Cross-cultural Adaptation and Validation of the Greek Voice Handicap Index-10 (GVHI-10) With Additional Receiver Operating Characteristic Analysis

Validation of the Singing Voice Handicap Index in Greek Singers: Normal and Voice-Disordered Participants

OBJECTIVES

The Singing Voice Handicap Index (SVHI) was culturally adapted and validated in Greek to examine the impacts of voice problems on a singer's everyday life.

METHODS

The translated version was administered to 120 singers in total, along with the translated version of the Voice Handicap Index (VHI), a sort voice history questionnaire, two Self-Rating Dysphonia Severity Scales (SRDSSs), and two visual analog scales. A week after the original completion of the Greek version of SVHI, a second copy of the SVHI was administered to 50% of the participants.

RESULTS

The results showed high test-retest reliability (Pearson correlation coefficient (PCC): 0.859, P = 0.000) and excellent internal consistency (Cronbach's Alpha = 0.960). A significant difference between healthy and voice disordered singers emerged (18.01 ± 13.213, 43.26 ± 20.196; K-W: P = 0.000; ROC: Area = 0.863, Std. = 0.041, P = 0.000). Also, high concurrent (Spearman's rho 0.55, P = 0.000) and face (Spearman's rho: SRDSS1 0.481, P = 0.000; SRDSS2 0.504, P = 0.000) validity scores were observed. Regarding the relation of the demographic variables or habits that could relate to voice disorders, only the years of experience (PCC: -0.240, P = 0.008) and singing lessons (Spearman's rho: -0.286, P = 0.002) had a strong correlation with SVHI.

CONCLUSIONS

In conclusion, the Greek version of the SVHI questionnaire was validated successfully as a reliable tool with proper internal consistency. It will serve as a suitable and valuable instrument for self-evaluation of a vocal difficulty's effects on a singer's day-to-day life.

Adaptation and Validation of the Persian Version of the Voice Handicap Index-10 (VHI-10)

OBJECTIVES

Voice disorders can profoundly impact health, quality of life, job performance, and social interactions. Traditional evaluations have expanded to include quality-of-life assessments, emphasizing self-reported outcomes. The Voice Handicap Index (VHI) stands out among relevant questionnaires, with the VHI-10 being a concise derivative. This study was conducted to translate and validate the Voice Handicap Index-10 (VHI-10) questionnaire for Persian speakers, enhancing clinical assessments of voice disorders and quality of life.

METHODS

This cross-sectional study, conducted in Iran, involved (1) translating the VHI-10 into Persian, (2) confirming face and content validity using Content Validity Ratio (CVR), and Content Validity Index (CVI), and (3) evaluating its reliability through a survey. A panel of experts confirmed the validity, and reliability of the study, which was assessed using Cronbach's alpha, Spearman-Brown, and Guttman coefficients. The survey involved 225 participants, including 150 healthy people and 75 patients with voice disorders, who were selected using a convenience sampling method.

RESULTS

All question items demonstrated a CVI greater than 0.79 and a CVR between 0.62 and 1. Reliability analysis yielded high Cronbach's alpha values for functional, physical, and emotional domains (0.909) and total (0.961). The mean overall scores of VHI-10 for healthy and disordered groups were 18.78 and 0.74, respectively. The VHI-10 effectively discriminated between healthy and disordered groups in all domains, with an accuracy of 97.33%. The determined cut-off point was 4.5, with a strong area under the Receiver Operating Characteristic (ROC) curve (0.989).

CONCLUSION

This study successfully adapted and validated the Persian version of the VHI-10. The questionnaire demonstrated high reliability and validity, distinguishing between individuals with and without voice disorders. This Persian version is now a valuable tool for speech and language pathologists conducting clinical voice evaluations in Iran and also it could be applied in studies to determine the effects of voice problems on participant's quality of life.

Development of a Voice Handicap Index for Clergymen: An Investigation of Its Validation and Reliability

OBJECTIVE

This study aims to is to develop a disorder-specific patient-reported outcome measure to be used in Islamic clergymen with voice disorders and to investigate its validity and reliability.

