Assessment of Vocal Quality Following Treatment of Advanced Pharyngo-laryngeal Carcinoma With a Protocol of Organ Preservation

Abstract

Advanced laryngeal and pharyngeal cancer, as well as methods to treat them, have a direct impact on voice function, speech communication and deglutition. Such alterations in function can influence employability and general quality of life.
To characterise the vocal status of the patients treated with an organ-preservation protocol, we report the voice outcomes of 17 patients who were alive and disease free at the time of the survey, with a minimum follow-up of 6 months, after a combination of radiotherapy and chemotherapy to treat advanced cancer. Objective voice assessment by means of spectrographic analysis, the GRBAS perceptual analysis system and the Voice Handicap Index was the methodology followed, which we suggest could be used in future large-scale investigations.
Normal or slightly dysphonic voices were observed in 5 patients (29.4%) and moderate/severe in 12 (70.6%). Spectrographically, the 17 samples were classified as normal in 4 cases (23.4%), Grade I in 3 cases (17.6%), Grade II in 3 (17.6%), Grade III in 4 (23.5%) and Grade IV in 2 (11.7%). The Voice Handicap Index questionnaire, which was completed by the patients themselves, gave normal results in all the patients except for 4 (23.5%).
The voice acoustic analysis of this series shows that the damage related to the organ-preservation protocol displays a relatively wide range of voice function outcomes. To characterise the vocal status of these patients reliably, we propose using homogeneous instruments (spectrography, GRBAS scale, Maximum Phonation Time and Voice Handicap Index) in future meta-analyses.

Full text

Acta
Otorrinolaringol
Esp.
2014;65(5):283---288
www.elsevier.es/otorrino
ORIGINAL
ARTICLE
Assessment
of
Vocal
Quality
Following
Treatment
of
Advanced
Pharyngo-laryngeal
Carcinoma
With
a
Protocol
of
Organ
Preservation夽
Marta
Morato-Galán,aMaría
Jesús
Caminero
Cueva,bJuan
Pablo
Rodrigo,a,c
Carlos
Suárez
Nieto,a,cFaustino
Nú˜
nez-Batallaa,∗
aServicio
de
Otorrinolaringología,
Hospital
Universitario
Central
de
Asturias,
Oviedo,
Asturias,
Spain
bServicio
de
Oncología
Radioterápica,
Hospital
Universitario
Central
de
Asturias,
Oviedo,
Asturias,
Spain
cInstituto
Universitario
de
Oncología
del
Principado
de
Asturias,
Universidad
de
Oviedo,
Oviedo,
Asturias,
Spain
Received
26
November
2013;
accepted
26
December
2013
KEYWORDS
Head
and
neck
cancer;
Voice
analysis;
Functional
outcomes
Abstract
Introduction
and
objectives:
Advanced
laryngeal
and
pharyngeal
cancer,
as
well
as
methods
to
treat
them,
have
a
direct
impact
on
voice
function,
speech
communication
and
deglutition.
Such
alterations
in
function
can
influence
employability
and
general
quality
of
life.
Patients
and
methods:
To
characterise
the
vocal
status
of
the
patients
treated
with
an
organ-
preservation
protocol,
we
report
the
voice
outcomes
of
17
patients
who
were
alive
and
disease
free
at
the
time
of
the
survey,
with
a
minimum
follow-up
of
6
months,
after
a
combination
of
radiotherapy
and
chemotherapy
to
treat
advanced
cancer.
Objective
voice
assessment
by
means
of
spectrographic
analysis,
the
GRBAS
perceptual
analysis
system
and
the
Voice
Handicap
Index
was
the
methodology
followed,
which
we
suggest
could
be
used
in
future
large-scale
investigations.
Results:
Normal
or
slightly
dysphonic
voices
were
observed
in
five
patients
(29.4%)
and
moderate/severe
in
12
(70.6%).
Spectrographically,
the
17
samples
were
classified
as
normal
in
four
cases
(23.4%),
Grade
I
in
three
cases
(17.6%),
Grade
II
in
three
(17.6%),
Grade
III
in
four
(23.5%)
and
Grade
IV
in
two
(11.7%).
