Voice Disorders in the General Greek Population and in Patients With Laryngopharyngeal Reflux. Prevalence and Risk Factors *Nikolaos Spantideas, *Eirini Drosou, †Anna Karatsis, and ‡Dimitrios Assimakopoulos, *Agios Dimitrios, Athens, and yAgios Nikolaos, Crete, and zIoannina, Greece
Summary: Objectives. To assess the prevalence of voice disorders in the general Greek population and in patients with laryngopharyngeal reflux (LPR) with the use of the reflux symptom index (RSI). Study Design. Prospective epidemiological adult participant survey. Setting. General Greek population. Method. The validated Greek version of the RSI was used to assess the prevalence of voice disorders in the general Greek population, as well as in patients with LPR, which were diagnosed using the RSI. The RSI questionnaire was completed by 340 (183 males and 157 females) randomly selected subjects. Subjects with RSI score of >13 were considered to be LPR patients. Results. The prevalence of voice disorders, which was determined by the participants giving a positive response to the field ‘‘hoarseness or a problem with your voice,’’ was found to be 38.5% in the general Greek population. In patients with LPR, ‘‘hoarseness or a problem with your voice’’ was present in 90.6%. The number of cigarettes smoked daily and the number of alcoholic drinks consumed daily, each correlated with the presence of voice disorders. No relationship was revealed between voice disorders and coexisting diseases and especially with gastroesophageal reflux disease, which was the most frequent reported disorder among peptic diseases. Conclusions. The prevalence of voice disorders, determined by a positive response to the question ‘‘hoarseness or a problem with your voice,’’ is high (38.5%) in the general population and very high (90.6%) in patients with LPR. The number of tobacco cigarettes smoked daily and the number of alcoholic drinks consumed daily were found to be related to voice disorders. Key Words: Voice disorders–Reflux symptom index–Laryngopharyngeal reflux–Gastroesophageal reflux–Reflux– Prevalence.
INTRODUCTION Although voice disorders seem to be very common in the general population, affecting nearly one-third of the population at some point of their life,1,2 the true prevalence of the problem remains undetermined. Epidemiological studies, showing the actual size of the problem, are relatively rare, and the reported prevalence of voice disorders in the existing small number of studies shows substantial variability, ranging from 0.65% to 41.6%.3–6 This variability in the reported prevalence estimates is mainly because of the different methodological approach selected by each study to define voice disorders, in addition to the differences in sample populations and sizes. The prevalence of voice disorders has been studied more extensively in certain professions, such as teachers, where the prevalence of voice disorders has been found to vary from 7% to 80%, depending on the studied groups, response rate, and the way the question was set.5,7–15 Most of these studies use general population subjects as a control group, and this is a source of data regarding prevalence of voice disorders in the Accepted for publication August 12, 2014. From the *Athens Speech and Language Institute, Agios Dimitrios, Athens, Greece; yPrivate Practice, Agios Nikolaos, Crete, Greece; and the zENT Department of University Hospital of Ioannina, Medical School of University of Ioannina, Ioannina, Greece. Address correspondence and reprint requests to Nikolaos Spantideas, Athens Speech and Language Institute, 10 Lontou Street, Glyfada, Athens 16675, Greece. E-mail: [email protected] Journal of Voice, Vol. 29, No. 3, pp. 389.e27-389.e32 0892-1997/$36.00 Ó 2015 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.08.006
general population. Roy et al1 reported that 58% of teachers experience voice problems at some point during their career, compared with 29% among nonteachers. Voice disorders are often caused by benign or self-limited conditions but may also be symptoms of serious diseases, and in these cases, early diagnosis is critical for the prognosis of the disease. Voice disorders have significant public health consequences for the patients’ quality of life and their ability to function in social or workplace settings.16,17 In addition to the impact on health and quality of life, voice disorders lead to frequent health care visits with high health care cost, which is accompanied by diminished productivity because of work absenteeism.18,19 Laryngopharyngeal reflux (LPR) seems to be very common in the general population, and one of the main symptoms is hoarseness. Several tests are used to diagnose LPR with different sensitivity and specificity values. The ambulatory 24-hour pH double-probe (simultaneous esophageal and pharyngeal) pH monitoring has an acceptable sensitivity for detecting LPR and has been considered as the gold standard for LPR diagnosis. However, given the invasive nature of the time-consuming method, it is doubtful whether this method will ever become widely used, for not only epidemiological studies but also routine clinical use. There is need for an easy, reliable, and practical method that can give comparable findings through different populations to carry out large-scale epidemiological studies on the general