METHODS AND PROCEDURES

Employing an exploratory sequential mixed-methods design, this study conducted in two phases. Initially, semistructured interviews were conducted with 10 clergymen experiencing voice disorders. Subsequently, the questionnaire underwent rigorous validation, encompassing content, construct, and criterion validity assessments, in addition to test-retest reliability and internal consistency analyses. The index was administered to a sample of 110 male clergy, including imams, muezzins, and Quran course teachers, with an age range from 19 to 61years.

RESULTS

Construct validity was established through factor analysis, resulting in a final 23-item scale categorized into two factors: physical-functional and emotional. Known group validity demonstrated a significant distinction between the study and control groups. Criterion validity reinforced the index's validity, displaying a correlation coefficient of 0.758 between the Voice Handicap Index for Clergymen and the well-established Voice Handicap Index. The questionnaire exhibited commendable internal consistency, with a Cronbach's Alpha (α) coefficient value of 0.971. Test-retest reliability analysis exhibited strong consistency, with a Pearson correlation coefficient of 0.863.

CONCLUSIONS

It is recommended that the developed valid and reliable handicap index in the present study be included in the voice assessment batteries of Islamic clergymen with voice complaints with the clinical and research purposes. In future studies, the validity of the questionnaire can be investigated more by examining the difference between the Voice Handicap Index for Islamic Clergymen (CVHI) scores obtained before and after treatment. Identifying a cut-off point that discriminates between dysphonic and normophonic clergymen may allow the use of the CVHI as a screening tool for this population.

Efficacy of platelet-rich plasma (PRP) in benign vocal fold lesions: a systematic review and meta-analysis

OBJECTIVES

To evaluate the efficacy of platelet-rich plasma (PRP) in benign vocal fold lesions.

METHODS

MEDLINE, Cochrane Central, Web of Science, and Scopus databases were searched in April 2023 for relevant clinical trials. Inclusion criteria were clinical trials evaluating the efficacy of PRP in benign vocal fold lesions. We conducted a comparative double-arm analysis using the pooled mean difference (MD) and 95% confidence interval (CI). Outcomes of interest included the vocal handicap index (VHI), the Jitter and Shimmer percentages, and the noise-to-harmonic ratio (NHR).

RESULTS

Six studies matched the inclusion criteria. The pooled analysis shows that PRP was associated with significantly lower VHI scores compared with the control (MD = - 5.06, p < 0.01). Regarding the Jitter percentage, the PRP group was not superior to the control group at 2 and 4 weeks. However, the results revealed that PRP significantly reduced the Jitter percentage at 3 months (MD = - 0.61, p = 0.0008). The overall analysis favored the PRP arm significantly (p < 0.001). As for the Shimmer percentage, the combined effect estimate favored the PRP group (MD = - 1.22, p = 0.002). Subgroup analysis according to the time did not reveal any significant differences between studies at 2 weeks, 4 weeks, and 3 months. The analysis of the NHR outcome revealed a significant difference between both groups (MD = -1.09, p = 0.01). However, at 4 weeks, the treatment group had a significantly lower NHR % compared to the control group (MD = - 0.61, p = 0.02). There was no significant difference at 3 months (MD = - 2.14, p = 0.14).

CONCLUSIONS

Platelet-rich plasma is effective in reducing VHI scores, Jitter and Shimmer percentages, and NHR values. This effect is more evident after follow-up, especially 3 months.

Psychometric Properties of the Voice Handicap Index-10 in Kannada

OBJECTIVES

This study aimed to derive the 10-item voice handicap index in the Kannada language (VHI-K10) from the existing VHI-30 in Kannada (VHI-K30). We also aimed to examine several psychometric properties of the newly derived VHI-K10, such as internal consistency, reliability, concurrent validity, discriminant validity, and diagnostic accuracy.

