Voice outcomes after radiotherapy treatment for early glottic cancer: assessment using multidimensional tools

Alterations in Emotional Expression Through Speech in Patients With Unilateral Vocal Fold Paralysis: A Preliminary Study

Unilateral vocal fold paralysis (UVFP) has a known impact on patients' quality of life. One of the potentially affected domains that has not been studied yet is emotional prosody. To produce and transmit an efficient emotional prosody, several vocal parameters are modulated by the speaker, principally the fundamental frequency, the speech rate, and the voice intensity. We retrieved 300 sentences produced by 10 patients suffering from UVFP, equally in neutral, anger, and sadness. A jury of six health care voice experts was asked to hear these sentences and choose an emotion for each vocalization, between neutral, anger, and sadness. The jury mainly considered the heard sentences as being in a neutral emotion. Vocal parameters analysis of the anger and sadness sentences that were mistaken as neutral showed the absence of significant difference in their fundamental frequencies and speech rates. By being unable to modulate their vocal parameters as needed to produce emotional prosody, specifically the fundamental frequency and speech rate, patients with UVFP suffer from limitations in their capacity to produce the emotional prosody wanted, making the emotions they feel hardly transmitted to their entourage, which can explain the social barriers these patients complain of.

Impact of Radiotherapy on Quality of Life in T2 and Early T3 Laryngeal Carcinoma

Objective- To acknowledge patient-perceived voice-related and overall quality of life (QOL) in addition to disability index based on the validated voice-related quality of life survey (VRQOL), WHOQOL-BREF, and WHO DAS II questionnaires in T2 and early T3 laryngeal tumors after definitive radiotherapy. Methods- 35 patients of T2(15) and early T3(20) tumors were enrolled, assessed with three questionnaires of VRQOL, WHOQOL-BREF, and WHO DAS II before the start of radiotherapy, then at 12 and 24 weeks after radiotherapy, and the results were analyzed. Results- All 35 (100%) patients had significant vocal deterioration with a raw VRQOL score of more than 25 at the beginning, which significantly improved at 12 weeks post-radiotherapy (p < 0.5). However, VRQOL scores at the 12th and 24th weeks were statistically insignificant. On comparing the WHOQOL-BREF and WHO DAS II, domains of physical health, psychological health, and participation in society showed significant improvement in both the groups after radiotherapy except distress scores in T2 laryngeal cancers, where pre and post-radiotherapy scores were not significantly different suggesting residual distress. Conclusion- The QOL parameters improve significantly with treatment, however, there exists a persistence of residual distress even at 24 weeks after radiotherapy and hence, routine involvement of clinical psychologists should be emphasized in practice to alleviate anxiety, distress, and concerns regarding disease outcome and recurrence. 12 to 24 weeks post-radiotherapy can be an optimum time to gauge the improvement in the patient-related QOL outcome parameters and does not differ much between these durations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-022-03397-3.

Voice Outcomes Following Head-Lift Exercises in Head and Neck Cancer: A Randomized Controlled Study

OBJECTIVES

This prospective randomized study aimed to investigate whether patients with dysphagia after treatment for head and neck cancer improve their vocal function from doing head lift exercises (Shaker's exercise).

METHODS

Patients were randomized into an intervention group (n = 24) or a control group (n = 26). Patients in the intervention group performed the head lift exercise three times a day for 8 weeks. At baseline and at follow-up after 8 weeks, participants' voices were evaluated perceptually with the Grade-Roughness-Breathiness-Asthenia-Strain (GRBAS) scale. Vocal fry (VF) was also perceptually evaluated and patients filled in the Voice Handicap Index (VHI).

RESULTS

Patients in the intervention group were perceptually evaluated as having less roughness and vocal fry in their voices at follow-up compared to the control group. There were no statistically significant changes between baseline and follow-up neither in the intervention nor the control group regarding GRBAS, VF, or VHI. Neither were there any statistically significant differences within the groups when results on the perceptual evaluations at baseline and follow-up were compared.

CONCLUSIONS

The voices of the participants in the intervention group were slightly better than the voices of the participants in the control group with less roughness and VF at follow-up. However, no improvement in the VHI or the remaining GRBAS variables was found. Therefore, this study can only give cautious support to the head lift exercise as a method for improving the voice of patients with dysphagia after treatment for head and neck cancer.

Long-term functional outcomes in tumour stage T2 glottic carcinoma after radiotherapy

OBJECTIVE

To evaluate the long-term functional outcomes in patients who received primary radiotherapy for tumour-node stage T₂N₀ glottic carcinoma, stratified for tumour extension.

METHODS

A cross-sectional study was performed on patients who were treated with radiotherapy for T₂N₀ glottic carcinoma. Four questionnaires were used to measure different aspects of functional outcome. In addition, objective evaluation and perceptual analysis were performed.

RESULTS

Fourteen patients were included in this study. The median time between the start of radiotherapy and assessment was 42 months (range, 26-143 months). Patients reported high-level functioning, with low symptom scores and good swallowing function, and showed a median dysphonia grade of 1.5. The median Voice Handicap Index-30 score was 17.5.

CONCLUSION

Patients with T₂N₀ glottic carcinoma treated with radiotherapy had good long-term quality of life, with low symptom scores, good swallowing functioning and slightly elevated voice outcome parameters.