389.e28 population. The development and evaluation of a standardized and validated patient-reported instrument, based mainly on self-assessment of symptoms, has the potential to facilitate or even establish an LPR diagnosis. Such a diagnostic tool could also be useful for epidemiologic studies. The reflux symptom index (RSI) introduced by Belafsky et al20 is a self-administered nine-item questionnaire designed to assess various symptoms related to LPR (Table 1). Each item is rated on a scale from 0 (no problem) to 5 (severe problem), with a maximum total score of 45, indicating the most severe symptoms. An RSI greater than 13 is considered abnormal and strongly indicative of LPR. The RSI has been compared with other LPR diagnostic methods, such as laryngoscopy and the ambulatory 24-hour pH double-probe pH monitoring, and has been proved to share similar diagnostic value.20–22 In this regard, RSI can be used as an alternative tool for LPR diagnosis. A key question of RSI is the experience of ‘‘hoarseness or other voice problems’’ during the previous month. Although hoarseness is a very well-defined symptom,23 the term ‘‘other voice problems’’ is a broader one, leaving space for reporting any kind of voice complaints without specific description and thus, including a heterogeneous grouping of voice-related complaints. In addition, RSI can give information not only about the prevalence of the included items in the questionnaire but also about their severity. Since the introduction of RSI, many studies have been conducted mainly to detect LPR prevalence, but no further analysis of the prevalence of each item included in the questionnaire has been presented. The primary aim of this study was to assess the prevalence of voice disorders in the adult general Greek population and in patients with diagnosed LPR, using the RSI. MATERIALS AND METHODS The study was carried out in the general Greek population during the period from September to November 2011. A random sample (n ¼ 1000) of adults living in Athens was initially approached through an ‘‘alert’’ telephone. During the communication, the scope of the study was explained, and permission to send the questionnaire to the subjects’ address was obtained.
Journal of Voice, Vol. 29, No. 3, 2015
The random selection of the participants was made through the telephone catalog of Athens City using a table of random numbers generated for the study. Five different investigators performed the calls 10 days before sending the questionnaire. Of the 1000 approached subjects, 450 accepted to participate and provided their personal details (name and address). The envelop that was sent to the participants involved a more detailed explanation for the scope of the study, detailed instructions for filling out the questionnaires, and a prepaid envelope, so that subjects could easily send back the filled-in questionnaire, and the signed informed consent (also involved) at no cost for them. Three hundred fifty individuals returned the questionnaires. Data related to voice disorders were gathered through the questionnaire with which information about demographic data of the participants, concomitant diseases, concurrent medication, as well as the RSI questions were acquired. The RSI questionnaire has been translated into Greek and has been validated in the Greek population.22 For the purpose of this study, voice disorders and their prevalence were detected on the basis of the response of the participants to the question ‘‘hoarseness or a problem with your voice.’’ The study protocol was approved by the Scientific Committee and Review Board of Athens Speech and Language Institute. Informed consent was obtained from all participants before inclusion in the study. Statistical methodology Statistical tests were performed using the SPSS statistical software. Descriptive statistics were used to summarize data for the subset of the population with voice disorders. Chi-square tests were used to compare the distribution of category variables among patients with voice disorders compared with those without voice disorders. The t test was used to compare continuous variables between patients with voice disorders in comparison to the rest of the population. A P value of 0.05). One hundred one subjects (29.7%) consumed alcohol (68.3% males and 31.7% females). Mean daily alcohol consumption was 2.43 ± 1.62 units for males and 2.17 ± 1.32 units for females without a statistically significant difference between the two genders (t test >0.05). The most commonly reported alcoholic drinks were wine (30 subjects) followed by beer (21 subjects) and whisky (18 subjects). One hundred forty-two (41.8%) of the participants reported one or more diseases. The reported diseases were cardiovascular 50 (35.2%), gastrointestinal 25 (17.6%), musculoskeletal 15 (10.6%), respiratory 10 (7.0%), thyroidopathy 9 (6.3%), anemia 3 (2.1%), and other diseases 30 (21.1%). One hundred thirty-seven (40.3%) of the participants reported one or more medication for the concomitant diseases. The reported medications were antihypertensive 43 (31.4%), anticholesterol 19 (13.9%), antiulcerants 19 (13.9%), antidiabetics 11 (8.0%), antiasthmatics/chronic obstructive pulmonary disease 11 (8.0%), antihypothyroidism 9 (6.6%), antiosteoporotics 7 (5.1%), and other medications 18 (13.1%).