METHODS

Initially, VHI-K10 was derived from the existing VHI-K30 through item reduction, consistent with the recommendations for item reduction of the voice handicap index. This newly derived VHI-K10 was administered to 273 individuals (199 individuals with dysphonia and 74 individuals with normal voice quality). We also obtained phonation and reading samples from the participants. The obtained data were subjected to appropriate statistical analysis to determine several psychometric properties.

RESULTS

The newly derived VHI-K10 was found to have a strong internal consistency (Cronbach's α = 0.93). We also found strong test-retest reliability for VHI-K10, with an intraclass correlation coefficient of 0.933. There was a strong statistically significant correlation between the VHI-K10 and the existing VHI-K30 for both individuals with dysphonia (ρ = 0.924, P < 0.001) and individuals with normal voice quality (ρ = 0.798, P < 0.001). However, the correlation of VHI-K10 with the auditory-perceptual measure of GRBAS was fair (ρ = 0.353, P < 0.001) for individuals with dysphonia and was not statistically significant for individuals with normal voice quality. Further, the diagnostic accuracy of VHI-K10 was found to be excellent, with an area under the curve (AROC) value of 0.926 with a cut-off point of ≥6.5, which was slightly superior to that of VHI-K30 (AROC = 0.909, cut-off point ≥21.5).

CONCLUSIONS

The shortened 10-item version of the voice handicap index in Kannada is consistent with versions of the VHI-10 in other languages. This version of the VHI-10 in Kannada is found to be a robust tool with strong psychometric properties.

Voice Handicap Index: Cut-Off Points for Screening European Portuguese With Voice Disorders

OBJECTIVES

To determine cut-off values of the Voice Handicap Index (VHI) and the shortened version (VHI-10) for European Portuguese (EP) with voice disorders. In addition, to analyze the discriminatory power of individual items of the VHI-10 and the ability to detect differences in various Ear Nose and Throat (ENT) diagnoses.

STUDY DESIGN

Cross-sectional cohort study.

METHODS

All participants completed the EP VHI and a 4-point self-assessment of voice disorder severity. The case group (subjects with voice disorders) underwent assessment through strobovideolaryngoscopy examinations by ENT surgeons and perceptual analyses by speech-language pathologists (SLPs). In contrast, the control group was evaluated solely by SLPs. Data were analyzed using a receiver-operating characteristic curve to determine the accuracy and cut-off values of the VHI and VHI-10.

RESULTS

The study involved a sample of 350 adults (171 cases and 179 controls), predominantly women aged 18-88 years. The area under curve (AUC) for VHI and VHI-10 was 0.997 [95% confidence interval (CI): 0.992-1] and 0.998 [95% CI: 0.995-0.999], respectively. Optimal cut-off values were identified as 13.5 for VHI (0.994 sensitivity and 0.989 specificity) and 5.5 for VHI-10 (0.977 sensitivity and 0.955 specificity). Each individual item within the VHI-10 significantly contributed to the overall assessment, exhibiting varying discriminatory power ranging from excellent (AUC = 0.937) to poor (AUC = 0.637). Significant differences were found in the case group between neurogenic disorders and healthy larynx (P = 0.014), structural and physiologic minor laryngeal abnormalities (P = 0.006), and inflammatory disorders (P = 0.043).

CONCLUSIONS

The VHI and the VHI-10 exhibited accurate screening properties for predicting EP speakers with voice disorders.

Internal Consistency of the Voice Handicap Index in Individuals With Dysphonia: A Systematic Review and Meta-Analysis

OBJECTIVE

To analyze the internal consistency of the Voice Handicap Index (VHI) for evaluating the vocal handicap of individuals with dysphonia.

METHODS

This is a systematic review. Studies with a cross-sectional design and including a population of individuals with dysphonia, which validated the VHI and analyzed its internal consistency, were included. The following electronic databases were searched: Cochrane Library, EMBASE, LILACS, and PubMed, including Medline, Scopus, and Web of Science. A manual search was performed in gray literature through the Biblioteca Digital Brasileira de Teses e Dissertações and ProQuest Dissertation & Theses. In addition, the list of references of studies selected in the electronic search was mapped, and an expert in the area was consulted. Two reviewers blindly and independently conducted the selection, data extraction, and analysis of the risk of bias, the certainty of the evidence, and good psychometric measures. A meta-analysis was performed with a random effects model using the JAMOVI 2.3.2 software.

