Vocal function following radiation for non-laryngeal versus laryngeal tumors of the head and neck

Normative Values of Client-Reported Outcome Measures and Self-Ratings of Six Voice Parameters via the VoiceEvalU8 App

OBJECTIVES

Ecological momentary assessments (EMA) and interventions (EMI) have the potential to assess and offer interventions repeatedly within the client's daily life through mobile app technology. Considering the development of the EMA VoiceEvalU8, the current work provided normative data by comparing traditional (i.e., paper and pencil) and electronic (i.e., VoiceEvalU8 app) administration modalities of client-reported outcome measures and client self-ratings of six voice parameters twice a day in their functional environment.

METHODS

In Experiment 1, 50 vocally healthy cisgender women and men completed the Voice Handicap Index (VHI)-30, VHI-10, and Vocal Fatigue Index (VFI) with paper and pencil and the VoiceEvalU8 app. The order of administration modality and perceptual scales was randomized for each participant. In Experiment 2, 104 vocally healthy cisgender women and men used the VoiceEvalU8 app across five days in the morning before talking all day and in the evening after talking all day to self-rate six voice parameters (i.e., overall quality, roughness, breathiness, strain, pitch, and loudness) on a scale from 0 - 100. Mann Whitney U tests were run for all measures. Means and standard deviations are reported for descriptive analysis and normative values.

RESULTS

In Experiment 1, results showed no significant differences between paper and pencil and VoiceEValU8 app administration for the VHI-30, VHI-10, and VFI for vocally healthy adults. Normative values in the current study were consistent with previous literature for the VHI-10 and VFI factor 1 and 2, but slightly higher for the VHI-30 and slightly lower for the VFI factor 3. In Experiment 2, results demonstrated significant differences for all six voice parameters between the morning and evening log sessions. Normative values demonstrated higher self-ratings in the morning as compared to the evening.

CONCLUSIONS

For vocally healthy adults, completing the VHI-30, VHI-10, and VFI via paper and pencil and the VoiceEvalU8 app yielded the same results. Client self-ratings of six voice parameters on a scale from 0 - 100 twice a day demonstrated that vocally healthy adults perceived voice to be worse in the morning before talking all day as compared to the evening after talking all day. The results from the current work are promising for EMA via the VoiceEvalU8 app and support the need for continued investigations with clients with voice differences, problems, and/or disorders.

Scoping review of the relationship between xerostomia and voice quality

PURPOSE

This scoping review aims to synthesize all of the currently available information on how xerostomia correlates with vocal function and the mechanisms that underpin it.

METHODS

Our scoping review used PubMed, Scopus, Embase, and Web of Science databases to review articles published between January 1999 and July 2022 in accordance with the PRISMA-ScR guidelines. In addition to the academic databases, we also conducted a manual search of Google Scholar. Further investigation was conducted on studies that examined the relationship between xerostomia and vocal function.

RESULTS

Of the 682 initially identified articles, 21 met our inclusion criteria. Among the included studies, two articles (n = 2) revealed the mechanistic relationship between xerostomia and vocal function. Most studies (n = 12) focused on xerostomia secondary to other underlying conditions or treatments, among which radiotherapy and Sjögren's syndrome were commonly investigated. Seven studies (n = 7) provided details about common vocal parameters measured in studies of xerostomia and the voice.

CONCLUSION

The literature currently lacks publications regarding the relationship between xerostomia and vocal function. Most of the studies included in this review were about xerostomia secondary to other conditions or medical treatments. Therefore, the impacts on the voice that were observed were very multifaceted and the role of xerostomia alone in phonation could not be ascertained. Nevertheless, it is clear that dryness in the mouth plays some role in vocal function and further research should focus on clarifying and finding the underlying mechanism behind this relationship by incorporating high-speed imaging and cepstral peak prominence analyses.

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.

Voice Outcomes after Radiotherapy for Laryngeal Cancer

Objective The study was aimed to assess changes in voice outcomes after radiotherapy in laryngeal cancer patients.

Materials and Methods The study included 60 laryngeal cancer patients treated with definitive radiotherapy or chemoradiotherapy between 2005 and 2012. The primary endpoint of this study was to assess abnormalities of the patients’ voices after the treatment. The Thai version of the Voice Handicap Index (VHI) and xerostomia questionnaire were conducted by telephone. Videostroboscopic examination was done to objectively assess voice outcomes.

Results The median age of patients was 63 years. Most patients had glottic cancer (84.1%) and T1–2 disease (84.1%). The median time from treatment to the study was 46 months. In terms of the total VHI score, most patients were in the normal and slight handicap groups (22% and 71.4%, respectively). Only 4.8% and 1.6% of the patients were in moderate and severe handicap group, respectively. Twenty-eight patients had significant xerostomia. Videostroboscopy examination was done in 23 patients and most common findings were telangiectasia (95.7%), abnormal mucosal wave (47.8%), and abnormal glottic closure configuration (34.8%). Regarding total VHI score, lower radiation dose, conventional radiation dose per fraction, longer period after treatment, and significant xerostomia status were significantly correlated with worse voice outcomes. There were no statistically significant correlations between the videostroboscopic findings and VHI scores.

Conclusion Voice outcomes in most of laryngeal cancer patients treated with radiotherapy had a normal or mild handicap at more than 1 year of follow-up. Only 4.8% and 1.6% of the patients had moderate and severe voice outcome handicap, respectively.

Radiobiological comparison of flattening filter (FF) and flattening filter-free (FFF) beam in rat laryngeal tissue

PURPOSE

The purpose of this study is to investigate the radioprotective effect of melatonin by analyzing histopathological changes and serum biochemical levels on experimental rat models exposed to flattening filter (FF) and flattening filter-free (FFF) beam.

MATERIALS AND METHODS

Forty-eight healthy adult Sprague Dawley rats were randomly divided into six groups. The control (Group 1) was given no treatment, the melatonin (Group 2) was given 10 mg/kg melatonin only, the FF (Group 3) and FFF (Group 5) were given fractionated dose (Total 32 Gy, 5 consecutive days) radiotherapy only, and the FF plus melatonin (Group 4) and FFF plus melatonin (Group 6) were given 10 mg/kg melatonin 15 minutes prior to irradiation. Rats were examined for histopathology and biochemical analysis 10 days after irradiation.

