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VOCAL FUNCTION EXERCISES AND VOCAL HYGIENE COMBINED TREATMENT APPROACH AS A
METHOD OF IMPROVING VOICE QUALITY IN IRRADIATED PATIENTS FOR LARYNGEAL CANCERS
IGNAZIO LA MANTIA^1 , FRANCESCO CUPIDO^2 , CLAUDIO ANDALORO^3 ¹Department of Medical Sciences, Surgical and Advanced Technologies, University of Catania, Catania, Italy - 2 Department of Surgical and Oncological Disciplines, University of Palermo, Palermo, Italy - 3 Ear Nose and Throat Unit, Santa Marta e Santa Venera Hospital, Acireale, Catania, Italy Introduction Laryngeal cancer is the second most common head and neck cancer and constitutes 30% of all head and neck malignancies(1). Well-known etiolog- ic factors of laryngeal cancer include smoking, alcohol, human papilloma virus, radiation and gas- tric acid reflux(2,3). The primary goal for treatment of laryngeal cancer is survival, but due to the important role in voice production and communication played by the larynx, organ preservation is increasingly desirable when considering treatment options(4). Early laryn- geal cancers are often treated with radiotherapy alone, while advanced laryngeal cancers are treated with a combination of radiotherapy and chemother- apy(5). Surgical options may range from conservation surgery to total laryngectomy. However, this last is associated with significant morbidity since it results in a permanent mutilation of the natural source of voicing(6)^ and significant functional and psychologi- Acta Medica Mediterranea, 2018, 34: 517 Received November 30, 2017; Accepted January 20, 2018 ABSTRACT Introduction : Despite the negative effects of radiation therapy on voice quality is well documented in literature few studies have focused on the efficacy of voice therapy in the irradiated laryngeal cancers population. The purpose of this study was to investi- gate the efficacy of an evidence-based voice therapy, known as Vocal Function Exercises (VFE) in a combined approach with Vocal Hygiene (VH) in improving vocal function in patients who have been irradiated for laryngeal cancers and compared to the results of VH alone treatment. Materials and methods : A prospective, randomized and controlled study involved patients with primary laryngeal cancer trea- ted with curatively intended radiotherapy. Study group (10 patients) was treated with VFE+VH approach and control group ( patients) was treated with a VH alone therapy; both interventions started one month following radiotherapy completion and lasted for 6 weeks. Voice Handicap Index (VHI) scores, laryngeal stroboscopy, high-speed laryngeal imaging, acoustic analysis, aerodyna- mic analysis, auditory-perceptual measures through the Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) rating scale and impact on Health-Related Quality of Life (HRQL) through the EORTC Quality of Life Questionnaire Head and Neck module (EORTC QLQ-H&N35) were evaluated at baseline and post-intervention. Results : VFE+VH combined approach shows better and statistically significant improvement after vocal intervention when compared to VH alone group for VHI (p=0.023), GRBAS (p=0.038), MPT (p<0.001), jitter (p=0.015), NMWA (p=0.011), NGG (p=0.026) and EORTC QLQ-H&N35 (p=0.047). Conclusions : The current investigation demonstrated that the VFE+VH combined approach was effective in improving the vocal function in irradiated patients with laryngeal cancers. Keywords : voice therapy, laryngeal cancer, radiotherapy. DOI: 10.19193/0393-6384_2018_2_