Change in Voice Quality after Radiotherapy for Early Glottic Cancer

Our aim was to track the changes in voice quality for two years after radiotherapy (RT) for early glottic cancer. A videoendostroboscopy, subjective patient and phoniatrician voice assessments, a Voice Handicap Index questionnaire, and objective acoustic measurements (F0, jitter, shimmer, maximal phonation time) were performed on 50 patients with T1 glottic carcinomas at 3, 12, and 24 months post-RT. The results were compared between the subsequent assessments, and between the assessments at 3 months and 24 months post-RT. The stroboscopy showed a gradual progression of fibrosis of the vocal folds with a significant difference apparent when the assessments at 3 months and 24 months were compared (p < 0.001). Almost all of the subjective assessments of voice quality showed an improvement during the first 2 years, but significant differences were noted at 24 months. Jitter and shimmer deteriorated in the first year after RT with a significant deterioration noticed between the sixth and twelfth months (p = 0.048 and p = 0.002, respectively). Two years after RT, only 8/50 (16%) patients had normal voices. The main reasons for a decreased voice quality after RT for early glottic cancer were post-RT changes in the larynx. Despite a significant improvement in the voice after RT shown in a few of the evaluation methods, only a minority of the patients had a normal voice two years post-RT.

Effect of voice rehabilitation following radiotherapy for laryngeal cancer - a 3-year follow-up of a randomised controlled trial

OBJECTIVES

This study aims to report on the effectiveness of voice rehabilitation following radiotherapy for laryngeal cancer in a long-term perspective, i.e., up to three years after completion of radiotherapy.

METHODS

The study included a total of 74 patients that were randomised into an intervention group (n = 37) or a control group (n = 37). Voice recordings with blinded assessment of voice quality with the GRBAS protocol (Grade, Roughness, Breathiness, Asthenia, Strain) and acoustic analysis was performed at baseline, 12 and 36 months following radiotherapy. Voice rehabilitation was performed in 10 sessions immediately following completion of radiotherapy. Patients also filled out the Swedish Self-Evaluation of Communication Experiences after Laryngeal cancer.

RESULTS

The S-SECEL demonstrated statistically significant improvements in the intervention group when comparing baseline and 36 months, and no changes in the control group. Acoustic measures did not reveal any significant changes. The perceptual analysis demonstrated that when comparing the changes within the groups between baseline and 36 months there were statistically significant differences between the intervention and control group regarding the voice qualities Roughness, Breathiness and Strain. In the control group, 50% demonstrated deterioration in roughness, while in the intervention group only 7% deteriorated during this time. In Breathiness and Strain, 57 and 50%, respectively, improved in the intervention group, while only 32% and 23% improved, respectively, in the control group.

CONCLUSION

Voice rehabilitation following radiotherapy for laryngeal cancer demonstrate positive effects in patient reported outcomes and perceptual measures of voice quality, and the effects remain up to three years following radiotherapy.

Change in dysphagia and laryngeal function after radical radiotherapy in laryngo pharyngeal malignancies - a prospective observational study

Background

Intensity modulated radiotherapy (IMRT) has the perceived advantage of function preservation by reduction of toxicities in the treatment of laryngo-pharyngeal malignancies. The aim of the study was to assess changes in dysphagia from baseline (i.e. prior to start of treatment) at three and six months post treatment in patients with laryngo-pharyngeal malignancies treated with radical radiotherapy ± chemotherapy. Functional assessment of other structures involved in swallowing was also studied.

Materials and methods

40 patients were sampled consecutively. 33 were available for final analysis. Dysphagia, laryngeal edema, xerostomia and voice of patients were assessed at baseline and at three and six months after treatment. Radiation was delivered with simultaneous integrated boost (SIB) using volumetric modulated radiation therapy (VMAT). Concurrent chemotherapy was three weekly cisplatin 100 mg/m².

Results

Proportion of patients with dysphagia rose significantly from 45.5% before the start of treatment to 57.6% at three months and 60.6% at six months post treatment (p = 0.019). 67% patients received chemotherapy and addition of chemotherapy had a significant correlation with dysphagia (p = 0.05, r = -0.336). Severity of dysphagia at three and six months correlated significantly with the mean dose received by the superior constrictors (p = 0.003, r = 0.508 and p = 0.024, r = 0.391) and oral cavity (p = 0.001, r = 0.558 and p = 0.003, r = 0.501). There was a significant worsening in laryngeal edema at three and six months post treatment (p < 0.01) when compared to the pre-treatment examination findings with 60.6% of patients having grade two edema at six months. Significant fall in the mean spoken fundamental frequency from baseline was seen at 6 months (p = 0.04), mean fall was 21.3 Hz (95% CI: 1.5-41 Hz) with significant increase in roughness of voice post treatment (p = 0.01).

Conclusion

There was progressive worsening in dysphagia, laryngeal edema and voice in laryngo-pharyngeal malignancies post radical radiotherapy ± chemotherapy.

Early-Stage Glottic Squamous Cell Carcinoma in the Era of Image-Guided Radiotherapy

Early-stage squamous cell cancer (SCC) of the glottis has a good prognosis. Therefore, patients have long survival outcomes and may potentially suffer from late toxicities of radiotherapy. Radiotherapy with a conventional parallel-opposed-pair or anterior-oblique beam arrangements for stage 1 and 2 glottic SCC have field borders that traditionally cover the entire larynx, exposing organs-at-risk (e.g. carotid arteries, contralateral vocal cord, contralateral arytenoid and inferior pharyngeal constrictor muscles) to high radiation doses. The potential long-term risk of cerebrovascular events has attracted much attention to the dose that carotid arteries receive. Swallow and respiratory motion of laryngeal structures has been an important factor that previously limited reduction of the radiation treatment volume. Motion has been evaluated using multiple imaging modalities and this information has been used to calculate PTV margins for generation of more limited target volumes. This review discusses the current literature surrounding dose-effect relationships for various organs-at-risk and the late toxicities that are associated with them. This article also reviews the currently available data and effects of laryngeal motions on dosimetry to the primary target. We also review the current limitations and benefits of a more targeted approach of radiotherapy for early-stage glottic SCCs and the evolution of CT-based IGRT and MR-guided radiotherapy techniques that may facilitate a shift away from a conventional 3D-conformal radiotherapy approach.

