The voice handicap index with post-laryngectomy male voices

BACKGROUND

Surgical treatment for advanced laryngeal cancer involves complete removal of the larynx ('laryngectomy') and initial total loss of voice. Post-laryngectomy rehabilitation involves implementation of different means of 'voicing' for these patients wherever possible. There is little information about laryngectomees' perception of their changed voice quality and communication status. Surgical voice restoration (SVR) has become the 'gold standard' rehabilitation, but there continue to be patients who use other methods of communication. There is no clear evidence comparing patients' perception of their voice handicap across different types of alaryngeal communication.

AIMS

To compare the self-assessed vocal handicap of laryngectomees using SVR with those using non-SVR methods of post-laryngectomy communication.

METHODS & PROCEDURES

Potential participants were identified from one Head and Neck cancer centre in South Wales. They included both male and female participants using all methods of post-laryngectomy communication. Each patient's Voice Handicap Index (VHI) score, sub-set scores, and group means were calculated. Two major confounding factors: age and time since surgery, and communication method (SVR/non-SVR), were considered to identify factors, other than method of communication, which may influence rehabilitation outcomes.

OUTCOMES & RESULTS

A total of 71 questionnaires were sent out and 62 (82%) were returned from 35 patients who had undergone SVR and 27 patients who used non-SVR methods of communication. Of the non-SVR group, twelve used oesophageal voice, eleven an electrolarynx, two writing and two mouthing for communication. The gender ratio (53:9), age (43-90 years) and time since surgery (1-40 years) were broadly representative of this population, but because of the small number of females, we excluded the women from further analysis. Individual VHI scores ranged from 4 to 106. Both the SVR and non-SVR group mean scores: 44.7 and 50.9, were within the range of moderately severe voice handicap. There was no significant difference between the groups for total VHI scores or two of the three sub-domains, nor any significant effect on voice handicap due to the confounding factors assessed: age or time since surgery. The total VHI score was better by 6.5 ( - 4.9 to 17.9) points in the SVR group (p = 0.3), probably reflecting the literature reporting superior voice in SVR.

CONCLUSIONS & IMPLICATIONS

The data suggest that where patient-assessed quality of life is concerned, SVR and non-SVR outcomes are comparable. This is an important consideration when planning and carrying out treatment recommendations. The study has clear clinical implications; understanding the potential of all methods of post-laryngectomy communication is essential for holistic patient management.

Electroglottographic and Perceptual Evaluation of Tracheoesophageal Speech

To optimize tracheoesophageal (TO) speech after total laryngectomy, it is vital to have a robust tool of assessment to help investigate deficiencies, document changes, and facilitate therapy. We sought to evaluate and validate electroglottography (EGG) as an important tool in the multidimensional assessment of TO speech. This study is a cross-sectional study of the largest cohort of TO speakers treated by a single surgeon. A second group of normal laryngeal speakers served as a control group. EGG analysis of both groups using connected speech and sustained vowels was performed. Two trained expert raters undertook perceptual evaluation using two accepted scales. EGG measures were then analyzed for correlation with treatment variables. A separate correlation analysis was performed to identify EGG measures that may be associated with perceptual dimensions. Our data from EGG analysis are similar to data obtained from conventional acoustic signal analysis of TO speakers. Sustained vowel and connected speech parameters were poorer in TO speakers than in normal laryngeal speakers. In perceptual evaluation, only grade (G) of the GRBAS scale and Overall Voice Quality appeared reproducible and reliable. T stage, pharyngeal reconstruction and method of closure, cricopharyngeal myotomy, and postoperative complications appear to be correlated with the EGG measures. Five voice measures-jitter, shimmer, average frequency, normalized noise energy, and irregularity-correlated well with the key dimensions of perceptual assessment. EGG is an important assessment tool of TO speech, and can now be reliably used in a clinical setting.

