Correlation between voice handicap index and voice laboratory measurements in dysphonic patients

Factors underlying voice disorders can be categorized into three distinct domains: emotional, physical, and functional. The Voice Handicap Index (VHI) subjectively evaluates voice disorders in terms of these three factors. On the other hand, Voice Laboratory Measurements (VLM) use objective criteria to evaluate the severity of voice disorders. Use of these two different tests (VHI and VLM) on dysphonic patients has, however, tended to yield results that vary widely in their conclusions. This report reviewed 135 testing sessions on dysphonia patients. Seventy-nine of the tests were VHI, and 56 were VLM. All VHI and VLM parameters were entered into a statistical program and analyzed using a Pearson correlation. The results show that each VHI parameter provides a significant level of reliability (P < 0.01) when compared with other VHI parameters. Four VLM parameters also demonstrated significant reliability (P < 0.01) in comparison with other VLM parameters. However, when comparing across testing methods, VHI and VLM parameter reliability is shown to be poor (P > 0.05). With such a large discrepancy between the results of VHI and VLM testing, no objective parameter can yet be regarded as a definitive prognostic factor in a subjective evaluation of dysphonic patients. Received: 31 July 2001 / Accepted: 13 September 2001     

患者自我评估与嗓音声学分析的比较

目的分析嗓音疾病患者自我评估的可靠性及其与嗓音声学检测的相关性。方法对35例嗓音疾病患者进行自我评估和嗓音声学检测。采用嗓音障碍指数(voice handicap index，VHI)和嗓音相关生活质量(voicerelated quality of life，V—RQOL)评估法。嗓音声学检测主要测试基频微扰、振幅微扰及标准化噪声能量三个参数，将自我评估结果与嗓音声学检测结果进行相关分析。结果VHI的功能、生理和情感三个范畴之间与V—RQOL的生理一功能、社会一情感两个范畴间有相关性；声学检测三个参数间相关性良好；而嗓音自我评估与声学参数间无相关性。结论嗓音疾病患者自我评估方法是获得患者全面信息的重要方法．客观检查不能预测主观评估的结果．     

经口CO2激光治疗早期声门型喉癌术后嗓音分析

目的探讨经口CO2激光手术治疗早期声门型喉癌术后的嗓音情况。方法回顾分析2016年3月—2019年6月接受经口CO2激光手术治疗的48例声门型喉癌患者嗓音资料,根据手术是否切除前连合分为未切除前连组合（n=29）和切除前连合组（n=19）。分别于手术前和手术后6个月的嗓音稳定期对患者进行主观嗓音障碍指数量表简化中文版（VHI 13）评分、频闪喉镜检查及嗓音声学分析。结果经口CO2激光手术后6个月检查VHI 13生理评分及总分均较手术前明显减低;频闪喉镜检查未切除前连合组以声带黏膜波减弱或消失为主要表现,而切除前连合组术后出现前连合粘连和室带代偿性发音的比例明显升高;嗓音声学分析发现,与术前比较,激光手术后基频（F0）增加,基频微扰(jitter)和振幅微扰(shimmer)增大,最长发声时间(MPT)缩短,嗓音障碍严重指数（DSI）减低;未切除前连合组患者振幅微扰较切除前连合组更低,最长发生时间更长,DSI更高。结论声门型喉癌经口CO2激光手术后患者的主观嗓音质量较术前有一定程度的改善,是否切除前连合与术后声带形态、嗓音质量有密切关系。     

Outcomes assessment following treatment of spasmodic dysphonia with botulinum toxin

Spasmodic dysphonia (SD), a disabling focal dystonia involving the laryngeal musculature, is most commonly treated by the intramuscular injection of botulinum toxin (BTX). Although the treatment is well tolerated and generally produces clinical voice improvement, it has never been statistically shown to alter the patient's perception of voice quality or general health. Declining resources for medical care mandate that treatment outcomes be documented. A prospective analysis of the effects of BTX on the patient's perception of voice and general health was undertaken. The Voice Handicap Index (VHI) and Short Form 36 (SF-36) surveys were administered to patients before treatment and 1 month after. Pretreatment and posttreatment scores were analyzed with a Student's t-test. On the VHI, improvements in the patients' perception of their functional, physical, and emotional voice handicap reached statistical significance (p < or = .0005). On the SF-36, patients had statistically significant improvements in mental health (p < or = .03) and social functioning (p < or = .04). Treatment of SD with BTX significantly lessened the patients' perception of dysphonia. In addition, it improved their social functioning and their perception of their mental health. These outcome measures justify the continued treatment of SD with BTX.     

