The impact of previous endoscopic treatments on functional outcome after cricotracheal resection

OBJECTIVES

Treatment options for benign subglottic stenosis include endoscopic techniques or open surgery. Although endoscopic treatment is less invasive, a considerable proportion of patients develop recurrent stenosis. Endoscopic pretreatments do not exclude patients from a later surgical repair; however, the impact of previous endoscopic treatment attempts on functional outcome after open surgery is unknown.

METHODS

All patients, who received a cricotracheal resection (CTR) between January 2017 and June 2023 at the Department of Thoracic Surgery, Medical University of Vienna, were included in this retrospective study. Patient characteristics, surgical variables and postoperative outcome including a detailed functional assessment were analysed.

RESULTS

A total of 65 patients received a CTR during the study period, of which 40 were treatment naïve and 25 had a median of 2 (range 1-9) endoscopic pretreatments. Less-invasive voice-sparing CTR or standard CTR were more often possible in treatment-naïve patients. In contrary, pretreated patients regularly required extended procedures (P = 0.049). Three or more endoscopic treatments resulted in a significantly lower mean fundamental frequency (F0) after open repair (P = 0.048). In addition, a trend towards smaller mean sound pressure levels, a higher voice handicap index, higher impairments in RBH scores (roughness, breathing and hoarseness) and a higher dysphagia severity index was found in pretreated patients. The respiratory outcome after surgery was comparable between both groups.

CONCLUSIONS

Multiple endoscopic pretreatments lead to worse voice quality after CTR. The impact of prior endoscopic treatment before surgical repair should be considered when discussing treatment options with patients suffering from subglottic stenosis.

Validity and Reliability of the Turkish Version of the Glottal Function Index

OBJECTIVES

A comprehensive evaluation is necessary for voice-related complaints, as it can benefit both the patient and physician in busy clinical settings. This study aimed to examine the Turkish adaptation of the Glottal Function Index (GFI-T), which can be quickly administered.

STUDY DESIGNS

Phase 1 methodological, phase 2 prospective cohort.

METHODS

This study was conducted in two phases. Firstly, the GFI was translated into Turkish, and its content validity was examined. The GFI-T was administered to 40 participants with voice disorders (M=41.3, SD=10) in the study group and 40 participants without voice disorders (M=37.5, SD=11.3) in the control group. Then GFI-T was readministered 2weeks later. The collected data were used for structural and convergent validity [correlation with Turkish version of the Voice Handicap Index-10 (VHI-10)], internal consistency, and test-retest reliability analyses. Secondly, 24 participants with vocal nodules were recruited separately from the first phase and were randomly divided into three groups. The first group underwent lax-vox therapy+vocal hygiene, the second group underwent resonance therapy+vocal hygiene, and the third group was provided only with vocal hygiene recommendations. The discriminative ability and construct validity of the GFI-T were examined by comparing pre- and post-assessments.

RESULTS

The results indicated that the content validity indexes were 0.98 in the experts and 0.99 in the participants. Confirmatory factor analysis of the scale confirmed that a single-factor structure and goodness-of-fit indices were suitable. The GFI-T correlated 0.92 with the Turkish version of the VHI-10. The internal consistency was 0.96, and the test-retest value was 0.99. Significant differences (P < 0.001) and correlations with the Turkish version of VHI-10 were found in intragroup comparisons.

CONCLUSIONS

The GFI-T is a reliable and valid tool for the self-assessment of voice disorders. The adaptation of this study to the pediatric population is recommended.

Functional data analysis of prosodic prominence in Parkinson's disease: a pilot study

This study aims to reveal dynamic changes in prosodic prominence patterns associated with Parkinson's disease (PD). To fulfill this purpose, the study proposes an exploratory methodology involving measuring a novel syllable-based prosody index (SPI) and performing functional principal component analyses (fPCAs) in a semi-automatic manner. First, SPI trajectories were collected from 31 speakers with PD before and after speech therapy and from 36 healthy controls. Then, the SPI trajectories were converted to continuous functions using B-splines. Finally, the functional SPIs were examined using fPCAs. The results showed that PD was associated with an increase of overall prominence for male speakers. The findings regarding higher prominence patterns in PD were supported by traditional phonetic measurements. For female speakers, however, there were no significant differences in prosodic prominence between speakers with PD and healthy controls. The results encourage to explore the proposed methodology also in analyses of other forms of atypical speech.

A novel technique of voice-sparing cricotracheal resection

Background

Cricotracheal resection (CTR) is considered the standard of care for patients suffering from idiopathic subglottic stenosis (iSGS). Although CTR results in permanent restoration of airway patency, it has a mild to moderate impact on voice quality. Here we propose modifications of the standard CTR technique to make it a voice-preserving procedure.

Methods

Five women with iSGS underwent voice-sparing CTR between January 2022 and January 2023. In this procedure, through several technical adaptations, the function of the cricothyroid joint was preserved. Outcomes of these voice-sparing CTRs were compared to outcomes in patients who underwent standard CTR in our institution. All patients underwent full functional preoperative and postoperative workups, including spirometry, voice measurements, patient self-assessment, and fiberoptic endoscopic evaluation of swallowing.

Results

All 5 patients in the study group suffered from iSGS with high-grade Myer-Cotton III° stenosis (100%); 1 patient had previously undergone endoscopic laser resection. Voice evaluation demonstrated a nearly unchanged fundamental pitch (mean preoperative, 191 ± 73.1 Hz; postoperative, 182 ± 64.2 Hz) and dynamic voice range (preoperative, 24.4 semitones; postoperative, 20.4 semitones). This was in contrast to the control group, in which significantly reduced voice quality was observed.

Conclusions

In selected patients suffering from iSGS, excellent functional results can be obtained with voice-sparing CTR.

