E v aluatio n o f t h e Dysphonic Patient (in: F u n c t i o n P re s e r v a t i o n i n La rynge al C an c er ) Chad W. Whited,

MD

a

, Seth H. Dailey,

MD

b,

*

KEYWORDS  Diagnosis  Dysphonia  Hoarseness  Voice  Cancer  Laryngoscopy  Stroboscopy KEY POINTS  Evaluation of the dysphonic patient begins as soon as the clinician can hear the patient’s voice. This evaluation involves a thorough history, head and neck examination, a perceptual evaluation of the voice, and a detailed assessment of the patient’s laryngeal anatomy and function.  Dysphonia results from a disruption in the anatomy and function of the vocal folds. Stroboscopy is critical in evaluating the function of the vocal fold vibratory characteristics.  High-speed digital imaging also can play an important role in patients with aperiodic vocal fold vibration.  Concerning lesions warrant a biopsy for pathologic diagnosis.  In the operating room, a telescope or microscope provides optimal visualization, mapping ability, and tactile evaluation of the tissue. Additionally, in-office biopsy is a cost-reducing and effective alternative in select patients for pathologic sampling.

INTRODUCTION

Dysphonia is defined as an impairment of the speaking or singing voice, and it affects up to one-third of people during their lifetime.1,2 The evaluation of dysphonia by general otolaryngologists varies with different practice patterns depending on

Neither C.W. Whited nor S.H. Dailey have any conflicts of interest, financial or otherwise, to disclose. a Otolaryngology-Head & Neck Surgery, University of Wisconsin at Madison, 600 Highland Avenue, BX7375 Clinical Science Cntr-H4, Madison, WI 53792-3284, USA; b Section of Laryngology and Voice Surgery, Otolaryngology-Head & Neck Surgery, University of Wisconsin at Madison, 600 Highland Avenue, BX7375 Clinical Science Cntr-H4, Madison, WI 53792-3284, USA * Corresponding author. E-mail address: [email protected] Otolaryngol Clin N Am - (2015) -–http://dx.doi.org/10.1016/j.otc.2015.04.003 0030-6665/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.

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Abbreviations CAPE-V DL Fo GRBAS HSDI NBI SLP VHI V-RQOL

Consensus Auditory Perceptual Evaluation of Voice Direct laryngoscopy Fundamental frequency Grade, roughness, breathiness, asthenia, strain High-speed digital imaging Narrow Band Imaging Speech-Language Pathologist(s) Voice Handicap Index Voice-related quality of life

training background, practice type, and available resources.3 There are multiple techniques to visualize the larynx from mirror laryngoscopy to high-speed digital imaging (HSDI). Some practices frequently employ speech-language pathologists (SLPs) to assess the perceptual, aerodynamic, and acoustic measurements, as well as treatment counseling and therapy. This lack of consensus in approach to dysphonia contributed to the Academy of Otolaryngology–Head and Neck Surgery to develop clinical practice guidelines on dysphonia.4 There are both benign and malignant factors that can cause dysphonia, but what is concerning is that up to 52% of patients with laryngeal cancer thought their hoarseness was harmless, leading to a delay in evaluation and treatment.5 The guidelines list comorbidities that should trigger a patient and clinician to suspect a serious underlying cause of the dysphonia (Box 1). This article builds on the invaluable article by Blitzer, elsewhere in this issue, regarding laryngeal anatomy and function, and presents a laryngologist’s focus on the different tools, highlights, and pitfalls in the evaluation of the dysphonic patient.

Box 1 Concerning signs with dysphonia Conditions leading to suspicion of a “serious underlying cause” Hoarseness with a history of tobacco or alcohol use Hoarseness with concomitant discovery of a neck mass Hoarseness after trauma Hoarseness associated with hemoptysis, dysphagia, odynophagia, otalgia, or airway compromise Hoarseness with accompanying neurologic symptoms Hoarseness with unexplained weight loss Hoarseness that is worsening Hoarseness in an immunocompromised host Hoarseness and possible aspiration of a foreign body Hoarseness in a neonate Unresolving hoarseness after surgery (intubation or neck surgery) From Schwartz S, Cohen S, Dailey S, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg 2009;141(3 Suppl 2):S1–31; with permission.