Glottic Malignant Fibrous Histiocytoma: A Case Report and Literature Review

Pleomorphic sarcoma of the larynx is a rare variant of laryngeal cancer. We present the case of a 59-year-old male patient who has been smoking for 40 years. He presented with signs and symptoms of an obstructive glottic mass. The diagnostic workup pointed to a malignant pathology; the histopathology report confirmed the diagnosis of glottic undifferentiated pleomorphic sarcoma (malignant fibrous histiocytoma).

Cost-effectiveness analysis of voice rehabilitation for patients with laryngeal cancer: a randomized controlled study

INTRODUCTION

Voice problems are common following radiotherapy for laryngeal cancer. Few studies exist covering the effect of voice rehabilitation, and no previous studies exist regarding the cost of said rehabilitation. This randomized controlled study aimed to analyze the cost-effectiveness of voice rehabilitation after radiotherapy for patients with laryngeal cancer.

MATERIAL AND METHODS

A total of 66 patients with laryngeal cancer with follow-up data 12 months post-radiotherapy were included. Patients were randomized into receiving either voice rehabilitation (n = 32) or no voice rehabilitation (n = 34). The patient outcome was measured as quality-adjusted life years (QALYs). The index range between 0 and 1, where 0 equals death and 1 represents perfect health. The QALYs were assessed with the European Organization for Research and Treatment of Cancer questionnaire QLQ-C30 mapped to EuroQoL 5 Dimension values. The cost of rehabilitation and other healthcare visits was derived from hospital systems. The patients reported the total amount of sick leave days during the first 12 months following radiotherapy. The cost-effectiveness of the voice rehabilitation was compared with no rehabilitation intervention based on the incremental cost-effectiveness ratio.

RESULTS

The cost per gained QALY with voice rehabilitation compared to no rehabilitation from a societal perspective was - 27,594 € (SEK - 250,852) which indicates that the voice rehabilitation is a cost-saving alternative compared to no rehabilitation due to lower costs and a slightly better health outcome. From a healthcare perspective, the voice rehabilitation indicates a cost 60,800 € (SEK 552,725) per gained QALY.

CONCLUSION

From a societal perspective, i.e., including the costs of production loss, voice rehabilitation compared to no voice rehabilitation following radiotherapy for laryngeal cancer seems to be cost-saving. When analyzing only the healthcare costs in relation to health outcomes, voice rehabilitation indicates an incremental cost of 60,800 € per gained QALY, which is just above the threshold of the maximum willingness to pay level.

Voice Quality, Function, and Quality of Life for Laryngeal Cancer: A Prospective Longitudinal Study Up to 24 Months Following Radiotherapy

OBJECTIVE

To study the potential changes of health-related quality of life (HRQL), voice quality, and communicative function up to 24 months following radiotherapy for patients with laryngeal cancer.

METHODS

A total of 28 patients with laryngeal cancer, treated by curatively intended radiotherapy were included in this prospective longitudinal descriptive study. Patients were followed pre-radiotherapy, 12 months, and 24 months post-radiotherapy. At each time point, voice recordings and patient-reported outcome instruments (European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire Core30, Head and Neck35, Swedish Self-Evaluation of Communication Experiences after Laryngeal Cancer) were completed. Perceptual analysis using the Grade-Roughness-Breathiness-Asthenia-Strain was performed using the voice recordings.

RESULTS

Voice quality remains inferior to the voices of healthy controls both before and up to 24 months post-radiotherapy, demonstrating no statistically significant changes during the study period. Self-perceived communicative function revealed a trend toward improvement. Health-related quality of life remains mostly at stable levels, however, with statistically significant deterioration regarding dry mouth and sticky saliva. Generally, patients reported inferior scores compared to a normal population.

CONCLUSION

This study demonstrated no statistically significant changes over time in HRQL and perceptual voice quality at pre-radiotherapy compared to 24 months post-radiotherapy. However, the values remain inferior to the voices of healthy controls or a normal population.

Long-Term Voice and Swallowing Outcomes for Oral and Oropharyngeal Cancer Following Primary or Adjuvant Chemoradiation

Objective:

Chemoradiation (CRT) for nonlaryngeal head and neck cancer (HNC) can lead to voice and swallowing dysfunction. The purpose of this study was to examine voice and swallowing from the patient’s perspective at least 5 years after treatment.

Design:

Patient survey.

Methods:

Twenty-eight patients treated with primary or adjuvant CRT at least 5 years ago (mean = 10.7 years, SD = 5.5, range, 5-28) completed a survey created based on previously validated questionnaires (the Patient Perception of Swallowing Function Questionnaire, PPSFQ; the Eating Assessment Tool, EAT-10; the Voice Handicap Index, VHI-10; the Voice Related Quality of Life, V-RQOL).

Results:

Patients reported some voice and swallowing dysfunction (39% of V-RQOL scores in categories of fair, poor, or worst possible and 32% of VHI-10 scores ≥20 or greater than 50% of the maximum; 39% of PPSFQ scores greater than 50% of the maximum and 32% of EAT-10 scores ≥20 or 50% of the maximum). There was a correlation between V-RQOL and VHI-10 scores (Pearson product moment correlation coefficient r = .96, calculated probability value p = 0), PPSFQ and EAT-10 scores (r = 0.87, p = 0.8 × 10−8), as well as between V-RQOL and PPSFQ/EAT-10 scores (r = .94, p = 0), VHI-10 and PPSFQ/EAT-10 scores (r = .97, p = 0).