Shouting affects temporal properties of the speech amplitude envelope

Distinguishing shouted from non-shouted speech is crucial in communication. We examined how shouting affects temporal properties of the amplitude envelope (ENV) in a total of 720 sentences read by 18 Swiss German speakers in normal and shouted modes; shouting was characterised by maintaining sound pressure levels of ≥80 dB sound pressure level (dB-SPL) (C-weighted) at a 1-meter distance from the mouth. Generalized additive models revealed significant temporal alterations of ENV in shouted speech, marked by steeper ascent, delayed peak, and extended high levels. These findings offer potential cues for identifying shouting, particularly useful when fine-structure and dynamic range cues are absent, for example, in cochlear implant users.

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.

Harnessing Machine Learning in Vocal Arts Medicine: A Random Forest Application for "Fach" Classification in Opera

Vocal arts medicine provides care and prevention strategies for professional voice disorders in performing artists. The issue of correct "Fach" determination depending on the presence of a lyric or dramatic voice structure is of crucial importance for opera singers, as chronic overuse often leads to vocal fold damage. To avoid phonomicrosurgery or prevent a premature career end, our aim is to offer singers an improved, objective fach counseling using digital sound analyses and machine learning procedures. For this purpose, a large database of 2004 sound samples from professional opera singers was compiled. Building on this dataset, we employed a classic ensemble learning method, namely the Random Forest algorithm, to construct an efficient fach classifier. This model was trained to learn from features embedded within the sound samples, subsequently enabling voice classification as either lyric or dramatic. As a result, the developed system can decide with an accuracy of about 80% in most examined voice types whether a sound sample has a lyric or dramatic character. To advance diagnostic tools and health in vocal arts medicine and singing voice pedagogy, further machine learning methods will be applied to find the best and most efficient classification method based on artificial intelligence approaches.

Treatment of Vocal Fold Nodules: Transnasal Steroid Injection Versus Microlaryngoscopic Phonomicrosurgery

OBJECTIVES

Vocal fold nodules (VFNs) are bilateral, mid-membranous, swellings of the vocal folds. Intralesional steroid injection was successfully tried in the management of benign vocal fold lesions including nodules. The aim of the present study was to compare treatment outcomes of vocal fold steroid injection (VFSI) and surgery in patients with VFNs in terms of lesion regression, subjective, and objective voice parameters.

STUDY DESIGN

Nonrandomized controlled clinical trial.

METHODS

This bicenter interventional study was conducted on 32 patients with VFNs, in the age range of 16-63 years. Sixteen patients underwent transnasal VFSI under local anesthesia (the injection group), and 16 underwent surgical excision of the nodules under general anesthesia (the surgery group). Prior to intervention and at the follow-up visit, participants were subjected to videolaryngoscopic examination with evaluation of nodules' sizes as well as subjective voice assessment by auditory perceptual assessment (APA) of voice and the international nine-item Voice Handicap Index (VHI-9i). Objective voice assessments including the measurements of cepstral peak prominence, jitter, shimmer, harmonic to noise ratio, and maximum phonation time were also administered.

RESULTS

The size of vocal fold nodules was significantly decreased postintervention in both studied groups. There was a decrease in the VHI-9i score, a decrease in the values of jitter and shimmer, together with an increase in the values of cepstral peak prominence and maximum phonation time after interventions indicating improvement of subjective and objective voice outcomes in both groups.

CONCLUSION

Office-based transnasal VFSI is a safe and tolerable therapy option for VFNs. Voice outcomes of VFSI were comparable to surgery, hereby VFSI can be considered a promising therapy for VFNs and could be used as an alternative to surgery in selected cases.

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.

Subjective Voice Handicap and Vocal Tract Discomfort in Patients With Cochlear Implant

OBJECTIVES

Changes in the auditory system, for example due to hearing impairment, can cause changes in breathing, phonation, and articulation. Aim of this study was to provide first data on subjective Voice Handicap and Vocal Tract Discomfort in subjects with hearing impairment and cochlear implant (CI) after initial fitting.

STUDY DESIGN

Prospective cross-sectional study METHODS: A total of 111 participants (57 female and 54 male) between 20 and 85 years of age (mean = 58.21, SD = 14.96) were recruited between October 2019 and March 2020 from the Clinic of Otorhinolaryngology at Medical University of Hannover. Participants were tested after initial CI fitting, six weeks after implantation, using the German version of the VTD (Vocal Tract Discomfort) Scale and VHI (9i) (Voice Handicap Index) as well as speech comprehension tests and a specifically developed questionnaire evaluating data concerning voice usage and other influential factors. Statistics included descriptive analysis, group comparisons (t-Test), Pearson correlation coefficient between VTD Scale and VHI, and hearing status.

RESULTS

Patients with CI did show low scores in VTD Scale and VHI-9i (VTD mean = 7.85 [SD = 10.4]; VHI-9i mean = 4.04 [SD = 5.77]). We found neither a correlation between any of the speech comprehension tests and the VTD Scale nor the VHI-9i. Further, we could show no correlation between subjective Voice Handicap and/or Vocal Tract Discomfort and age or the kind of treatment.

CONCLUSION

Patients included in this study did not show more subjective Voice Handicap or Vocal Tract Discomfort than normal hearing peers. Scores of VTD Scale and VHI-9i did not depend on the duration of hearing loss, speech comprehension, kind of treatment or age.