Evaluation of the Dysphonic Patient

HISTORY

Often clinicians have a referring diagnosis or physical examination finding from a colleague to guide an evaluation. However, referring diagnoses are commonly inaccurate, and a myopic evaluation can overlook findings that may influence treatment. The differential diagnosis for dysphonia is extensive (Box 2), and a thoughtful history can direct testing, treatment, and prognosis counseling. Therefore, the first part of any evaluation is a thorough and complete history. Elements include standard concerning signs and symptoms regarding pain, weight loss, and neck masses. Inquiring about cigarette smoking and alcohol consumption are crucial, as both are wellestablished risks factors for both laryngeal cancer and dysphonia.6 With the dysphonic patient, additional details must be investigated. History of prior intubations, neck surgery, radiation, or trauma can all affect vocal quality. Upper aerodigestive tract diseases, such as gastroesophageal reflux disease, asthma, allergies, sinusitis, and inhaler use, can all contribute to dysphonia. A surgeon must consider the larynx in terms of its 3 main roles: voice, breathing, and swallowing. Evaluating one without the others can lead to incomplete decision-making. Similar to the evaluation of pain, a surgeon must evaluate all of the aspects associated with the dysphonic complaint, including onset, duration, quality, frequency, severity, and alleviating and aggravating factors. Gradual onset can often imply a functional dysphonia or a small growing lesion. Abrupt onset is often associated with a hemorrhagic polyp or an acute injury. An onset associated with endotracheal tube intubation or anterior neck or thoracic operation could implicate an injury to the cricoarytenoid joint or vagus/recurrent laryngeal nerves. Persistent dysphonia after an upper respiratory tract infection could suggest a nerve paresis or residual inflammatory changes. When a physician asks a patient about his or her voice, the common response is “it’s just hoarse” or “it doesn’t sound like my normal voice.” Asking the patient to describe the nature of the vocal complaints without using the term “hoarse” can elucidate what it is exactly about the voice that is causing distress. Descriptors such as effortful, weak, short of breath, sore, lower pitch, or poor clarity are all part of a medical vernacular that a surgeon can use to narrow the differential diagnoses. A “breathy” or “effortful” voice is often due to incomplete closure of the vocal folds during phonation. Specific examples might include unilateral vocal fold paralysis or paresis, fixation from tumor invasion of the thyroarytenoid muscle or cricothyroid joint, vocal fold atrophy in presbylarynges, or a large posterior granuloma impeding closure. A “rough” or “strained” voice might be attributable to irregular vocal fold oscillation during phonation due to glottic asymmetry. Pathologies that could lead to roughness include muscle tension dysphonia, vocal fry, benign vocal lesions, anterior glottic web, neoplasm, leukoplakia, or vocal fold scar. It is useful to evaluate the variability of the dysphonia and its pattern throughout the day. A voice that is consistently dysphonic with little fluctuating could implicate a constant anatomic abnormality. If a patient describes a period of normalcy surrounded by the dysphonic voice, this could represent a fluctuating nonorganic etiology, such as muscle tension dysphonia. An overall decline raises concern for a progressing neoplasm. It is important to inquire about voice demands at work as well as previous vocal training. This may uncover compounding factors, such as fume or allergen exposure, or unhealthy vocal demands at a construction site, hair salon, or a large classroom. A patient’s vocal experience also can guide the specificity of pretreatment counseling on vocal expectations, treatment decisions, and the extensiveness of posttreatment voice therapy.

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Box 2 Differential diagnosis for dysphonia Differential diagnosis dysphonia Laryngitis Chronic Viral Bacterial Fungal Allergic Reflux Sicca Benign lesions Polyp Varices Cyst Pseudocyst Nodules Granuloma Reinke edema Reactive lesion Hemorrhage Laryngocele Airway stenosis Web Scar Presbylarynges/Atrophy Muscle tension dysphonia Neurologic and neuromuscular Vocal fold paralysis Vocal fold paresis Spasmodic dystonia Tremor Clonus Cerebral vascular accident Parkinson disease Amyotrophic lateral sclerosis Myasthenia gravis Recurrent respiratory papillomatosis Leukoplakia Neoplasm Verrucous

Evaluation of the Dysphonic Patient

Squamous cell Granular cell Metastatic Systemic disease Rheumatologic lesions Systemic lupus erythematosus Sarcoidosis Granulomatosis with polyangitis (Wegener) Amyloidosis Tuberculosis Hypothyroidism Syphilis Polychondritis Laryngeal trauma Cricoarytenoid dislocation Cricoarytenoid fixation Vocal fold tear