Conclusions:

Perceived voice and swallowing dysfunction following CRT for nonlaryngeal HNC can persist or worsen beyond 5 years.

Voice Quality in Laryngeal Cancer Patients: A Randomized Controlled Study of the Effect of Voice Rehabilitation

OBJECTIVES

The study aimed to investigate the short-term and long-term effects of voice rehabilitation in patients treated with radiotherapy for laryngeal cancer as measured by both the acoustic measure smoothed cepstral peak prominence (CPPS) and perceptual measures. A secondary aim was to investigate the relationship between acoustic and perceptual measures.

METHODS

In total, 37 patients received voice rehabilitation post-radiotherapy and 37 patients constituted the irradiated control group. Outcome measures were mean CPPS for connected speech and ratings with the auditory-perceptual Grade, Roughness, Breathiness, Asthenia and Strain (GRBAS) scale. Outcome measures were analyzed 1 (baseline), 6, 12, and 24 months post-radiotherapy, where voice rehabilitation was conducted between the first two time-points. Additional recordings were acquired from vocally healthy participants for comparison.

RESULTS

CPPS values of the voice rehabilitation group and vocally healthy group were not significantly different at 24 months post-radiotherapy. Ten out of 19 patients who received voice rehabilitation yielded a CPPS value above the threshold for normal voice 24 months post-radiotherapy, compared to 11 out of 26 in the irradiated control group. No statistically significant correlations were found between CPPS and perceptual parameters of GRBAS.

CONCLUSION

Voice rehabilitation for irradiated laryngeal cancer patients may have positive effects on voice quality up to 24 months post-radiotherapy. The relationship between CPPS and GRBAS as well as the applicability of CPPS for evaluation over several points of measurement needs to be studied further.

Quality of life in Chinese patients with laryngeal cancer after radiotherapy

This retrospective study explored the quality of life (QoL) in Chinese patients with laryngeal cancer (LC) after radiotherapy.Fifty-nine eligible patients with Tis-T4 LC were included in this retrospective study. All patients received radiotherapy. Outcomes were measured by the core measure Questionnaire-C30 (QLQ-C30), and the disease-specific Head & Neck cancer module (QLQ-H&N35). All outcomes were assessed before and 3 months after the radiotherapy.Three months after the radiotherapy, all items of QLQ-C30 and QLQ-H&N35 scales changed significantly (P < .05), except the social functioning (P = .09), role activities (P = .81), and global (P = .12) in QLQ-C30 scale and social contacts (P = 1.00), teeth problems (P = .21), trismus (P = 1.00), and feeling ill (P = .07) in QLQ-H&N35 scale, compared with these items before the radiotherapy.The results of this study showed that most items of QoL changed significantly after 3 months of radiotherapy in Chinese patients with LC.

Effect of voice rehabilitation training on the patients with laryngeal cancer after radiotherapy

This retrospective study examined the effect of voice rehabilitation training (VRT) for patients with laryngeal cancer (LC) after radiotherapy.Eighty-three eligible patients with LC were included. Forty-three patients were assigned to a treatment group, and underwent VRT, while the other 40 subjects were assigned to a control group, and were at waiting list. Primary outcome was measured by the Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) scale. Secondary outcome was measured by Patient Perception Measures. All outcomes were measured before and 3 months after VRT intervention.Patients in the treatment group did not show better outcomes, measured by GRBAS scale (Grade, P = .78; Roughness, P = .61; Breathiness, P = .83; Ashenia, P = .89; and Strain, P = .41), and Patient Perception Measures (Vocal quality, P = .17; Acceptability, P = .35; Hoarseness, P = .23; Vocal fatigue, P = .39; and Ashamed, P = .51), compared with patients in the control group.The results of this study did not exert better outcomes in patients received VRT than those at waiting list.

A Multidimensional Study of Vocal Function Following Radiation Therapy for Laryngeal Cancers

Background:

Radiation therapy (XRT) has proven to be an effective curative modality in the treatment of laryngeal cancers. However, XRT also has deleterious effects on vocal function.

Aim:

To demonstrate the multidimensional nature of deficits in vocal function as a result of radiation therapy for laryngeal cancer.

Study Design:

Cohort study.

Methodology:

Vocal function parameters were chosen from the 5 domains of voice assessment to complete a multidimensional assessment battery. Adults irradiated (XRT group) for laryngeal cancers were compared to a control group of individuals with no history of head and neck cancers or radiation therapy. The control group was matched in age, sex, and pack years of smoking.

Results:

Eighteen participants were recruited for the study. The XRT group demonstrated significantly worse clinical values as compared to the control group across select parameters in the each of the 5 domains of voice assessment.

Discussion:

Radiation therapy for laryngeal cancers results in multidimensional deficits in vocal function. Notably, these deficits persist long term. In the present study sample, multidimensional deficits were persistent 2 to 7 years following completion of XRT. The observed multidimensional persistent vocal difficulties highlight the importance of vocal rehabilitation in the irradiated larynx cancer population.

Voice rehabilitation after laryngeal cancer: Associated effects on psychological well-being

Purpose

Psychological distress after laryngeal cancer treatment is prevalent. Although voice rehabilitation has shown to improve functional outcomes and positively affect health-related quality of life, to date, there has been limited study of the associated effect of behavioural voice intervention on psychological well-being/distress post laryngeal cancer.