The
Voice
Handicap
Index
questionnaire,
which
was
completed
by
the
patients
themselves,
gave
normal
results
in
all
the
patients
except
for
four
(23.5%).
Conclusions:
The
voice
acoustic
analysis
of
this
series
shows
that
the
damage
related
to
the
organ-preservation
protocol
displays
a
relatively
wide
range
of
voice
function
outcomes.
To
characterise
the
vocal
status
of
these
patients
reliably,
we
propose
using
homogeneous
instru-
ments
(spectrography,
GRBAS
scale,
maximum
phonation
time
and
Voice
Handicap
Index)
in
future
meta-analyses.
©
2013
Elsevier
Espa˜
na,
S.L.U.
and
Sociedad
Espa˜
nola
de
Otorrinolaringología
y
Patología
Cérvico-Facial.
All
rights
reserved.
夽Please
cite
this
article
as:
Morato-Galán
M,
Caminero
Cueva
MJ,
Rodrigo
JP,
Suárez
Nieto
C,
Nú˜
nez-Batalla
F.
Valoración
de
la
calidad
vocal
tras
el
tratamiento
del
carcinoma
faringolaríngeo
avanzado
en
un
protocolo
de
preservación
de
órgano.
Acta
Otorrinolaringol
Esp.
2014;65:283---288.
∗Corresponding
author.
E-mail
address:
fnunezb@telefonica.net
(F.
Nú˜
nez-Batalla).
2173-5735/$
–
see
front
matter
©
2013
Elsevier
Espa˜
na,
S.L.U.
and
Sociedad
Espa˜
nola
de
Otorrinolaringología
y
Patología
Cérvico-Facial.
All
rights
reserved.
Document downloaded from http://www.elsevier.es, day 29/06/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.

284
M.
Morato-Galán
et
al.
PALABRAS
CLAVE
Cáncer
de
cabeza
y
cuello;
Análisis
de
voz;
Resultados
funcionales
Valoración
de
la
calidad
vocal
tras
el
tratamiento
del
carcinoma
faringolaríngeo
avanzado
en
un
protocolo
de
preservación
de
órgano
Resumen
Introducción
y
objetivos:
Los
carcinomas
avanzados
de
faringe
y
laringe
y
los
distintos
métodos
que
se
emplean
para
su
tratamiento
tienen
un
impacto
directo
en
la
función
vocal,
la
comu-
nicación
oral
y
la
deglución,
alteraciones
que
pueden
influir
en
la
capacidad
laboral
y
en
la
calidad
de
vida
general.
Pacientes
y
métodos:
Con
el
fin
de
conocer
la
salud
vocal
de
los
pacientes
tratados
mediante
un
protocolo
de
preservación
de
órgano
presentamos
los
resultados
vocales
de
17
pacientes
tras
ser
tratados
mediante
una
combinación
de
radioterapia
y
quimioterapia,
y
que
han
sido
segui-
dos
un
mínimo
de
6
meses,
encontrándose
vivos
sin
evidencia
de
enfermedad
en
el
momento
del
estudio.
Se
realiza
una
valoración
objetiva
de
la
voz
mediante
espectrografía,
análisis
per-
ceptual
por
el
sistema
GRABS
y
el
Voice
Handicap
Index
como
metodología
aconsejada,
que
puede
ser
empleada
en
el
futuro
en
estudios
más
extensos.
Resultados:
Se
observaron
voces
normales
o
levemente
disfónicas
en
5
pacientes
(29,4%),
y
moderadas/severas
en
12
(70,6%).
Espectrográficamente,
las
17
muestras
se
clasificaron
como
normales
en
4
casos
(23,4%),
Grado
I
en
3
casos
(17,
6%),
Grado
II
en
3
(17,6%),
Grado
III
en
4
(23,5%)
y
Grado
IV
en
2
(11,7%).
Las
puntuaciones
en
el
cuestionario
Voice
Handicap
Index
se
encontraron
dentro
de
los
rangos
normales
en
todos
los
casos,
excepto
en
4
(23,5%).
