Journal of Surgical Oncology 44:lO-14 (1990)

Evaluation of Voice by Patients and Close Relatives Following Different Laryngeal Cancer Treatments D A V I D E. SCHULLER, MD, MICHAEL TRUDEAU, PhD, JANE BISTLINE, From The Ohio State University, Columbus

AND

KAREN LAFACE

The purpose of this study was to assess perception of life style change among laryngeal cancer patients. Seventy-five patients (total laryngectomy 35, supraglottic laryngectomy 15, hemilaryngectoiny 12, radiotherapy eight, laser cordectomy five) and close relatives responded to a questionnaire and interview eliciting perception of 1) posttreatment voice quality; 2) side effects of treatment vocationally and socially; and 3) degree of vocal or communicative change associated with vocational or social change. Whereas 43% of the patients reported vocational change and 37% reported social change, 88% expressed satisfaction with their posttreatment voices. This may have been due to the perceptions of the relatives, who generally had a more positive view of the patients’ voices. Although laryngeal cancer had an impact on patient life style, patients seldom related this to vocal dysfunction. ~

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KEY WORDS: questionnaire and interview assessment, life style, laryngectomy

INTRODUCTION Current options for treating patients with laryngeal carcinoma involve radiation therapy and/or surgery. The literature supports the curative effectiveness of either irradiation [ I ] or surgery [2,3] for early-stage disease and of combined approaches using surgery and radiotherapy [4] for more advanced disease. Radiotherapy as the sole treatment for superficial supraglottic or cordal lesions has documented efficacy [5-71. Surgical techniques in the management of this cancer vary greatly in degree of conservation of laryngeal functions, ranging from laser excision of small, mucosal, noninvasive tumors with minimal or no laryngeal impairment to total laryngectomy. First reported as a treatment for cancer in 1873 [8], total laryngectomy remained the treatment of choice for decades. In the 1940s, surgeons’ reports [9] of more sparing procedures began to emerge. The supraglottic laryngectomy and the hemilaryngectomy [6,10-1.51 provided oncologically sound options that preserved laryngeal functions in deglutition and phonation. Successful therapeusis for laryngeal carcinoma encompasses long-term survival of the patients and raises, 0 1990 Wiley-Liss, Inc.

therefore, the issue of the patient’s quality of life once medical management is complete. The psychosocial impact of total laryngectomy has received some attention in the professional literature [ 16-21]; however, the effects of more conservative procedures are less well documented. Because one of the most noticeable and persisting sequelae of laryngeal cancer is alteration of voice and speech, the focus of the present investigation is to describe the perceptual voice and speech characteristics of posttreatment laryngeal cancer patients and their reactions to their voices. Three questions are raised: 1) To what degree are these patients satisfied or dissatisfied with their post treatment voice and speech, and to what degree does this satisfaction vary as a function of the type of treatment? 2) Has there been a change in life style for these patients as a result of cancer treatment and do

Accepted for publication December 29, 1989. Presented at the American Society for Head and Neck Surgery Meeting, May 7, 1986, in Paliii Beach, Florida. Address reprint requests to David E. Schuller, MD. Department of Otolaryngology, The Ohio State University, 456 West Tenth Ave.. Columbus, OH 43210.