RESULTS

When results of FF and FFF radiotherapy only groups are compared to control group, statistically significant difference in histopathological and biochemical parameters are observed; however, melatonin administration in radiotherapy plus melatonin groups improved these parameters (p <.05). In addition, there was no statistically significant difference between FF and FFF beams (p > .05).

CONCLUSIONS

The effect of low- and high-dose beams on the rat larynx and serum samples were investigated histopathologically and biochemically for the first time. We observed that melatonin supplemented before FF and FFF radiotherapy protected early period radiotherapy-induced laryngeal mucosal damage. Since the radiobiological results of FF and FFF beams are similar, FFF beams can be safely applied in laryngeal irradiation. However, more experimental rat and clinical studies are needed to clarify the radiobiological uncertainy concerning dose rate on cancerous and healthy tissue.

Optimizing laryngeal sparing with intensity modulated radiotherapy or volumetric modulated arc therapy for unilateral tonsil cancer

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Early stage tonsillar cancers may be treated with unilateral neck radiotherapy (RT).

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We performed a dosimetric study comparing three common radiotherapy modalities.

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No significant differences in target coverage existed between all plans.

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Laryngeal doses were reduced using whole-field intensity modulated RT and VMAT.

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Shorter treatment times and required monitor units were also associated with VMAT.

Background and purpose

Minimizing radiation dose exposure to nearby organs is key to limiting clinical toxicities associated with radiotherapy. Several treatment modalities such as split- or whole-field intensity-modulated radiotherapy (SF-IMRT, WF-IMRT) and volumetric modulated arc therapy (VMAT) are being used to treat tonsillar cancer patients with unilateral neck radiotherapy. Herein, we provide a modern dosimetric comparison of all three techniques.

Materials and methods

Forty patients with tonsillar cancer treated with definitive, ipsilateral neck SF-IMRT were evaluated. Each patient was re-planned with WF-IMRT and VMAT techniques, and doses to selected organs-at-risk (OARs) including the larynx, esophagus, and brainstem were compared.

Results

No significant differences in target coverage existed between plans; however, the heterogeneity index improved using WF-IMRT and VMAT relative to SF-IMRT. Compared to SF-IMRT, WF-IMRT and VMAT plans had significantly lower mean doses to the supraglottic larynx (31 Gy, 18.5 Gy, 17 Gy; p < 0.01), the MDACC-defined larynx (13.4 Gy, 10.5 Gy, 9.8 Gy; p < 0.01), and RTOG-defined larynx (15.8 Gy, 12.1 Gy, 11.1 Gy; p < 0.01), respectively. Mean esophageal dose was lowest with SF-IMRT over WF-IMRT and VMAT (5.9 Gy, 12.2 Gy, 11.1 Gy; p < 0.01) but only in the absence of lower neck disease. On average, VMAT plans had shorter treatment times and required less monitor units than both SF-IMRT and WF-IMRT.

Conclusion

In the setting of unilateral neck radiotherapy, WF-IMRT and VMAT plans can be optimized to significantly improve dose sparing of critical structures compared to SF-IMRT. VMAT offers additional advantages of shorter treatment times and fewer required monitor units.

The "Morning Voice": The Effect of 24 Hours of Sleep Deprivation on Vocal Parameters of Young Adults

Fatigue following sleep deprivation adversely affects various aspects of human performance. It also induces recognizable voice changes, but the literature is inconsistent regarding their nature. The current study used acoustical analyses to assess the effect of 24 hours of sleep deprivation on vocal parameters of young adults. Forty-seven participants (23 females and 24 males) were tested after nocturnal sleep and after 24 hours of sleep deprivation. Different voice samples were recorded (sustained phonation, words, and sentences) and analyzed for fundamental frequency (F₀, in Hz), vocal intensity (in dB), harmonic-noise ratio (HNR, in dB), jitter, and shimmer (in %). The main finding was significantly higher HNR values following sleep deprivation than nocturnal sleep for females, across all voice samples. The HNR is a measure of the degree of acoustic periodicity, or the amount of noise compared to the harmonic quality present in the voice. As its values are higher, the voice quality is perceptually better. The current results indicate that females had a significantly higher ratio of vocal harmonics compared to vocal noise when they were sleep deprived. In contrast, following nocturnal sleep, the ratio of vocal harmonics compared to vocal noise was lower, which means the voice quality was poorer. This may explain the common perceptual impressions of decreased voice quality after sleep, which may be more pronounced in females.

Predicting feeding tube and tracheotomy dependence in laryngeal cancer patients

CONCLUSIONS

The two scales reliably measure laryngeal edema and dysfunction in laryngeal cancer patients. The eight categories from these scales, and abnormal pharyngeal squeeze, can be used to form a new rating scale intended to help clinicians identify and circumvent swallowing complications after chemo-irradiation.

OBJECTIVES

The objectives were to compare two laryngeal edema rating scales in laryngeal cancer patients and determine if post-radiation +/- chemotherapy edema predicts dependence on a feeding tube and/or tracheostomy.

METHODS

A retrospective chart review between 2005-2008 revealed 28 laryngeal cancer patients status post-radiation +/- chemotherapy, with video laryngoscopies performed within 6 months after treatment. Four raters evaluated videos based on the Laryngopharyngeal Edema Scale (LES) and the Reflux Finding Score (RFS). Tracheostomy and feeding tube outcomes were then correlated with the two scales.

RESULTS

Feeding tube and tracheostomy dependence were associated with pre-treatment vocal cord paralysis, advanced T stage, and chemoradiation. Eight categories from the LES and RFS scales were significantly associated with the need for a feeding tube.

Effects of electrical stimulation on vocal functions in patients with nasopharyngeal carcinoma

OBJECTIVES/HYPOTHESIS

This study aimed to evaluate the effects of neuromuscular electrical stimulation (NMES) on vocal functions in patients with nasopharyngeal carcinoma following radiation therapy.

STUDY DESIGN

Prospective, randomized controlled trial.

METHODS

One hundred forty newly treated NPC patients were recruited and randomized into NMES or traditional swallowing exercise (TE) group. Participants received intensive NMES or traditional swallowing therapy and were followed up until 12 months postrandomization. Fifty-seven participants completed the treatment and all of the follow-up assessments. The Voice Handicap Index-30 (VHI-30) was used to measure the vocal functions of the participants.

RESULTS

The NMES group showed no significant changes to their vocal functions, whereas the TE group showed a short-term deterioration of voice functions at the 6-month follow-up. VHI-30 scores returned to the baseline level for both groups at the 12-month follow-up.