Prosodic features in Finnish-speaking adults with Parkinson´s disease

The aim of this study was to assess prosodic features in Finnish speakers with (n = 16) and without (n = 20) Parkinson's disease (PD), as there are no published studies to date of prosodic features in Finnish speakers with PD. Chosen metrics were articulation rate (syllables/second), pitch (mean F₀) and pitch variability (standard deviation F₀), energy proportion below 1 kHz (epb1kHz), normalised pairwise variability index (nPVI), and a novel syllabic prosody index (SPI). Four statistically significant results were found: (1) energy was distributed more to lower frequencies in speakers with PD compared to control speakers, (2) male PD speakers had higher pitch and (3) higher syllabic prosody index compared to control males, and (4) female PD speakers had narrower pitch variability than controls. In this study, PD was manifested as less emphatic and breathier voice. Interestingly, male PD speakers' dysprosody was manifested as an effortful speaking style, whereas female PD speakers exhibited dysprosody with a monotonous speaking style. A novel syllable-based prosody index could be a potentially useful tool in analysing prosody in disordered speech.

Velopharyngeal Inadequacy-Related Quality of Life Assessment: The Instrument Development and Application Review

Objective

For the patient-reported outcome (PRO) measures related to patients with velopharyngeal inadequacy (VPI), different quality of life (QOL) instruments have been developed. The present systematic review was designated to identify current VPI-related QOL instrument development, validation, and applicability.

Methods

Pubmed, Cochrane, Embase, Web of Science, and EBSCO databases were searched in January 2022. “Velopharyngeal” or “palatopharyngeal” and “quality of life” or “life quality” were searched in title, abstract, and keywords. This study followed Preferred Reporting Items for Systematic Review and Meta-analysis (PRISMA) guidelines. Two investigators independently reviewed abstracts and full texts of the identified literature. An established checklist was used to evaluate the measurement properties of each identified instrument.

Results

A total of 375 articles and 13 instruments were identified, which can be divided into nine types of families according to their development procedures. Developmental and measurement characteristics, evidence of conceptual model, content validity, reliability, construct validity, scoring, interpretation, respondent burden, and presentation for all instruments were shown.

Conclusion

The patient's self-report assessment and parent-proxy assessment are both valuable. The conclusion that any QOL instrument is absolutely the best for patients with velopharyngeal inadequacy could not be drawn. Understanding the development and characteristics of different QOL instruments, including their reliability, validity, aim, target, language, and resource, should be important before application in clinic or research.

Quality of life and phonatory and morphological outcomes in cognitively unimpaired adolescents with Pierre Robin sequence: a cross-sectional study of 72 patients

Background

Pierre Robin sequence (PRS) is a heterogeneous condition involving retro(micro)gnathia, glossoptosis and upper airway obstruction, very often with posterior cleft palate. Patients with PRS, either isolated or associated with Stickler syndrome have good intellectual prognosis. Nevertheless, the quality of life in adolescence and the phonatory and morphological outcomes are rarely analysed. We assessed the phonatory and morphological outcomes of 72 cognitively unimpaired adolescents with PRS, studied their oral (COHIP-SF19), vocal (VHI-9i) and generic quality of life (QoL; KIDSCREEN-52), and searched for determinants of these outcomes.

Results

Two-thirds of our adolescents retained low or moderate phonation difficulties, but risk factors were not identified. For 14%, morphological results were considered disharmonious, with no link to neonatal retrognathia severity. Only one vs two-stage surgery seemed to affect final aesthetic results. The oral QoL of these adolescents was comparable to that of control patients and was significantly better than that of children with other craniofacial malformations (COHIP-SF19 = 17.5, 15.4 and 25.7, respectively). The oral QoL of the adolescents with non-isolated PRS was significantly worse (COHIP-SF19 = 24.2) than that of control patients and close to that of children with other craniofacial malformations. The vocal QoL of the adolescents (mean [SD] VHI-9i = 7.5 [5.4]) was better than that of patients with other voice pathologies and better when phonation was good. The generic QoL of the adolescents was satisfactory but slightly lower than that of controls, especially in dimensions concerning physical well-being, relationships and autonomy. QoL results were lower for adolescents with non-isolated than isolated PRS. Only non-isolated PRS and low oral QoL affected generic QoL.

Conclusion

Morphological or phonatory impairments remain non-rare in adolescents with PRS but do not seem to be directly responsible for altered QoL. These adolescents, especially those with non-isolated PRS, show self-confidence and social-relation fragility. We must focus on long-term functional and psychological results for PRS patients and improve therapy protocols and follow-up, notably those affecting the oral aspects of the disease.

Validation and Classification of the 9-Item Voice Handicap Index (VHI-9i)

The international nine-item Voice Handicap Index (VHI-9i) is a clinically established short-scale version of the original VHI, quantifying the patients’ self-assessed vocal handicap. However, the current vocal impairment classification is based on percentiles. The main goals of this study were to establish test–retest reliability and a sound statistical basis for VHI-9i severity levels. Between 2009 and 2021, 17,660 consecutive cases were documented. A total of 416 test–retest pairs and 3661 unique cases with complete multidimensional voice diagnostics were statistically analyzed. Classification candidates were the overall self-assessed vocal impairment (VHIs) on a four-point Likert scale, the dysphonia severity index (DSI), the vocal extent measure (VEM), and the auditory–perceptual evaluation (GRB scale). The test–retest correlation of VHI-9i total scores was very high (r = 0.919, p < 0.01). Reliability was excellent regardless of gender or professional voice use, with negligible dependency on age. The VHIs correlated best with the VHI-9i, whereas statistical calculations proved that DSI, VEM, and GRB are unsuitable classification criteria. Based on ROC analysis, we suggest modifying the former VHI-9i severity categories as follows: 0 (healthy): 0 ≤ 7; 1 (mild): 8 ≤ 16; 2 (moderate): 17 ≤ 26; and 3 (severe): 27 ≤ 36.

[Linguistic adaptation and validation of the voice handicap index (VHI)-30 in patients with dysphonia into Russian]

Purpose of the study is to assess the internal consistency, reliability of retesting and clinical reliability of the Russian version of the Voice Handicap Index (VHI)-30 questionnaire.