A thorough history includes a review of past medical history, operations, and medications. Progressive neurologic diseases, such as tremor, Parkinson disease, and amyotrophic lateral sclerosis, all involve the larynx and voice in different forms. Upper and lower airway disease could lead to chronic inflammation from post nasal drip, productive pulmonary secretions, or chronic throat clearing. Previous anterior cervical surgeries, such as anterior cervical discectomy and fusion, thyroidectomy, or carotid endarterectomy, all place the recurrent laryngeal nerve and external branch of the superior laryngeal nerve at risk for injury with subsequent dysphonia. Previous intubations can lead to paresis, paralysis, arytenoid immobility, or granuloma. Medications can produce a rough voice, as is often a result from the drying effects of diuretics. Angiotensin-converting enzyme inhibitors have the well-known side effect of cough, which can lead to chronic irritation and dysphonia. OFFICE EXAMINATION

Performer and music teacher Manuel Patricio Garcia of Spain first introduced the mirror laryngoscopy. It was subsequently adapted to the medical profession with modifications by Turk and Czermak.7 A thorough mirror examination has often been the combination of art and science, and culminates as a rite of passage or clinical diagnostic skill exclusive to otolaryngologists. With the tongue drawn forward, the patient phonates “e” to elevate the larynx and protrude the base of tongue anteriorly for optimal viewing of the endolarynx.8 Although the mirror provides a convenient and inexpensive examination, there are well-known limitations. It lacks magnification for finer lesions, anterior glottic visualization can be difficult, and the inability to record examinations limits patient education and review capabilities. The mirror laryngoscopy also precludes performing most voice tasks during the examination.

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Rigid endoscopy is performed by placing a Hopkins rod through the mouth to the posterior oropharynx. Topical anesthesia may be needed to reduce the gag reflex. The Hopkins rod has an alternating air-lens system that permits transmission of the image from the distal to the proximal end with minimal distortion. The distal end of the rod has an angled lens, typically 70 or 90 , to permit a view of the inferiorly situated larynx. The endoscope is coupled to a high-intensity light source while relaying a magnified image to the proximal eyepiece. The rod also can be coupled to a stroboscopic light source or a high-speed digital camera (see later in this article). The naked eye can be used through the eyepiece, or a video-capturing device can be attached to the eyepiece for recording and reviewing of images later. The technique is similar to the mirror examination in that the patient is in the seated sniffing position with the tongue drawn forward. The rigid endoscope enables the physician to acquire highquality images and detect the subtlest abnormalities. Similar to the mirror examination, the rigid examination limits the voice tasks, such as connected speech, because the device is occupying the oral cavity. In a direct comparison between mirror laryngoscopy and rigid angled indirect laryngoscopy, the use of the rigid endoscope produced significantly less gagging and pain for the patient.9 In addition, the rigid endoscope provided a more complete examination when compared with the mirror laryngoscopy, especially of the anterior glottis. Fiberoptic flexible laryngoscopy involves using a small-diameter cable with optical fibers that transmit both light from the proximal source and the image from the distal target. Similar to the rigid endoscope, the eyepiece may be used with the naked eye or connected to an image-capturing device for recording and review. Unique to the flexible scope is that it passes through the nasal cavity, nasopharynx, and oropharynx, limiting the gag reflex. Topical nasal anesthesia is sometimes used for this examination, although its use has not been demonstrated to significantly reduce patients’ discomfort.10 Initially, these scopes were plagued with poor light intensity and image quality, making them substandard to rigid endoscopic examination. However, flexible endoscopes with small cameras placed at the distal tip of the scope have enhanced image resolution that is of essentially the same quality as rigid endoscopes. The advantages of flexible laryngoscopy include the ability to evaluate the palatal function, as well as a full range of connected speech, breathing, and singing tasks. The smaller sizes also allow pediatric laryngeal evaluation. Regular white light laryngoscopy is excellent at identifying lesions, but lacks the ability to assess the vibratory characteristics. Fortunately, stroboscopy also can be performed via flexible examination. Stroboscopy uses a strobe light source synchronized to the vibratory frequency of the vocal folds to provide an image that appears to be still or in slow motion, depending on the settings selected. This uses the phenomena of flicker-free perception of light and the apparent motion from individual images.11 As mentioned, either rigid or flexible endoscopes can be used to perform stroboscopy. The technique relies on the ability to capture the frequency of the patient with either a microphone or electroglottographic transducer and synchronize it with that strobe light source. Exact frequency synchronization provides what appears as a still image from a single point in the vibratory cycle. Quasi-synchronization (1–2 Hz above frequency) provides an image that appears to be in continuous motion of successive points in the vibratory cycle, giving the appearance of a slow-motion vibratory cycle. This feature allows detailed evaluation of the vibratory cycle and the viscoelastic properties of the mucosal vocal folds as the body-cover relationship can be inspected for any alteration. Vocal fold vibratory characteristics have been demonstrated to be critical in evaluating voice disorders, as the use of videostroboscopy leads to a change in treatment decisions in 14% to 33% of patients.12–14 As mentioned, videostroboscopy