Conclusiones:
El
análisis
acústico
de
la
voz
de
los
pacientes
de
esta
serie
demuestra
que
el
da˜
no
que
se
produce
tras
un
tratamiento
de
preservación
de
órgano
causa
un
amplio
rango
de
resultados
vocales.
No
obstante,
la
sensación
de
incapacidad
de
estos
pacientes
es
mínima.
En
este
estudio
se
propone
el
uso
de
instrumentos
homogéneos
(espectrografía,
GRABS,
Tiempo
Máximo
de
Fonación
y
Voice
Handicap
Index)
para
ser
usados
en
futuros
metaanálisis.
©
2013
Elsevier
Espa˜
na,
S.L.U.
and
Sociedad
Espa˜
nola
de
Otorrinolaringología
y
Patología
Cérvico-Facial.
Todos
los
derechos
reservados.
Introduction
Function
preservation
is
a
crucial
aspect
in
assessing
the
therapies
used
in
head
and
neck
cancer,
where
it
is
noted
that
organ
preservation
does
not
imply
preservation
of
functions.
The
study
of
functional
outcomes
has
become
a
very
important
aspect
in
assessing
alternative
therapeutic
options
with
similar
oncological
results.
Although
the
main
purpose
of
cancer
treatment
is
the
complete
eradication
of
the
disease,
the
preservation
of
an
effective
voice
is
another
significant
consideration
when
selecting
treatment
for
advanced
head
and
neck
cancer.
Head
and
neck
cancer
patients
experience
a
series
of
respiratory,
phonation,
and
deglutition
problems,
as
well
as
other
physical
limitations
which
radically
alter
how
they
live
their
daily
lives.
Examples
of
this
are
how
participa-
tive
the
patients
may
be
in
a
social
dining
situation,
their
ability
to
be
responsible
for
their
own
personal
hygiene,
their
speech
communication,
and
their
employability.
The
WHO1stated
that
all
these
aspects
may
be
summed
up
under
the
term
‘‘functional’’.
Functional
assessment
fol-
lowing
head
and
neck
cancer
has
become
a
key
component
in
the
most
recent
clinical
trials,
insofar
as
the
severity
of
functional
alterations
are
linked
with
survival
as
an
inde-
pendent
predictive
factor.2 --- 4 Comparisons
should
therefore
be
established
between
foreseeable
functional
outcomes
of
equivalent
therapies,
aimed
at
offering
patients
a
more
detailed
prognosis
of
their
effects
when
advising
on
which
treatment
to
select.5
Another
major
concept
here
is
that
of
‘‘quality
of
life
in
its
relationship
to
health’’
which
represents
the
patient’s
subjective
and
psychological
notion
of
their
state
of
health.
This
notion
is
multidimensional,
encompassing
emotional,
physical,
social,
and
behavioural
aspects
of
wellbeing,
as
well
as
functional
capacity
from
the
patient’s
point
of
view.
Despite
the
great
interest
and
consequently
large
number
of
publications
addressing
this
issue,
it
is
difficult
to
extract
global
conclusions
for
clinical
application.
This
is
partly
due
to
trial
limitations
(low
number
of
cases,
imprecise
details
on
tumour
location
and
tumour
treatment)
or
a
lack
of
criteria
definition
to
value
a
function,
as
well
as
the
het-
erogeneity
of
instruments
used
for
their
assessment.6
This
study
focuses
on
the
assessment
of
the
voice
func-
tion
remaining
after
treatment
for
advanced
head
and
neck
cancer
with
protocols
of
organ
preservation.
Since
voice
is
a
multidimensional
phenomenon,
it
must
be
assessed
through
a
battery
of
tools
used
to
measure
the
dif-
ferent
important
parameters
that
define
its
quality.
Firstly
voice
quality
is
measured
objectively,
as
is
the
auditory
per-
ception
of
the
examiner
and
this
is
followed
by
the
patient’s
subjective
sensation
of
the
quality
of
their
life
related
to
their
voice.
In
this
study,
bias
was
added
for
functional
capacity
from
the
point
of
view
of
the
disability
associated
with
voice
alteration.