MATERIAL AND METHODS

It is prospective observational study. The original English version of the VHI-30 questionnaire was translated into Russian by two independent researchers (professional translators). The final Russian version (VHI-30rus) was formulated by a third researcher (otorhinolaryngologist) on the basis of these two translations, and then translated back into English. The 181 participants were included in this study. The main group patients (n=91) were additionally divided into subgroups in accordance with the form of dysphonia: 65 (71.4%) patients had functional and organic dysphonia, 8 (8.8%) had chronic inflammatory diseases of the larynx, 7 (7.7%) - benign neoplasms of the larynx (singing nodules, polyps, cysts), 11 (12.1%) - unilateral laryngeal paralysis. The control group consisted of 90 people without voice disorders. Internal consistency (Cronbach's α coefficient), retest reliability (intraclass correlation coefficient (ICC) VHI-30, comparison of VHI-30 indicators of patients and studied control group (Mann-Whitney U-test, Kruskal-Wallis test) and correlation with the overall severity of dysphonia (Spearman's ρ rank correlation coefficient) were determined.

RESULTS

In the patient group, we observed excellent internal consistency for VHI-30rus (α=0.95) and good internal consistency for all VHI-30rus subscales: physical (α=0.88), functional (α=0.88), and emotional (α=0.88). The intraclass correlation coefficient (ICC) indicated high retest reliability for patients (0.99) and control group subjects (0.84). The 30-item mean total values for patients with dysphonia were statistically significantly higher than for control group participants (p<0.001). A correlation was found between the overall VHI-30rus value and the overall severity of dysphonia (ρ=0.748, p<0.001). In the patient's group, female and male participants showed a statistically insignificant difference in the total value of VHI-30rus (Mann-Whitney U-test, p<0.001). There was a correlation in terms of VHI-30rus indicators in different subgroups of the patient group and the control group (Spearman's correlation coefficient: functional dysphonia - 0.942; chronic laryngitis - 0.756; unilateral laryngeal paralysis - 0.888; benign neoplasms - 0.982; control group studied - 0.882).

CONCLUSION

As a result of this study, the VHI-30 questionnaire was translated from English into Russian for use in the Russian-speaking environment. The study showed good internal consistency, retest reliability, and clinical validity for the Russian version of the VHI-30rus questionnaire. The VHI-30rus questionnaire can be recommended for use in clinical practice for patients with dysphonia.

Cross-Validation and Normative Values for the German Vocal Tract Discomfort Scale

Purpose The Vocal Tract Discomfort Scale (VTD Scale) is a self-rating questionnaire investigating physical symptoms in the larynx associated with vocal pathology. The aim of this work was to investigate the reliability, validity, sensitivity, and specificity of the first German version and to provide normative data with thresholds for pathology and a scaling scheme. Study Design A retrospective multicenter study was performed. Method A total of 571 participants (409 female and 162 male), with a mean age of 47.2 years, were recruited at three German centers; of these, there were 447 participants with voice disorder and 124 vocally healthy participants. The clinical examination consisted of patient history, visual laryngeal examination, acoustic and aerodynamic assessment, perceptual analysis by the Grading-Roughness-Breathiness-Asthenia-Strain Scale, and subjective evaluation using the VTD Scale and the Voice Handicap Index (VHI). Statistics included group comparisons (t test and analysis of variance), Pearson correlation coefficient (between VTD Scale and VHI), and Cronbach's alpha to assess validity and reliability. Analysis of receiver operating characteristics was performed to examine VTD Scale's discriminatory ability and provide a cutoff score. Additionally, percentiles were applied to provide VTD Scale ranges. Results There were highly significant differences between healthy participants and participants with voice disorder regarding the total score and both subscales of the VTD Scale. Internal consistency was excellent (α = .928). We found moderate, positive correlation between the VTD Scale and VHI (ρ = .596, p < .001). Receiver operating characteristics analysis showed an area under the curve of 0.876 (p < .001, 95% confidence interval [0.846, 0.906]). VTD Scale ranges were no (score: 0-13), mild (score: 14-26), moderate (score: 27-40), and severe (score: 41-96) disorder. Conclusions Results confirm an excellent reliability and validity of the German VTD Scale. It provides additional and independent diagnostic information and is a useful instrument to complement voice assessment. The scaling into four severity subgroups allows the tool to be used for screening patients and considers a transferral to a voice specialist.

[Voice diagnostics in phonosurgical interventions]

Stimmdiagnostische Untersuchungen vor und nach phonochirurgischen Eingriffen dienen zum einen der detaillierten Planung der chirurgischen Vorgehensweise und zum anderen der Nachvollziehbarkeit des postoperativen Ergebnisses. Die Stimmdiagnostik verfolgt dabei eine vielschichtige Vorgehensweise und umfasst Aspekte aus perzeptiver Stimmklangbeurteilung, Laryngostroboskopie, Stimmakustik, Aerodynamik und der Selbsteinschätzung durch die Patient*innen. Die Auswahl stimmdiagnostischer Methoden sollte sich dabei immer am aktuellen Wissensstand orientieren und das einrichtungsinterne Vorgehen prägen.