Method

Sixty-three patients with Tis-T4 laryngeal cancer treated with (chemo)radiotherapy were prospectively recruited and randomised to either a voice rehabilitation (VR, n = 31) or control group (n = 32). The VR group received 10 speech pathology sessions consisting of both direct and indirect voice intervention post (chemo)radiotherapy. The control group received general voice education but not specific intervention. As part of a multidisciplinary assessment battery, psychological well-being/distress was measured using the Hospital Anxiety and Depression Scale (HADS) pre, six and 12 months post VR.

Results

Within-group analysis revealed a significant (p = 0.03) reduction in the proportion of patients with anxiety in the VR group between baseline and 12 months. No change over time was observed in controls. Between-group analysis revealed a trend for fewer VR cases demonstrating anxiety (p = 0.06) or depression (p = 0.08) at 6 months and significantly fewer demonstrating anxiety (p = 0.04) and depression (p = 0.04) at 12 months, compared to controls. Significant correlations were observed between patients’ voice perceptions and reduced anxiety (r_pb = −0.38) and depression (r_pb = −0.66) within the VR group at 12 months.

Conclusions

The positive correlations and between-group analyses indicate a positive effect on psychological well-being associated with completing voice rehabilitation. Results highlight potential additional benefits of behavioural voice intervention beyond achieving direct change to voice function.

Association between late effects assessed by physicians and quality of life reported by head-and-neck cancer survivors

BACKGROUND

Many survivors of head-and-neck cancer (HNC) suffer from late effects. Their overall quality of life deteriorates during treatment, followed by a slow recovery up to five years after treatment. We examined the association between the severity of physician-assessed late effects and the health-related quality of life (HRQoL) reported by survivors of HNC.

MATERIAL AND METHODS

The analysis was based on data collected during follow-up for 136 survivors of cancer in the oral cavity, pharynx, larynx, or salivary glands. Physicians' assessments of dysphagia, xerostomia, fibrosis, and hoarseness, derived from reports to of the Danish Head and Neck Cancer Group database and patient-reported overall quality of life and social, role, emotional, cognitive, and physical functioning reported on the European Organization for Research and Treatment of Cancer questionnaire. Linear regression models were used to examine the association between the severity of each late effect and HRQoL.

RESULTS

Quality of life was decreased among patients with moderate to severe dysphagia compared to patients without dysphagia (-16 points; 95% CI -21;-3). Also role functioning (-20 points; 95% CI -38;-2), emotional functioning (-19 points; 95% CI -34;-4) and social functioning (-27 points; 95% CI -41;-13) decreased compared with patients without dysphagia. Mild dysphagia was also associated with decreased overall quality of life (-12 points; 95% CI -21;-3). Moderate to severe hoarseness was significantly associated with poorer social functioning (-25 points; 95% CI -41;-10). There was no association between fibrosis or xerostomia and HRQoL.

CONCLUSION

Physician-assessed moderate to severe hoarseness and mild, moderate, or severe dysphagia are associated with clinically relevant decreases in patient-reported quality of life and functioning. Fibrosis and xerostomia of any severity were not associated with changes in any scale of functioning in this study population.

Dysphagia, Speech, Voice, and Trismus following Radiotherapy and/or Chemotherapy in Patients with Head and Neck Carcinoma: Review of the Literature

Introduction. Patients with head and neck cancer suffer from various impairments due to the primary illness, as well as secondary consequences of the oncological treatment. This systematic review describes the effects of radiotherapy and/or chemotherapy on the functions of the upper aerodigestive tract in patients with head and neck cancer. Methods. A systematic literature search was performed by two independent reviewers using the electronic databases PubMed and Embase. All dates up to May 2016 were included. Results. Of the 947 abstracts, sixty articles met the inclusion criteria and described one or more aspects of the sequelae of radiotherapy and/or chemotherapy. Forty studies described swallowing-related problems, 24 described voice-related problems, seven described trismus, and 25 studies described general quality of life. Only 14 articles reported that speech pathologists conducted the interventions, of which only six articles described in detail what the interventions involved. Conclusion. In general, voice quality improved following intervention, whereas quality of life, dysphagia, and oral intake deteriorated during and after treatment. However, as a consequence of the diversity in treatment protocols and patient characteristics, the conclusions of most studies cannot be easily generalised. Further research on the effects of oncological interventions on the upper aerodigestive tract is needed.

A prospective longitudinal study of voice characteristics and health-related quality of life outcomes following laryngeal cancer treatment with radiotherapy

Background To investigate potential changes in perceptual, acoustic and patient-reported outcomes over 12 months for laryngeal cancer patients treated with radiotherapy. Material and methods A total of 40 patients with Tis-T3 laryngeal cancer treated with curative intent by radiotherapy were included in this prospective longitudinal descriptive study. Patients were followed pre-radiotherapy, one month, six months and 12 months post-radiotherapy, where voice recordings and patient-reported outcome instruments (European Organization for Research and Treatment of Cancer Quality-of-Life Questionnaire Core30, Head and Neck35, Swedish Self-Evaluation of Communication Experiences after Laryngeal Cancer) were completed at each appointment. Perceptual analysis, using the Grade-Roughness-Breathiness-Asthenia-Strain scale and vocal fry parameters, and acoustic measures including harmonics-to-noise ratio (HNR), jitter, shimmer and mean spoken fundamental frequency (MSFF) were produced from voice recordings. Results All patients presented with dysphonic voices pre-radiotherapy, where 95% demonstrated some degree of vocal roughness. This variable improved significantly immediately post-radiotherapy, however, then deteriorated again between six and 12 months. Vocal fry also increased significantly at 12 months. Acoustic measures were abnormal pre- and post-treatment with no significant change noted except for MSFF, which lowered significantly by 12 months. Health-related quality of life (HRQL) deteriorated post-radiotherapy but returned to pretreatment levels by 12 months. Conclusion By 12 months, most perceptual, acoustic, patient-reported voice and HRQL outcomes for laryngeal cancer patients treated by radiotherapy had showed no significant improvements compared to pretreatment function. Further studies are required to investigate potential benefits of voice rehabilitation following radiotherapy.

