Sleep Breath DOI 10.1007/s11325-014-1092-8

ORIGINAL ARTICLE

The effect of obstructive sleep apnea syndrome and continuous positive airway pressure treatment on voice performance Doğan Atan & Kürşat Murat Özcan & Aykut İkincioğulları & Sabri Köseoğlu & Mehmet Ali Çetin & Serdar Ensari & Hüseyin Dere

Received: 7 April 2014 / Revised: 28 September 2014 / Accepted: 21 October 2014 # Springer-Verlag Berlin Heidelberg 2014

Abstract Objective Obstructive sleep apnea syndrome (OSAS) may affect voice performance due to alterations that occur in the upper respiratory tract. The aim of the study was to assess the effect of OSAS and continuous positive airway pressure (CPAP) treatment on voice performance. Materials and methods Twenty-seven patients with moderate to severe OSAS (apnea-hypopnea index ≥15/h) who underwent polysomnographic examination and 28 age- and gender-matched normal control subjects were enrolled in the study. The patients and the control subjects completed Voice Handicap Index (VHI) questionnaires, and their acoustic voice analyses were performed. Fundamental frequency (F0), jitter %, and shimmer % parameters were statistically compared. Acoustic analyses were performed again 1 month after regular CPAP use in OSAS patients, and the parameters before and after the treatment were compared. Results F0 was 160.82 Hz, jitter was 0.70 %, shimmer was 1.05 %, and VHI was 1.18 in the control group. In OSAS patients before CPAP treatment, F0 was 157.04 Hz, jitter was 0.82 %, shimmer was 1.33 %, and VHI was 13.11. These results showed that shimmer and VHI parameters were significantly worse in OSAS patients. After CPAP treatment, F0 was 169.19 Hz, jitter was 0.62 %, shimmer was 0.93 % and VHI was 5.00. The differences were statistically significant in all parameters.

D. Atan : K. M. Özcan : A. İkincioğulları : S. Köseoğlu : M. A. Çetin : S. Ensari : H. Dere Department of Otorhinolaryngology, Head and Neck Surgery, Ankara Numune Education and Research Hospital, Ankara, Turkey D. Atan (*) Ankara Numune Eğitim ve Araştırma Hastanesi KBB kliniği, Samanpazarı, Ankara, Turkey e-mail: [email protected]

Conclusion The acoustic parameters of OSAS patients differed from those of the normal control subjects. The patients’ voice performance improved after a regular use of CPAP treatment for 1 month. Keywords Sleep apnea . Polysomnography . Voice . CPAP ventilation

Introduction Obstructive sleep apnea syndrome (OSAS) is diagnosed by the symptoms of daytime sleepiness, fatigue, abnormal sleep, witnessed apnea, and apnea-hypopnea index (AHI) values (≥5/h with symptoms or ≥15/h with no symptoms) [1]. The prevalence of OSAS has been reported to range from 0.3 to 15.0 % in different studies. This difference may be attributed to the study methods and diagnostic criteria. When considering these differences, OSAS is reported to be observed in approximately 1–5 % of adults [2]. The central nervous system and activator, vibrator, resonator, and articular organs should work together in harmony for voice production. The structural abnormalities of the resonating cavities (thickened and slack soft palate, thickened pharyngeal wall, hypertrophic tonsils, and tongue base lymphoproliferation) which are usually seen in OSAS patients affect the voice resonance [3]. Resonances are defined by the size and shape of the acoustic spaces of the oral, nasal, and pharyngeal cavities and the coupling between those spaces. Resonances define the vowel produced and significantly contribute to the overall vocal quality. Perceptual and acoustic characteristics of vocal quality change when there are structural abnormalities in the upper airway [4]. There have not been any studies evaluating voice performance in OSAS patients so far.

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Currently, positive airway pressure is the most effective treatment modality for OSAS [5]. The upper respiratory tract (URT) is exposed to positive pressure by continuous positive airway pressure (CPAP), and several changes and adaptations can be seen in the nose, pharynx, and larynx. Supporting the presence of pharyngeal soft tissue swelling in untreated OSA is the reported reduction in the upper airway edema following treatment of these patients with CPAP treatment. Following the CPAP treatment, increase in pharyngeal volume, decrease of tongue volume, and resolution of the upper airway edema were noted [6, 7]. These structural changes in the upper respiratory tract may lead to alterations in voice resonance which may result in changes in the voice quality. The aim of the study was to assess the effect of OSAS and the regular usage of CPAP treatment on voice performance.