Evaluation of the Dysphonic Patient

relies on the ability to capture and synchronize with the patient’s frequency. Patients with aperiodic vibratory cycles are unable to be synchronized with stroboscopy. Stroboscopy is ineffective at evaluating voice onset and offset, as a small amount of time is needed to synchronize before image production. There are different aspects of the vocal folds that can be evaluated with videostroboscopy. One of the most recent and popular rating systems listed here provides a framework by which examinations can be evaluated in a systematic manner (Fig. 1).15 The rater is asked to evaluate amplitude, vertical level match, mucosal wave, and the nonvibratory portion of the musculomembranous portion of the vocal fold. Supraglottic activity can be measured in a medial-to-lateral and an anterior-toposterior compression pattern. The vocal fold edge is evaluated by both smoothness and straightness. Phase closure rates the percentage of time the vibratory cycle is in

Fig. 1. The stroboscopy evaluation and rating form (SERF). (From Poburka BJ. A new stroboscopy rating form. J Voice 1999;13(3):403–13; with permission.)

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Fig. 1. (continued).

the closed or open phase, whereas phase symmetry rates the percentage of time the mucosal vibration is in symmetric phase. Regularity measures the percentage of time that one vibratory cycle is like the next. Glottal closure describes the quality or characteristic of the glottal closure pattern. Videostroboscopy allows for a more detailed functional and anatomic evaluation of the vocal folds and their vibratory viscoelastic characteristics. Stroboscopy can reveal benign, premalignant, and malignant epithelial changes; however, it has been unable to consistently differentiate among these lesions based on vibratory characteristics alone.16,17 High-speed digital imaging may have utility beyond stroboscopy in the evaluation of vibratory properties of the vocal folds (Fig. 2).18 It uses a rigid endoscope similar to rigid videostroboscopy, but instead of giving the illusion of glottal cycle frame-byframe examination, HSDI captures images at the rate of 2000 to 5000 frames per second.19 This allows for onset and offset examination, as well as patients with an aperiodic vibratory cycle or frequency fluctuation. Based on computer memory limitations, only approximately 2 to 8 seconds of phonation is recorded; however, this provides

Evaluation of the Dysphonic Patient

Fig. 2. HSDI. Montage from high-speed video at 2000 frames per second. (From Krausert CR, Olszewski AE, Taylor LN, et al. Mucosal wave measurement and visualization techniques. J Voice 2011;25(4):395–405; with permission.)

thousands of images. The frequency speed of image capturing can be increased as can the use of color imaging instead of black and white. However, both come with the trade-off of image quality. HSDI can be expensive and time-consuming; however, the quality of images and universal application to aperiodic voice pathologies make it clinically useful in certain scenarios. The gold standard for laryngeal epithelial examination is still direct laryngoscopy (DL) in the operating room under general anesthesia. DL with a rigid endoscopic magnification allows for a close-up, magnified visual examination of the glottis. Angled endoscopes provide a refined examination of the ventricle, caudal surface of the vocal folds, the anterior commissure, the infraglottis, and the subglottis. Using the operating microscope frees up the surgeon’s hands for precise palpation and proprioceptive examination of the entire vocal fold epithelium and body. These advantages allow an increased detection of rate of glottal lesions and altering the surgical plan.20 Although DL is the gold standard, it is important to note that the larynges of all patients may not be able to be exposed in the operating room. Patients with trismus, an anterior larynx, postradiation neck changes, or previous cervical spinal pathology may still be best examined in the clinic or through a modified indirect approach in the operating room using a laryngeal mask anesthesia and flexible instrumentation. Narrow band imaging (NBI) is another recent adjuvant to laryngeal examination. NBI applies a filtered light via flexible or rigid endoscope to the mucosa, highlighting the underlying superficial vasculature. Through filtering specific green and blue wavelengths corresponding to the peaks of hemoglobin absorption, the capillaries and superficial veins within the epithelium and lamina propria are enhanced.21 NBI relies on the principle that neoplasms require neovascularization and, at the least, create a distortion of normal vascular patterns. These vascular pattern changes allow tumors