Voice Range Profile and Health-related Quality of Life Measurements Following Voice Rehabilitation After Radiotherapy; a Randomized Controlled Study

PURPOSE

The aim of the present study was to investigate the effects of voice rehabilitation in patients treated with radiotherapy for laryngeal cancer.

METHOD

A total of 42 patients with laryngeal cancer who are treated with radiotherapy with curative intent participated in a randomized controlled study. The collected data were voice range profiles (VPRs) and patient-reported outcome (PRO) instruments for measurement of self-perceived communication function (Swedish Self-Evaluation for Communication Experiences after Laryngeal cancer (S-SECEL)) and health related quality of life (HRQL) (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30/Head and Neck module). Data were collected 1 month (pre voice rehabilitation), 6 months, and 12 months postradiotherapy. Of the patients, 19 received voice rehabilitation, whereas 23 constituted a control group.

RESULTS

There were several statistically significant improvements in the study group concerning the HRQL and self-perceived communication function. The largest improvements occurred between occasions 1 (prevoice rehabilitation) and 2 (6-month postradiotherapy) and then remained constant. VRP area demonstrated a statistically significant difference when comparing changes over time, where the study group improved more than the control group.

CONCLUSION

HRQL and self-perceived communication function showed improvement in the study group and trends of impairment in the control group. This result might suggest that it would be beneficial for the patients as well as in a health economic perspecitve, to receive voice rehabilitatiom to make a faster improvement of the HRQL and self-perceived communication function.

Structured review of papers reporting specific functions in patients with cancer of the head and neck: 2006 - 2013

Health-related quality of life (HRQoL) focuses on 4 core domains: physical and psychological function, social interaction, disease, and treatment-related symptoms, and is a key outcome in patients with cancer of the head and neck. We reviewed papers published between 2006 and 2013 that used validated questionnaires to report functional outcome in this group. A total of 572 papers were identified and 118 of them concerned function. Specific outcomes included anxiety, chewing, maxillectomy, mucositis, pain, shoulder function, and trismus. The specific functions most often identified were xerostomia, speech or voice, and swallowing or dysphagia. A considerable body of evidence has now accumulated on HRQoL and functional outomes although the precise role of HRQoL during the planning of treatment remains controversial. Over time, the emphasis of the studies included has tended to move away from the reporting of outcomes in general to more hypothesis-driven and group-specific work.

Effects of voice rehabilitation on health-related quality of life, communication and voice in laryngeal cancer patients treated with radiotherapy: a randomised controlled trial

OBJECTIVE

This study aims to assess the effect of voice rehabilitation on health-related quality of life (HRQL) and communication experience for laryngeal cancer patients treated with radiotherapy.

METHOD

This prospective randomised controlled trial included 74 patients with Tis-T4 laryngeal cancer treated curatively by radiotherapy, of which 37 constituted the intervention group receiving voice rehabilitation and 37 patients as a control group. Patients were followed at one and six months post-radiotherapy, with voice rehabilitation conducted between these time-points. Endpoints included patient reported outcomes, including HRQL as measured by European Organisation for Research and Treatment of Cancer (EORTC) Core30 (C30) and Head & Neck35 (H&N35) as well as communication function as measured by Swedish Self-Evaluation of Communication Experiences after Laryngeal cancer (S-SECEL).

RESULTS

The intervention group reported statistically significant improvements in communication experience as measured by S-SECEL environmental, attitudinal and total score domains compared to the control group. Similar improvements were seen in EORTC H&N35 Speech domain and the EORTC C30 domain Global quality of life. Moderate correlations were noted (r = 0.51-0.59) between three of four S-SECEL domains and the EORTC domains Speech and Global quality of life.

CONCLUSION

Laryngeal cancer patients treated with radiotherapy who receive voice rehabilitation appear to experience beneficial effects on communication function and selected HRQL domains. Voice rehabilitation following radiotherapy is recommended but further research investigating potential target groups and long-term effects is required.

Interpretation of the Swedish Self Evaluation of Communication Experiences after Laryngeal cancer: Cutoff levels and minimum clinically important differences

BACKGROUND

The purpose of this study was to establish minimum clinically important difference (MCID) scores for the Swedish Self-Evaluation of Communication Experiences after Laryngeal Cancer (S-SECEL) in order to facilitate clinical interpretation and identify cutoff values for voice rehabilitation.

METHOD

One hundred nineteen patients with laryngeal cancer completed the S-SECEL instrument and an anchor question regarding acceptability of speech in a social context pretreatment and 12-month postoncologic treatment. Receiver operating characteristic (ROC) curves analysis was used for calculation of cutoff values.

RESULTS

Voice rehabilitation cutoff values were identified for all domains (Total = 20; General = 4; Environmental = 16, and Attitudinal = 5), presenting acceptable sensitivity and specificity. Initial MCID estimates were obtained for all domains; improvement of -13 points (p < .0001) or a deterioration of +8 points (p = .035) for the Total domain.

CONCLUSION

MCID and cutoff scores for the S-SECEL have been identified and may be used in clinical practice to help identify patients with laryngeal cancer in need of voice rehabilitation.

Health-related quality of life and voice following radiotherapy for laryngeal cancer--a comparison between glottic and supraglottic tumours

BACKGROUND

To provide further information about short-term effects on voice quality and health-related quality of life (HRQL) following radiotherapy for laryngeal cancer, comparing glottic and supraglottic tumours.