CONCLUSIONS

NMES is shown to provide a short-term benefit on vocal functions for NPC patients following radiation therapy.

LEVEL OF EVIDENCE

1b Laryngoscope, 127:1119-1124, 2017.

[Head and neck intensity-modulated radiation therapy: Normal tissues dose constraints. Pharyngeal constrictor muscles and larynx]

Radio-induced pharyngolaryngeal chronic disorders may challenge the quality of life of head and neck cancer long survivors. Many anatomic structures have been identified as potentially impaired by irradiation and responsible for laryngeal edema, dysphonia and dysphagia. Some dose constraints might be plausible such as keeping the mean dose to the pharyngeal constrictor muscles under 50 to 55Gy, the mean dose to the supra-glottic larynx under 40 to 45Gy and, if feasible, the mean dose to the glottic larynx under 20Gy. A reduction of the dose delivered to the muscles of the floor of the mouth and the cervical esophagus would be beneficial as well. Nevertheless, the publications available do not provide an extensive enough level of proof. One should consider limiting as low as possible the dose delivered to these structures without compromising the quality of irradiation of the target tumor volumes.

Assessment of voice, speech, and related quality of life in advanced head and neck cancer patients 10-years+ after chemoradiotherapy

OBJECTIVES

Assessment of long-term objective and subjective voice, speech, articulation, and quality of life in patients with head and neck cancer (HNC) treated with concurrent chemoradiotherapy (CRT) for advanced, stage IV disease.

MATERIALS AND METHODS

Twenty-two disease-free survivors, treated with cisplatin-based CRT for inoperable HNC (1999-2004), were evaluated at 10-years post-treatment. A standard Dutch text was recorded. Perceptual analysis of voice, speech, and articulation was conducted by two expert listeners (SLPs). Also an experimental expert system based on automatic speech recognition was used. Patients' perception of voice and speech and related quality of life was assessed with the Voice Handicap Index (VHI) and Speech Handicap Index (SHI) questionnaires.

RESULTS

At a median follow-up of 11-years, perceptual evaluation showed abnormal scores in up to 64% of cases, depending on the outcome parameter analyzed. Automatic assessment of voice and speech parameters correlated moderate to strong with perceptual outcome scores. Patient-reported problems with voice (VHI>15) and speech (SHI>6) in daily life were present in 68% and 77% of patients, respectively. Patients treated with IMRT showed significantly less impairment compared to those treated with conventional radiotherapy.

CONCLUSION

More than 10-years after organ-preservation treatment, voice and speech problems are common in this patient cohort, as assessed with perceptual evaluation, automatic speech recognition, and with validated structured questionnaires. There were fewer complaints in patients treated with IMRT than with conventional radiotherapy.

RETRACTED: Laryngeal Function After Radiation Therapy

Laryngeal function after oncologic treatment is a key aspect and focus of interest in the contemporary management of head and neck cancers. Although historically the treatment of most locally advanced laryngeal cancers has been total laryngectomy, recent innovations in radiation therapy and combined chemotherapy and radiation therapy have shown that organ and function preservation can be achieved with good oncologic outcomes. Technical improvements, along with better understanding of tumor biology and dose tolerance of critical organs involved in speech and swallowing function, have paved the way for better outcomes. This article reviews in comprehensive detail the recent data of laryngeal function after radiotherapy.

Communication changes following non-glottic head and neck cancer management: The perspectives of survivors and carers

PURPOSE

Head and neck cancer (HNC) survivors may experience functional changes to their voice, speech and hearing following curative chemoradiotherapy. However, few studies have explored the impact of living with such changes from the perspective of the HNC survivor and their carer. The current study employed a person-centred approach to explore the lived experience of communication changes following chemoradiotherapy treatment for HNC from the perspective of survivors and carers.

METHOD

Participants included 14 survivors with non-glottic HNC and nine carers. All participants took part in in-depth interviews where they were encouraged to describe their experiences of living with and adjusting to communication changes following treatment. Interviews were analysed as a single data set.

RESULT

Four themes emerged including: (1) impairments in communication sub-systems; (2) the challenges of communicating in everyday life; (3) broad ranging effects of communication changes; and (4) adaptations as a result of communication changes.

CONCLUSION

These data confirm that communication changes following chemoradiotherapy have potentially negative psychosocial impacts on both the HNC survivor and their carer. Clinicians should consider the impact of communication changes on the life of the HNC survivor and their carer and provide adequate and timely education and management to address the needs of this population.

Vocal Fold Paralysis as a Delayed Consequence of Neck and Chest Radiotherapy

Objective

To describe a series of cases of vocal fold paralysis years after radiation therapy, including presentation, clinical course, and treatment.

Study Design

Case series with chart review.

Setting

Tertiary care center.

Subjects and Methods

A review of 8 years of patient records yielded 10 patients (8 male and 2 female; average age 57 years [range, 29-76 years]) with vocal fold paralysis and a history of radiation therapy to the head, neck, or mediastinum. These patients did not have other possible etiologies of vocal fold paralysis. Demographic, diagnostic, clinical course, and treatment data were collected.

Results

On average, 21 years (range, 1-27 years) elapsed between completion of radiation and presentation with vocal fold paralysis. Original pathologies included Hodgkin lymphoma (5), squamous cell carcinoma of the head and neck (4), and peripheral T-cell lymphoma (1). Eight patients had unilateral left vocal fold paralysis, and 2 had bilateral neuropathy; none recovered spontaneously. All patients had dysphonia, and nearly all patients also complained of dysphagia. Six elected not to be treated. Four underwent injection augmentation with resolution of voice complaints.

Conclusions

Radiation therapy has the potential to cause laryngeal neuropathy years to decades after treatment. The potential for recovery is low, but injection augmentation can relieve symptoms. Development of contralateral neuropathy and altered tissue response are considerations in treatment.

Patient-reported voice and speech outcomes after whole-neck intensity modulated radiation therapy and chemotherapy for oropharyngeal cancer: prospective longitudinal study

PURPOSE

To describe voice and speech quality changes and their predictors in patients with locally advanced oropharyngeal cancer treated on prospective clinical studies of organ-preserving chemotherapy-intensity modulated radiation therapy (chemo-IMRT).