Evaluation of Voice After Cancer Treatments

11

injections of the larynx following heniilaryngectomy. All the patients were decannulated and eating by mouth. Treat men t Number Eight patients had curative dosages of radiation ther35 Total laryngectomy with vocal restoration apy (6,500 rads), and none required any type of surgical 15 Supraglottic laryngectomy intervention. All the patients were eating by mouth. 12 Hemilnryngectomy 8 Radiation therapy Five patients had endoscopic cordectomy using the 5 Endoscopic laher cordectomy carbon dioxide laser attached to the microscope. None underwent tracheotomy. This was a selective group of patients who had only superficially invasive squamous these patients feel that alteration in voice contributed to cell carcinoma. The technique of ablation involved vathe change in life style? 3) How do significant others porization of the upper portions of the involved segment perceive the posttreatment vocal abilities of these pa- of vocal cord, including a portion of the vocalis muscle, tients and how do their perceptions compare with those using the carbon dioxide laser as a means of vaporizing tissue. Following the initial vaporization, multiple frozen of the patient’? sections of the depths of anterior and posterior extent of the resection were used to verify the absence of residual MATERIALS AND METHODS tumor. Healing was allowed to occur secondarily by way The 75 patients in this study were all from the case of mucosal migration. Voice rest was maintained for 2 load of the Department of Otolaryngology, The Ohio weeks postoperatively. At the time of the interview, all State Univerqity. The time of treatment ranged from patients displayed normal, bilateral vocal cord mobility 1966 to 1985. At the time of the study, all patients were and were eating by mouth. Each patient’s life style and perception of voice qualdisease-free. The distribution of treatments are listed in ity were assessed by means of a questionnaire (Appendix Table I. A) completed by the patient at the time of a personal The largest group of patients (35) underwent total laryngectomy. Fifteen of these patients had concomitant interview with one of the investigators (J.B.). The perneck dissection. Total laryngectomy was performed in ception of the patient’s voice quality by a relative was the standard manner, with a multilayered closure of the similarly assessed. These relatives had lived or were livhypopharyngeal defect. Cricopharyngeal myotoniy was ing with the patients and knew the patient before and not performed. Five of these patients used esophageal after the treatment. Sixty-two were currently living with speech as their means of vocal communication and had the patient. Fifty-seven were wives, and the remainder speech therapy to train them in this form of speech. were sons, daughters, sisters, or husbands. These relaThirty had voice restoration via tracheoesophageal (t-e) tives had lived with the patient an average of 34.4 years, puncture, 21 at the time of the laryngectomy and nine as with a range of 4-72 years. Both assessments occurred a second procedure. The patients undergoing primary t-e from 5 months to 19 years following treatment (mean puncture vs. secondary puncture were not separated be- interval 4.8 years). cause our experience [22] indicated no appreciable difRESULTS ference between groups with respect to successful restoration. Nine of the patients required some degree of Of 75 patients, 47 were working when diagnosis was speech therapy beyond the instruction associated with the made and 27 returned to their pretreatment job status. initial insertion of the voice prosthesis. All had com- Among these 27, the interval between treatment and repleted therapy beyond the instruction associated with the turn to work was 1-3.3 months, with a mean of 2.3 initial insertion of the voice prosthesis. All had com- months. The distribution by treatment modality was laser pleted therapy prior to this study. Of the 15 patients with cordectomy , three of three; radiotherapy, three of four; supraglottic laryngectomy. four had associated radical total laryngectomy , 12 of 20; supraglottic laryngectomy , neck dissection. None received cricopharyngeal myot- five of 1 1 ; and hemilaryngectomy four of nine. omy. Laryngeal resuspension to either the mandible or In terms of vocational change, those patients who did the subniental soft tissue was performed in all of the not return to work rarely cited voice-related problems as patients. All the patients were decannulated and were the salient reason. Reasons for not returning to work eating by mouth. were typical of characteristics of this population: onset of There were 12 patients with hemilaryngectomy who the disease often coincides with retirement age and the had tissue inserted into the area of the resected cord to patient accepts retirement, and this group often has other facilitate approximation of the remaining cord. Pyriform health problems, e.g., emphysema or liver disease, sinus mucosa was mobilized to cover partially the inter- which with the cancer treatment remove the patient from posed soft tissue. None of these patients received Teflon the work force. Two patients specifically noted alteration TABLE I. Treatment Modalities ~

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Schuller et al.

TABLE 11. Patient's Perception of Posttreatment Voice Supraplottic laryngectomy (n = IS)

Laser (n S)

Heinilaryngectomy (n = 12)

Total laryngectorny wivocal restoration (n = 3)

Radiotherapy ( n = 8)

-

E"

A

U

E

A

U

E

A

U

E

A

U

E

A

U

Overall voice Loudness Comprehension Pitch

2 2 3 Hh 0

3 3 2

0 0 0 L 0

4

I0 II 9

I

4

3 1

2

8 10

0 0

7

0 L I

0 I 2 H 0

7 6

S II

22 27 22 S 27

7 6

5 tl 0

6 2 8 H 0

I I 0 1.