RESULTS

Forty-nine studies were analyzed. In risk of bias assessment, the studies were classified as having inadequate structural validity and very good internal consistency. The analysis of good psychometric properties indicated indeterminate structural validity and insufficient internal consistency. The overall value of Cronbach's alpha was estimated at 0.94, thus suggesting a very good internal consistency. However, there was high heterogeneity. The level of certainty of the evidence was too low for internal consistency.

CONCLUSION

The VHI proved to be a consistent and reliable patient-reported outcome measure to evaluate voice handicap in individuals with dysphonia; however, studies are heterogeneous, and the certainty of evidence is very low.

Prevalence of Self-Reported Voice Concerns and Associated Risk Markers in a Nonclinical Sample of Military Service Members

INTRODUCTION

Difficult communication environments are common in military settings, and effective voice use can be critical to mission success. This study aimed to estimate the prevalence of self-reported voice disorders among U.S. military service members and to identify factors that contribute to their voice concerns.

METHOD

A nonclinical sample of 4,123 active-duty service members was recruited across Department of Defense hearing conservation clinics. During their required annual hearing evaluation, volunteers provided responses to voice-related questions including a slightly adapted version of the Voice Handicap Index-10 (VHI-10) as part of a larger survey about communication issues. Changepoint detection was applied to age and years of service to explore cohort effects in the reporting of voice concerns. Logistic regression analyses examined multiple available factors related to communication to identify factors associated with abnormal results on the VHI-10.

RESULTS

Among the respondents, 41% reported experiencing vocal hoarseness or fatigue at least several times per year, and 8.2% (n = 336) scored above the recommended abnormal cut-point value of 11 on the VHI-10. Factors independently associated with the greatest risk for self-reported voice concerns were sex (female), cadmium exposure, vocal demands (the need for a strong, clear voice), and auditory health measures (frequency of experiencing temporary threshold shifts; self-reported hearing difficulties).

CONCLUSIONS

Based on self-reported voice concerns and false negative rates reported in the literature, the prevalence of dysphonia in a large sample of active-duty service members is estimated to be 11.7%, which is higher than that in the general population. Certain predictors for voice concerns were expected based on previous literature, like female sex and voice use, but frequency of temporary threshold shifts and exposure to cadmium were surprising. The strong link between voice and auditory problems has particular implications regarding the need for effective communication in high-noise military and other occupational environments.

Validation of the Polish Version of Voice Handicap Index-10

PURPOSE

The aim of this study was to adapt and evaluate the psychometric properties of the Polish version of the VHI-10.

METHODS

We enrolled 183 subjects-118 patients with voice disorders and 65 without voice disorders.

RESULTS

All items were correlated with each other and were strongly correlated with the total score (rho ≥ 0.70), the only exception being item five (rho = 0.56). Internal consistency was very high, with Cronbach's alpha = 0.92. There was a statistically significant difference between patients with voice disorders and healthy controls in terms of VHI-10 global score (U = 251.0; P < 0.001). There was a statistically significant negative correlation between mean phonation time (MPT) and VHI-10 (rho = -0.30; P < 0.01). Only the amplitude perturbation quotient (APQ) was correlated positively with the global score (rho = 0.22; P = 0.020). There were statistically significant and positive correlations between VHI-10 scores and GRBAS evaluation. Correlations between global scores of VHI-30 and VHI-10, and between VHI-30 subscales and the corresponding items from VHI-10, were very strong (respectively 0.97 and 0.89-0.94). In the patient group, there was high test-retest reproducibility (intraclass correlation = 0.91). A cut-off value of 8.5 points was estimated.

CONCLUSION

The Polish version of VHI-10 showed excellent internal consistency, good test-retest reproducibility, and had clinical validity. It is a useful brief tool for self-reported evaluation and reliable assessment of patients with voice disorders.