T1a Glottic Cancer: Advances in Vocal Outcome Assessment after Transoral CO2-Laser Microsurgery Using the VEM

Patients with unilateral vocal fold cancer (T1a) have a favorable prognosis. In addition to the oncological results of CO₂ transoral laser microsurgery (TOLMS), voice function is among the outcome measures. Previous early glottic cancer studies have reported voice function in patients grouped into combined T stages (Tis, T1, T2) and merged cordectomy types (lesser- vs. larger-extent cordectomies). Some authors have questioned the value of objective vocal parameters. Therefore, the purpose of this exploratory prospective study was to investigate TOLMS-associated oncological and vocal outcomes in 60 T1a patients, applying the ELS protocols for cordectomy classification and voice assessment. Pre- and postoperative voice function analysis included: Vocal Extent Measure (VEM), Dysphonia Severity Index (DSI), auditory-perceptual assessment (GRB), and 9-item Voice Handicap Index (VHI-9i). Altogether, 51 subjects (43 male, eight female, mean age 65 years) completed the study. The 5-year recurrence-free, overall, and disease-specific survival rates (Kaplan–Meier method) were 71.4%, 94.4%, and 100.0%. Voice function was preserved; the objective parameter VEM (64 ± 33 vs. 83 ± 31; mean ± SD) and subjective vocal measures (G: 1.9 ± 0.7 vs. 1.3 ± 0.7; VHI-9i: 18 ± 8 vs. 9 ± 9) even improved significantly (p < 0.001). The VEM best reflected self-perceived voice impairment. It represents a sensitive measure of voice function for quantification of vocal performance.

[Outcome of Phoniatric Rehabilitation of Dysphagia in Patients with Head and Neck Cancer]

Surgical and nonsurgical management options for head and neck cancer frequently lead to impaired swallowing. Swallowing outcome can be assessed using subjective measures like inventories or applying clinical assessments concerning food selection, eating duration or the necessity of a percutaneous endoscopic gastrostomy (PEG) and instrumental assessments like fiberoptic endoscopic evaluation of swallowing (FEES).The objective of this study was to investigate the outcomes of an in-patient rehabilitation in patients with dysphagia after the treatment of head and neck cancer. At the begin and after completion of this treatment 219 participants (138 male) aged 62.8 ± 10.2 years completed the German version of the Eating Assessment Tool (EAT-10). Integrating anamnestic and clinical assessment data a rating following the Bogenhausener Dysphagiescore (BODS) was conducted at both times.Swallowing function improved significantly in both assessments, but both parameters were only moderately correlated. Improvements in both parameters were not correlated.Both dimensions of dysphagia, expert assessment and subjective measures should be used complementary.

Pathology-Related Influences on the VEM: Three Years' Experience since Implementation of a New Parameter in Phoniatric Voice Diagnostics

The vocal extent measure (VEM) represents a new diagnostic tool to express vocal capacity by quantifying the dynamic performance and frequency range of voice range profiles (VRPs). For VEM calculation, the VRP area is multiplied by the quotient of the theoretical perimeter of a circle with equal VRP area and the actual VRP perimeter. Since different diseases affect voice function to varying degrees, pathology-related influences on the VEM should be investigated more detailed in this retrospective study, three years after VEM implementation. Data was obtained in a standardized voice assessment comprising videolaryngostroboscopy, voice handicap index (VHI-9i), and acoustic-aerodynamic analysis with automatic calculation of VEM and dysphonia severity index (DSI). The complete dataset comprised 1030 subjects, from which 994 adults (376 male, 618 female; 18-86 years) were analyzed more detailed. The VEM differed significantly between pathology subgroups (p < 0.001) and correlated with the corresponding DSI values. Regarding VHI-9i, the VEM reflected the subjective impairment better than the DSI. We conclude that the VEM proved to be a comprehensible and easy-to-use interval-scaled parameter for objective VRP evaluation in all pathology subgroups. As expected, exclusive consideration of the measured pathology-related influences on the VEM does not allow conclusions regarding the specific underlying diagnosis.

The effectiveness of voice therapy on voice-related handicap: A network meta-analysis

BACKGROUND

Treatment approaches for voice therapy are diverse, yet their differential effects are not well understood. Evaluations of treatment effects across approaches are important for clinical guidance and evidence-based practice.

OBJECTIVE OF REVIEW

To quantify the evidence of treatment effectiveness on the outcome measure Voice Handicap Index with the 30-items (VHI-30) from existing randomised controlled/clinical trials (RCT) of voice therapy using the statistical approach of a network meta-analysis (NMA) with a random effects model.

TYPE OF REVIEW

Meta-analysis.

SEARCH STRATEGY

We searched in MEDLINE (PubMed, 1950 to 2019), Embase (1974 to 2019) and Science Citation Index (1994 to 2019) using five key terms. The inclusion criteria were reports of randomised controlled/clinical trials (RCTs) published in English or German which evaluated the effectiveness of a specific voice therapy treatment using VHI-30 as an outcome measure in adult participants with non-organic or organic voice disorders. Studies were excluded if participants had been diagnosed with neurological motor speech disorders or who were vocally healthy. Furthermore, no medical, pharmacological or instrumental (eg voice amplification) treatments were considered.

EVALUATION METHOD

The primary outcome variable was VHI-30 with a score from 0 to 120. The pre-post treatment change in VHI-30 scores was an average score of 13 points related to various VHI-30 test-retest results.

RESULTS

We retrieved 464 publications (ie with duplicates) and included 13 RCTs, which evaluated nine interventions, in the final analysis. The most effective intervention with a significant and clinically relevant effect was Stretch-and-Flow Phonation (SFP) (mean pre-post difference -28.37, 95% confidence interval [CI], -43.05 to-13.68). Resonant Voice (RV), the Comprehensive Voice Rehabilitation Program (CVRP) and Vocal Function Exercises (VFE) also demonstrated significant improvements.

CONCLUSIONS

Of the nine voice interventions identified with the present NMA, SFP, RVT, CVRP, and VFE effectively improved VHI-30 scores from pre- to post-treatment. SFP proved to be the most significant and clinically relevant treatment. Further contributions of high-quality intervention studies are needed to support evidence-based practice in vocology.