TABLE 2. Participants’ Age and Gender Variable
Group
N
%
Gender
Female Male
157 183 340 2 (2 M) 71 (29 M + 42 F) 131 (78 M + 53 F) 88 (43 M + 45 F) 45 (30 M + 15 F) 3 (1 M + 2 F) 340
46.2 53.8 100.0 0.6 20.9 38.5 25.9 13.2 0.9 100.0
Total Age Mean: 46.86 ± 14.54
Total
80
Group Age 80 Total
0
1
2
3
4
5
Total
2 54 76 46 28 3 209
0 11 22 8 3 0 44
0 3 22 15 7 0 47
0 2 8 14 5 0 29
0 1 2 5 1 0 9
0 0 1 0 1 0 2
2 71 131 88 45 3 340
One hundred thirty-one subjects or 38.5% of the participants reported ‘‘hoarseness or a problem with their voice.’’ Seventyone (54.2%) were males and 60 (45.8%) were females with no statistical difference in reporting voice disorders between the two genders (P > 0.05). Out of 131 subjects with voice disorders, 91 (69.5%) reported mild severity of voice-related symptoms (scores 1 and 2), 29 subjects (22.1%) reported moderate severity (score 3), and 11 subjects (8.4%) reported severe voice problems (scores 4 and 5) (Table 5). Of the 340 participants of our study, 64 subjects (18.8%) presented an RSI of >13 and were considered LPR positive compared with 276 subjects with an RSI of 13), voice disorders were reported by 58 (90.6%). Contrary to what the case was in the general population, where the severity of voice disorders was mild to moderate, in subjects with LPR (RSI >13), the severity of voice disorders was moderate to severe, as 47 subjects of 64 (73.4%) reported scores 3–5 (20 subjects reported score 3, 19 reported score 4, and eight reported score 5). We may conclude that voice disorders in subjects with RSI of >13 (patients with LPR) are severe (Table 5). Also, Figure 1 demonstrates that there is a linear correlation between the RSI score and the severity of voice disorders, meaning that the higher the RSI, the higher the severity score of voice disorders. From 131 subjects with voice disorders, 86 (65.6%) were smokers. Table 6 shows that about half of the smokers are at risk of presenting with voice disorders (86 of 174 [50.6%]). On the other hand, only 45 of 166 nonsmokers (27.1%) presented voice disorders. Chi-square analysis showed a statistically significant variation in voice disorders among smokers and nonsmokers (P value 13)
N
%
N
%
44 47 29 9 2 131
33.6 35.9 22.1 6.9 1.5 100
6 9 21 20 8 64
9.38 14.06 32.80 31.25 12.50 100
analysis revealed that the number of cigarettes rather than the duration of smoking is related to voice disorders. No significant statistical difference was found between males and females in the correlation of voice disorders and smoking. From 131 subjects with voice disorders, 52 (39.7%) were alcohol drinkers (Table 7). Chi-square analysis showed a statistically significant relationship between alcohol consumption and voice disorders (P value 13), voice disorders were found to be 90.6%, meaning that voice disorders are very common among patients with LPR. This finding is in line with the findings of other investigators.28,29 Voice disorders were more severe in patients with LPR compared with subjects with voice disorders but without LPR. Statistically significant association was found between voice disorders and the number of cigarettes smoked daily but not with smoking duration. Roy et al2 also did not find any association between voice disorders and duration of tobacco smoking, but they did not look at the number of cigarettes smoked daily. Best and Fakhry30 reported a weak association with tobacco use. A statistically significant relationship was also found between voice disorders and the number of alcoholic drinks consumed daily but not with the duration of alcohol drinking.