Polish Translation and Validation of the Voice Handicap Index (VHI-30)

Traditional voice evaluations, including imaging techniques, auditory-perceptual ratings, and acoustic and aerodynamic analyses, fail to assess the global handicap that a patient experiences as a result of a voice disorder. The Voice Handicap Index (VHI) is currently one of the most widely used and psychometrically robust instruments for measuring voice disability. The aim of the study is to translate and validate a Polish version of the VHI. The original English-language version of VHI-30 was translated into Polish. We enrolled 188 subjects-123 patients (91 women and 32 men) with voice disorders and 65 controls (53 women and 12 men) without voice disorders. Results obtained by the patients were significantly higher than those obtained by the controls on the Emotional subscale (U = 519.0; p < 0.001), Functional (U = 829.0; p < 0.001), Physical (U = 331.0; p < 0.001), and the global score (U = 390.0; p < 0.001). There were statistically significant negative correlations between maximum phonation time and global score (rho = -0.31; p < 0.01) as well as all three subscales. Shimmer and Smoothed Amplitude Perturbation Quotient were correlated positively with the global score (rho = 0.22; p < 0.05; rho = 0.25; p < 0.01, respectively) and with all three subscales. There were also statistically significant correlations between VHI scores and auditory perceptual evaluation. In the patient group, there was excellent internal consistency (α = 0.97) and strong test-retest reliability (intraclass correlation = 0.94). The cut-off value equal to 17 points was estimated. The Polish VHI showed excellent internal consistency, good test-retest reproducibility, and clinical validity. It is a useful tool for evaluating the voice disability perceived by a patient.

Autologous Fat Plus Platelet-Rich Plasma versus Autologous Fat Alone on Sulcus Vocalis

Sulcus vocalis is a frequent cause of glottic insufficiency that leads to incomplete vocal fold closure during phonation. Type II sulcus vocalis is defined as a partial defect of the lamina propria (LP). Treatment with fillers, such as fat or hyaluronic acid (HA), in the vocal folds is widely used, but the duration of effect is variable. Platelet-rich plasma (PRP) can enhance the survival of autologous fat in fat grafting, and also is used to treat sulcus vocalis. This study aimed to compare the effectiveness of autologous fat graft versus fat graft plus PRP to treat type II sulcus vocalis. Thirty-four patients with a voice handicap index (VHI) ≥ 11 were randomized to two groups, which received LP injections of fat graft (n = 17) or fat graft plus PRP (n = 17). At 1 month and 6 months after injection, the VHI decreased significantly in both groups. The fat plus PRP group had better Jitter, Shimmer, and noise to harmonic ratio (NHR) in 1 month and 6 months after surgery. The fat plus PRP group resulted in lower VHI scores one month after surgery, and stroboscopy revealed sustained smaller gaps after six months. These results indicate that a combination of fat graft plus PRP is safe and effective for treating sulcus vocalis type II and associated vocal atrophy.

Checking for voice disorders without clinical intervention: The Greek and global VHI thresholds for voice disordered patients

Voice disorders often remain undiagnosed. Many self-perceived questionnaires exist for various medical conditions. Here, we used the Greek Voice Handicap Index (VHI) to address the aforementioned problem. Everyone can fill in the VHI questionnaire and rate their symptoms easily. The innovative feature of this research is the global cut-off score calculated for the VHI. Therefore, the VHI is now capable of helping clinicians establish a more customizable treatment plan with the cut-off point identifying patients without normal phonation. For the purpose of finding the global cut-off point, a group of 180 participants was recruited in Greece (90 non-dysphonic participants and 90 with different types of dysphonia). The voice disordered group had higher VHI scores than those of the control group. In contrast to previous studies, we provided and validated for the first time the cut-off points for all VHI domains and, finally, a global cut-off point through ROC and precision-recall analysis in a voice disordered population. In practice, a score higher than the well-estimated global score indicates (without intervention) a possible voice disorder. Nevertheless, if the score is near the threshold, then the patient should definitely follow preventive measures.