Outcomes of structural fat grafting for paralytic and non-paralytic dysphonia

Aims of this prospective study were to evaluate the results of vocal fold structural fat grafting for glottic insufficiency and to compare the outcomes obtained in unilateral vocal fold paralysis (UVFP) and congenital or acquired soft tissue defects in vocal folds. Sixty-six consecutive patients with breathy dysphonia, in 43 cases (aged 16-79 years) related to UVFP and in 23 cases (aged 16-67 years) related to vocal fold iatrogenic scar or sulcus vocalis, underwent autologous structural fat grafting into vocal folds. Lipoaspirates were centrifuged at 1200 g for 3 min to separate and remove blood, cell debris and the oily layer. The refined fat was injected under direct microlaryngoscopy in a multilayered way. The main outcome measures were grade, roughness, breathiness, asthenicity and strain (GRBAS) perceptual evaluation, maximum phonation time (MPT), self-assessed Voice Handicap Index (VHI), and voice acoustic analysis, considered pre-operatively and at 3 and 6 months after fat grafting. After surgery, MPT, VHI, G and B improved in both groups (p < 0.05). In particular, G and VHI functional subscales showed a significantly greater decrease in patients with UVFP (p < 0.05). The acoustic variables improved significantly only in the UVFP group (p < 0.005). From 3 to 6 months postoperatively, most variables showed a trend with further improvement. Vocal fold structural fat grafting was significantly effective in treating glottic insufficiency due to UVFP or soft tissue defects. Perceptual, acoustic and subjective assessments confirmed that patients with UVFP had better outcomes than those with soft tissue defects.     

嗓音训练治疗30例功能性嗓音障碍的疗效观察

目的观察嗓音训练治疗功能性嗓音障碍的疗效。方法对30例诊断为功能性嗓音障碍的患者进行嗓音治疗（嗓音卫生教育、改善呼吸及增强共鸣）,并在治疗前后进行评估。结果30例功能性嗓音障碍患者接受训练后嗓音障碍指数值（Voice Handicap Index,VHI）由67．8±10．1分降至30．7±8．2分,差异有统计学意义（P〈0．01）,患者在功能、生理和情感上均有明显改善;同时最长发声时间（Maximum Phonation Time,MPT）由9．2±2．6秒延长至13．5±3．1秒,基频微扰由0．59％±0．07％降至0．42％±0．05％,振幅微扰由2．23±0．45降至1．78±0．27,噪谐比由0．185±0．088降至0．142±0．065,差异有统计学意义（P〈0．05）。结论嗓音训练能够降低嗓音障碍程度,改善嗓音质量,同时恢复患者的交流和情感功能,增强与他人交流的信心。     

Posterior cordectomy. Our experience

ObjectiveSeveral surgical procedures have been proposed for the treatment of respiratory distress secondary to bilateral cord palsy. We performed a retrospective study of our experience in posterior cordectomy with a laser CO₂, analysing the improvement of dyspnoea and voice quality after surgery.MethodsThis was a retrospective study of 13 cases (9 female, 4 male). The age range was 25-79 years. Iatrogenic post-thyroidectomy (4 cases) was the most common aetiology of bilateral laryngeal palsy in our study.We assessed the subjective improvement of respiratory function and voice quality after laser surgery using the Spanish adaptation of the Voice Handicap Index (VHI).ResultsDyspnoea improved in all patients. Two cases had a worsening of dyspnoea in the immediate postoperative period and one case was successfully solved with a new surgical intervention.After surgery, most of patients suffered from mild or middle dysphonia.ConclusionsThe posterior cordectomy is an easy, safe and effective treatment for dyspnoea secondary to bilateral laryngeal palsy, maintaining acceptable voice quality.     