S S

2 5 H 0

s

L

1.7

2

s L 8

6 S 6

2

"E. excellent: A , adequate: C, unsatisfactory 'H. high: S. satisfactory: L, low.

of voice as directly affecting their decisions not to return to work: One was a police dispatcher and the other was a factory worker whose job required a strong voice. Two-thirds of the patients (47) reported that they experienced no social change as a result of treatment. The 28 patients who felt an alteration in social activity provided 35 reasons for the alteration. Nineteen of these reasons were for factors other than voice, e.g., inability to continue swimming due to a tracheostomy; nine described reduced loudness as a problem, and seven described increased difficulty of others in understanding the patient's speech. The most common nonvocal complaint for altered social activities was a hesitancy to eat in public due to difficulty swallowing. This was more frequently noted by those patients in the relatively recent postoperative period. A majority of the patients (39:)reported that they preferred others to talk for them. This was typically associated with feelings that the voice lacked adequate loudness or fatigued easily. Although a majority prefcrred others to talk for them, nine of ten felt that they had ad-lusted to the vocal alteration and were able to function with their current level of phonatory ability. By method of treatment, those patients with total laryngectomies were more likely to prefer othcrs to speak for them ( 18 of 35); however, none of the patients who had laser cordectomy indicated a preference for this. Of the patients treated by other methods, the preference for others to speak for them was found among thrce of eight who underwent radiotherapy, six of 12 who underwent hemilaryngectomy, and 12 of 15 who had supraglottic laryngectomy. Only six patients reported lowered self-esteem following treatment. Five of these were in the total laryngectomy group. The patients' self-analysis of voice quality (Table 11) revealed 16 (21%) assessed voice quality as excellent, 50 (67%) as adequate, and nine (12%7) as unsatisfactory. None of the patients from the laser or heniilaryngectomy

groups were dissatisfied with their voices. Of those dissatisfied, one each were from the supraglottic and radiotherapy groups, and the remaining seven were from the total laryngectomy group. Although radiotherapy may be considered the least invasive method of treatment and the most sparing of laryngeal function. none of these patients reported excellent voice quality. Six reported adequate quality. Voice quality reported by the supraglottic and hemilaryngectomy groups was remarkably similar. Our expectation was that satisfaction would be lower among the hemilaryngectomy group because of the presence of only one vocal cord. All 12 of the patients with hemilaryngectomies reported excellent or satisfactory voice in comparison with 14 of 15 patients with supraglottic laryngectomies. The relatives' overall satisfaction with posttreatment voice (Table 111) was slightly higher than that of the patients, with 28 vs. 16 ratings in the excellent category. Aside from this tendency to evaluate voice quality sornewhat more positively than the patients. the relatives' response were highly congruent with the patients'. In only one instance did a relative rate voice quality lower than did the patient.

DISCUSSION The initial information regarding job status demonstrated that about 43% of the patients who were working did not return to work after completing treatment. However. in the group who did not return to work, the change in either voice loudness or understandability was identified as the reason for a stop in employment in only 43% of the responses. Reasons other than voice change were more commonly identified (57%). Only 28 patients reported negative effects of the cancer treatment on their social activities. In citing factors adversely affecting social activity, this group was more likely to identify nonvoice or speech-related issues (54% of responses) than to specify communicative dysfunction

Evaluation of Voice After Cancer Treatments

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TABLE 111. Relative’s Perception of Posttreatment Voice Supraglottic laryngectomy ( n = 15)

Laser (n = 5 ) E Overall voice Loudness Comprehension

4 3 4

‘

A 1

2 I

U 0 0 0

Hemilaryngectomy (n = 12)

Total laryngectomy wivocal restoration ( n = 3)

Radiotherapy (n = 8)