389.e31
Roy et al2 did not find any relationship between voice disorders and drinking an average of one or more alcoholic beverages per week for 1 year or longer. The difference between our findings and those reported by Roy et al can be explained by the higher mean alcoholic beverage consumption (2.43 ± 1.62 units per day for males and 2.17 ± 1.32 units per day for females) of the participants of our study. This could be attributed to cultural differences. Roy et al analyzing the combined effects of esophageal reflux, tobacco smoking, and alcohol drinking on ever having had a voice disorder found that participants with a history of any one of these conditions were at higher risk of reporting a previous voice disorder.2 In our study, tobacco smoking participants also tend to be alcohol drinkers, and in this regard, our result has to be considered as a combined effect of tobacco smoking and alcohol drinking. Because hoarseness in tobacco smokers is associated with an increased frequency of polypoid vocal fold lesions and head and neck cancer,31 the early diagnosis and management of voice disorders is a key factor for the prognosis of these disorders. No statistical correlation was found between voice disorders and concurrent diseases. It is interesting that this lack of correlation also applied to the symptoms ‘‘heartburn, chest pain, indigestion, or stomach acid coming up,’’ which are the key symptoms and the best indicators of gastroesophageal reflux. Other studies describing population-based voice disorders reported associations of vocal disorders with medical comorbidities of arthritis, thyroid problems, esophageal reflux, stomach or duodenal ulcers, respiratory allergies, and depression.2,30 No statistically significant relationship was found between voice disorders and concomitant medication. The lack of relationship between voice disorders and concurrent diseases or concomitant medication in our study can be attributed to the small number of participants with concurrent diseases or concomitant medication. The number of tobacco cigarettes smoked daily and the daily number of alcoholic drinks were found to be related with voice disorders. The aforementioned study has certain limitations, the main one being the definition of voice disorders. Of course, a statement like ‘‘hoarseness or a problem with your voice’’ may be a very simple way to diagnose the existence of voice disorders. Further discussion is necessary to acquire common specifications for voice disorders. Because in this study the smokers were also alcohol drinkers, it is not clear whether smoking and alcohol consumption are each a predisposing factor for voice disorders or if the combination of these two factors correlates with voice disorders. Further studies comparing prevalence of voice disorders among nonalcohol drinking tobacco smokers or nonsmoking alcohol drinkers could target this question.
CONCLUSIONS The prevalence of voice disorders reported as ‘‘hoarseness or a problem with your voice’’ is high (38.5%) in the general Greek population and very high (90.6%) in patients with LPR.
389.e32 If we consider that voice disorders, especially the persistent or progressive ones, could be the presenting symptoms of serious diseases, the early diagnosis with an easy, reliable, and low cost method could be a very useful tool in every day clinical practice. Future studies may benefit from more strict criteria regarding the definition of voice disorders and specific investigation procedures regarding population sampling so that reported data can be comparable. REFERENCES 1. Roy N, Merrill RM, Thibeault S, Parsa RA, Gray SD, Smith EM. Prevalence of voice disorders in teachers and the general population. J Speech Lang Hear Res. 2004;47:281–293. 2. Roy N, Merrill RM, Gray SD, Smith EM. Voice disorders in the general population: prevalence, risk factors, and occupational impact. Laryngoscope. 2005;115:1988–1995. 3. Morely DE. A ten-year survey of speech disorders among university students. J Speech Hearing Disord. 1952;17:25–31. 4. Laguaite JK. Adult voice screening. J Speech Hear Disord. 1972;37: 147–151. 5. Smith E, Lemke J, Taylor M, Kirchner HL, Hoffman H. Frequency of voice problems among teachers and other occupations. J Voice. 1998;12: 480–488. 6. Flataw T, Gutzmann H. The Voice of School Children. Arch Laryngol. 1908;20:327–348. 7. de Jong FI, Kooijman PG, Thomas G, Huinck WJ, Graamans K, Schutte HK. Epidemiology of voice problems in Dutch teachers. Folia Phoniatr Logop. 2006;58:186–198. 8. Preciado J, Perez C, Calzada M, Preciado P. Epidemiological study of voice disorders among teaching professionals of La Rioja, Spain. J Voice. 2008; 22:489–508. 9. Simberg S, Sala E, Vehmas K, Laine A. Changes in the prevalence of vocal symptoms among teachers during a twelve-year period. J Voice. 2005;19: 95–102. 10. Sala E, Laine A, Simberg S, Pentti J, Suonp€a J. The prevalence of voice disorders among day care center teachers compared with nurses. A questionnaire and clinical study. J Voice. 2001;15:413–423. 11. Russell A, Oates J, Greenwood KM. Prevalence of voice problems in teachers. J Voice. 1998;12:467–479. 12. Mattiske JA, Oates JM, Greenwood KM. Vocal problems among teachers: a review of prevalence, causes, prevention, and treatment. J Voice. 1998;12: 489–499. 13. Sapir S, Keidar A, Mathers-Schmidt B. Vocal attrition in teachers: survey findings. Eur J Disord Commun. 1993;28:177–185.