Monitoring the Outcome of Phonosurgery and Vocal Exercises with Established and New Diagnostic Tools

Instrument-assisted measuring procedures expand the options within phoniatric diagnostics by quantifying the condition of the voice. The aim of this study was to examine objective treatment-associated changes of the recently developed vocal extent measure (VEM) and the established dysphonia severity index (DSI) in relation to subjective tools, i.e., self-evaluation via voice handicap index (VHI-12) and external evaluation via auditory-perceptual assessment of hoarseness (H). The findings for H (3 raters' group assessment), VHI-12, DSI, and VEM in 152 patients of both sexes (age range 16–75 years), taken before and 3 months after phonosurgery or vocal exercises, were compared and correlated. Posttherapeutically, all of the recorded parameters improved (p < 0.001). The degree of H reduced on average by 0.5, the VHI-12 score sank by 5 points, while DSI and VEM rose by 1.5 and 19, respectively. The correlations of these changes were significant but showed gradual differences between H and VHI-12 (r = 0.3), H and DSI (r = −0.3), and H and VEM (r = −0.4). We conclude that all investigated parameters are adequate to verify therapeutic outcomes but represent different dimensions of the voice. However, changes in the degree of H as gold standard were best recognized with the new VEM.

[Drug-induced dysphonia]

Drug-induced dysphonia is a non-life-threatening adverse drug reaction, however, this complication can significantly worsen the quality of life of patients, especially those in voice-speaking professions. The aim of the work was to search for information about the prevalence, etiology, pathogenesis, and features of treatment and prevention of drug-induced dysphonia. In the case of some drugs, the true prevalence may be higher than described in the literature, due to the fact that dysphonia is in most cases mild, reversible and, in comparison with other undesirable drug reactions, rarely attracts the attention of both the patient and practitioners.

Gender-specific reference ranges of the vocal extent measure in young and healthy adults

Objective: The recently developed vocal extent measure (VEM) quantifies a patient's vocal capacity as documented in the voice range profile (VRP). This study presents the first reference ranges of the VEM for young subjects without voice complaints. Furthermore, this study investigates the influence of gender on the VEM as well as the correlation of the VEM with the dysphonia severity index (DSI).Patients and methods: Reference ranges were captured by combining a retrospective analysis of subjects who received a medical fitness certificate of a healthy voice (n = 135) and a prospective analysis of adult volunteers without voice complaints (n = 67). Every participant obtained a standardized voice assessment comprising videolaryngostroboscopy, auditory-perceptual analysis, acoustic analysis, VRP, and the Voice Handicap Index (VHI-9i).Results: A total of 202 subjects were recruited and investigated. Due to our stringent selection criteria, 51 participants had to be excluded from further analysis. The remaining data of 151 participants (52 males, 99 females), aged 18-39 years (mean 24, SD 5), were analysed in more detail. The mean of the VEM amounted to 123.7 (SD 12.6) for males and 114.4 (SD 13.3) for females. The values differed significantly between both sexes and correlated significantly with the corresponding DSI values.Conclusion: By introducing the first reference values, this study represents the next step of implementing the VEM in daily phoniatric diagnostics. These values serve as a basis to interpret the VEM regarding the degree of severity of voice disorders and to evaluate treatment success.

Transcultural Adaptation and Validation of the Voice Handicap Index-10 into the Serbian Language

BACKGROUND

The Voice Handicap Index-10 (VHI-10) is used in clinics because of its validity and ease of use by patients.

OBJECTIVES

The aim of this paper was to evaluate the internal consistency, reliability, and clinical validity of the Serbian version of the VHI-10.

METHOD

In this cross-sectional study, we translated the original English version of the VHI-10 into Serbian, after which it was back-translated into English. The Serbian version of the VHI-10 was completed by 161 patients with voice disorders, divided into 4 groups according disease etiology (structural, neurological, functional, and inflammatory) and 73 healthy control subjects.

RESULTS

The VHI-10 internal consistency was 0.88. Spearman's rank correlation coefficient for VHI-10 test-retest reliability was ρ = 0.991 (p< 0.001). Patients with voice disorders had higher median total VHI-10 scores compared with controls (p< 0.001). The patients' Grade, Instability, Roughness, Breathiness, Asthenia, and Strain (GIRBAS) scale scores were significantly correlated with the VHI-10 test scores (ρ = 0,682, p < 0.001) and VHI-10 retest scores (ρ = 0.716, p < 0.001).

CONCLUSION

The Serbian version of the VHI-10 had good validity and reliability and can be used by Serbian patients with voice disorders.

Efficacy of microsurgery in Reinke's oedema evaluated by traditional voice assessment integrated with the Vocal Extent Measure (VEM)

SUMMARY

There are few data analysing to what specific extent phonomicrosurgery improves vocal function in patients suffering from Reinke's oedema (RE). The recently introduced parameter vocal extent measure (VEM) seems to be suitable to objectively quantify vocal performance. The purpose of this clinical prospective study was to investigate the outcomes of phonomicrosurgery in 60 RE patients (6 male, 54 female; 56 ± 8 years ([mean ± SD]) by analysing its effect on subjective and objective vocal parameters with particular regard to VEM. Treatment efficacy was evaluated at three months after surgery by comparing pre- and postoperative videolaryngostroboscopy (VLS), auditory-perceptual assessment (RBH-status), voice range profile (VRP), acoustic-aerodynamic analysis and patient's self-assessment using the voice handicap index (VHI-9i). Phonomicrosurgically, all RE were carefully ablated. VLS revealed removal or substantial reduction of oedema with restored periodic vocal fold vibration. All subjective and most objective acoustic and aerodynamic parameters significantly improved. The VEM increased on average from 64 ± 37 to 88 ± 25 (p #x003C; 0.001) and the dysphonia severity index (DSI) from 0.5 ± 3.4 to 2.9 ± 1.9. Both parameters correlated significantly with each other (rs = 0.70). RBH-status revealed less roughness, breathiness and overall grade of hoarseness (2.0 ± 0.7 vs 1.3 ± 0.7). The VHI-9i-score decreased from 18 ± 8 to 12 ± 9 points. The average total vocal range enlarged by 4 ± 7 semitones, and the mean speaking pitch rose by 2 ± 4 semitones. These results confirm that: (1) the use of VEM in RE patients objectifies and quantifies their vocal capacity as documented in the VRP, and (2) phonomicrosurgery is an effective, objectively and subjectively satisfactory therapy to improve voice in RE patients.