Patients
and
Methods
The
study
included
17
patients
with
advanced
laryngeal
and
pharyngeal
cancer,
treated
according
to
the
organ
preser-
vation
protocol
reached
between
the
Radiation
Oncology,
Medical
Oncology
and
Otolaryngology
Departments
of
the
Document downloaded from http://www.elsevier.es, day 29/06/2015. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.

Vocal
Quality
Following
Treatment
With
Organ
Preservation
Protocol
285
Table
1
Patients
Included
in
the
Study.
Sample
Gender
Age
(years)
Primary
Tumour
Stage
QT
RT
Surgery
1
V
64
Larynx
T3N2aM0
3
doses
Concomitant
No
2
V
53
Supraglottis
T3N2aM0
3
doses
Concomitant
No
3
V
67
Hipopharynx
T2N2cM0
3
doses
Concomitant
No
4
V
52
Hipopharynx
T3N1M0
3
doses
Concomitant
No
5
V
64
Larynx
T3N0M0
3
doses
Concomitant
No
6
V
52
Hipopharynx
T3N1M0
3
doses
Concomitant
No
7
V
62
Larynx
T3N2bM0
3
doses
Concomitant
VCFr
8
V
43
Larynx
T3N0M0
3
doses
Concomitant
No
9
M
51
Larynx
T3N1M0
3
doses
Concomitant
Tracheotomy
10
V
60
Hipopharynx
T3N3M0
3
doses
Concomitant
VCFr
11
V
53
Larynx
T3N0M0
3
doses Concomitant
No
12
M
49
Supraglottis
T3N0M0
3
doses
Concomitant
No
13
M
67
Supraglottis
T3N0M0
3
doses
Concomitant
No
14
V
60
Hipopharynx
T2N2bM0
3
doses
Concomitant
VCFr
15
M
57
Supraglottis
T2N3M0
3
doses
Concomitant
VCFr
16
V
59
Larynx
T3N2M0
3
doses
Concomitant
Tracheotomy
17
V
56
Hipopharynx
T3N2bM0
3
doses
Concomitant
VCFr
M:
woman;
QT:
chemotherapy;
RT:
radiotherapy;
MeV:
megaelectronvoltage;
V:
man;
VCFr:
emergency
functional
cervical
emptying.
In
chemotherapy
75
mg/m2cisplatin
is
administered
on
days
1,
21,
and
43
of
radiotherapy.
In
radiotherapy
70
Gy
are
administered
with
a
photon
accelerator
of
6
MeV.
University
Hospital
Central
de
Asturias.
Four
of
the
patients
were
women
and
13
men.
Ages
ranged
between
43
and
67,
with
a
mean
age
of
56.7.
Voice
function
assessment
was
made
6
months
after
treatment
termination.
All
lesions
were
classified
according
to
criteria
from
the
American
Joint
Committee
on
Cancer,7the
data
from
which
is
contained
in
Table
1.
100%
of
patients
were
treated
for
primary
tumours
and
in
accordance
with
the
organ
preservation
protocol
approved
in
our
hospital,
which
consisted
of
single-cycle
induction
chemotherapy,
following
the
protocol
described
by
Urba
et
al.8:
100
mg/m2cisplatin
administered
daily,
and
1000
mg/m2/day
5-fluorouracil
administered
continu-
ously
for
24
h
over
5
days.
Final
response
was
assessed
3
weeks
after
chemotherapy
termination
using
a
CT
scan
and
a
medical
examination.
Response
was
defined
as
50%
or
more
reduction
of
highest
tumour
dimension,
in
accor-
dance
with
RECIST.9Patients
who
responded
were
treated
with
concurrent
chemoradiation
(75
mg/m2cisplatin
on
days
1,
21
and
43,
standard
radiotherapy
using
a
linear
accel-
erator
unit
with
6
MV
photons,
with
a
2
Gy
fractionation
in
35
fractions
for
a
total
dose
of
70
Gy).
Patients
who
did
not
respond
were
treated
with
surgery,
followed
by
radiotherapy
if
appropriate.
