ACOUSTIC DIFFERENCE IN VOICE OF THE PATIENTS WITH AND WITHOUT ORGANIC LESION IN FUNCTIONAL VOICE DISORDERS
Summary
In this article, the objective and subjective differences of voices in functional voice disorders with and without organic lesion were discussed. 72 functional voice disorders without any organic lesion and 77 functional voice disorders with an organic lesion were included to this study. Organic lesions were 25 kissing nodules, 29 vocal cord polyp, 15 Reinke edema and 8 vocal cord cyst. Control group consist of 74 nondysphonic volunteers. The diagnosis of voice disorders was established by videolaryngoscopy using a 70º rigid scope. Auditive and acoustic analysis, voice range profile, maximum phonation time and the Disphonia Severity Index (DSI) were measured. Statistical analysis was performed using paired sample T-Test and ANOVA. There was a statistically significant difference in RBH, jitter% and DSI scores of the 3 groups. The voice quality of the FVD without any organic lesion was relatively better than FVD with any organic lesion group. A mass lesion over the vocal folds makes the voices worser in functional voice disorders.Introduction
Functional dysphonia refers to impairment of voice production in the absence of mucosal or neurogenic disease of the larynx[1]. Vocal misuse and abuse are frequently claimed to be causes of voice problems. If left untreated, and the vocal hygiene guidelines were not followed, they are thought to contribute to the laryngeal tissue changes, such as localized or diffuse mucosal thickening, submucosal edema, ulceration, cyst formation etc..In this article, the objective and subjective differences of voices in functional voice disorders with and without organic lesion were discussed.
Methods
72 functional voice disorders without any organic lesion patients, 28 males and 44 females, aged between 19 and 58 years old were included to the study. The mean age was 38 years. 77 functional voice disorders with an organic lesion patients were icluded to the study. They consist of 25 kissing nodules, 29 vocal cord polyp, 15 Reinke edema and 8 vocal cord cyst. 46 males and 31 females, aged between 18 and 61, mean age was 44. The diagnosis of voice disorders was established by videolaryngoscopy using a 70º rigid scope (Karl Storz, Tuttlingen, Germany). Control group consist of 74 nondysphonic volunteers, 67 males and 7 females, aged between 19 and 67 years. The mean age was 41 years.RBH (Auditive analysis)
Roughness(R), breathiness(B), and hoarseness(H) were estimated by the author with the patients reading a passage from the turkish text “Kasagi“ by Omer Seyfettin. These parameters are estimated as 0 = normal or absent deviance, 1 = slight deviance, 2 = moderate deviance, 3 = severe deviance.
Acoustic analysis
Analysis of jitter (%) allows the relative evaluation of the period-to-period variability of the pitch within the analyzed voice sample. These parameter were analyzed on a sustained /a:/ using the Multi Dimensional Voice Program (MDVP) with the Computerized Speech Lab CSL 4300B (Kay Elemetrics Ltd., Lincoln Park, NJ, USA).
Voice Range Profile (VRP)
Voice range profile identifies the minimal I(low) and maximal amplitude and the lowest and highest frequency F0(high) of the voice range. Measured with Computerized Speech Lab CSL 4300B (Kay Elemetrics Ltd., Lincoln Park, NJ, USA)
Maximum Phonation Time (MPT)
MPT is the simplest aerodynamic parameter of phonation in seconds. This parameter was measured on a sustained /a:/ after full inspiration in a comfortable loudness.
Disphonia Severity Index (DSI)
In assessing the dysphonia severity, the formula
[DSI= 0.13xMPT+0.0053xF0(high)-0.26xI(low)-1.18x jitter(%)+12.4] is used [2].
These examinations were performed as recommended by the Union of European Phoniatricians (UEP)[3]. Statistical analysis was performed using paired sample T-Test and analysis of variance (ANOVA).