Journal of Voice, Vol. 29, No. 3, 2015 14. Munier C, Kinsella R. The prevalence and impact of voice problems in primary school teachers. Occup Med (Lond). 2008;58:74–76. 15. Angelillo M, Di Maio G, Costa G, Angelillo N, Barillari U. Prevalence of occupational voice disorders in teachers. J Prev Med Hyg. 2009;50: 26–32. 16. Cohen SM, Dupont WD, Courey MS. Quality-of-life impact of nonneoplastic voice disorders: a meta-analysis. Ann Otol Rhinol Laryngol. 2006;115:128–134. 17. Roy N, Merrill RM, Thibeault S, Gray SD, Smith EM. Voice disorders in teachers and the general population: effects on work performance, attendance, and future career choices. J Speech Lang Hear Res. 2004;47: 542–551. 18. Ramig LO, Verdolini K. Treatment efficacy: voice disorders. J Speech Lang Hear Res. 1998;41:S 101–S 116. 19. Titze IR, Lemke J, Montequin D. Populations in the U.S workforce who rely on voice as a primary tool of trade. A preliminary report. J Voice. 1997;11:254–259. 20. Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI). J Voice. 2002;16:274–277. 21. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009;141:S1–S31. 22. Printza A, Kyrgidis A, Oikonomidou E, Triaridis S. Assessing laryngopharyngeal reflux symptoms with the reflux symptom index: validation and prevalence in the Greek population. Otolaryngol Head Neck Surg. 2011; 145:974–980. 23. Behlau M, Zambon F, Guerrieri A, Roy N. Epidemiology of voice disorders in teachers and nonteachers in Brazil: prevalence and adverse effects. J Voice. 2012;26:665.e9–665.e18. 24. Roy N, Stemple J, Merrill RM, et al. Epidemiology of voice disorders in the elderly: preliminary findings. Laryngoscope. 2007;117:628–633. 25. Golub JS, Chen PH, Otto KJ, et al. Prevalence of perceived dysphonia in a geriatric population. J Am Geriatr Soc. 2006;54:1736–1739. 26. Coyle SM, Weinrich BD, Stemple JC. Shifts in relative prevalence of laryngeal pathology in a treatment-seeking population. J Voice. 2001;15: 424–440. 27. Herrington-Hall BL, Lee L, Stemple JC, Niemi KR, McHone MM. Description of laryngeal pathologies by age, sex, and occupation in a treatment seeking sample. J Speech Hear Disord. 1988;53:57–64. 28. Gregory ND, Chandran S, Lurie D, Sataloff RT. Voice disorders in the elderly. J Voice. 2012;26:254–258. 29. Dymek A, Dymek L, Starczewska-Dymek L, Bozek A, Dymek T, Nowak K. Laryngopharyngeal reflux in patients with persistent hoarseness. Otolaryngol Pol. 2012;66:33–38. 30. Best SR, Fakhry C. The prevalence, diagnosis, and management of voice disorders in a National Ambulatory Medical Care Survey (NAMCS) Cohort. Laryngoscope. 2011;121:150–157. 31. Matsuo K, Kamimura M, Hirano M. Polypoid vocal folds. A 10-year review of 191 patients. Auris Nasus Larynx. 1983;10:S37–S45.
Summary: Objectives. To assess the prevalence of voice disorders in the general Greek population and in patients with laryngopharyngeal reflux (LPR) with the use of the reflux symptom index (RSI). Study Design. Prospective epidemiological adult participant survey. Setting. General Greek population. Method. The validated Greek version of the RSI was used to assess the prevalence of voice disorders in the general Greek population, as well as in patients with LPR, which were diagnosed using the RSI. The RSI questionnaire was completed by 340 (183 males and 157 females) randomly selected subjects. Subjects with RSI score of >13 were considered to be LPR patients. Results. The prevalence of voice disorders, which was determined by the participants giving a positive response to the field ‘‘hoarseness or a problem with your voice,’’ was found to be 38.5% in the general Greek population. In patients with LPR, ‘‘hoarseness or a problem with your voice’’ was present in 90.6%. The number of cigarettes smoked daily and the number of alcoholic drinks consumed daily, each correlated with the presence of voice disorders. No relationship was revealed between voice disorders and coexisting diseases and especially with gastroesophageal reflux disease, which was the most frequent reported disorder among peptic diseases. Conclusions. The prevalence of voice disorders, determined by a positive response to the question ‘‘hoarseness or a problem with your voice,’’ is high (38.5%) in the general population and very high (90.6%) in patients with LPR. The number of tobacco cigarettes smoked daily and the number of alcoholic drinks consumed daily were found to be related to voice disorders. Key Words: Voice disorders–Reflux symptom index–Laryngopharyngeal reflux–Gastroesophageal reflux–Reflux– Prevalence.