METHODS AND MATERIALS

Ninety-one patients with stage III/IV oropharyngeal cancer were treated on 2 consecutive prospective studies of definitive chemoradiation using whole-field IMRT from 2003 to 2011. Patient-reported voice and speech quality were longitudinally assessed from before treatment through 24 months using the Communication Domain of the Head and Neck Quality of Life (HNQOL-C) instrument and the Speech question of the University of Washington Quality of Life (UWQOL-S) instrument, respectively. Factors associated with patient-reported voice quality worsening from baseline and speech impairment were assessed.

RESULTS

Voice quality decreased maximally at 1 month, with 68% and 41% of patients reporting worse HNQOL-C and UWQOL-S scores compared with before treatment, and improved thereafter, recovering to baseline by 12-18 months on average. In contrast, observer-rated larynx toxicity was rare (7% at 3 months; 5% at 6 months). Among patients with mean glottic larynx (GL) dose ≤20 Gy, >20-30 Gy, >30-40 Gy, >40-50 Gy, and >50 Gy, 10%, 32%, 25%, 30%, and 63%, respectively, reported worse voice quality at 12 months compared with before treatment (P=.011). Results for speech impairment were similar. Glottic larynx dose, N stage, neck dissection, oral cavity dose, and time since chemo-IMRT were univariately associated with either voice worsening or speech impairment. On multivariate analysis, mean GL dose remained independently predictive for both voice quality worsening (8.1%/Gy) and speech impairment (4.3%/Gy).

CONCLUSIONS

Voice quality worsening and speech impairment after chemo-IMRT for locally advanced oropharyngeal cancer were frequently reported by patients, underrecognized by clinicians, and independently associated with GL dose. These findings support reducing mean GL dose to as low as reasonably achievable, aiming at ≤20 Gy when the larynx is not a target.

Dosimetric predictors of dysphonia after intensity-modulated radiotherapy for oropharyngeal carcinoma

AIMS

To investigate dosimetric predictors of voice changes after whole-field intensity-modulated radiotherapy (IMRT).

MATERIALS AND METHODS

Patients treated with whole-field IMRT for oropharyngeal/unknown primary tumours were selected for the present retrospective study having grossly uninvolved larynx at the time of radiotherapy and at least one follow-up visit. Voice changes were prospectively scored at each follow-up examination according to the Common Terminology Criteria for Adverse Events (CTCAE) v3.0 scale and self-reported by two items (HN4 and HN10) of the Functional Assessment of Cancer Therapy-Head and Neck Scale (FACT-HN) questionnaire. Predictors of toxicity were investigated at logistic regression, including various patient and tumour characteristics, as well as individual dosimetric data.

RESULTS

With a median follow-up of 18 months (range 3-46 months), peak CTCAE dysphonia was graded as 2 in 13 patients (10.5%), whereas 45 patients (36.3%) reported peak grade 0-1 voice changes according to FACT-HN4. Communication (FACT-HN10) was barely affected. At multivariate analysis, the mean laryngeal dose was an independent predictor of both grade 2 CTCAE dysphonia (odds ratio = 1.10, 95% confidence interval 1.01-1.20, P = 0.025) and grade 0-1 FACT-HN4 voice changes (odds ratio = 1.11, 95% confidence interval 1.04-1.18, P = 0.001). Further stratification optimised by a receiver operating characteristic (ROC) analysis showed that, to minimise the risk of grade 0-1 FACT-HN4 voice changes, the mean dose to the larynx has to be kept ≤ 49.4 Gy.

CONCLUSION

Voice changes after whole-field IMRT are common, but mild, and are strictly correlated to the dose received by the uninvolved larynx; in order to minimise the risk of side-effects, the mean dose to the larynx should be kept ≤ 50 Gy.

Radiation fibrosis of the vocal fold: from man to mouse

OBJECTIVES/HYPOTHESIS

To characterize fundamental late tissue effects in the human vocal fold following radiation therapy. To develop a murine model of radiation fibrosis in order to ultimately develop both treatment and prevention paradigms.

DESIGN

Translational study using archived human and fresh murine irradiated vocal fold tissue.

METHODS

1) Irradiated vocal fold tissue from patients undergoing laryngectomy for loss of function from radiation fibrosis was identified from pathology archives. Histomorphometry, immunohistochemistry, and whole-genome microarray, as well as real-time transcriptional analyses, were performed. 2) Focused radiation to the head and neck was delivered to mice in a survival fashion. One month following radiation, vocal fold tissue was analyzed with histomorphometry, immunohistochemistry, and real-time PCR transcriptional analysis for selected markers of fibrosis.

RESULTS

Human irradiated vocal folds demonstrated increased collagen transcription, with increased deposition and disorganization of collagen in both the thyroarytenoid muscle and the superficial lamina propria. Fibronectin were increased in the superficial lamina propria. Laminin decreased in the thyroarytenoid muscle. Whole genome microarray analysis demonstrated increased transcription of markers for fibrosis, oxidative stress, inflammation, glycosaminoglycan production, and apoptosis. Irradiated murine vocal folds demonstrated increases in collagen and fibronectin transcription and deposition in the lamina propria. Transforming growth factor (TGF)-β increased in the lamina propria.

CONCLUSION

Human irradiated vocal folds demonstrate molecular changes leading to fibrosis that underlie loss of vocal fold pliability occurring in patients following laryngeal irradiation. The irradiated murine tissue demonstrates similar findings, and this mouse model may have utility in creating prevention and treatment strategies for vocal fold radiation fibrosis.

Voice outcomes after concurrent chemoradiotherapy for advanced nonlaryngeal head and neck cancer: a prospective study

BACKGROUND

The voice impact of treatment for nonlaryngeal head and neck primary sites remains unknown.

METHODS

We conducted a prospective study of a consecutive sample of patients undergoing chemoradiation for nonlaryngeal head and neck cancer. The Voice Symptom Scale (VoiSS) was completed, and voice recordings were made at 3 time-points.

RESULTS

Of 42 recruited patients, 34 completed the measures before and in the early posttreatment phase (mean 16.5 weeks), while 21 patients were assessed at the final time-point (mean, 20.4 months). VoiSS scores showed statistically significant progressive deterioration in the total score (p = .02) and impairment subscale (p < .0001) through to the final assessment. Acoustic measures and perceptual ratings deteriorated significantly (p < .001) in the early posttreatment weeks and improved at the final assessment, but not to the baseline. Interrater agreement was excellent for expert measures.