Self‐assessment of voice therapy for chronic dysphonia

Self‐assessment of voice therapy for chronic dysphonia The effects of voice therapy in a group of chronically dysphonic patients are determined using two quality‐of‐life (QOL) instruments: the Voice Handicap Index (VHI), and a simple three‐item outcome scale (three visual analogue scales). Both instruments measure changes in the quality of the voice itself and in the extent of impairment resulting from the dysphonia as experienced by the patient in social and occupational settings. Statistical tests conducted on pre‐ and post‐treatment data indicated significant improvements on both instruments for the group as a whole. At the individual level, however, the effects were diverse. For roughly 50% of the subjects, a significant improvement could be established. The positive changes as measured with the three‐item scale were greater than those measured with the VHI. The results suggest that the two QOL instruments measure slightly different aspects of the subjective perception of the therapy effects. In order to obtain a general evaluation of the patient's handicap, it may suffice to ask some simple questions.     

Factors predicting patient perception of dysphonia caused by benign vocal fold lesions

OBJECTIVES/HYPOTHESIS: To assess factors that may be predictive of patient perception of dysphonia severity, as quantified by the Voice Handicap Index (VHI) score. We hypothesize that 1) level of vocal demand; 2) auditory-perceptual evaluation of dysphonia severity; and 3) vocal function, as defined by phonatory glottal closure and mucosal wave vibration, are the most significant predictors of VHI score. STUDY DESIGN:: Retrospective review of 100 patients with benign vocal fold lesions. METHODS: Variables assessed for predictive value to VHI score are level of vocal demands, auditory-perceptual evaluation of dysphonia severity, integrity of mucosal wave vibration and phonatory glottal closure, lesion type, duration of current complaint, smoking, age, and sex. Harmonic to noise ratio was assessed in a subset of 50 patients. RESULTS: Patients with routine voice use had significantly lower VHI scores than those with more intensive (nonsinging/acting) vocal demands. Patients who quit smoking had greater VHI scores than those who currently smoke or never started. Patients with long-standing dysphonia tended to have lower VHI scores than those with shorter duration vocal complaints. Auditory-perceptual assessment of dysphonia severity and harmonic to noise ratio were weak predictors of VHI score. Age, sex, lesion type, phonatory glottal closure, and mucosal wave vibration were not significant predictors of VHI score. CONCLUSIONS: Patient perception of dysphonia severity is independent of many factors commonly assessed during the evaluation of voice disorders. It appears to be an important independent element in the assessment of the effect of a benign vocal fold lesion and critical to therapeutic decision-making.     

Clinical evaluation of Parkinson's-related dysphonia

OBJECTIVES: Nearly one third of patients with idiopathic Parkinson's disease (IPD) cite dysphonia, characterized subjectively as causing a harsh and breathy voice, as their most debilitating deficit. Medical or behavioral treatments may lead to voice improvement. The purpose of this study was 1) to determine whether vocal fold injection of Cymetra (micronized form of collagen, elastin, proteoglycans; Lifecell Co.) is associated with changes in dysphonic voice characteristics in subjects with IPD, as judged perceptually using a standard instrument Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), and (2) which acoustic and aerodynamic measurements of voice are most reflective of any observed perceptual changes in voice. STUDY DESIGN: Prospective clinical evaluation of patients with Parkinson's-related dysphonia (PRD). METHODS: Six patients with PRD were evaluated before treatment for the presence of dysphonia and glottal gap. All subjects underwent transoral vocal fold collagen injection using topical anesthesia in the otolaryngology clinic as part of their clinical care. At the initial clinic visit, and 10 to14 days after vocal fold collagen injection, patients were asked to complete the Voice Handicap Index (VHI), a questionnaire concerning voice-related quality of life, and perceptual analyses of voice quality were performed. In addition, patients underwent acoustic (pitch/loudness range, maximum phonation time [MPT], and aerodynamic phonation threshold pressure [PTP]) voice analysis. RESULTS: Five of six subjects had self-perceived improvements in voice after treatment, as determined by the VHI (range, +8 to -24). All five subjects who completed testing demonstrated decreased PTP (range, -1.3 to -2.7, P = .002). Five of six subjects demonstrated statistically significant improvements in MPT (range, -2-16 s, P = .05). Five of six subjects had improved pitch range (-26-343 Hz), whereas all subjects had increased intensity range (0.6-23 db) after injection. CONCLUSIONS: Transoral collagen injection in patients with PRD is safe, well tolerated, and is an effective temporary method of subjectively improving voice and speech in selected patients with IPD. Reduction of glottal gap with collagen improves MPT and subglottal PTP. The resulting gain of vocal efficiency may reduce vocal fatigue and provide a useful adjunct to voice therapy for PRD.     