Bedeutung psychosozialer Faktoren bei der Stimmrehabilitation nach Laryngektomie

BACKGROUND

Often it is assumed that psychosocial and sociodemographic factors cause the success of voice rehabilitation after laryngectomy. Aim of this study was to analyze the association between these parameters.

METHODS

Based on tumor registries of six ENT-clinics all patients were surveyed, who were laryngectomized in the years before (N = 190). Success of voice rehabilitation has been assessed as speech intelligibility measured with the postlaryngectomy-telephone-intelligibility-test. For the assessment of the psychosocial parameters validated and standardized instruments were used if possible. Statistical analysis was done by multiple logistic regression analysis.

RESULTS

Low speech intelligibility is associated with reduced conversations (OR 0.970) and social activity (OR 1.049). Patients are more likely to talk with esophageal voice when their motivation for learning the new voice was high (OR 7.835) and when they assessed their speech therapist as important for their motivation (OR 4.794). The risk to communicate merely by whispering is higher when patients live together with a partner (OR 5.293), when they talk seldomly (OR 1.017) and when they are not very active in social contexts (OR 0.966).

CONCLUSIONS

Psychosocial factors can only partly explain how voice rehabilitation after laryngectomy becomes a success. Speech intelligibility is associated with active communication behaviour, whereas the use of an esophageal voice is correlated with motivation. It seems that the gaining of tracheoesophageal puncture voice is independent of psychosocial factors.

Voice reconstruction using the free ileocolon flap versus the pneumatic artificial larynx: a comparison of patients' preference and experience following laryngectomy

This study compares the psychological adjustment and voice function of patients undergoing voice rehabilitation using the free ileocolon flap for creation of a voice tube shunt and patients undergoing voice rehabilitation using the pneumatic artificial larynx. Twelve laryngectomy patients were included; six underwent free ileocolon transfer following a period of pneumatic artificial larynx use. Mean duration after laryngectomy was 5.2 years. Mean follow-up was 210 days. A chart review, questionnaires and a prospective evaluation were performed. Voice tube shunt patients had better speech function and higher self-esteem. People's discrimination and appearance when speaking were important in the patients' choice of method for rehabilitation. There was a high preference for choosing the voice tube shunt and a higher motivation and willingness to use that voice mechanism in the voice tube shunt group. Patients who undergo free flap reconstruction of voice have better speech function and self-esteem than patients who continue to use the external pneumatic device. Psychological assessments are important for surgical patients in order to evaluate a critical aspect of our perceived success - the patients' perception.

[Therapy options of advanced laryngeal carcinomas with regard to the quality of life of the patients]

Advanced laryngeal carcinomas are in most cases still associated with a very poor prognosis and highly reduced quality of life. This case report shows the various and severe complications that occurred after a total laryngectomy in spite of intensive medical treatment. Currently the development and introduction of new organ preserving procedures in advanced laryngeal cancer, without a loss of the prognostical outcome, represents one of the most up to date clinical oncological fields of research in head and neck cancer. This case report critically scrutinizes the current options of therapy available for patients suffering from advanced laryngeal carcinomas, as it is essential in the author's opinion that the decision on treatment is made within the scope of an intensive interdisciplinary strategy of therapy, and is reached by including all possible options available in order to achieve the best possible quality of life for the patients.

[The role of a psychologist in a rehabilitation of the patients with laryngeal cancer after total laryngectomy with implantation of the voice prostheses]

The new possibilities of voice rehabilitation in patients with laryngeal cancer who undergo total laryngectomy have been opened with the surgical insertion of voice prostheses after performing of the tracheoesophageal shunt. This method enables to achieve a voice of better quality which leads to improved patients' general well-being. The cornerstone of the rehabilitation after an implantation of voice prosthesis is an appropriate psychosocial attitude of a patient towards combating of a cancer and his motivation for a verbal communication. In this review we have characterized both a role of the psychologist in the diagnostic and therapeutic team and psychological attitudes of the patients with cancer. These problems were illustrated by the clinical cases.