CONCLUSION

To the best of our knowledge, this is the first prospective study to show that chemoradiation therapy for nonlaryngeal head and neck cancer has a significant effect on the patients' self-reported voice quality, even in the long term.

Pathologic effects of external-beam irradiation on human vocal folds

OBJECTIVES

We sought to better characterize pathologic changes that occur in the human vocal fold after radiotherapy for head and neck cancer.

METHODS

In a blinded, controlled study of archived tissue, we evaluated postirradiation salvage laryngectomy vocal fold tissue without evidence of malignant disease. Clinical and demographic patient data were collected. In a blinded fashion, irradiated tissue was compared to nonirradiated, benign control tissue. Histomorphometric analysis was used to assess muscle and collagen organization, superficial lamina propria (SLP) and vocal ligament thickness, vocalis muscle fiber area, collagen content, and hyaluronic acid content. Immunohistochemical analysis was used to assess the content of type I collagen, type IV collagen, vimentin, fibronectin, alpha-smooth muscle actin, matrix metalloproteinase 9, and laminin.

RESULTS

Twenty irradiated vocal folds were evaluated and compared to control specimens. Collagen and muscle disorganization was noted in the irradiated specimens. The SLP and vocal ligament thicknesses and the mean muscle fiber diameters did not differ significantly. The SLP fibronectin and the vocalis muscle and SLP collagen content were significantly increased in the irradiated vocal folds, and the SLP collagen content increased significantly with time between irradiation and resection. The laminin content of irradiated vocalis muscles was significantly decreased.

CONCLUSIONS

Radiotherapy results in significant vocal fold tissue changes. Having more precisely defined these changes, we plan continued investigation seeking targeted preventive and therapeutic interventions for improved vocal quality following radiotherapy.

Quality of voice after radiotherapy in early vocal cord cancer

Early glottic cancer (T1, T2N0M0), a disease of the voice box, mainly affects the voice. It can be effectively treated with both surgery and radiotherapy. Preservation of the voice while treating vocal cord cancer is not simply retaining the ability to vocalize. It is the determinant of choice of treatment and quality of life following curative management. Radiotherapy has resulted in excellent control rates with voice preservation and has been the standard of care for many decades. Several patient- (e.g., smoking, age, amount of talking during treatment), disease- (e.g., extent and site of lesion) and treatment- (e.g., radiation field size and dose, voice therapy) related factors adversely affect the quality of voice after radiotherapy. Several studies have evaluated voice quality either subjectively or objectively. Still, little is known about it. Voice quality after radiotherapy improves but does not reach the standard of the normal controls.

Multidisciplinary approach in the treatment of T1 glottic cancer. The role of patient preference in a homogenous patient population

BACKGROUND AND PURPOSE

To compare oncological outcome and voice quality among a uniform and well-defined subset of patients with T1 glottic carcinoma.

PATIENTS AND METHODS

Patients, affected by laryngeal glottic carcinoma, treated by laser CO2 surgery or radiotherapy, have been analyzed. Overall survival and disease-free survival were calculated. In order to verify differences in functional outcomes and voice quality, all patients were interviewed during their last follow-up visit during 2009 using the VHI (Voice Handicap Index) questionnaire. The data were analyzed using the MedCalc software.

RESULTS

A total of 143 patients were analyzed: 73 underwent surgery and 70 underwent radiotherapy. No statistically significant differences were found between the two groups in terms of overall survival and disease-free survival; dividing patients into stages T1a and T1b also made no difference. In order to evaluate the differences in outcomes for surgery and radiotherapy, patients were interviewed using the VHI questionnaire. Better scores for each category in the VHI were found for patients receiving radiotherapy compared to surgery (physical: p = 0.0023; functional: p < 0.0001; environmental: p < 0.001). The median VHI score for radiotherapy patients was 4, while for surgical patients it was 18 (p < 0.0001).

CONCLUSION

This study confirms the well-known knowledge that results from radiotherapy and surgery in early glottic cancer treatment are equivalent. Furthermore, the role of patient preference in the treatment modality choice and the value of a multidisciplinary approach for a detailed and multi-oriented discussion with the patient are outlined.

In vivo and in vitro models of ionizing radiation to the vocal folds

BACKGROUND

Radiation therapy (RT) to the head and neck often results in damage to the vocal folds (VF) and surrounding structures. Characterization and treatment of these sequelae is limited, likely due to the lack of experimental models.

METHODS

Larynges from rats exposed to 2 fractionation schedules (40 Gy total) were analyzed histologically. In vitro, reactive oxygen species (ROS) synthesis, and transcription of select genes associated with ROS, inflammation, and fibrosis were examined in VF fibroblasts after single-dose radiation.

RESULTS

Although radiation-induced histologic alterations are made to VF architecture, 1 fractionation schedule was accompanied by significant morbidity and mortality. In vitro, radiation increased ROS synthesis and inflammatory and profibrotic gene expression.

CONCLUSION

Our data suggest that hyperfractionated RT is more tolerable. Utilizing this model, RT-induced histologic aberrations are made to the VF mucosa. In addition, a relationship between radiation, ROS, and inflammatory and fibrotic gene expression was observed in vitro.

[Normal tissue tolerance to external beam radiation therapy: larynx and pharynx]

For head and neck cancers, the radiation dose usually needed to sterilize a macroscopic tumour is at least 70 Gy in conventional fractionation. In the larynx, this dose level enables optimal tumour control while exposing the patient to a limited risk of severe complications. For oropharynx and nasopharynx tumors, it is sometimes possible to limit the dose received by the larynx according to the extent of the primary lesion. Thus, if the tumour constraints permit, the maximum dose to the larynx must be less than 63 to 66 Gy. To reduce the risk of laryngeal edema, it is recommended if possible to limit the mean non-involved larynx dose to 40 to 45 Gy. In the pharynx, literature's data suggested to minimize the volume of the pharyngeal constrictor muscles receiving a dose greater than or equal to 60 Gy. Limiting the volume receiving a dose greater than or equal to 50 Gy reduces the risk of dysphagia. These dose constraints should be tailored to each patient taking into account the extent of the initial primary lesion, the possible addition of chemotherapy or a modified fractionation radiotherapy.

Radiation dose-volume effects in the larynx and pharynx

The dose-volume outcome data for RT-associated laryngeal edema, laryngeal dysfunction, and dysphagia, have only recently been addressed, and are summarized. For late dysphagia, a major issue is accurate definition and uncertainty of the relevant anatomical structures. These and other issues are discussed.

