83 0.016
0.41 ± 0.59
0.67 ± 0.89 0.339
1.08 ± 1.50
1.50 ± 1.07 0.011
0.87 ± 1.25
– = The correlation and t cannot be computed because the standard error of the difference is 0; IA = initial assessment; FA = followup assessment.
Voice Therapy Voice therapy was administered by one of the authors. It was individualized, based on the degree of glottal incompetence as well as on the type and degree of the compensatory behaviors used by the patient. The adopted voice therapy program included modified pushing exercises and the Smith accent method. The patients were asked to produce a hard glottal attack with the addition of stretching the vowel while gliding down to a lower pitch. They practiced modified hard glottal attack with vowels and words twice a day for 1 week. If progress was made, the patients incorporated isometric push to the exercise program. Progress was judged using the auditory-perceptual assessment, the patient’s subjective perception of improvement and endoscopic monitoring. If progress was not observed after the termination of voice therapy sessions, modified hard glottal attack was tried for another week, after which the accent method was started. Patient performance was monitored to guard against supraglottic hyperfunction using the auditory-perceptual voice analysis and endoscopic signs of supraglottic hyperfunction. The Smith accent method was applied as 20-min sessions twice weekly for 16 sessions [11].
Early Voice Therapy in UVFP
Follow-Up All groups were reassessed, using the same protocol as described above, after a period of 2 months to determine changes in vocal performance. Ethics The Institutional Review Board at the Faculty of Medicine, Alexandria University, Egypt, approved the protocol of this study, and written informed consent was obtained. Statistical Analysis The χ2 test was used to compare groups as regards qualitative variables, for example, gender. The Kruskal-Wallis H test was performed to compare the three studied groups, while paired t tests were used to assess differences between means obtained at the initial and follow-up assessment of the same group. All statistical analyses were performed using the SPSS software package version 13.0. p values