[Quality of life and voice handicap of laryngectomees using tracheoesophageal substitute voice]

BACKGROUND

Health-related quality of life (QoL) and subjective health have become popular constructs for the evaluation of both efficacy and efficiency of diagnostic and therapeutic procedures in medicine. QoL is considered a multidimensional construct encompassing physical, mental and social facets of life. It is an accepted outcome parameter not only in international classification systems such as ICIDH and ICF, but as well in clinical guidelines and disease management programs. Measuring quality of life allows for comparison of different diseases though it certainly lacks disease specific aspects. Thus, it has to be assumed that in patients with distinct functional deficits QoL cannot cover all aspects that are important for the individual patient. This study focuses on laryngectomies and their self-evaluation of post-laryngectomy speech. It is well known that these patients experience a decreased QoL compared to patients after partial laryngectomy or healthy persons. In this study, the impact of voice restoration on the laryngectomies' QoL was evaluated.

PATIENTS AND METHODS

In 20 male laryngectomies aged 62 +/- 8 years, relations between QoL and voice handicap were evaluated using two instruments as proposed in the international literature, i. e. the Short-Form Health Survey (SF-36) and the Voice Handicap Index (VHI). All patients had successfully been using tracheoesophageal substitute voice for at least one year. Complete data sets were available from all patients. Data were analysed using Microsoft Excel and Sigma Plot, Jandel Corp. software packages.

RESULTS

Results of both the SF-36 and the VHI reveal wide interindividual ranges. There are statistically significant correlations (p < 0.05) between the SF-36's scales General Health and Vitality and the VHI, whereas no correlations were found between social and psychological scales and the voice handicap.

DISCUSSION

Wide ranges of the data obtained reveal that obviously both health related quality of life and voice handicap are not affected in a group specific way. So, both tests are of clinical value to depict individual aspects of wellbeing after laryngectomy. The combination of VHI and SF-36 illuminates correlations between general and special subjective aspects. Strikingly, the laryngectomies' social and psychological status is not related to their voice handicap. Data allow for conclusion that laryngectomies' substitute voice problems do not affect social aspects of quality of life in a disease specific way, at least as long as voice restoration was successful at all.

Voice Handicap of Laryngectomees with Tracheoesophageal Speech

The evaluation of diagnostics and therapies includes more and more subjective, i.e. emotional and social aspects. Focussing on the handicap experienced by dysphonic patients, the Voice Handicap Index (VHI) has previously been found to be of significant clinical and scientific value for different voices. In this study the VHI questionnaire was applied to demonstrate the voice handicap of 20 male laryngectomees using tracheoesophageal voice (Provox), aged 65.5 +/- 8.7 years. Their VHI was 45.5 +/- 24.1, which was significantly higher than the score of patients with functional voice disorders, but differed only slightly from patients with organic laryngeal dysphonia. Focussing on individual data, VHI scores ranged from values similar to persons without voice disorder to maximum handicap of 101. Comparing the VHI scores with the laryngectomees' gradual self-perception of voice disorder severity, no consistent relationship was found. Considering the large interindividual differences, the VHI may serve as a valuable instrument for the assessment of individual interventional needs rather than for the identification of a general laryngectomees' handicap.

[Quality of life for patients after laryngectomy and surgical voice rehabilitation. Experience with the Provox prosthesis]

BACKGROUND

Our study included 52 patients who received follow-up care after laryngectomy; a Provox I prosthesis was used for voice rehabilitation.

METHODS

The EORTC Quality of Life Questionnaire was used to assess the postoperative quality of life of these patients with voice prostheses.

RESULTS

Of the patients, 36.1% complained of a lack of energy, and 22% experienced sadness suggesting a reactive depression. Of the 55.6% of patients who expressed satisfaction with managing their disease, more than two-thirds were afraid of a potential deterioration of their health. More than 90% of the patients received extensive support from family and friends. As many as 52.8% expressed themselves satisfied with their current life, which is perhaps attributable to the successful rehabilitation of their voice. Eating problems, i.e., varying degrees of dysphagia as a result of treatment, were experienced by 47.3% of the patients.