Material and methods Subjects This was a prospective study performed at Ankara Numune Education and Research Hospital. Two groups of subjects were enrolled. The patient group consisted of 27 patients who were newly diagnosed with moderate to severe OSAS (apnea-hypopnea index ≥15/h) by polysomnographic examination in Ankara Numune Education and Research Hospital Sleep Disorders Laboratory between November 2012 and July 2013 and had an indication for CPAP treatment. A group of 28 healthy subjects with no history of sleep apnea or voice disorders and who did not have a voice problem were included into the control group. Two groups had similar gender, age, and BMI distributions. The inclusion criteria for the patient group were an AHI ≥15 shown by polysomnography and a regular use of CPAP (minimum six nights a week and minimum 4 h at night) as determined by the analysis of the CPAP card data (average 5.03±0.67 h/day, average 6.55±0.50 day/a week) Patients who discontinued CPAP were excluded from the study. The patients who were found not to receive CPAP treatment regularly as a result of voice performance evaluation were enrolled into neither the control group nor the patient group. The other exclusion criteria for both the patient and control groups were smoking, comorbid diseases likely to affect the voice, using medications, history of laryngeal, pulmonary or neurologic diseases likely to change voice production, active URT infection and a pathological condition and/or obstruction in the oral cavity-oropharynx, nasal cavity or larynx. The patients with any of such symptoms as excessive daytime sleepiness, loud snoring, observed episodes of breathing cessation during sleep, abrupt awakenings accompanied by shortness of breath, awakening with dry mouth or sore throat were not included into the control group.

The study protocol was approved by our institutional Ethics Committee, and informed consent was obtained from all the participants. The Alice PSG polysomnograph (Philips Respironics, The Netherlands) was used for the polysomnographic measurements. PSG was performed under the supervision of a sleep technician during spontaneous sleep. Electroencephalogram (EEG), submental and bilateral tibialis anterior electromyograms (EMG), electrooculogram (EOG), nasal airflow, thoracic and abdominal respiratory efforts, blood oxygen saturation (pulse oximetry) and body positions were recorded. The PSG data were scored manually by an ENT physician who had a sleep diseases and PSG certificate according to the standard criteria set by the American Academy of Sleep Medicine. All of the subjects underwent clinical examination including flexible nasopharyngoscopy and videolaryngoscopy after obtaining their detailed medical history. Videolaryngostroboscopic examination was performed in all subjects to investigate whether there was any evidence of laryngeal pathology that can affect the voice. It was found to be normal in both patient and control groups. All patients and control subjects also underwent clinical examination and a functional evaluation by objective (acoustic voice analysis) and subjective methods Voice Handicap Index (VHI) questionnaires. Apnea was scored when there was a drop in the peak signal excursion by ≥90 % of pre-event baseline and the duration of the ≥90 % drop in sensor signal was ≥10 s. Obstructive apnea was scored when it met apnea criteria and was associated with continued or increased inspiratory effort throughout the entire period of absent airflow. Central apnea was scored when it met apnea criteria and was associated with absent inspiratory effort throughout the entire period of absent airflow. Mixed apnea was scored when it met apnea criteria and was associated with absent inspiratory effort in the initial portion of the event, followed by resumption of inspiratory effort in the second portion of the event. Hypopnea was scored when the peak signal excursions dropped by ≥30 % of pre-event baseline using nasal pressure (diagnostic study), for ≥10 s in association with either ≥3 % arterial oxygen desaturation or an arousal [8]. Nasal CPAPs were used together with their moisturizers.

Voice handicap index The VHI consists of 30 questions measuring physical, emotional, and functional effects of voice disorders on a five-point scale ranging from 0 to 4. The total score varies between 0 and 120, and a higher score denotes a greater degree of handicap. There is not a standardized value discriminating normal from pathologic conditions in VHI. Increased VHI scores indicate an increase in the severity of voice problems. Both CPAP and the control groups completed the VHI at the beginning of the