cal sequelae which may create a negative impact on the quality of life of these individuals(7). Consequently, following results from several studies, an increasing number of patients with laryngeal cancers have been treated primarily with radiation therapy, with or without chemotherapy, with the intent of preserving laryngeal structure and function(8). However, preservation of structure through radiation therapy has not necessarily led to preservation of function. Several studies have demonstrated poor voice and swallowing outcomes as a result of radiation toxicity including excessive compensatory compression of laryngeal structures during phonation, which lead to significant abnor- malities in vocal fold vibratory characteristics and impacting perceptual vocal quality(9), audiopercep- tual findings of hoarseness and persistent voice changes(10), increased perturbation and noise mea- sures(11)^ and aerodynamic measures that reveal increased laryngeal airway resistance(12). In this contest voice rehabilitation postradia- tion therapy assume relevant consideration and warrants attention. Unfortunately, there is a paucity of research with respect to voice rehabilitation in the irradiated population. Only a few studies have investigated the effects of voice therapy in post- radiated laryngeal cancer patients(13). A well-known evidence-based voice therapy is the Vocal Function Exercise (VFE) program, it includes a series of systematic voice exercises designed to strengthen and balance the laryngeal musculature, increase or improve vocal fold adduc- tion, and coordinate the subsystems of voice pro- duction(14). Although VFEs have been employed successfully in treating a variety of voice disorders, the efficacy of this approach for improving vocal function in patients who have undergone radiother- apy for laryngeal cancer has not been established. The objective of the present study was to investigate the effect of VFE in a combined approach with VH on vocal function in adults irra- diated for laryngeal cancers, comparing the results with the VH alone treatment. The primary outcome measure was the change in pre- and post-intervention Voice Handicap Index (VHI) scores. Secondary outcome measures include laryngeal stroboscopy, high-speed laryngeal imag- ing, acoustic analysis, aerodynamic analysis, audi- tory-perceptual measures through the Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) rating scale and impact on Health-Related Quality of Life (HRQL) through the EORTC Quality of Life Questionnaire Head and Neck module (EORTC QLQ-H&N35) Materials and methods We carried out a prospective randomized con- trolled trial between June 2016 and November 2017 in the Otolaryngology Unit of the Santa Marta e Santa Venera Hospital in Acireale, Catania, Italy, after the approval by the ethical committee of the Unità Operativa Complessa (UOC) Otorinolaringoiatria - ASP 3 CT and the signed information consent by every patient. The study involved patients with primary laryngeal cancer treated with curatively intended radiotherapy. Inclusion criteria were adults over 18 years of age, previously irradiated for laryngeal cancer (with or without chemotherapy) at least 6 months prior to study participation and deemed cancer-free by the treating physician at the time of study recruitment, good cognitive abilities and adequate language competency in order to independently complete the questionnaires as well as participate in voice reha- bilitation sessions. A presence of vocal fold paraly- sis or surface vocal fold pathology at the time of study recruitment constituted exclusion from the study. Subjects who met all of the inclusion criteria were then randomly allocated, using a statistical computing web programming (www.graphpad.com/quickcalcs), into two groups: an intervention group undergoing combining voice rehabilitation VFE+VH and a control group receiv- ing only VH. Voice interventions were conducted in line with a structured protocol by a certified speech-lan- guage pathologist not involved in this study and trained specifically in the care of patients with laryngeal cancer. Treatment plans started approxi- mately one month following radiotherapy comple- tion (baseline) and lasted for 6 weeks. VH counseling involved educating and informing patients regarding factors that influence voice use and voice care. Sessions generally revolved around strategies that enhance and main- tain vocal health according to standard practice(15), stressing hydration and dietary considerations since significant changes in salivary status and tissues are noted during this period. VFE, as described by Stemple et al.(16), were designed to strengthen and rebalance the subsys- tems involved in voice production (i.e., respiration, 518 Ignazio La Mantia, Francesco Cupido et Al
