KBB-Forum 2005 , Cilt 4 , Sayı 1

VOICE HANDICAP INDEX (VHI) IN PARTIAL LARYNGECTOMY PATIENTS

Tolga KANDOGAN,MD; Aylin SANAL,MD
Department of ENT,Hospital of SSK, İzmir, Türkey

Summary

Voice handicap Index (VHI), This patient self-assessment consist of 10 items in three domains: emotional, physical and functional aspects. The functional subscale includes statements which describe the impact of a person’s voice on his daily activities. The emotional subscale indicates the patient’s affective responses to the voice disorder. The items in the physical subscale are statements that relate to either the patient’s perception of laryngeal discomfort or the voice output characteristics, such as the pitch being too low or too high. The VHI was designed to assess all types of voice disorders. In our study, we applied the VHI to partial laryngectomized patients. Though surgical technics were different, we assessed the patient’s perception of vocal handicap after surgery, and the functional, emotional or physiological impacts of their new-voices. There were no statistically significant difference between the VHI and VHI-F, VHI-P, VHI-E scores in 3 patient groups. All of the patients evaluated, that their new voices have similar functional, physical and emotional impact on their life. In all of our study group patients, the quality of voice was found to be sufficient to hold a normal individual conversation.

Introduction

In 1998, Jacobson et al. proposed a measure of voice handicap known as Voice handicap Index (VHI) [1]. This patient self-assessment consists of 10 items in three domains: emotional, physical and functional aspects. Initially, it was an 85-item survey comprised of questions which were selected primarly from patient reports in order to ensure that the scale had had both content and face validity. The functional subscale includes statements which describe the impact of a person’s voice on his daily activities. The emotional subscale indicates the patient’s affective responses to the voice disorder. The items in the physical subscale are statements that relate to either the patient’s perception of laryngeal discomfort or the voice output characteristics, such as the pitch being too low or too high. Later, this original 85-item test was reduced to a 30-item test (Table 1).

VHI has been developed to help patients and clinicians quantify the amount of disability that a voice disorder is causing [2]. At the completion of the VHI, the score can be summed in a VHI score ranging from 0 to 120. The higher the number, the greater the amount of disability noted due to a voice-related problem.

Table 1: Voice Handicap Index VHI-F= VHI-Functional, VHI-P= VHI-Physical, VHI-E=VHI-Emotional (1).

It is important to remember that the VHI score is only a small assessment tool and is not a substitute for a formal evaluation by a voice care specialist, nor does it provide diagnostic information. The sole purpose of the VHI is to provide some preliminary information regarding the severity of one's voice problem in regard to his or her most common activities in the daily life.

In our study, we applied the VHI to partial laryngectomized patients. Though surgical techniques were different, we assessed the patient’s perception of vocal handicap after surgery, and the functional, emotional or physical impacts of their new-voices.

Methods

Twenty nine male patients, aged between 48 and 67 were enrolled in the study. The average age was 53.9 years. There were 8 patients with cricohyoidopexy (CHP), 10 patients with cordectomy (3 with arytenoidectomy) and 11 patients with fronto-lateral laryngectomy with epiglottic pull down reconstruction ( Table 2). The time interval between the operation and VHI-test was between 4 months and 26 months. None of the patients have surgery-related problems at the time of VHI-test; that is, all of them were under the same circumstances.

Table 2: Patients, surgeries performed and their Voice Handicap Index scores. VHI= Voice Handicap Index, VHI-F= VHI-Functional, VHI-P= VHI-Physical, VHI-E=VHI-Emotional, EPD Rec= Epiglottic pull down reconstruction

The patients were instructed that, these statements are that which many people have used to describe their voices and the effects of their voices on their lives. The patients marked the response that indicates how frequently they have the same experience. 0=Never 1=Almost Never 2= Sometimes 3=Almost Always 4=Always. Interpretation of the VHI scores was explained in Table 3.

Table 3: Voice Handicap Index (1)

Statistical analysis was carried out using analysis of variance (ANOVA) and Post- Hoc group comparisons after Bonferroni and Scheffé-procedure.

Results

Voice Handicap Index (VHI) and VHI-Functional (VHI-F), VHI-Physical (VHI-P), VHI-Emotional (VHI-E) mean values and standard deviations were given in Table 4. There were no statistically significant differences between the VHI and VHI-F, VHI-P, VHI-E scores in all 3 groups (p=0,972). All of the patients have stated that their new voices had similar functional, physical and emotional impact on their life.

Table 4: Number of patient groups and VHI, VHI-F, VHI-P and VHI-E mean values and standard deviations (SD). There were no statistically significant differences between the 3 groups (p=0,972).

Discussion

To our knowledge, though there were manuscripts about VHI, this is the first study in which VHI was applied to the partial laryngectomized patients.

A handicap, as described by the World Health Organization (WHO), is defined as a social, economic, or environmental disadvantage resulting from an impairment or disability [3]. The WHO considers health as a multi-dimensional concept which encompasses physical, mental, and social states of being. The VHI was designed to assess all types of voice disorders, even those encountered by tracheoesophageal speakers [4].

Despite the development of treatment with irradiation and chemotherapy, the most effective treatment of laryngeal cancer is still surgery [5]. If untreated, laryngeal cancer will ultimately progress to death within several months to years. Fortunately, aggressive treatment is often curative. In general, small cancers (T1 or T2) limited to the glottis or supraglottis are curable with surgery. Surgery may be conservative, sparing most or some of the larynx. The primary goal in the treatment of laryngeal cancer is always the survival of the patient. The secondary goal is vocal preservation. Early diagnosis of a laryngeal cancer provides the means for carrying out conservative surgery, which allows for preservation of the basic functions of the larynx; namely respiration, phonation and most importantly protection of the airway [5].

Vocal results after cordectomy and fronto-lateral laryngectomy may seem to be unsatisfactory, since there is a glottic defect after removal of a considerable amount of tissue. After CHP, the results are even worse, since both vocal folds were excised and a neoglottis formation is anticipated at best. Interestingly, though statistically insignificant, cordectomy group have given the highest scores (mean= 67,50 SD=17,34) and the cricohyoidopexy group have given the lowest scores (mean=57,63 SD=10,78) to VHI-test in this study. It could be said that perceived voice is irrelevant with the laryngeal tissue excised. Another point of discussion is, according to this study results, it could be hypothesized, that the surgeon can perform more extensive laryngeal surgery without thinking the voice outcomes, since it is irrelevant with the laryngeal tissue excised, from the patients point of view. But, this hyopthesis needs further investigation.

Conclusion

In all of our patients, the quality of voice was found to be sufficient to hold a normal individual conversation, but the voice is defined as hoarse and dull. It is insufficient to make a conversation in a noise atmosphere, since it can not be raised satisfactorily.