Results
There was a statistically significant difference (p=0) in RBH, jitter% and DSI scores of the 3 groups. (Table 1,2 and 3) Table 1: The comparison of the mean values of RBH auditive analysis scores in control, functional dysphonia and in functional dysphonia with an organic lesion group.){kind=link}
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Discussion
The diagnosis of a voice disorder can be established only after a complete history, visualisation of the vocal folds, and objective and subjective assessment of voice. Measurements of acoustic, aerodynamic, and perceptual voice parameters are essential in the management of voice disorders. Laryngeal stroboscopic evaluation may be usefull in cases where there is a suspicion in vocal folds' vibratory patterns. But, first of all, when the larynx appears normal or relatively normal on mirror examination and the voice is poor, that is when the voice is disproportionately poor compared to laryngeal findings, a functional voice disorder should be suspected[4].By definition, a functional voice disorder is the result of misuse or abuse of the anatomically and physiologically intact vocal apparatus but also may result from maladaptive compensatory maneuvers as a consequence of an organic condition[4]. Misuse suggests voice production behaviors that distort the normal propensity of the phonatory mechanism to work effectively and efficiently. Abusive behaviors are harsher than misuse and it will cause trauma to the laryngeal mucosa with a great likelihood. The line between misuse and abuse is a very thin one, and perhaps rather than there being a division between the two, the behaviors might be thought of as existing along a continuum[5].
Vocal fold nodules, polyps, some kind of cysts and Reinke edema are usually thought to be the result of vocal abuse. They are a reaction of the tissue to the constant stress induced by frequent, hard oppositional movement of the vocal folds[5]. Hoarseness and breathiness are the major perceptual signs of the vocal fold organic lesions.
Acoustically, a patient with a vocal fold mass will exhibit increased (frequency perturbation) jitter. Phonational range may be markedly reduced, especially at the upper end. The patient may also show reduced dynamic range, with an inability to produce high sound pressure levels. The fundamental frequency may be within normal limits or decreased. The extra mass along the medial edge of the vibrating vocal folds results in increased aperiocity of vibration, and greater hoarseness. Depending on the on the size of the mass, glottal closure will be affected. Incomplete closure results in the perception of breathiness[5].
In our study it came out that the voices of the FVD with/without any organic lesion were statistically significant different from the control group.
In the subjective evaluation of voice of FVD patients without any organic lesion, eg. RBH system, the mean values are (0,8), (0,45) and (0,8) respectively. As mentioned in the material and method section, these parameters are estimated as 0 = normal or absent deviance, 1 = slight deviance, 2 = moderate deviance, 3 = severe deviance. So the FVD without any organic lesion groups voices are between 0 and 1, close to slight deviance. Their mean DSI score was in accordance with RBH score, eg. 4,26. The voices of the FVD patients with any organic lesion; in RBH system, are (1,2), (0,92) and (1,28) respectively. So the FVD with any organic lesion groups voices are between 1 and 2, worser than the FVD without any organic lesion group. Their mean DSI score was also in accordance with RBH score, eg. 2,22.
According to this findings, it could be said, that the voice qualities of the FVD with/without any organic lesion group was not normal, slight to moderate deviated from normal. Also, objectively and subjectively, the voices with a mass lesion of the vocal folds are worser than others in functional voice disorders.
Reference
1) Bridger MW, Epstain R. Functional voice disorders: a review of 109 patients. J Laryngol Otol 1983;97:1145-48 [ Özet ]
2) Wuyts FL, Molenberghs G, Remacle M, Heylen L, Millet B, Van Lierde K, Raes J, Van de Heyning PH. The Dysphonia Severity Index: An Objective Measure of Vokal Quality Based on a Multiparameter Approach. Journal of Speech, Language, and Hearing Research 2000;43:796-809 [ Özet ]
3) Schutte HK, Seidner W. Recommendation by the Union of European Phoniatricians (UEP): Standardizing voice area measurement/phonetography. Folia phoniatr. 1983;35:286-288 [ Özet ]
4) Koufman JA, Blalock PD. Functional voice disorders Otolaryngol Clin North America 1991:(24);1059-73 [ Özet ]