MATERIAL AND METHODS

Sixty-seven male patients who received radiotherapy for glottic and supraglottic tumours were included. Voice recordings were performed and patient reported outcome questionnaires filled in before radiotherapy and one-month post-completion. Acoustic and temporal measures were produced from the recordings and compared to an age-matched, vocally healthy control group (n = 23).

RESULTS

Deterioration of HRQL post-radiotherapy was noted for both the glottic and supraglottic cohort. Pre- radiotherapy the glottic cohort demonstrated acoustic and temporal measures that were statistically different from healthy controls, with improvements post-radiotherapy where several measures showed no statistically significant differences compared to healthy controls. The supraglottic cohort revealed voice measures comparable to the healthy controls but demonstrated statistically significant impairments in HRQL compared to the glottic cohort following radiotherapy.

CONCLUSION

Patients with supraglottic tumours may experience more eating and swallowing related problems prior to radiotherapy compared to glottic tumours and demonstrate a more significant reduction in HRQL following treatment. However, in terms of voice measurements, subjective measures correlate poorly with objective acoustic parameters, thereby emphasising the importance of patient-reported outcomes as part of treatment evaluation.

Prospective clinical study on long-term swallowing function and voice quality in advanced head and neck cancer patients treated with concurrent chemoradiotherapy and preventive swallowing exercises

Concurrent chemoradiotherapy (CCRT) for advanced head and neck cancer (HNC) is associated with substantial early and late side effects, most notably regarding swallowing function, but also regarding voice quality and quality of life (QoL). Despite increased awareness/knowledge on acute dysphagia in HNC survivors, long-term (i.e., beyond 5 years) prospectively collected data on objective and subjective treatment-induced functional outcomes (and their impact on QoL) still are scarce. The objective of this study was the assessment of long-term CCRT-induced results on swallowing function and voice quality in advanced HNC patients. The study was conducted as a randomized controlled trial on preventive swallowing rehabilitation (2006-2008) in a tertiary comprehensive HNC center with twenty-two disease-free and evaluable HNC patients as participants. Multidimensional assessment of functional sequels was performed with videofluoroscopy, mouth opening measurements, Functional Oral Intake Scale, acoustic voice parameters, and (study specific, SWAL-QoL, and VHI) questionnaires. Outcome measures at 6 years post-treatment were compared with results at baseline and at 2 years post-treatment. At a mean follow-up of 6.1 years most initial tumor-, and treatment-related problems remained similarly low to those observed after 2 years follow-up, except increased xerostomia (68%) and increased (mild) pain (32%). Acoustic voice analysis showed less voicedness, increased fundamental frequency, and more vocal effort for the tumors located below the hyoid bone (n = 12), without recovery to baseline values. Patients' subjective vocal function (VHI score) was good. Functional swallowing and voice problems at 6 years post-treatment are minimal in this patient cohort, originating from preventive and continued post-treatment rehabilitation programs.

The effect of singing training on voice quality for people with quadriplegia

OBJECTIVES

Despite anecdotal reports of voice impairment in quadriplegia, the exact nature of these impairments is not well described in the literature. This article details objective and subjective voice assessments for people with quadriplegia at baseline and after a respiratory-targeted singing intervention.

STUDY DESIGN

Randomized controlled trial.

METHODS

Twenty-four participants with quadriplegia were randomly assigned to a 12-week program of either a singing intervention or active music therapy control. Recordings of singing and speech were made at baseline, 6 weeks, 12 weeks, and 6 months postintervention. These deidentified recordings were used to measure sound pressure levels and assess voice quality using the Multidimensional Voice Profile and the Perceptual Voice Profile.

RESULTS

Baseline voice quality data indicated deviation from normality in the areas of breathiness, strain, and roughness. A greater percentage of intervention participants moved toward more normal voice quality in terms of jitter, shimmer, and noise-to-harmonic ratio; however, the improvements failed to achieve statistical significance.

CONCLUSIONS

Subjective and objective assessments of voice quality indicate that quadriplegia may have a detrimental effect on voice quality; in particular, causing a perception of roughness and breathiness in the voice. The results of this study suggest that singing training may have a role in ameliorating these voice impairments.

Clinical Assessment and Treatment of the Dysfunctional Larynx after Radiation

Objective

To review the pathophysiology of early and late radiation-related tissue changes, methods to differentiate these changes from disease recurrence, and treatment of these changes in the irradiated larynx.

Data Sources

Peer-reviewed publications.

Review Methods

PubMed database search.

Conclusions/Implications for Practice

Early and late radiation-related changes in the larynx manifest variably between individual patients. Severe radiation-related tissue changes in the larynx and recurrent malignancy share many clinical characteristics, and the presence of malignancy must be considered in these patients. Positron emission tomography may help select patients who need operative biopsy to rule out recurrence. In patients with a cancer-free but dysfunctional larynx, both surgical and nonsurgical treatment options, including hyperbaric oxygen, are available for attempted salvage. Further investigation is needed before hyperbaric oxygen can be considered standard-of-care treatment for these patients.

Voice outcome in patients treated for laryngeal cancer: efficacy of voice rehabilitation

OBJECTIVE

To investigate the efficacy of voice rehabilitation regarding acoustically measured voice quality as well as self-perceived function after radiotherapy for laryngeal cancer.

STUDY DESIGN

Prospective intervention study.

METHODS

Twenty male patients irradiated for laryngeal cancer participated in the study. Voice recordings and self-assessment of voice function (hoarseness, vocal fatigue, and vocal loudness) were made one and 6 months after completion of radiotherapy. The recordings were analyzed with the program Praat. Ten of the patients received 10 sessions of structured voice rehabilitations between the recordings and 10 worked as a control group.