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to be detected when they otherwise would have been missed using traditional white light imaging (Fig. 3).22 NBI has been demonstrated to enhance the sensitivity and accuracy of delineating suspicious lesions in the larynx.23 Second, the borders between neoplasm and healthy epithelium are more distinguishable, aiding in preserving healthy mucosa during staging and treatment.24 VOICE EVALUATION MEASURES

Unfortunately, there is no “voice-o-gram” a clinician can use to quantitatively define the degree and quality of dysphonia in a fashion standardized across all patients. Therefore, we must rely on a combination of tools assessing psychosocial impact, perceptual analysis, acoustic analysis, and aerodynamic analysis (Box 3). This is important for many reasons, one of which is being able to compare outcome measures in the most patient-centered, meaningfully way possible. PATIENT-BASED PSYCHOSOCIAL IMPACT

One way to evaluate dysphonia is by measuring its impact on a patient’s quality of life. How dysphonia impacts a patient’s function, activity performance, or role in society touches on the World Health Organization’s International Classification of Impairments, Disabilities, and Handicaps. Multiple instruments have been founded and validated based on this approach to quality of life including the Voice Handicap Index (VHI), VHI-10, Voice-Related Quality of Life (V-RQOL), Voice Outcome Survey, Voice Activity and Participation Profile, and Voice Symptom Scale.25 The VHI is a 30-item questionnaire designed to examine the psychosocial consequences of voice disorders (Table 1).26 This is broken down into emotional, physical, and functional responses to dysphonia with an 18-point difference representing a significant shift in impact. Another quality-of-life assessment tool is the V-QROL, which includes a physical component score and a mental component score.27 Both the VHI and V-RQOL have been validated and used by many investigators to evaluate dysphonia in relation to laryngeal cancer and treatment outcomes.28–32 AUDITORY PERCEPTUAL MEASURES

Perceptual measures rely on the human auditory processing to make judgments of a patient’s voice. It is exactly this perceptual change that often brings patients into the physician’s office to be evaluated. Perceptual analysis should be an instantaneous

Fig. 3. (A) An in-office flexible endoscopic examination using white light. (B) An in-office flexible endoscopic examination using NBI. NBI demonstrates enhanced visualization of vascular stippling in neoplastic aryepiglottic fold mucosa.

Evaluation of the Dysphonic Patient

Box 3 Voice evaluation measures (psychosocial, perceptual, acoustic, aerodynamic) Psychosocial impact Voice Handicap Index (VHI) VHI 10 Voice-Related Quality of Life (V-RQOL) Voice Activity and Participation Profile Voice Outcomes Survey Voice Symptom Scale (VoiSS) Singing VHI Perceptual analysis “Severity, Roughness, Breathiness, Strain, Pitch, Loudness, Resonance, Tension, Fry, Breaks” Grade, roughness, breathiness, asthenia, strain (GRBAS) Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) Buffalo III Voice Profile Stockholm Voice Evaluation Approach Voice Profile Analysis Acoustic analysis Fundamental frequency Intensity Voice range profile Spectography and spectral measures Perturbation Nonlinear measures Aerodynamic analysis Volume: maximum phonation time (MPT) Airflow Pressure: phonation threshold pressure, offset pressure, resistance

and continuous process of the physician’s examination and evaluation. However, perceptual scoring is plagued with difficulties and inconsistencies given the reliance on the evaluator’s subjective interpretation, experience, and vocabulary. This subjective quality makes perceptual measures as much of an art as it is a science.33 Despite its limitations, perceptual analysis has its role in the clinical evaluation of a patient and outcomes measurements. Grade, roughness, breathiness, asthenia, strain (GRBAS) is a protocol rated on a 0 to 3-point scale for each measure, with the higher the score, the worse the perceptual effect.34 The Consensus Auditory Perceptual Evaluation of Voice (Fig. 4) (CAPE-V) was developed by the American Speech-Language Hearing Association with the intention of improving consistency across practitioner evaluations.35,36 CAPE-V evaluates severity, roughness, breathiness, strain, pitch, and loudness on a 100-mm analogue visual scale to be completed after standardized voice tasks. Studies have demonstrated slightly improved rater reliability with the CAPE-V,

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Table 1 VHI Questionnaire PART I: Functional aspect 1. Do people have difficulty understanding your voice?