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study, and CPAP group completed the VHI once more 1 month after a regular CPAP use. Acoustic voice analysis Acoustic voice analysis was performed using XION Medical DİVAS 2.5 Digital Voice Analysis Software program by an ENT physician. The subjects took a seat comfortably in front of the microphone (USB Audio CODEC microphone connected to the preamplifier) placed at a distance of 30 cm from their mouths, and were asked to phonate the vowel “/a/” three times with a normal voice for a duration of 5 s. The mean fundamental frequency (F0), jitter % and shimmer % were measured. Phonating only the vowel “/a/” for at least 5 s in acoustic voice analysis has been reported to appropriate in evaluation of voice performance [9, 10]. F0 refers to the number of resonances of the vocal cord at 1 s. Males usually speak at F0 frequencies of 100–150 Hz and females speak at F0 frequencies of 180–250 Hz. Jitter % and shimmer % are measurements of perturbation and show abnormalities in a cycle. Jitter % refers to variations in the periodicity of glottic cycles and its normal value is below 1 %. Shimmer % indicates variations in the amplitude of glottic cycles and its normal value is less than 3 % [11]. The results of acoustic voice analyses in the morning may differ from those in the afternoon [12]. In the present study, both the patients in the study group and the control group underwent acoustic voice analyses in the morning, which prevented their voices from being affected by circadian changes. The analyses were performed in the control subjects and in all patients before CPAP treatment. F0, jitter % and shimmer %, and VHI parameters were compared between the patient group before CPAP treatment and the control group in order to reveal the effect of OSAS on voice performance. Acoustic analyses were performed again in OSAS patients 1 month after a regular CPAP use, and the parameters (F0, jitter %, shimmer %, and VHI) were compared with the pretreatment values in order to reveal the effect of the CPAP treatment on voice performance.

Statistical analysis Statistical analyses of the data obtained were performed using IBM® SPSS® Statistics 20 for Mac (IBM Corp, Los Angeles, California, USA). The descriptive characteristics of the data were presented as mean standard deviation and median (minimum-maximum) values. Shapiro-Wilk test was used to assess normality.

Differences between independent groups were evaluated by T test for homogeneously distributed data, and Mann-Whitney U test for heterogeneously distributed data. The differences between the dependent groups for repeated measurements were evaluated by T-Test and Wilcoxon test. Relationships of quantitative variables were evaluated by Pearson’s correlation test and rho and P values were given. p value 0.05). The body mass index was (BMI) was 30.52±5.30 in the patient group and 28.30±3.33 in the control group (P=0.067) (Table 1). The mean AHI value was 49.24/28.78 (mean/SD) in the patient group. Before CPAP treatment, the analyzed parameters were as follows in the patient group: F0 was 157.04±34.20 Hz, jitter was 0.82±0.31 %, shimmer was 1.33±0.51 %, and VHI was 13.11±12.98. In the control group, the analyzed parameters were as follows: F0 was 160.82±32.58 Hz, jitter was 0.70± 0.38 %, shimmer was 1.05±0.50 %, and VHI was 1.18±2.50. The patient group had significantly higher and worsened VHI values when compared to the control group. The subjective evaluations showed that the patient group had significantly worse voice functions than the control group. The mean shimmer % values, which indicate perturbation, were found to be significantly higher in OSAS patients when compared to the control subjects. The shimmer %, one of the parameters of objective voice analyses, significantly differed between the patient and the control groups and the voice quality was worse in the OSAS patients. There were no statistically significant differences in F0 or jitter % values between the two groups (Table 2).

Table 1 Patient characteristics

Age Gender

Male Female

BMI BMI body mass index

OSAS group

Control group

P value

48.56±6.41 22 5 30.52±5.30

47.61±9.06 22 6 28.30±3.33

0.657 0.787 0.067

Sleep Breath Table 2 The results of the acoustic voice analysis and Voice Handicap Index (VHI) in the control subjects and in OSAS patients before CPAP treatment Parameter

Group

Mean±standard deviation Min-max

F0 (Hz)

Control 160.82±32.58 Patient 157.04±34.20 Jitter % Control 0.70±0.38 Patient 0.82±0.31 Shimmer % Control 1.05±0.50 Patient 1.33±0.51 VHI Control 1.18±2.50 Patient 13.11±12.98

P value

117–223 0.676 105–229 0.26–1.78 0.2 0.35–1.62 0.42–2.47 0.043 0.65–2.71 0–9 15. Acoustic voice analysis and VHI were performed preoperatively and 6 months after the operation. The preoperative mean VHI score was 66 while this score was 34 6 months after surgery, and there was a significant reduction in this score [25]. In a prospective study, Greene at al. performed

Parameter

Group

Mean±standard deviation

Min-max

P value

F0 (Hz)

Before treatment After treatment Before treatment After treatment Before treatment After treatment Before treatment After treatment

157.04±34.20 169.19±40.14 0.82±0.31 0.62±0.34 1.33±0.51 0.93±0.41 13.11±12.98 5.00±6.45

105–229 103–246 0.3–1.62 0.29–1.92 0.65–2.71 0.35–2.01 0–48 0–24

0.001

Jitter % Shimmer % VHI

0.006

The effect of obstructive sleep apnea syndrome and continuous positive airway pressure treatment on voice performance.

Obstructive sleep apnea syndrome (OSAS) may affect voice performance due to alterations that occur in the upper respiratory tract. The aim of the stud...
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