CONCLUSIONS

After the laryngectomy, 11% continue to smoke and 46% regularly consume alcohol. For this reason, rehabilitation measures should place more emphasis on patient education and on programs designed to help patients stop smoking and drinking alcohol.

[Coping strategies in laryngectomy patients]

BACKGROUND

Over the last few years, paradigms for judging the results of treatment of tumor patients have shifted. In addition to characteristics such as the complete excision of the tumor and the duration of patient survival, restoring the quality of life has become an equally important aim. There is still a lack of systematic (and sufficient) research on coping strategies as a means of dealing with malignant tumors of the head and neck.

PATIENTS AND METHOD

In a cross-sectional study, 25 laryngectomees, whose voices had been successfully restored with a Provox voice prosthesis,were examined for their coping strategies and the effects of the illness on their lives. The standardized Trier Scales of Coping Strategies and a custom-made questionnaire, which helped to structure the anamnesis of disease specific functional restrictions and the state of rehabilitation, were used as the means of inquiry.

RESULTS

A high percentage of patients were content despite objective and subjective restrictions. Voice replacement was mainly experienced as unproblematic,with psychosocial restraints more commonly being felt in connection with pain and difficulties ingesting food. A correlation between the patients' evaluation of physical,psychological and social experiences and the coping strategies applied could not be verified. The way laryngectomees deal with their illness does not differ from the strategies of patients suffering from malignant or chronic diseases of other organ systems.

CONCLUSION

The Trier Scales of Coping Strategies is a suitable means for determining the coping strategies of laryngectomees who have been successfully rehabilitated with the help of voice prostheses. The patients examined here did not apply different coping strategies from groups of patients with other severe illnesses. Obviously, the limitations on communication do not constitute a determining factor in coping with the disease. This finding is useful when planning psychological and social rehabilitation, e.g. by psychosomatic interventions.

The acceptability of secondary tracheo-oesophageal fistula creation in long standing laryngectomees

The use of a tracheo-oesophageal voice prosthesis was introduced to the Glasgow Royal Infirmary Otolaryngology, Head and Neck Surgery unit in 1986. Although it was the authors' impression that most total laryngectomees since then had been offered this method of voice restoration, it was thought that long standing laryngectomees were seldom offered tracheo-oesophageal fistula (TOF) speech. Therefore all 58 total laryngectomees currently attending the combined head and neck surgery/radiotherapy clinic were assessed. Thirty-two had a tracheo-oesophageal fistula with voice prosthesis. All of these patients had undergone their total laryngectomy since 1986 and 83 per cent had achieved TOF speech. The remaining 26 patients (who mostly had their laryngectomy before 1986) had not been offered TOF speech. An outpatient consultation was arranged for these patients and 63 per cent of those offered, accepted TOF creation and a voice prosthesis. When compared to those who refused, it was found that good oesophageal speech, age or interval since laryngectomy were not good predictors of likely refusal. This study indicates that all fit long standing laryngectomees should be offered secondary TOF creation.

Communication options for intubated patients

The number of communication options available to intubated patients is rapidly increasing. Selection of an appropriate augmentative communication approach depends on the decision-making practices of a team of experts. A series of oral and nonoral augmentative communication options is reviewed here, with particular emphasis on patients who are candidates for each approach.

Evaluation of the electrolarynx in the short-term hospital setting

We evaluated the effectiveness of the electrolarynx as a communication tool in the short-term hospital setting with 22 tracheostomized patients. Following an initial training period, we found that 14 of 22 patients achieved good results in communicating with the electrolarynx, three patients had fair results, and five patients had poor results. There were no differences in success rates for older or younger patients or for men or women; we could not correlate specific disease diagnosis with success or failure. The instrument could be effectively cleaned at the bedside. With the exception of patients who are severely confused or who have undergone extensive head and neck surgery, all tracheostomized patients can be considered candidates for this method of communication.