E

A

U

E

A

U

E

A

U

E

A

U

5 3 3

9 10 II

1

3 2 6

9

0 I 0

14 6 8

20 23 23

1

2 0 3

5 7 4

I I

2 1

9

6

6 4

1

”E, excellent; A, adequate; U. unsatisfactory.

as the agent. When communicative dysfunction was specified, the patients reported reduction in loudness or i n understandability a s the main problems. In numerical terms, 13 patients of 75 felt that alteration in voice or speech had a negative effect on their social activities. Thirty-nine (52%) of the patients preferred others to talk during conversation. Most of these patients identified early voice fatiguability and difficulty in being heard in crowded restaurants as the reason for preferring others to talk. The majority of the patients (91%), however, responded that they had adjusted to and accepted their new voice quality. In fact, there were only six patients (8%) who stated that they have experienced a lower selfesteem following completion of treatment. In those few patients with lowered self-esteem, the alterations in voice loudness and understandability were identified as the reasons. This adjustment to the posttreatment voice with rare negative effect on self-esteem may be the reasons for the infrequent alterations in employment or social activities attributable to changes in the voice. The posttreatment voice quality was surprising because of the number (88%) who classified their voices as being either excellent or adequate. This enthusiastic response to the overall voice quality was similar to characterization of loudness, understandability, and pitch of the posttreatment voice. The patients’ positive assessments were echoed by relatives. This group reported the voice as being excellent or adequate in 96% of the study population. This assessment of overall voice quality was similar to the relative’s perception of the loudness and understandability of the patient’s voice. The assumption had been that hemilaryngectomy with removal of one true vocal cord more drastically decreases the quality of the voice than supraglottic laryngectomy, in which the true vocal cords are preserved. However, the analysis of the results of this study demonstrated that neither the patient’s nor the relative’s reaction to the quality of voice was drastically different with these two procedures. Although a difference may occur acoustically, the perceptual response to voice following the two procedures is very similar.

CONCLUSIONS In overview, these evaluations of posttreatment voice provided by patients and relatives indicate that the quality of the posttreatment voice is acceptable for vocational and social functioning, and there are no notable differences among the different surgical approaches or even between surgical approaches and radiation therapy. These voice alterations, of themselves, do not drastically affect the patient’s employment, social activities, or selfesteem. ACKNOWLEDGMENTS This investigation was supported in part by PHS grants P-30-CA-16068-11 (D.E.S.) and 2-R25-CA18016-08Al (M.T.) awarded by the National Cancer Institute, DHHS. REFERENCES 1 Ennuyer A, Pataini P: Treatment of supraglottic carcinoma by

telecobalt therapy. Br J Radio1 38:661-668, 1965. 2 Ogura JH, Biller HF: Conservative surgery in cancer of the head and neck. Otolarynol Clin North Am 2:641-665. 1969. 3 Som ML: Conservation surgery for carcinoma of the supraglottis. J Laryngol Otol 84:655-663. 1970. 4. Wang CC. Schultz MD, Miller D: Combined radiation therapy and surgery for carcinoma of the supraglottic and pyriform sinus. Am J Surg 124551-554. 1972. 5 . Goffinet DR, Eltringhani JR, Glastein E, Bagshaw MA: Carcinoma of the larynx: Results of radiation therapy in 213 patients. Am J Roentgen01 Radium Therapy Nuclear Med 117:553-564. 1973. 6. Coates HL, DeSanto LW, Devine KD, Elveback LA: Carcinoma of the supraglottic larynx. A review of 221 cases. Arch Otolarynol 102686-689, 1976. 7 . Verrnund H: Role of radiotherapy in cancer of the larynx as related to the TNM system of staging. A review. Cancer 25:485-504, 1970. 8. Billroth CAT, Gussenbauer C: Uber die erste durch The. Billroth am menchen ausgefuhrte kehlkopf extirepation und die anwendung eines kunstlichen kehlopfes. Arch Klin Chir 17343-356, 1874. [Cited in Keith R, Darley F (eds): “Laryngectomes Rehabilitation.” San Diego. College-Hill Press, 1986. 9. Alonso JM: Conservation surgery of cancer of the larynx. Trans Am Acad Ophthalmol Otolarynol 51:633-642. 1947. 10. Ogura JH: Supraglottic subtotal laryngectorny and radical neck dissection for carcinoma of the epiglottis. Laryngoscope 68:983 1003. 1958. I I . Som ML: Surgical treatment of carcinoma of the epiglottis by

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12. 13. 14.