INTRODUCTION Although voice disorders seem to be very common in the general population, affecting nearly one-third of the population at some point of their life,1,2 the true prevalence of the problem remains undetermined. Epidemiological studies, showing the actual size of the problem, are relatively rare, and the reported prevalence of voice disorders in the existing small number of studies shows substantial variability, ranging from 0.65% to 41.6%.3–6 This variability in the reported prevalence estimates is mainly because of the different methodological approach selected by each study to define voice disorders, in addition to the differences in sample populations and sizes. The prevalence of voice disorders has been studied more extensively in certain professions, such as teachers, where the prevalence of voice disorders has been found to vary from 7% to 80%, depending on the studied groups, response rate, and the way the question was set.5,7–15 Most of these studies use general population subjects as a control group, and this is a source of data regarding prevalence of voice disorders in the Accepted for publication August 12, 2014. From the *Athens Speech and Language Institute, Agios Dimitrios, Athens, Greece; yPrivate Practice, Agios Nikolaos, Crete, Greece; and the zENT Department of University Hospital of Ioannina, Medical School of University of Ioannina, Ioannina, Greece. Address correspondence and reprint requests to Nikolaos Spantideas, Athens Speech and Language Institute, 10 Lontou Street, Glyfada, Athens 16675, Greece. E-mail: [email protected] Journal of Voice, Vol. 29, No. 3, pp. 389.e27-389.e32 0892-1997/$36.00 Ó 2015 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.08.006
general population. Roy et al1 reported that 58% of teachers experience voice problems at some point during their career, compared with 29% among nonteachers. Voice disorders are often caused by benign or self-limited conditions but may also be symptoms of serious diseases, and in these cases, early diagnosis is critical for the prognosis of the disease. Voice disorders have significant public health consequences for the patients’ quality of life and their ability to function in social or workplace settings.16,17 In addition to the impact on health and quality of life, voice disorders lead to frequent health care visits with high health care cost, which is accompanied by diminished productivity because of work absenteeism.18,19 Laryngopharyngeal reflux (LPR) seems to be very common in the general population, and one of the main symptoms is hoarseness. Several tests are used to diagnose LPR with different sensitivity and specificity values. The ambulatory 24-hour pH double-probe (simultaneous esophageal and pharyngeal) pH monitoring has an acceptable sensitivity for detecting LPR and has been considered as the gold standard for LPR diagnosis. However, given the invasive nature of the time-consuming method, it is doubtful whether this method will ever become widely used, for not only epidemiological studies but also routine clinical use. There is need for an easy, reliable, and practical method that can give comparable findings through different populations to carry out large-scale epidemiological studies on the general
389.e28 population. The development and evaluation of a standardized and validated patient-reported instrument, based mainly on self-assessment of symptoms, has the potential to facilitate or even establish an LPR diagnosis. Such a diagnostic tool could also be useful for epidemiologic studies. The reflux symptom index (RSI) introduced by Belafsky et al20 is a self-administered nine-item questionnaire designed to assess various symptoms related to LPR (Table 1). Each item is rated on a scale from 0 (no problem) to 5 (severe problem), with a maximum total score of 45, indicating the most severe symptoms. An RSI greater than 13 is considered abnormal and strongly indicative of LPR. The RSI has been compared with other LPR diagnostic methods, such as laryngoscopy and the ambulatory 24-hour pH double-probe pH monitoring, and has been proved to share similar diagnostic value.20–22 In this regard, RSI can be used as an alternative tool for LPR diagnosis. A key question of RSI is the experience of ‘‘hoarseness or other voice problems’’ during the previous month. Although hoarseness is a very well-defined symptom,23 the term ‘‘other voice problems’’ is a broader one, leaving space for reporting any kind of voice complaints without specific description and thus, including a heterogeneous grouping of voice-related complaints. In addition, RSI can give information not only about the prevalence of the included items in the questionnaire but also about their severity. Since the introduction of RSI, many studies have been conducted mainly to detect LPR prevalence, but no further analysis of the prevalence of each item included in the questionnaire has been presented. The primary aim of this study was to assess the prevalence of voice disorders in the adult general Greek population and in patients with diagnosed LPR, using the RSI. MATERIALS AND METHODS The study was carried out in the general Greek population during the period from September to November 2011. A random sample (n ¼ 1000) of adults living in Athens was initially approached through an ‘‘alert’’ telephone. During the communication, the scope of the study was explained, and permission to send the questionnaire to the subjects’ address was obtained.