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2. Do people have difficulty understanding you in noisy environments?

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3. Does your family have difficulty hearing you when you call them at home?

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4. Do you stop using the telephone because of your voice?

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5. Do you avoid groups of people because of your voice?

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6. Do you talk less to friends, neighbors and relatives because of your voice?

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7. Do people ask you to repeat yourself when talking to you face-to-face?

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8. Does your voice restrict you in your personal and social lives?

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9. Do you feel left out in conversations or discussions because of your voice?

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10. Has your voice problem caused you to lose your job?

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PART II: Physical aspect 1. Do you feel breathless when talking?

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2. Does your voice vary during the day?

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3. Do people ask, “What’s wrong with your voice?”

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4. Does your voice feel hissy or dry?

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5. Do you struggle to produce your voice?

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6. Is the clarity of your voice unpredictable?

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7. Do you try to change your voice to sound different?

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8. Does it take a lot of effort to speak?

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9. Is your voice worse at the end of the day?

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10. Does your voice fail in the middle of a conversation?

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PART III: Emotional aspect 1. Do you feel tense when talking to other people because of your voice?

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2. Do people get irritated because of your voice?

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3. Do you feel other people do not understand your voice problem?

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4. Does your voice bother you?

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5. Are you less sociable because of your voice?

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6. Do you feel impaired because of your voice problem?

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7. Do you dislike it when people ask you to repeat yourself?

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8. Do you feel embarrassed when people ask you to repeat yourself?

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9. Does your voice make you feel incompetent?

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10. Do you feel ashamed of your voice problem?

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0, Never; 1, Almost never; 2, Sometimes; 3, Almost always; 4, Always. Courtesy of the American Speech-Language-Hearing Association, Rockville, MD; with permission.

relatively good reliability between GRBAS and CAPE-V, but weak agreement with patient-based questionnaires, such as V-QROL.36,37 ACOUSTIC MEASURES

Acoustic analysis is based on the source-filter theory of speech production, where the glottal spectrum sound source is then filtered into a modified output waveform.38 As the glottal spectrum travels through the supralaryngeal cavity, individual

Evaluation of the Dysphonic Patient

Fig. 4. Consensus auditory perceptual evaluation of voice. (The CAPE-V was developed by the American Speech-Language-Hearing Association’s Special Interest Group 3 (formerly known as Special Interest Division 3), Voice and Voice Disorders, and is used and reproduced herein under license. Ó [2006, 2010] American Speech-Language-Hearing Association. All rights in and to the CAPE-V are reserved and held by the American Speech-Language-Hearing Association.)

frequency components are either maximized into formants or minimized. Different acoustic measures include fundamental frequency (Fo), perturbation indices (jitter and shimmer), nonlinear measures, voice range profiles, and spectral and cepstral measures. Fo is determined by the vocal fold oscillation rate as measured in hertz (Hz). It is dependent on characteristics of the vocal folds themselves, including mass, length, and tension. Varying these variables changes the subsequent frequency of the voice. Children, with shorter and thinner folds, have an Fo of 220 to 240 Hz, which

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subsequently diverges in adulthood to a female range of 200 to 220 Hz or adult male range of 100 to 120 Hz.39 Vocal intensity, or loudness, as measured in decibels is a product of subglottic pressure and vocal fold vibratory amplitude. Changes in the ability to generate subglottic pressure, poor glottal valve competency, or viscoelastic properties changes that restrict mucosal excursion all result in reduced intensity. The voice range profile, or phonetogram, is a visual representation of the relationship between intensity and pitch (Fig. 5). It represents the minimum and maximum of intensity and frequency, and there have been demonstrated restrictions and changes in the phonetogram after endoscopic cordectomy for glottic cancer.40 The vocal range profile is something most patients often are not mindful of until it has been reduced from cancer or its subsequent treatment. Knowledge of it should guide the surgeon in counseling that posttreatment voice outcomes will be limited in range and intensity. Spectography and cepstral-based measures estimate irregular formant patterns and voice disruption in continuous speech. A meta-analysis on acoustic measures and overall voice quality found the cepstral metric the most promising and robust acoustic measure to dysphonia severity.41 AERODYNAMIC MEASURES