RESULTS

Jitter and shimmer improved for both groups. Harmonics-to-noise-ratio and maximum phonation time improved for the patients who received voice rehabilitation while it deteriorated for the control group. The self-assessment questions about vocal fatigue and vocal loudness showed improvement for both groups while hoarseness showed no change.

CONCLUSION

General improvement was seen for both the study group and the control group. Despite the lack of statistical significant difference, there are trends where greater improvement in perturbation and self-assessment measures are noted in the study group. The results suggest positive effects of voice rehabilitation in both voice quality and self-perceived function.

Prospective evaluation of voice outcome during the first two years in male patients treated by radiotherapy or laser surgery for T1a glottic carcinoma

In this prospective cohort study, we assessed voice outcome in patients before and up to 2 years after treatment for early glottic cancer either by radiotherapy or by laser surgery; 106 male patients, treated for T1aN0M0 glottic cancer either by endoscopic laser surgery (n = 67) or by radiotherapy (n = 39), participated in the study. Patients’ voices were recorded and analysed pre-treatment and 3, 6, 12 and 24 months post-treatment at their routine visit at the outpatient clinic. Average fundamental frequency (F0), percent jitter, percent shimmer and normalized noise energy (NNE) were determined. After 2 years, local control rate was 95% in the radiotherapy group and 97% in the laser surgery group. Larynx preservation rate was 95% after radiotherapy and 100% after laser surgery. Voice outcome recovers more quickly in patients treated with laser surgery in comparison to radiotherapy: 3 months after laser surgery there is no longer a difference with regard to normal voices except for the fundamental frequency, which remains higher pitched, even in the longer term. For patients treated with radiotherapy it takes longer for jitter, shimmer and NNE to become normal, where jitter remains significantly different from normal voices even after 2 years. According to these results, we believe that laser surgery is the first treatment of choice in the treatment of selected cases of T1a glottic carcinomas with good functional and oncological results.

Measuring voice outcomes following treatment for laryngeal cancer

Laryngeal cancer is the most commonly diagnosed head and neck malignancy. Treatment of laryngeal tumors is dependent upon disease stage at diagnosis, and may involve surgery, radiation, chemotherapy or a combination of modalities. Regardless of tumor stage or treatment provided, quality of life (QOL) can be drastically affected. Voice-related outcomes are almost universally affected and can have a negative impact on overall QOL. Thus, treatment outcomes must extend beyond issues of oncological cure alone. Measures of voice and voice-related QOL following treatment for laryngeal cancer are important markers of treatment success. This article will broadly outline laryngeal cancer and its treatment, vocal rehabilitation, and provide insight into the various methods of assessing post-treatment voice and the influence of voice change on quality of life in these patients.

Voice quality after organ-preservation therapy with definitive radiotherapy for laryngeal cancer

BACKGROUND

The purpose of this study was to analyze voice quality among patients treated by definitive radiotherapy for laryngeal cancer.

METHODS

Ten patients with laryngeal cancer who had completed radiotherapy were involved in this pilot study. A standardized protocol was administered assessing: (1) sustained vowel production following maximal inspiration, (2) sustained vowel production for a 7-second duration repeated 5 times, and (3) spontaneous speech for 10 seconds.

RESULTS

The acoustic parameters among patients with early-stage cancer were not statistically different from healthy age-corresponding controls, except for shimmer (0.20 vs 0.16 dB, ρ = 0.01) and maximum phonation duration (24.37 vs 30.10 seconds, ρ = 0.04). For patients with locally advanced cancer, differences with controls were observed with shimmer (2.29 vs 0.16 dB, ρ = 0.01), jitter (7.49% vs 1.04%, ρ = 0.01), harmonics-to-noise ratio (2.67 vs 9.22, ρ = 0.01), and maximum phonation duration (14.12 vs 30.10 seconds, ρ = 0.01).

CONCLUSIONS

Despite the subtle differences in voice quality that existed, radiotherapy as a curative treatment for laryngeal cancer allows maintenance of a functional voice.

Effects of chemoradiotherapy on voice and swallowing

PURPOSE OF REVIEW

Chemotherapy has been found to result in comparable survival rates to surgery for head and neck cancer. However, toxicity can often be worse after chemoradiotherapy, with impairment in voice, swallowing, nutrition, and quality of life. Investigators are attempting to modify radiotherapy treatment regimens to spare organs that have an impact on swallowing. This review will highlight voice and swallowing impairment seen after chemoradiotherapy, as well as treatment for voice and swallowing disorders in this population. Results of newer radiotherapy regimens will also be highlighted.

RECENT FINDINGS

Specific oropharyngeal swallowing motility disorders after chemoradiotherapy have been identified. Damage to specific structures has been correlated with specific pharyngeal phase swallow impairment. Swallowing function and quality of life have been examined over time, with improvement seen in both. Preventive/prophylactic swallow exercise programs have been encouraging. Chemoradiotherapy effects on voice have been identified in terms of acoustic, aerodynamic, and patient and clinician-rated perception of function. Improvement in voice has also been observed over time after chemoradiotherapy. Voice therapy has been found to have a positive impact on voice and perceptual measures in this population.

SUMMARY

Current studies show some improvement in swallow function after swallow and voice therapy in patients treated with chemoradiotherapy. Further, there is a suggestion of improved swallow function with sparing of organs with specific radiotherapy protocols. Future research needs to focus on specific voice and swallow treatment regimens in the head and neck cancer patient treated with chemoradiotherapy, specifically, timing, frequency, duration, and specific treatment types.