Journal of Voice, Vol. 29, No. 3, 2015
The random selection of the participants was made through the telephone catalog of Athens City using a table of random numbers generated for the study. Five different investigators performed the calls 10 days before sending the questionnaire. Of the 1000 approached subjects, 450 accepted to participate and provided their personal details (name and address). The envelop that was sent to the participants involved a more detailed explanation for the scope of the study, detailed instructions for filling out the questionnaires, and a prepaid envelope, so that subjects could easily send back the filled-in questionnaire, and the signed informed consent (also involved) at no cost for them. Three hundred fifty individuals returned the questionnaires. Data related to voice disorders were gathered through the questionnaire with which information about demographic data of the participants, concomitant diseases, concurrent medication, as well as the RSI questions were acquired. The RSI questionnaire has been translated into Greek and has been validated in the Greek population.22 For the purpose of this study, voice disorders and their prevalence were detected on the basis of the response of the participants to the question ‘‘hoarseness or a problem with your voice.’’ The study protocol was approved by the Scientific Committee and Review Board of Athens Speech and Language Institute. Informed consent was obtained from all participants before inclusion in the study. Statistical methodology Statistical tests were performed using the SPSS statistical software. Descriptive statistics were used to summarize data for the subset of the population with voice disorders. Chi-square tests were used to compare the distribution of category variables among patients with voice disorders compared with those without voice disorders. The t test was used to compare continuous variables between patients with voice disorders in comparison to the rest of the population. A P value of 0.05). One hundred one subjects (29.7%) consumed alcohol (68.3% males and 31.7% females). Mean daily alcohol consumption was 2.43 ± 1.62 units for males and 2.17 ± 1.32 units for females without a statistically significant difference between the two genders (t test >0.05). The most commonly reported alcoholic drinks were wine (30 subjects) followed by beer (21 subjects) and whisky (18 subjects). One hundred forty-two (41.8%) of the participants reported one or more diseases. The reported diseases were cardiovascular 50 (35.2%), gastrointestinal 25 (17.6%), musculoskeletal 15 (10.6%), respiratory 10 (7.0%), thyroidopathy 9 (6.3%), anemia 3 (2.1%), and other diseases 30 (21.1%). One hundred thirty-seven (40.3%) of the participants reported one or more medication for the concomitant diseases. The reported medications were antihypertensive 43 (31.4%), anticholesterol 19 (13.9%), antiulcerants 19 (13.9%), antidiabetics 11 (8.0%), antiasthmatics/chronic obstructive pulmonary disease 11 (8.0%), antihypothyroidism 9 (6.6%), antiosteoporotics 7 (5.1%), and other medications 18 (13.1%).
TABLE 2. Participants’ Age and Gender Variable
Group
N
%
Gender
Female Male
157 183 340 2 (2 M) 71 (29 M + 42 F) 131 (78 M + 53 F) 88 (43 M + 45 F) 45 (30 M + 15 F) 3 (1 M + 2 F) 340
46.2 53.8 100.0 0.6 20.9 38.5 25.9 13.2 0.9 100.0
Total Age Mean: 46.86 ± 14.54
Total
80
Group Age 80 Total
0
1
2
3
4
5
Total
2 54 76 46 28 3 209
0 11 22 8 3 0 44
0 3 22 15 7 0 47
0 2 8 14 5 0 29
0 1 2 5 1 0 9
0 0 1 0 1 0 2
2 71 131 88 45 3 340
One hundred thirty-one subjects or 38.5% of the participants reported ‘‘hoarseness or a problem with their voice.’’ Seventyone (54.2%) were males and 60 (45.8%) were females with no statistical difference in reporting voice disorders between the two genders (P > 0.05). Out of 131 subjects with voice disorders, 91 (69.5%) reported mild severity of voice-related symptoms (scores 1 and 2), 29 subjects (22.1%) reported moderate severity (score 3), and 11 subjects (8.4%) reported severe voice problems (scores 4 and 5) (Table 5). Of the 340 participants of our study, 64 subjects (18.8%) presented an RSI of >13 and were considered LPR positive compared with 276 subjects with an RSI of 13), voice disorders were reported by 58 (90.6%). Contrary to what the case was in the general population, where the severity of voice disorders was mild to moderate, in subjects with LPR (RSI >13), the severity of voice disorders was moderate to severe, as 47 subjects of 64 (73.4%) reported scores 3–5 (20 subjects reported score 3, 19 reported score 4, and eight reported score 5). We may conclude that voice disorders in subjects with RSI of >13 (patients with LPR) are severe (Table 5). Also, Figure 1 demonstrates that there is a linear correlation between the RSI score and the severity of voice disorders, meaning that the higher the RSI, the higher the severity score of voice disorders. From 131 subjects with voice disorders, 86 (65.6%) were smokers. Table 6 shows that about half of the smokers are at risk of presenting with voice disorders (86 of 174 [50.6%]). On the other hand, only 45 of 166 nonsmokers (27.1%) presented voice disorders. Chi-square analysis showed a statistically significant variation in voice disorders among smokers and nonsmokers (P value 13)