A
temporary
tracheostomy
was
required
in
two
patients
who
presented
with
dyspnoea
and
cervical
emptying
in
five
patients
(Table
1).
Objective
voice
assessment
and
a
study
on
the
quality
perceived
both
by
the
examiners
and
patients
6
months
after
treatment
termination
were
performed:
-
The
Kay
Elemetrics
CSL
4400
was
used
for
acoustic
speech
analysis.
Sampling
frequency
was
44,100
Hz
and
a
high
frequency
resolution
microphone
was
used.
The
micro-
phone
was
placed
25
cm
distance
from
the
patient’s
mouth
whilst
vowel
phonation/intensity
and
comfortable
tones
were
expressed
in
a
sound-proofed
chamber.
A
narrow-
band
spectrogram
was
made
(45
Hz).
Spectrograms
were
grouped
into
four
types,
according
to
Yanagihara10 crite-
ria:
Grade
I,
when
the
harmonic
components
mix
with
the
noise
components,
mainly
in
the
area
vowel
formant
area;
Grade
II,
when
the
noise
components
predominate
over
the
harmonics
of
the
second
formant;
there
are
slight
high
frequency
noise
components
above
3
kHz;
Grade
III,
when
it
is
observed
that
the
second
formant
is
completely
replaced
by
noise;
the
high
frequency
noise
component
intensifies
its
energy
and
expands
its
range,
and
Grade
IV,
when
the
first
formant
loses
its
periodic
components
and
noise
components
are
observed,
and
in
high
frequencies
the
noise
is
even
more
highly
intensified.
Subharmonics
are
also
recorded
in
the
spectrum.
-
For
aerodynamic
assessment
we
used
the
maximum
phonation
time
(MPT)
for
the
vowel.
-
The
GRBAS
scale
was
used
for
subjective
voice
assessment
by
the
examiners.
This
scale
assesses
five
aspects:
overall
level
of
dysphonia
(G),
harsh
voice
(R),
weak
voice
(A),
breathless
voice
(B)
and
strained
voice
(S),
in
its
four
levels
of
normal
(0),
mild
(1),
moderate
(2)
and
severe
(3).11
-
Quality
of
life
relating
to
the
vocal
function
perceived
by
patients
was
assessed
with
the
Voice
Handicap
Index
validated
for
Spanish,12 self-assessment
questionnaire
completed
by
the
patient.
This
comprises
30
questions
which
explore
three
areas:
functional,
physical
and
emo-
tional.
Each
question
is
given
a
score
of
between
0
and
4
(from
lower
to
higher
disability).
The
maximum
pos-
sible
score
for
each
item
is
40
points,
classified
into
mild
incapacity
(under
20
points),
moderate
incapacity
(21---30
points)
and
severe
incapacity
(over
30
points).
The
sum
of
the
three
scales
is
a
maximum
obtainable
score
of
120
points,
and
is
divided
into:
mild
incapacity
(under
30
points),
moderate
incapacity
(31---60
points)
and
severe
incapacity
(61---90
points).
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286
M.
Morato-Galán
et
al.
Table
2
Outcomes
of
the
Objective
and
Subjective
Voice
Assessment.
Sample
TMF
(seg)
Spectrogram
G
R
A
B
S
Disability
Level
1
27
0
1
1
0
0
0
I
(5%)
2
10
0
0
0
0
0
0
Does
not
have
3
15
III
with
sub
2
2
0
1
0
I
(7%)
4
20
0
0
0
0
0
0
Does
not
have
5
22
III
with
sub
2
2
0
2
1
I
(7%)
6
15
0
0
0
0
0
0
Does
not
have
7
7
III
with
sub
3
3
0
3
2
IIa
(18%)
8
6
IV
3
0
0
3
3
IIa
(23%)
9
6
IV
3
0
0
3
3
IIa
(23%)
10
6
II
2
2
0
0
1
IIa
(23%)
11
14
III
with
sub 3
2
0
1
2
I
(11%)
12
8
II
with
sub
2
1
0
1
1
IIa
(12%)
13
5
I
1
1
0
1
0
IIa
(23%)
14
6
II
with
sub
3
2
0
0
1
IIa
(23%)
15
6
I
2
1
0
1
2
IIa
(23%)
16
9
I
2
2
0
0
1
IIa
(12%)
17
27
II
2
2
0
0
1
I
(7%)
Sub:
subharmonics;
TMF:
maximum
phonation
time
for
vowel.