Cervical Spine Disability in Correlation with Subjective Voice Handicap in Patients With Voice Disorders: A Retrospective Analysis

OBJECTIVE

Neck muscle dysfunction has been considered as risk factor or consequence of voice disorders. This study investigates the correlation between neck and voice-related subjective symptoms in patients with voice disorders.

STUDY DESIGN

Retrospective case-control study.

METHODS

100 adult patients (59 female and 41 male) over 18 years with a mean age of 50.01 years (SD 16, range 24-87), of which 68 were under 60 years, were included. 50 patients had organic voice pathologies and 50 functional dysphonia. Outcome measures were the Voice Handicap Index 9 international (VHI-9i) and the Neck Disability Index (NDI-G). Spearman rank order coefficient was applied to determine the correlation between overall and single item VHI and NDI results. Subanalyses were done for functional vs. organic disorder, gender and age ± 60 years.

RESULTS

Mean overall VHI-9i (13.93, SD = 7.81, range = 0-31) and mean NDI-G (6.07, SD = 7.71, range = 0-43) showed a significant mild correlation (r_s = 0.220, P = 0.02). Split into subgroups the relation was stronger in patients with organic pathologies (r_s = 0.297, P = 0.03), but not significant in functional disorders (r = 0.148, P = 0.30). There was a moderate relation in men (r_s = 0.317, P = 0.04). Single item correlation was highest between VHI-9i item P4 (physiological) and NDI-G item reading (cognitive functioning) (r_s = 0.480, P = 0.002).

CONCLUSION

Specifically patients with organic voice disorders showed increased voice symptoms with the presence of neck dysfunction. This indicates a risk for a functional imbalance of the muscles surrounding the larynx, which in extreme cases may hinder functional voice rehabilitation even after phonosurgery. Therefore, neck dysfunction should be considered in voice diagnostics.

Efficacy of Phonosurgery, Logopedic Voice Treatment and Vocal Pedagogy in Common Voice Problems of Singers

INTRODUCTION

Functional and organic impairments of the singing voice are common career-threatening problems of singers presenting in phoniatric and laryngological departments. The objective was to evaluate the efficacy of phonosurgery, logopedic voice treatment and vocal pedagogy in common organic and functional voice problems of singers, including investigation of the recently introduced parameter vocal extent measure (VEM).

METHODS

In a prospective clinical study, the analysis of treatment outcome in 76 singers [57 female, 19 male; 38 ± 11 years (mean ± SD)] was based on pre- and post-therapeutic voice function diagnostics and videolaryngostroboscopy. Examination instruments included auditory-perceptual voice assessment, voice range profile (VRP), the VEM calculated from area and shape of the VRP, acoustic-aerodynamic analysis, and patients' self-assessment (e.g., Singing Voice Handicap Index).

RESULTS

While 28% of all singers (21/76) presented with functional dysphonia, 72% (55/76) were diagnosed with organic vocal fold changes, of which marginal edema (n = 25), nodules (n = 9), and polyps (n = 8) were the most common pathologic changes. Of the 76 singers, 57% (43) received phonosurgery, 43% (33) had conservative pedagogic (14) and logopedic (19) treatment. Three months post-therapeutically, most parameters had significantly improved. The dysphonia severity index (DSI) increased on average from 6.1 ± 2.0 to 7.4 ± 1.8 (p < 0.001), and the VEM from 113 ± 20 to 124 ± 14 (p < 0.001). Both parameters correlated significantly with each other (r_s = 0.41). Phonosurgery had the largest impact on the improvement of vocal function. Conservative therapies provided smaller quantitative enhancements but also qualitative vocal restoration with recovered artistic capabilities.

CONCLUSIONS

Depending on individual medical indication, phonosurgery, logopedic treatment and voice teaching are all effective, objectively and subjectively satisfactory therapies to improve the impaired singing voice. The use of VEM in singers with functional and organic dysphonia objectifies and quantifies their vocal capacity as documented in the VRP. Complementing the established DSI, VEM introduction into practical objective voice diagnostics is appropriate and desirable especially for the treatment of singers.

The Vocal Extent Measure: Development of a Novel Parameter in Voice Diagnostics and Initial Clinical Experience

Voice range profile (VRP) and evaluation using the dysphonia severity index (DSI) represent essentials of instrument-based objective voice diagnostics and are implemented in different standardized registration programs. The respective measurement results, however, show differences. The aim of the study was to prove these differences statistically and to develop a new parameter, the Vocal Extent Measure (VEM), which is not influenced by the measurement program. VRPs of 97 subjects were recorded by two examiners using the established registration programs DiVAS (XION medical) and LingWAVES (WEVOSYS) simultaneously. The VEM was developed on the basis of VRP area and perimeter. All 194 VRP files were analyzed for various parameters and gender independence. The registration programs exhibited significant differences in several vocal parameters. A significant gender influence for DSI was found with DiVAS (p < 0.01), but not with LingWAVES. The VEM quantified the dynamic performance and frequency range by a unidimensional, interval-scaled value without unit, mostly between 0 and 120. This novel parameter represents an intelligible and user-friendly positive measure of vocal function, allows simple and stable VRP description, and seems to be suitable for quantification of vocal capacity. In contrast to DSI, the VEM proved to be less susceptible to registration program and gender.

The use of injectable calcium hydroxylapatite in the surgically pretreated larynx with glottal insufficiency

OBJECTIVES/HYPOTHESIS

To evaluate the efficacy of vocal fold (VF) augmentation with calcium hydroxylapatite (CaHA) microspheres in the surgically pretreated larynx with glottal insufficiency.