Laser resection of T1a glottic carcinomas: results and postoperative voice quality

OBJECTIVES: To calculate recurrence, mortality and complication rates and evaluate postoperative voice quality after laser resection of T(1a) glottic carcinoma. MATERIAL AND METHODS: Since 1995 we have treated 118 patients with a T(1a) glottic carcinoma with laser surgery. In order to evaluate postoperative voice quality, patients who were alive and free of recurrence were sent the Voice Handicap Index (VHI) questionnaire containing 30 questions concerning how their voice affects their daily life physically, emotionally and socially. RESULTS: Twelve patients (10%) had a local recurrence and received further treatment, either a second laser treatment, radiotherapy or a total laryngectomy. One patient (0.84%) died due to the laryngeal cancer. Ninety-nine patients were sent the VHI questionnaire and 94 of the completed questionnaires were included in the study and analyzed. The mean total score was 13.2, with mean subscores of 6.5 (physical), 4.1 (functional) and 2.5 (emotional). CONCLUSIONS: The results indicate that these patients as a group do not consider that their voice has a negative impact on their daily life. Good surgical technique is essential to obtain a good functional result. The laser strength should be kept low and the surgical margins small in order to minimize scarring and vocal cord stiffness.     

Graduierung des Voice-Handicap-Index

Background

The Voice Handicap Index (VHI) questionnaire is currently regarded as the gold standard for the measurement of subjective suffering caused by dysphonia. The object of this study was to show how to weight or grade the result yielded by the VHI. To this end, the result obtained with the VHI was graded against the external criterion of health-related quality of life and also compared with the VHI results obtained in persons not affected by dysphonia.

Patients and methods

A total of 101 patients (61 women, 40 men) aged between 19 and 86 (48.4±14.6) years and suffering from benign dysphonia (organic in 62%, functional in 38%: 62% and 38%, respectively in the women, 63% and 37%, respectively, in the men) took part in the study. The instruments used were a German version of the VHI and the SF-36 Health Survey on health-related quality of life, which is commercially available.

Results

There are two subscales to the SF-36, but only the values for physical health were significantly reduced and correlated significantly with the results on the VHI scale. This subscale was therefore used as the external standard for grading of the VHI results. Following the separation of the VHI results recorded in the nondysphonic test subjects a four-point grading of the VHI results emerged.

Conclusions

VHI values of 0–11 are classified as grade 0 suffering (almost certainly not noticeable), while values of 12–28 reflect grade 1 (more likely unnoticeable than conspicuous) suffering; values of 29–56 reflect grade 2 suffering (more probably noticeable than not), and values of 57–120 suggest a classification of certainly noticeable and are graded as grade 3 suffering.     

Self-assessment of voice therapy for chronic dysphonia

The effects of voice therapy in a group of chronically dysphonic patients are determined using two quality-of-life (QOL) instruments: the Voice Handicap Index (VHI), and a simple three-item outcome scale (three visual analogue scales). Both instruments measure changes in the quality of the voice itself and in the extent of impairment resulting from the dysphonia as experienced by the patient in social and occupational settings. Statistical tests conducted on pre- and post-treatment data indicated significant improvements on both instruments for the group as a whole. At the individual level, however, the effects were diverse. For roughly 50% of the subjects, a significant improvement could be established. The positive changes as measured with the three-item scale were greater than those measured with the VHI. The results suggest that the two QOL instruments measure slightly different aspects of the subjective perception of the therapy effects. In order to obtain a general evaluation of the patient's handicap, it may suffice to ask some simple questions.     