Patient self-assessment Although VHI score was found to be reduced by VFE+VH and VH only, the change from base- line to after treatment was statistically significant only for the combining approach. Auditory-Perceptual Ratings GRBAS scale significantly improved in VFE+VH group after treatment (9.23±1.06 vs. 6.62±0.88; p<0.05), conversely, there was no statis- tically change in VH only group (8.88±0.86 vs. 8.12±0.74). Health-related quality of life assessment An overall improvement in EORTC QLQ- H&N35 was observed across both groups after 6 weeks of treatment. However, further testing revealed that VFE+VH group had the highest increase of 5.40 as compared to 1.50 in VH only group (p =0.047). Stroboscopic examination and high-speed parameters NMWA and NGG significantly improved in VFE+VH group after treatment (5.03 and -1.23, respectively). The VH only group did not show any statistically pre-post changes in these parameters (0.23 and - 0.21, respectively). Acoustic Analysis Jitter significantly improved in VFE+VH group (1.46±1.17 vs. 0.68±0.34), but there was no statistically significant change in VH only group (1.73±0.65 vs. 1.66±0.48). Despite the slight decrease in shimmer, no significant change was observed neither in pre-post values for both groups nor between the two groups (p=0.077). Aerodynamic assessment MPT significantly increased in VFE+VH group (13.51±4.84 vs. 19.73±3.85). On the con- trary, a slight decrease was detected in patients in VH only group, although, no statistically significant (18.54±4.55 vs. 17.67±3.62). No significant change was observed neither in pre-post values for both 520 Ignazio La Mantia, Francesco Cupido et Al Characteristics VFE+VH N=10^ VH only N=9^ Overall N=19 p-value Age, in years Mean ± SD 68.4 ± 5.21 64.1 ± 7.18 40.7 ± 11.25 0. Median 61 60 39 - Range 54-73 53-69 27-60 - Gender, n (%) Male 8 (80.0) 8 (88.9) 16 (84.2)
Female 2 (20.0) 1 (11.1) 3 (15.8) Stage of the disease (TNM) T1N0M0 3 (30.0) 2 (22.2) 5 (26.3) 0. T2N0M0 4 (40.0) 3 (33.3) 7 (36.8) 0. T2N1M0 1 (10.0) 0 (0) 1 (5.3) 0. T3N0M0 2 (20.0) 4 (44.5) 6 (31.6) 0. Treatment type Narrow field irradiation 3 (30.0)^ 2 (22.2)^ 5 (26.3)^ 0. Wide field irradiation 6 (60.0) 7 (77.8) 13 (68.4) 354 Chemotherapy+ irradiation 1 (10.0)^ 0 (0)^ 1 (5.3)^ 0. Smoking status Non-smoker 2 (20.0) 3 (33.3) 5 (26.3) 0. Smoker 2 (20.0) 2 (22.2) 4 (21.1) 0. Quit smoking >12 m 6 (60.0) 4 (44.5) 10 (52.6) 0. Table 1 : Patient demographic characteristics between groups. VFE: Vocal Function Exercises; VH: Vocal Hygiene; SD: stan- dard deviation; *p < 0. VFE+VH N= VH only N= Subjective Outcomes Baseline After treatment Baseline After treat ment - VHI 38.45 ± 11.16 30.22 ± 8.19* 27.69 ± 10.14 25.43 ± 9. GRBAS 9.23 ± 1.06 6.62 ± 0.88* 8.88 ± 0.86 8.12 ± 0. EORTC QLQ-H&N (overall) 48.45 ± 12.55^ 53.85 ± 11.45^ 50.15 ± 10.15^ 51.65 ± 10. Objective Outcomes NMWA (units) 5.63 ± 2.35 10.66 ± 4.65 6.02 ± 2.16 6.25 ±2. NGG (units) 1.48 ± 1.87 0.25 ± 0.05* 1.43 ± 1.16 1.22 ± 1. Jitter (%) 1.46 ± 1.17 0.68 ± 0.34* 1.73 ± 0.65 1.66 ± 0. Shimmer (%) 2.74 ± 1.88 2.15 ± 0.99 2.18 ± 1.76 2.04 ± 1. MPT (sec) 13.51 ± 4.84 19.73 ± 3.85* 18.54 ± 4.55 17.67 ± 3. MFR (ml/sec) 161.23±37.52 164.14±35.84 155.16±28.47 163.75±29. Table 2 : Subjective and objective outcomes at baseline and after treatment in the two study groups. VFE: Vocal Function Exercises; VH: Vocal Hygiene; VHI: Voice Handicap Index; GRBAS: Grade, Roughness, Breathiness, Asthenia, Strain; EORTC QLQ-H&N35: EORTC Quality of Life Questionnaire Head and Neck module; NMWA: Normalized mucosal wave amplitude; NGG: normalized glottal gap; MPT: maximum phonation time; MFR: mean flow rate; *p < 0.