STUDY DESIGN

Prospective clinical pilot study.

METHODS

After several prior reconstructive attempts (following tumor resection, VF paralysis, in sulcus vocalis, and VF scarring), CaHA was injected under general anaesthesia using a transoral microlaryngoscopic approach in 10 patients with residual glottal insufficiency ≤1.5 mm. The postinterventional result was assessed after 1 day, and 1 and 3 months. Evaluation of augmentation comprised intraoperative video/photo documentation, pre-/postoperative videolaryngostroboscopy, as well as established subjective and objective voice function diagnostics (Grade, Roughness, Breathiness [GRB] Scale; Voice Handicap Index; voice range profile; and acoustic-aerodynamic analysis).

RESULTS

In the pretreated VF with no or minimal lamina propria remaining, the exact placement of CaHA was not possible due to unpredictable propagation into the scarred tissue. The results showed an insufficient postoperative augmentation. Accordingly, the voice function did not improve. However, a significant increase of the vocal range from 6.2 ± 3.2 to 8.7 ± 3.9 semitones was observed in the speaking voice profile (P =.02). All other acoustic and aerodynamic parameters remained on the whole unchanged; the slight differences between pre- and postoperative findings were not significant.

CONCLUSIONS

The application of CaHA in the surgically pretreated scarred larynx is not reliable to achieve a sufficient glottal closure and a satisfactory improvement of voice. Though CaHA is a welcome addition to our armamentarium against glottal insufficiency, the suitability for augmentation of scar tissue in the larynx must be considered carefully in each individual case.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:1125-1130, 2017.

Adaptation and Validation of the Voice Handicap Index (VHI)-30 into Serbian

OBJECTIVES

To evaluate the internal consistency, test-retest reliability, and clinical validity of the Serbian version of the self-administered Voice Handicap Index (VHI)-30.

STUDY DESIGN

Cross-sectional study.

METHODS

The English version of VHI-30 was translated into Serbian and then back-translated into English. The Serbian VHI-30 was administered to 91 patients divided into four groups according to voice pathology: structural, inflammatory, neurologic, and functional groups. The control group included 90 subjects with no voice problems. The internal consistency (Cronbach's alpha coefficient α), test-retest reliability (interclass correlation coefficient) of VHI-30, comparison of patient's and control's VHI-30 scores (Mann-Whitney U test; Kruskal-Wallis test), and correlation with overall severity of dysphonia (Spearman correlation coefficient, ρ) were calculated.

RESULTS

In the patient group, we observed excellent internal consistency for the Serbian VHI-30 (α = 0.95) and good internal consistency for all VHI-30 subscales: physical (α = 0.88), functional (α = 0.88), and emotional (α = 0.88). The interclass correlation coefficient indicated strong test-retest reliability for patients (0.99) and controls (0.84). The mean scores of all 30 items in dysphonic participants were significantly higher than in controls (P < 0.001). Good correlation was obtained between the total scores of VHI-30 and patients' self-perceived overall severity of dysphonia (ρ = 0.748, P < 0.001). Within the patient group, the female participants displayed significantly higher VHI-30 scores than male participants (Mann-Whitney U test, P < 0.001). The VHI-30 scores showed strong correlation within different patient groups and controls (Spearman correlation coefficient: structural, 0.942; inflammatory, 0.756; neurologic, 0.888; functional, 0.982; controls, 0.882).

CONCLUSIONS

The Serbian VHI-30 is a useful and valuable tool for the evaluation of patients with vocal disorders and for making subsequent clinical decisions.

Diagnostic and therapeutic pitfalls in benign vocal fold diseases

More than half of patients presenting with hoarseness show benign vocal fold changes. The clinician should be familiar with the anatomy, physiology and functional aspects of voice disorders and also the modern diagnostic and therapeutic possibilities in order to ensure an optimal and patient specific management. This review article focuses on the diagnostic and therapeutic limitations and difficulties of treatment of benign vocal fold tumors, the management and prevention of scarred vocal folds and the issue of unilateral vocal fold paresis.

Utility of the voice handicap index as an indicator of postthyroidectomy voice dysfunction

OBJECTIVES/HYPOTHESES

The Voice Handicap Index (VHI) is a simple, reliable, self-administered questionnaire that has been used to identify negative voice outcomes after thyroidectomy. This study provides an updated report of a multiyear study examining the predictive ability of the VHI to classify normal versus negative voice outcomes (VOs).

STUDY DESIGN

Prospective observational, longitudinal study of the patient reported impact of voice changes after thyroidectomy using the VHI. Since the preliminary report, the sample size doubled and methods for classifying voice outcomes (VOs) were refined.

METHODS

Ninety-one adults provided voice assessment data preoperatively (baseline) and at approximately 2 weeks postthyroidectomy. VO was defined according to endoscopic laryngeal examination, acoustic, auditory perceptual, and patient report parameters. The VHI was tested for its sensitivity and specificity for identifying VO.

RESULTS

Twenty-two participants (24.2%) qualified as having adverse VOs during the early postoperative period. A change from baseline in VHI of 13-16 points had a diagnostic accuracy of 86% sensitivity and 88% specificity for classifying early VO and had 70% and 95% positive and negative predictive values, respectively. The Functional and Physical subscales of the VHI had higher predictive value than the Emotional subscale. Adjunctive analyses of a two-subscale version of the VHI and of the 10 items that comprises the VHI-10 also revealed high predictive value for differentiating groups by VO.

CONCLUSIONS

Balanced sensitivity and specificity are achieved at a change in the total VHI score of 13-16. These results are generally consistent with several other studies examining voice problems over time. The VHI, as well as its alternate versions, appear to be useful and should be incorporated into the diagnostic process for identifying patients with voice problems after thyroidectomy.