NTCP modeling of subacute/late laryngeal edema scored by fiberoptic examination

PURPOSE

Finding best-fit parameters of normal tissue complication probability (NTCP) models for laryngeal edema after radiotherapy for head and neck cancer.

METHODS AND MATERIALS

Forty-eight patients were considered for this study who met the following criteria: (1) grossly uninvolved larynx, (2) no prior major surgery except for neck dissection and tonsillectomy, (3) at least one fiberoptic examination of the larynx within 2 years from radiotherapy, (4) minimum follow-up of 15 months. Larynx dose-volume histograms (DVHs) were corrected into a linear quadratic equivalent one at 2 Gy/fr with alpha/beta = 3 Gy. Subacute/late edema was prospectively scored at each follow-up examination according to the Radiation Therapy Oncology Group scale. G2-G3 edema within 15 months from RT was considered as our endpoint. Two NTCP models were considered: (1) the Lyman model with DVH reduced to the equivalent uniform dose (EUD; LEUD) and (2) the Logit model with DVH reduced to the EUD (LOGEUD). The parameters for the models were fit to patient data using a maximum likelihood analysis.

RESULTS

All patients had a minimum of 15 months follow-up (only 8/48 received concurrent chemotherapy): 25/48 (52.1%) experienced G2-G3 edema. Both NTCP models fit well the clinical data: with LOGEUD the relationship between EUD and NTCP can be described with TD50 = 46.7 +/- 2.1 Gy, n = 1.41 +/- 0.8 and a steepness parameter k = 7.2 +/- 2.5 Gy. Best fit parameters for LEUD are n = 1.17 +/- 0.6, m = 0.23 +/- 0.07 and TD50 = 47.3 +/- 2.1 Gy.

CONCLUSIONS

A clear volume effect was found for edema, consistent with a parallel architecture of the larynx for this endpoint. On the basis of our findings, an EUD <30-35 Gy should drastically reduce the risk of G2-G3 edema.

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

BACKGROUND

This is the first prospective study to use instrumental and both clinician- and client-rated auditory-perceptual measures to examine voice and voice-related quality of life changes in patients after curative radiotherapy for early glottic cancer.

METHOD

Thirty patients undergoing curative radiotherapy treatment for early glottic cancer completed the following: 3 voice tasks for acoustic, aerodynamic, and auditory-perceptual voice measures (therapist-rated); a patient self-report rating of voice quality; and a voice-related quality of life assessment before and 12 months after radiotherapy.

RESULTS

Patients' perceptions of their voice quality and their voice-related quality of life significantly improved posttreatment, as did acoustic, aerodynamic, and auditory-perceptual voice measures. Mean speaking fundamental frequency did not change significantly, although breathiness and strain in the voice recordings were demonstrably reduced.

CONCLUSION

In describing postradiotherapy voices in this study, pertinent measures of voice outcomes have been established, setting the benchmark for comparison in future cohort studies.

Posttreatment FDG-PET uptake in the supraglottic and glottic larynx correlates with decreased quality of life after chemoradiotherapy

PURPOSE

Inflammation and increased metabolic activity associated with oxidative stress in irradiated normal tissues may contribute to both complications following radiotherapy and increased glucose uptake as detected by posttherapy fluorodeoxyglucose (FDG)-PET imaging. We sought to determine whether increased glucose uptake in normal tissues after chemoradiotherapy is associated with increased toxicity.

METHODS AND MATERIALS

Consecutive patients with locoregionally advanced head and neck cancers treated with intensity-modulated radiation therapy and free of recurrence at 1 year were studied. FDG-PET imaging was obtained at 3 and 12 months posttreatment. Standardized uptake value (SUV) levels were determined at various head and neck regions. Functional outcome was measured using a quality of life questionnaire and weight loss and type of diet tolerated 1 year after therapy. A one-tailed Pearson correlation test was used to examine associations between SUV levels and functional outcome measures.

RESULTS

Standardized uptake value levels in the supraglottic and glottic larynx from FDG-PET imaging obtained 12 months posttreatment were inversely associated with quality of life measures and were correlated with a more restricted diet 1 year after therapy. SUV levels at 3 months after therapy did not correlate with functional outcome. Increases in SUV levels in normal tissues between 3 and 12 months were commonly found in the absence of recurrence.

CONCLUSION

Altered metabolism in irradiated tissues persists 1 year after therapy. FDG-PET scans may be used to assess normal tissue damage following chemoradiotherapy. These data support investigating hypermetabolic conditions associated with either inflammation, oxidative stress, or both, as causal agents for radiation-induced normal tissue damage.

Dosimetric Predictors of Laryngeal Edema

PURPOSE

To investigate dosimetric predictors of laryngeal edema after radiotherapy (RT).

METHODS AND MATERIALS

A total of 66 patients were selected who had squamous cell carcinoma of the head and neck with grossly uninvolved larynx at the time of RT, no prior major surgical operation except for neck dissection and tonsillectomy, treatment planning data available for analysis, and at least one fiberoptic examination of the larynx within 2 years from RT performed by a single observer. Both the biologically equivalent mean dose at 2 Gy per fraction and the cumulative biologic dose-volume histogram of the larynx were extracted for each patient. Laryngeal edema was prospectively scored after treatment. Time to endpoint, moderate or worse laryngeal edema (Radiation Therapy Oncology Group Grade 2+), was calculated with log rank test from the date of treatment end.

RESULTS

At a median follow-up of 17.1 months (range, 0.4- 50.0 months), the risk of Grade 2+ edema was 58.9% +/- 7%. Mean dose to the larynx, V30, V40, V50, V60, and V70 were significantly correlated with Grade 2+ edema at univariate analysis. At multivariate analysis, mean laryngeal dose (continuum, hazard ratio, 1.11; 95% confidence interval, 1.06-1.15; p < 0.001), and positive neck stage at RT (N0-x vs. N +, hazard ratio, 3.66; 95% confidence interval, 1.40-9.58; p = 0.008) were the only independent predictors. Further stratification showed that, to minimize the risk of Grade 2+ edema, the mean dose to the larynx has to be kept < or =43.5 Gy at 2 Gy per fraction.

CONCLUSION

Laryngeal edema is strictly correlated with various dosimetric parameters; mean dose to the larynx should be kept < or =43.5 Gy.