Outcomes of botulinum toxin treatment for patients with spasmodic dysphonia

BACKGROUND: Spasmodic dysphonia (SD) is a focal dystonia of the larynx. Although individuals with SD have variable degrees of difficulty in everyday communication and speaking, many report significant impairments. The impact of SD on the quality of life of people with the disorder has not been well measured. OBJECTIVES: To assess the impact of SD using a voice-specific, validated outcomes instrument, the Voice Handicap Index (VHI), and to evaluate the effect of botulinum toxin treatment on quality of life. METHODS: The VHI measures 3 subscales (physical, functional, and emotional) of impact of a voice disorder as well as a total impact score. The VHI was completed by 30 consecutive patients with SD before receiving botulinum toxin injection and 2 to 4 weeks after injection. Pretreatment scores on the VHI were compared with posttreatment scores. RESULTS: Pretreatment scores on the VHI showed significant impairment in all 3 subscales (physical, 25.5; functional, 21.4; and emotional, 20.4) and the total score (67.6). Statistically significant improvements occurred in all 3 subscale scores and the total score (P =.001) for the 22 patients who completed the posttreatment survey. CONCLUSIONS: Spasmodic dysphonia has a significant impact on patients' perception of quality of life as measured by the VHI. Significant improvements in all 3 subscale scores and the total score on the VHI occur after treatment with botulinum toxin.     

Vocal outcome after endoscopic thyroarytenoid myoneurectomy in patients with adductor spasmodic dysphonia

Spasmodic dysphonia (SD) remains one of the most difficult of laryngeal pathologies to treat. With limited role for speech therapy, various surgical modalities have been tried with various success rates. The objective of the study is to report the results of vocal outcome after thyroarytenoid myoneurectomy in patients of adductor spasmodic dysphonia (ASD). 15 patients of ASD were selected. GRBAS, and voice handicap index (VHI) were used for perceptual evaluation of voice. Thyroarytenoid myoneurectomy was performed by vaporizing the muscular layer of the vocal fold with CO₂ laser, at an intensity of 6 W with 1.2 mm diameter in scanner mode. Voice analysis was repeated at 12, 24 and 48 months follow-up. Preoperative GRBAS scores and VHI score of all the patients were poor. At 12 months 12/15 (80 %) patients having strain score of 0. There was marked improvement in VHI scores at 6 months. 10/15 (67 %) patients have been followed up for 24 months. 5/10 (50 %) patients have strain (S) value of 0. VHI scoring of 5/10 (50 %) patients was <30. Two of the four patients completed 48 months follow-up had a strain (S) value of 0, one patient has strain value of 1 and one patient had strain value of 2. 2/4 patients had VHI score of <30; one patient had that of 40. Trans-oral CO₂ laser thyroarytenoid myoneurectomy shows significant long-term improvement in voice quality in terms of reduced speech brakes, effort and strain in voice.     

Nonpharmacologic effects of botulinum toxin on the life quality of patients with spasmodic dysphonia

OBJECTIVE: Botulinum toxin (BT) injection improves objective and subjective voice measurements in spasmodic dysphonia; however, it is not clear whether the results are entirely caused by the neuromuscular blocking effects of BT or whether other factors (e.g., psychological or emotional) play a part. The aim of this study is to investigate whether nonpharmacologic factors contribute to the changes observed in the quality of life (QoL) after BT treatment of spasmodic dysphonia. STUDY DESIGN: Prospective cohort study. METHODS: Thirty-eight consecutive spasmodic dysphonic patients attending for repeat BT injections were investigated by recording their Voice Handicap Index (VHI) scores at three time points: 1) immediately prior to injection (baseline), 2) 1 day postinjection (when least pharmacologic change is expected), and 3) 2 weeks postinjection (when most pharmacologic change is expected). The changes in the total and domain VHI scores were compared between the two postinjection scores and the baseline value using two-way analysis of variance and the post hoc Bonferroni test. RESULTS: Most of the change in VHI score occurred between the baseline and first postinjection measurement. For two of the domains (total and emotional), the change was statistically significant. The change between the two postinjection assessments was minimal, and no domain showed statistically significant change. CONCLUSIONS: Our data indicate that the early improvements in QoL after BT injection can only in small part be attributed to the neurotoxic effects of the agent. We cannot say whether the reported effects in our study are attributable to a strong placebo response or are a real consequence of the patient's changing emotional state.     