Aerodynamic analysis of the voice involves measuring different quantitative values along the vocal tract. These include flow volume, maximum phonation time, phonation

Fig. 5. Phonetogram (Voice Range Profile [VRP]). A selection of average/norm VRP for the female voice. (From Pabon P, Stallinga R, So¨dersten M, et al. Effects on vocal range and voice quality of singing voice training: the classically trained female voice. J Voice 2014;28(1):36–51; with permission.)

Evaluation of the Dysphonic Patient

threshold pressure and flow, and offset pressure. Increasing the area of endoscopic cordectomy increases phonation threshold pressure and flow rate, leading to a breathy and rough voice.42 Also, increased phonation threshold pressure is correlated to increased vocal fatigue and effort.43 Briefly, it is important to emphasize the role of the SLP in laryngeal cancer. In addition to the collection and interpretation of the previously mentioned voice measures, the SLP provides expertise in posttreatment voice and swallowing rehabilitation.44,45 The SLP provides an integral piece of the continuity of patient care, strengthening the relationship with the patient, and providing an extra resource the surgeon may not have time or the knowledge to fulfill. DIAGNOSTIC SPECIMEN

The culmination of the evaluation of the dysphonic patient is the biopsy of any concerning lesions for pathologic diagnosis. Tissue diagnosis is required before any intervention of a presumed malignant lesion. Traditionally, this is performed in the operating room with the patient under general anesthesia with a DL. There are multiple descriptions of the proper technique for DL and an arsenal of laryngoscopes designed for unique scenarios.46,47 The underlying principles are all the same. There must be a preoperative assessment of the anesthesia risks of the patient, including heart and lung disease. A surgeon must avoid injuring normal structures, such as teeth, lips, gums, tongue, and pharyngeal and laryngeal mucosa. One prospective study demonstrated a 37% risk of a minor complication after suspension laryngoscopy, including taste and swallowing disturbances, with the average effects lasting 11 days.48 A DL consists of a thorough evaluation of all of the structures in the upper aerodigestive tract with biopsies of any concerning lesions. Although biopsies must be adequate for diagnosis, particularly on the vocal folds, they must all avoid injuring uninvolved epithelium and unnecessary subsequent permanent dysphonia. Overzealous biopsies or stripping run the risks of permanently damaging the viscoelastic properties of the lamina propria. Scar and sulcus formation of the epithelium can lead to permanent dysphonia that is difficult to rehabilitate. This caution must be viewed in light of the entire clinical picture given the severity or lack thereof in a patient’s disease and their likely treatment pathway. Another option that is emerging as a safe, effective, and cost-reducing method for obtaining permanent tissue diagnosis is the in-office biopsy.49–51 In-office biopsy bypasses risks involved with anesthesia, negates the need to manage a difficult intubation, and reduces the overall cost of treatment. This report demonstrated that in-office biopsy reduces the cost of tissue diagnosis from approximately $9000 to $2000, while reducing the time to overall treatment from approximately 48 days to 24 days. Success from in-office biopsy ranges from 94% to 98%. SUMMARY

Evaluation of the dysphonic patient begins as soon as the patient walks in the door with attentive listening of his or her voice and can lead all the way to the operating room, as appropriate. Training one’s ear to appreciate the subtleties of voice characteristics will allow the physician to hone the pretest probability of a diagnosis before any laryngeal examination. The mirror laryngoscopy may be a convenient, initial examination; however, any patient with a persistent vocal complaint warrants a more detailed inspection of the vocal folds with a magnified, reviewable technique. There are multiple numerous voice evaluation measures, and their specific application value is still being determined. However, they do provide the clinician with objective measures by which to gauge and demonstrate the effects of treatment. The SLP is an

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important member of the treatment team, providing skills in voice evaluation, treatment counseling, and functional rehabilitation. Finally, for concerning or persistent lesions, biopsy, whether in the operating room or the office, provides the definitive diagnosis to guide subsequent counseling and treatment. REFERENCES

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