Radiation Doses to Structures Within and Adjacent to the Larynx are Correlated With Long-Term Diet- and Speech-Related Quality of Life

PURPOSE

To test the hypothesis that radiation dose to key sites in the upper aerodigestive tract is associated with long-term functional outcome after (chemo)radiotherapy for head-and-neck cancers.

METHODS AND MATERIALS

This study examined the outcome for 27 patients treated with intensity-modulated radiotherapy for definitive management of their head-and-neck cancer who were disease free for at least 1 year after treatment. Head-and-neck cancer-specific quality of life (QoL) was assessed before treatment and at 1 year after treatment. Type of diet tolerated, presence of a feeding tube, and degree of weight loss 1 year after treatment were also used as outcome measures. Radiation doses delivered to various points along the upper aerodigestive tract, including base of tongue, lateral pharyngeal walls, and laryngeal structures, were determined from each treatment plan. Radiation doses for each of these points were tested for correlation with outcome measures.

RESULTS

Higher doses delivered to the aryepiglottic folds, false vocal cords, and lateral pharyngeal walls near the false cords correlated with a more restrictive diet, and higher doses to the aryepiglottic folds correlated with greater weight loss (p < 0.05) 1 year after therapy. Better posttreatment speech QoL scores were associated with lower doses delivered to structures within and surrounding the larynx.

CONCLUSION

Our data show an inverse relationship between radiation dose delivered to laryngeal structures and speech and diet and QoL outcomes after definitive (chemo)radiation treatment. These findings suggest that efforts to deliver lower doses to laryngeal structures may improve outcomes after definitive (chemo)radiation therapy.

Voice in early glottic cancer compared to benign voice pathology

The purpose of this study is to compare (Dutch) Voice Handicap Index (VHIvumc) scores from a selected group of patients with voice problems after treatment for early glottic cancer with patients with benign voice disorders and subjects from the normal population. The study included a group of 35 patients with voice problems after treatment for early glottic cancer and a group of 197 patients with benign voice disorders. Furthermore, VHI scores were collected from 123 subjects randomly chosen from the normal population. VHI reliability was high with high internal consistency and test-retest stability. VHI scores of glottic cancer patients were similar to those of patients with voice problems due to benign lesions. Both groups of patients were clearly deviant from the normal population. Within the normal population, 16% appeared to have not-normal voices. Based on ROC curves a cut-off score of 15 points was defined to identify patients with voice problems in daily life. A clinical relevant difference score of 10 points was defined to be used for individual patients and of 15 points to be used in study designs with groups. Patients with voice problems after treatment for early glottic cancer encounter the same amount of problems in daily life as the other voice-impaired patients. The VHI proved to be an adequate tool for baseline and effectiveness measurement of voice.

Optimising outcome assessment of voice interventions, I: reliability and validity of three self-reported scales

Background:

There is an increasing choice of voice outcome research tools, but good comparative data are lacking.

Objective:

To evaluate the reliability and validity of three voice-specific, self-reported scales.

Design:

Longitudinal, cohort comparison study.

Setting:

Two UK voice clinics: the Freeman Hospital, Newcastle upon Tyne, and the Glasgow Royal Infirmary.

Participants:

One hundred and eighty-one patients presenting with dysphonia.

Main outcome measures:

All patients completed the vocal performance questionnaire, the voice handicap index and the voice symptom scale. For comparison, each patient's voice was recorded and assessed perceptually using the grade–roughness–breathiness–aesthenia–strain scale. The reliability and validity of the three self-reported vocal performance measures were assessed in all subjects, while 50 completed the questionnaires again to assess repeatability.

Results:

The results of the 170 participants with completed data sets showed that all three questionnaires had high levels of internal consistency (Cronbach's alpha = 0.81–0.95) and repeatability (voice handicap index = 0.83; vocal performance questionnaire = 0.75; voice symptom scale = 0.63). Concurrent and criterion validity were also good, although, of the grade–roughness–breathiness–aesthenia–strain subscales, roughness was the least well correlated with the self-reported measures.

Conclusion:

The vocal performance questionnaire, the voice handicap index and the voice symptom scale are all reliable and valid instruments for measuring the patient-perceived impact of a voice disorder.

Choosing an intensity-modulated radiation therapy technique in the treatment of head-and-neck cancer

PURPOSE

With the emerging use of intensity-modulated radiation therapy (IMRT) in the treatment of head-and-neck cancer, selection of technique becomes a critical issue. The purpose of this article is to establish IMRT guidelines for head-and-neck cancer at a given institution.

METHODS AND MATERIALS

Six common head-and-neck cancer cases were chosen to illustrate the points that must be considered when choosing between split-field (SF) IMRT, in which the low anterior neck (LAN) is treated with an anterior field, and the extended whole-field (EWF) IMRT in which the LAN is included with the IMRT fields. For each case, the gross tumor, clinical target, and planning target volumes and the surrounding critical normal tissues were delineated. Subsequently, the SF and EWF IMRT plans were compared using dosimetric parameters from dose-volume histograms.

RESULTS

Target coverage and doses delivered to the critical normal structures were similar between the two different techniques. Cancer involving the nasopharynx and oropharynx are best treated with the SF IMRT technique to minimize the glottic larynx dose. The EWF IMRT technique is preferred in situations in which the glottic larynx is considered as a target, i.e., cancer of the larynx, hypopharynx, and unknown head-and-neck primary. When the gross disease extends inferiorly and close to the glottic larynx, EWF IMRT technique is also preferred.

CONCLUSION

Depending on the clinical scenario, different IMRT techniques and guidelines are suggested to determine a preferred IMRT technique. We found that having this treatment guideline when treating these tumors ensures a smoother flow for the busy clinic.

Voice-related quality of life in T1 glottic cancer: irradiation versus endoscopic excision

OBJECTIVES

Several studies have explored posttreatment voice outcomes for early glottic cancer with varying results. To further clarify the voice-related quality of life (QOL) of T1 glottic cancer patients treated by external beam radiotherapy (EBRT) compared to endoscopic carbon dioxide laser excision (CLE), we performed a meta-analysis.

METHODS

We performed a meta-analysis review for the years 1966 to 2005 for the Voice Handicap Index (VHI), laryngeal cancer, voice outcome, voice quality, and quality of life. Studies in which the VHI was assessed at least 3 months after treatment for T1 glottic cancer were identified and analyzed by meta-analysis techniques.