-
Assignation
of
disability
level:
the
disability
level
classi-
fication
responds
to
the
unified
technical
criteria,
fixed
by
the
limits
described
in
Appendix
I,
published
in
Royal
Decree
1971/1999,
of
December
23.13 The
level
of
disabil-
ity
is
expressed
in
percentages.14
Results
The
results
of
the
objective
voice
assessment
are
summari-
sed
in
Table
2,
together
with
the
TMF
values.
Table
2
also
shows
the
results
from
the
GRBAS
assess-
ment.
Normal
or
light
voices
are
observed
in
five
patients
(29.4%),
and
moderate
or
severe
dysphonias
in
the
other
cases.
Spectrographically,
the
17
samples
are
classified
accord-
ing
to
the
Yanagihara
criteria
as
normal
in
four
cases,
Grade
I
in
four
(23.5%),
Grade
II
in
three
(17.6%),
Grade
III
in
four
(23.5%)
and
Grade
IV
in
two
(11.7%).
Six
of
the
cases
also
showed
subharmonics
on
the
spectrum
(35.2%).
Scores
from
the
Voice
Handicap
Index
version
30
and
ver-
sion
10,
which
were
completed
by
the
patients
themselves,
are
shown
in
Table
3:
four
cases
(23.5%)
have
pathological
scores,
of
which
three
are
severe,
and
one
mild.
Regarding
disability
levels
(Table
3),
eight
of
the
patients
present
no
disability
or
mild
disability
below
7%.
The
other
patients
were
classified
as
Grade
IIa,
with
a
disability
per-
centage
between
12%
and
23%.
Discussion
This
study
presents
a
short
but
sufficiently
illustrative
series
of
the
speech
results
obtained
following
treatment
with
an
organ
preservation
protocol
in
advanced
pharyngeal
cancer
patients.
Said
results
were
analysed
with
widely
distributed
and
accessible
tools,
such
as
the
spectrograph,
the
GRBAS
system,
the
Voice
Handicap
Index
validated
for
Spanish
use,
and
the
TMF.
The
cases
we
provided
may
be
added
to
future
meta-analysis
since
few
studies
exist
regarding
objective
assessment
of
phonatory
function
following
organ
preser-
vation
treatment.15 A
disability
level
assessment
is
also
included,
in
keeping
with
official
figures,
which
may
be
of
interest
for
establishing
a
prognostic
of
functional
capacity
related
to
voice,
to
be
expected
after
organ
preservation
treatment.
Quality
of
life
after
cancer
treatment
is
an
important
aspect.
In
the
case
of
pharyngeal
tumours,
it
is
closely
linked
with
phonatory
and
deglutory
functions,
since
their
alter-
ations
profoundly
affect
the
patients’
social
life.
They
are
no
longer
able
to
carry
out
basic
daily
activities,
such
as
oral
communication
or
participation
in
family
meals.
Previous
studies
on
this
subject
using
small
series
of
patients
for
objective
voice
assessment
aimed
at
introducing
methodology
which
could
be
used
in
future
large-scale
inves-
tigations.
They
showed
voice
assessment
results
encompass
a
wide
functional
range
and
suggested
there
was
a
need
for
large
patient
series
to
be
used
to
reliably
determine
voice
status.16,17
As
was
to
be
expected,
preservation
of
the
larynx
explains
why
maximum
phonation
time
does
not
fall
under
5
s,
as
sufficient
glottic
closure
is
maintained.
This
parame-
ter
may
be
significantly
altered
following
resection
with
CO2
laser
of
a
stage
T1
cancer
of
the
vocal
cords.18
Dysphonia
is
the
alteration
of
one
of
the
three
voice
acoustic
characteristics:
intensity,
tone
and
pitch.