groups nor between the two groups (p=0.077). No significant change in MFR was observed in the VFE+VH and VH only group after 6 weeks of treatment or between the two groups (p=0.102). Discussion Voice rehabilitation interventions following radiotherapy for laryngeal cancer have been scarce- ly addressed in previous studies. Traditionally, VH approaches are the most commonly used interven- tion method for voice rehabilitation in this popula- tion. Studies in this context have reported improve- ments in VHI scores for patients irradiated for early glottic cancers following VH interventions(21), a beneficial effect on the mean VHI, percent jitter, and shimmer also after more than one year of fol- low-up(22), a significant improvements in voice qual- ity and self-rated vocal function(23)^ and a greater improvement on patient's self-perception of vocal quality with no functional decline in vocal rough- ness 6-12 months post radiation therapy as a result of VH than the control group(10). Voice rehabilitation, in studies reported above, included vocal hygiene with non-specified voice and breathing exercises compared to a control group which generally, did not receive any voice treatment. The present study was designed to investigate the effectiveness, in improving vocal function in adults irradiated for laryngeal cancers, of a specific voice therapy approach, the VFE. VFEs are a set of laryngeal manipulations which are aimed at strengthening and rebalancing the three subsystems of voice production(16). To date, several studies have demonstrated the efficacy of VFEs in different situ- ation like elite voice users, normal voices, patho- logical voice disorders and elderly people(14, 24-27)^ but, the efficacy of VFEs in patients irradiated for laryn- geal cancers has poorer studied. To this end, the present study compared the efficacy of VFE + VH combined treatment to VH treatment alone in improving vocal function using perceptual ratings (GRBAS), aerodynamic assess- ment (MPT, MFR), acoustic analysis (jitter, shim- mer), vibratory analysis (NMWA, NGG), VHI, and the impact of voice vocal treatment on QoL (EORTC QLQ-H&N35). Although MFR and shim- mer didn’t change significantly between the two groups, the present study indicated significant improvements in GRBAS, MPT, jitter, NMWA, NGG, VHI and EORTC QLQ-H&N35 after the combined approach compared with the VH alone treatment. Our results support previous findings which have demonstrated improvements in voice-related quality of life and auditory perceptual measures of voice as a result of voice therapy interventions fol- lowing radiation therapy for laryngeal cancers(10,21-23). Moreover, our experience adds further support to the evidence that VH is more effective when paired with a more physiologic voice therapy approach, the VFE, as reported by previous studies(14,28). Trying to explain our results from a theoretical point of view we can say that VFEs have proved to be effective in improving vocal function, slowing down or nullify post-radiotherapy injury, facilitating activity-depen- dent plasticity, oxidative metabolic capacity and quantity of neuromuscular junctions through vocal exercise stimulation as noted in some experimental studies(29), improving in this way vocal fold vibrato- ry function. Our study has some limitations. The measure- ment of the NMWA and NGG is affected by differ- ent conditions of pitch, loudness and compensatory activity of extrinsic muscles so this may lead to bias in the estimation of their values. We attempted to correctly and consistently obtain NMWA and NGG by taking measurements during vocal fold vibration Vocal function exercises and vocal hygiene combined treatment approach as a method of improving ... 521 VFE+VH N= VH only N=9 p-Value Subjective Outcomes VHI -8.23 -2.26 0.023* GRBAS -2.61 -0.76 0.038* EORTC QLQ-H&N (overall) 5.4^ 1.5^ 0.047* Objective Outcomes NMWA (units) 5.03 0.23 0.011* NGG (units) -1.23 -0.21 0.026* Jitter (%) -0.78 -0.07 0.015* Shimmer (%) -0.59 -0.14 0. MPT (sec) 6.22 -0.87 <0.001* MFR (ml/sec) 2.91 8.59 0. Table 3 : Mean change in scores by treatment group. VFE: Vocal Function Exercises; VH: Vocal Hygiene; VHI: Voice Handicap Index; GRBAS: Grade, Roughness, Breathiness, Asthenia, Strain; EORTC QLQ-H&N35: EORTC Quality of Life Questionnaire Head and Neck module; NMWA: Normalized mucosal wave amplitude; NGG: normalized glottal gap; MPT: maximum phonation time; MFR: mean flow rate; *p < 0.
patients with vocal nodules. Phonetics and Speech Sciences 2009; 1: 37-42.
- Roy N, Gray SD, Simon M, Dove H, Corbin-Lewis K, Stemple JC. An evaluation of the effects of two treat- ment approaches for teachers with voice disorders: a prospective randomized clinical trial. J Speech Lang Hear Res 2001; 44: 286-96.
- McMullen CA, Butterfield TA, Dietrich M, Andreatta RD, Andrade FH, Fry L, et al. Chronic stimulation- induced changes in the rodent thyroarytenoid muscle. J Speech Lang Hear Res 2011; 54: 845-53.
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Corresponding author IGNAZIO LA MANTIA Department of Medical Sciences, Surgical and Advanced Technologies, GF Ingrassia Via Santa Sofia, 78 95123 Catania (Italy) Vocal function exercises and vocal hygiene combined treatment approach as a method of improving ... 523