RESULTS

Six studies with 208 patients (6 T1b and 202 T1a) treated with CLE and 91 patients (6 T1b and 85 T1a) treated with EBRT were identified. The posttreatment VHI scores were similar for the EBRT- and CLE-treated patients (p = .1, Wilcoxon rank sum test).

CONCLUSIONS

We conclude that CLE and EBRT provide comparable levels of voice handicap for patients with T1 glottic cancer.

The efficacy of voice therapy in patients after treatment for early glottic carcinoma

BACKGROUND

After treatment for early glottic carcinoma, a considerable number of patients end up with voice problems that interfere with daily life activities. The objective of this randomized and controlled study was to assess the efficacy of voice therapy in these patients.

METHODS

Of 177 patients, 6-120 months after treatment for early glottic carcinoma, 70 patients (40%) suffered from voice impairment based on a 5-item screening questionnaire. Approximately 60% of those 70 patients were not interested in participating in the current study. Twenty-three patients who were willing to participate were assigned randomly either to a voice therapy group (n = 12 patients) or to a control group (n = 11 patients). Multidimensional voice analyses (the self-reported Voice Handicap Index [VHI], acoustic and perceptual voice quality analysis, videolaryngostroboscopy, and the Voice Range Profile) were conducted twice: before and after voice therapy or with 3 months in between for the control group.

RESULTS

Statistical analyses of the difference in scores (postmeasurement minus premeasurement) showed significant voice improvement after voice therapy on the total VHI score, percent jitter, and noise-to-harmonics ratio in the voice signal and on the perceptual rating of vocal fry.

CONCLUSIONS

Voice therapy proved to be effective in patients who had voice problems after treatment for early glottic carcinoma. Improvement not only was noticed by the patients (VHI) but also was confirmed by objective voice parameters.

Voice and swallowing outcomes of an organ-preservation trial for advanced laryngeal cancer

INTRODUCTION

Organ-preservation treatment approaches for advanced laryngeal cancer patients that use combination chemoradiotherapy result in cure rates similar to primary laryngectomy with postoperative radiotherapy. In the national VA Larynx Cancer Trial, successful organ preservation was associated with an overall improvement in quality of life but not in subjective speech compared with long-term laryngectomy survivors. As part of a Phase II clinical trial, a prospective study of speech and swallowing results was conducted to determine if larynx preservation is associated with improved voice and swallowing compared with results in patients who require salvage laryngectomy.

SUBJECTS

A total of 97 patients with advanced laryngeal cancer (46 Stage III, 51 Stage IV) were given a single course of induction chemotherapy (cisplatin 100 mg/m2 on Day 1 and 5-FU 1,000 mg/m2/day x 5 days), followed by assessment of response. Patients with less than 50% response underwent early salvage laryngectomy, and patients with 50% or better response underwent concurrent chemoradiation (72 Gy and cisplatin 100 mg/m2 on Days 1, 22, and 43), followed by two cycles of adjuvant chemotherapy (DDP/5-FU). Direct laryngoscopy and biopsy were performed 8 weeks after radiation therapy to determine final tumor response. Late salvage surgery was performed on patients with persistent or recurrent disease.

METHODS

Completed survey data on voice and swallowing utilizing the Voice-Related Quality of Life Measure (V-RQOL) and the List Performance Status Scale for Head and Neck Cancer Patients (PSS-HN) were obtained from 56 patients who were alive and free of disease at the time of survey, with a minimum follow-up of 8 months. Comparisons were made between patients with an intact larynx (n = 37) vs. laryngectomy (n = 19), as well as early (n = 12) vs. late salvage laryngectomy (n = 7). Multivariate analysis was performed to determine factors predictive of voice and swallowing outcomes. Overall 3-year determinant survival was 87%, with median follow-up of 40 months.

RESULTS

Patients with an intact larynx demonstrated significantly higher (p = 0.02) mean V-RQOL scores (80.3) than did laryngectomy patients (65.4). This finding was consistent in the social-emotional (p = 0.007) and physical functioning domains (p = 0.03). No differences in V-RQOL scores were found in comparisons between early and late salvage laryngectomy. Multiple linear regression revealed that predictors of higher total V-RQOL scores include lower T stage (p = 0.03), organ preservation (p = 0.0007), and longer duration since treatment (p = 0.01). Understandability of speech was better in patients with an intact larynx (p = 0.001). Overall swallowing function was comparable between groups. Multiple logistic regression revealed that longer duration since treatment (p = 0.03, odds ratio = 1.1) and lower maximal mucositis grade (p = 0.03, odds ratio = 0.3) were predictive of higher likelihood of eating in public. Nutritional mode consisting of oral intake alone without nutritional supplements was achieved in 88.9% of patients with an intact larynx compared with 64.3% of laryngectomees (p = 0.09).

CONCLUSIONS

Voice-related quality of life is better in patients after chemoradiation therapy compared with salvage laryngectomy. Earlier salvage, although known to be associated with fewer surgical complications, did not result in improved voice; however, the number of patients analyzed is small. Overall swallowing function is good in all patients; however, patients with an intact larynx are more likely to obtain nutrition with oral intake alone without supplements. Such measures of function and quality of life are important endpoints to help judge overall effectiveness as newer, more aggressive treatment protocols with added toxicities are developed and evaluated.

Méthodes actuelles d’évaluation des dysphonies

OBJECTIVES

The aim of this review article was to provide an update on current techniques for evaluation of dysphonia in routine clinical practice.

MATERIALS AND METHODS

Recent medical and other scientific literature was reviewed and pertinent current theories concerning the physiology of laryngeal function described.

RESULTS

Perceptual voice quality evaluation by a professional jury of listeners is still considered to be the most reliable and complete means of evaluating pathologic voice, even though it is difficult to perform in routine and the results lack reproducibility. The objective evaluation of the vocal fundamental frequency and its variations and the spectral characteristics of voice has the advantage of being simple to perform, reproducible and quantifiable. However, automatic measurements need to be analyzed with precaution for severe dysphonia, the computer algorithms being designed for voices retaining a certain periodicity. Aerodynamic measurements are quantifiable and reproducible and provide information as to the quality of laryngeal function as a transducer of aerodynamic energy into acoustic energy. Videostroboscopy and electroglottography provide information as to the quality of the laryngeal vibrations, the source of sound production.

CONCLUSIONS

All of these types of analysis are complementary, informing as to different aspects of vocal quality and laryngeal function. No one measurement alone can diagnose or characterize dysphonia.