The
latter
is
the
most
frequently
altered
in
voice
function
disorders,
which
is
why
the
term
dysphonia
is
accepted
as
a
synonym
for
change
in
voice
pitch.
The
study
of
dysphonia
from
a
physical
viewpoint
may
be
multifactorial
since
no
single
parameter
may
be
used
to
define
all
of
its
aspects.
Spectrographic
analysis
of
patients’
voices
in
the
sam-
ple
series
shows
that
deterioration
after
organ
preservation
treatment
is
wide
in
range
of
severity:
from
a
normal
voice
function
to
significant
alteration.
Spectrograms
with
greater
impact
correspond
to
those
patients
with
tumours
which
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Vocal
Quality
Following
Treatment
With
Organ
Preservation
Protocol
287
Table
3
Scores
From
the
Voice
Handicap
Index
Versions
30
and
10.
Patient Functional
VHI
(maximum
40)
Physical
VHI
(maximum
40)
Emotional
VHI
(maximum
40)
Overall
VHI
(maximum
120)
VHI
10
(maximum
40)
1
4
1
0
5
4
2
0
2
0
2
0
3
0
2
0
2
0
4
0
0
0
0
0
5
0
7
0
7
2
6
1
2
0
3
0
7
24
22
28
74
23a
8
29
24
12
65
21a
9
35
36
24
95
32a
10
0
6
0
6
0
11
5
7
0
12
4
12
1
11
0
12
6
13
0
2
0
2
0
14
7
10
4
21
5
15
2
3
0
5
3
16
7
17
1
25
13a
17
2
11
0
13
3
VHI:
Voice
Handicap
Index.
Values
of
the
Voice
Handicap
Index-10
in
a
healthy
population:
up
to
7.2
for
men
and
7.6
for
women.
aPathological
score
for
the
Voice
Handicap
Index-10.
primary
affected
the
larynx.
However,
a
lower
number
of
patients
gave
pathological
scores
on
the
Voice
Handicap
Index.
This
shows
that
dysphonia
as
a
physiopathological
laryngeal
product
is
to
be
considered
and
so
too
are
the
effects
this
could
entail
on
the
patients’
quality
of
life.
The
patient’s
perception
of
dysphonia
is
complex
and
subjec-
tive,
based
on
many
factors.
These
include
both
the
sound
of
the
voice,
and
the
physical
sensation,
the
level
at
which
the
voice
covers
communicative
needs,
patient
expectations,
cultural
prejudices,
and
the
patient’s
ability
to
overcome
a
disability.19
Regarding
disability
grades
found
in
the
series,
eight
patients
had
none,
or
it
was
under
12%,
whilst
the
others
scored
a
maximum
of
Grade
IIa
and
23%
disability
for
oral
communication
(moderate
limitation),
which
is
interpreted
as
a
general
disability
level
of
14%.
It
should
be
noted
that
the
laryngectomised
person
who
has
not
been
rehabilitated
presents
a
Grade
IIIb
and
59%
disability,
through
to
a
IIb
and
35%
in
cases
in
which
successful
rehabilitation
has
taken
place
through
erigmophonia
or
tracheoesophageal
puncture.
This
study
proposes
a
multidimensional
method
of
eval-
uating
the
outcomes
of
the
phonatory
function
using
accessible
and
widely
distributed
tools,
which
help
to
under-
stand
the
potential
of
different
therapies
used
in
advanced
head
and
neck
cancers.
Conclusions
-
The
impact
of
the
phonatory
function
after
organ
preser-
vation
treatment
in
advanced
laryngeal
and
pharyngeal
cancer
has
a
wide
range
of
severity,
from
normal
to
dys-
phonia
Grade
IV.
-
The
score
results
from
the
Voice
Handicap
Index
shows
less
perception
of
severity
than
the
objective
trials.
-
Maximum
phonation
time
scores
are
no
less
than
5
s
for
larynx
organ
preservation.
-
The
disability
grade
found
in
the
series
does
not
alter
from
Grade
IIa
or
23%.
Conflict
of
Interests
The
authors
have
no
conflict
of
interests
to
declare.
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