N
%
N
%
44 47 29 9 2 131
33.6 35.9 22.1 6.9 1.5 100
6 9 21 20 8 64
9.38 14.06 32.80 31.25 12.50 100
analysis revealed that the number of cigarettes rather than the duration of smoking is related to voice disorders. No significant statistical difference was found between males and females in the correlation of voice disorders and smoking. From 131 subjects with voice disorders, 52 (39.7%) were alcohol drinkers (Table 7). Chi-square analysis showed a statistically significant relationship between alcohol consumption and voice disorders (P value 13), voice disorders were found to be 90.6%, meaning that voice disorders are very common among patients with LPR. This finding is in line with the findings of other investigators.28,29 Voice disorders were more severe in patients with LPR compared with subjects with voice disorders but without LPR. Statistically significant association was found between voice disorders and the number of cigarettes smoked daily but not with smoking duration. Roy et al2 also did not find any association between voice disorders and duration of tobacco smoking, but they did not look at the number of cigarettes smoked daily. Best and Fakhry30 reported a weak association with tobacco use. A statistically significant relationship was also found between voice disorders and the number of alcoholic drinks consumed daily but not with the duration of alcohol drinking.
389.e31
Roy et al2 did not find any relationship between voice disorders and drinking an average of one or more alcoholic beverages per week for 1 year or longer. The difference between our findings and those reported by Roy et al can be explained by the higher mean alcoholic beverage consumption (2.43 ± 1.62 units per day for males and 2.17 ± 1.32 units per day for females) of the participants of our study. This could be attributed to cultural differences. Roy et al analyzing the combined effects of esophageal reflux, tobacco smoking, and alcohol drinking on ever having had a voice disorder found that participants with a history of any one of these conditions were at higher risk of reporting a previous voice disorder.2 In our study, tobacco smoking participants also tend to be alcohol drinkers, and in this regard, our result has to be considered as a combined effect of tobacco smoking and alcohol drinking. Because hoarseness in tobacco smokers is associated with an increased frequency of polypoid vocal fold lesions and head and neck cancer,31 the early diagnosis and management of voice disorders is a key factor for the prognosis of these disorders. No statistical correlation was found between voice disorders and concurrent diseases. It is interesting that this lack of correlation also applied to the symptoms ‘‘heartburn, chest pain, indigestion, or stomach acid coming up,’’ which are the key symptoms and the best indicators of gastroesophageal reflux. Other studies describing population-based voice disorders reported associations of vocal disorders with medical comorbidities of arthritis, thyroid problems, esophageal reflux, stomach or duodenal ulcers, respiratory allergies, and depression.2,30 No statistically significant relationship was found between voice disorders and concomitant medication. The lack of relationship between voice disorders and concurrent diseases or concomitant medication in our study can be attributed to the small number of participants with concurrent diseases or concomitant medication. The number of tobacco cigarettes smoked daily and the daily number of alcoholic drinks were found to be related with voice disorders. The aforementioned study has certain limitations, the main one being the definition of voice disorders. Of course, a statement like ‘‘hoarseness or a problem with your voice’’ may be a very simple way to diagnose the existence of voice disorders. Further discussion is necessary to acquire common specifications for voice disorders. Because in this study the smokers were also alcohol drinkers, it is not clear whether smoking and alcohol consumption are each a predisposing factor for voice disorders or if the combination of these two factors correlates with voice disorders. Further studies comparing prevalence of voice disorders among nonalcohol drinking tobacco smokers or nonsmoking alcohol drinkers could target this question.
CONCLUSIONS The prevalence of voice disorders reported as ‘‘hoarseness or a problem with your voice’’ is high (38.5%) in the general Greek population and very high (90.6%) in patients with LPR.
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