15.

16. 17.

Schuller et al. lateral pharyngeotomy. Trans Am Acad Ophthalmol Otolarynol 63:28-49, 1959. Bocca E: Supraglottic cancer. Laryngoscope 85:1318-1326, 1975. Ogura JH. Sessions DG. Spector GJ: Conservation surgery for epidermoid carcinoma of the supraglottic larynx. Laryngoscope 85: 1808-1 8 15, 1975. Ogura JH, Sessions DG, Ciralsky RH: Supraglottic laryngectomy with extension to the arytenoid. Laryngoscope 85: 1327-1 33 I , 1975. Kirchner JA, Owen JR: Five hundred cancers of the larynx and pyrifotm sinus. Results of treatment of radiation and surgery. Laryngoscope 87:1288-1303, 1977. Gardner WH: Adjustment problems of laryngectomized women. Arch Otolaryngol 83:31-42, 1966. Amster WW. Love RJ, Menzel OJ, Sandler J , Sculthorpe WB,

18.

19.

20. 21, 22.

Gross FM: Psychosocial factors and speech after laryngectomy. J Commun Disord 5:l-18. 1972. Gilmore SI: Social and vocational acceptability of esophageal speakers compared to normal speakers. J Speech Hearing Res 17599-607, 1974. Blood G, Blood I: A tactic for facilitating social interaction with laryngectomies. J Speech Hearing Disord 47:416-419, 1982. Byles PL. Forner LL, Stemple JC: Communication apprehension in esophageal and tracheoesophageal speakers. J Speech Hearing Disord 50:114-119. 1985. Natvig K: Laryngectoniies in Norway. Study No. 1: Social, personal, and behavioral factors related to present mastery of the laryngectomy event. J Otolaryngol 12155-162. 1983. Trudeau MD, Hirch SM. Schuller DE: Vocal restorative surgery: Why wait'? Laryngoscope 96:975-977, 1986.

APPENDIX PATIENT QUESTIONNAIRE Patient Number 1. 2. 3. 4. 5. 6. 7.

My occupation before treatment was After completion of all my treatment, I did not return to my job for-months. After treatment, 1 returned to my usual job. Yes-NoI was not able to perform my usual job because my voice was not loud enough. Yes-NoI was not able to perform my usual job because others could not understand my voice. Yes-NoI did not return to my usual job because of reasons other than my voice change. Yes-NoPlease list all of your social activities, such as attending movies or eating at restaurants before your treatment (include sports activities).

c. d.

8. 9. 10. 11. 12.

13. 14. 15. 16. 17.

18. 19. 20.

After treatment. my social activities changed. Yes-NoIF YOUR ANSWER TO #8 WAS YES, THEN ANSWER QUESTIONS #9, 10. AND 11. My social activities changed because my voice was not loud enough. Yes-NoMy social activities changed because others could not understand my voice. Yes-NoMy social activities changed for reasons not related to my voice change. Yes-NoI feel that I have adjusted to my changed voice aince completion of treatment. Yes-NoSince completion of treatment, I prefer others to talk more than I do during conversations. Yes-NoIF YOUR ANSWER TO # I 3 WAS YES, PLEASE ANSWER #14, 15. AND 16. I rely more on others during conversations becuase of my mental outlook. Yes-NoI rely more on others because my voice is not loud enough. Yes-NoI rely more on others because others cannot understand my voice. Yes-NoSince completion of treatment, 1 feel that I have less self-esteem. Yes-NoIF YOUR ANSWER TO QUESTION #I7 WAS YES, PLEASE ANSWER #18. 19. AND 20. I have less self-esteem because my voice is not loud enough. Yes-NoI have less self-esteem because others cannot understand my voice. Yes-No1 have less self-esteem because of reasons other than my voice change. Yes-No-