Determination of subjective impairment in dysphonia. A methodological comparison

OBJECTIVE: The purpose of this study was to estimate the correlation between the voice handicap index (VHI) and the voice related quality of life (VRQOL) questionnaire with respect to gender and diagnosis (functional vs organic dysphonia). MATERIALS AND METHODS: A total of 52 German speaking patients aged 48.8+/-22.0 years suffering from dysphonia of different benign etiologies (functional dysphonia: 18 women, 9 men; organic dysphonia: 13 women, 12 men) completed German versions of both the VHI and the VRQOL questionnaire without prior information on their individual diagnosis. Another 52 individuals without voice complaints served as age and sex matched controls. Complete data sets of all participants were analyzed using the Microsoft Excel and MATLAB software packages. RESULTS: The results of both questionnaires correlate at a significant level, both for total score (r=-0.9) and the subscores (r=-0.74-r=-0.84) with only slight differences when comparing women and men and patients with functional and organic voice disorders. CONCLUSIONS: Both questionnaires provide very similar results. Thus, for clinical purposes, it seems justified to restrict oneself to using only one of the questionnaires. Whenever basic information on the patients' self perception of a voice disorder is required, the VRQOL questionnaire with only ten items may be easier to handle than the VHI questionnaire with 30 items.     

Long-term follow-up results of selective laryngeal adductor denervation-reinnervation surgery for adductor spasmodic dysphonia

Selective laryngeal adductor denervation-reinnervation surgery for the treatment of adductor spasmodic dysphonia was reported in 1999 in 21 patients with encouraging results. Here, we report long-term results of this procedure. Surgical outcome was evaluated using patient surveys and perceptual voice assessment. Measured outcomes included Voice Handicap Index (VHI)-10 scores, patient questionnaire, and perceptual evaluation for voice breaks and breathiness. Patient survey was obtained from 83 patients, and perceptual voice evaluation was performed in voice samples from 46 patients. Average follow-up interval was 49 months. Mean VHI-10 scores improved from a mean of 35.6 to 12.7. Eighty-three percent showed significantly improved VHI-10 scores, representing improved physical, social, and emotional well-being. There was a high degree of patient satisfaction, with 91% agreeing that their voice is more fluent after the surgery. Perceptual evaluation of postoperative voice samples revealed voice breaks in 26% (15% mild, 4% moderate, 7% severe) and breathiness in 30% (11% mild, 13% moderate, 6% severe). A majority of patients had stable, long-lasting resolution of spasmodic voice breaks.     

Voice-related quality of life in T1 glottic cancer: irradiation versus endoscopic excision

OBJECTIVES: Several studies have explored posttreatment voice outcomes for early glottic cancer with varying results. To further clarify the voice-related quality of life (QOL) of T1 glottic cancer patients treated by external beam radiotherapy (EBRT) compared to endoscopic carbon dioxide laser excision (CLE), we performed a meta-analysis. METHODS: We performed a meta-analysis review for the years 1966 to 2005 for the Voice Handicap Index (VHI), laryngeal cancer, voice outcome, voice quality, and quality of life. Studies in which the VHI was assessed at least 3 months after treatment for T1 glottic cancer were identified and analyzed by meta-analysis techniques. RESULTS: Six studies with 208 patients (6 T1b and 202 T1a) treated with CLE and 91 patients (6 T1b and 85 T1a) treated with EBRT were identified. The posttreatment VHI scores were similar for the EBRT- and CLE-treated patients (p = .1, Wilcoxon rank sum test). CONCLUSIONS: We conclude that CLE and EBRT provide comparable levels of voice handicap for patients with T1 glottic cancer.     

„Voice Handicap Index“ (VHI) in der stationären Stimmrehabilitation

Background

The focus of this study was to determine if the Voice Handicap Index (VHI) is a valid tool for evaluating an inpatient voice rehabilitation program.

Patients and methods

A total of 39 German-speaking patients were asked to complete a German version of the VHI questionnaire at the beginning and 3 months after attending a voice rehabilitation program on an inpatient basis at the Bad Gögging voice center. The data collected were documented and assessed using Microsoft Excel and MATLAB.

Results

A significant reduction of the VHI summary score was achieved by 10 of 39 patients. An increased number of voice therapy sessions before the program diminished (!) the VHI score 3 months after the program. Work disability because of the dysphonia before the beginning of the voice rehabilitation program showed no significant correlation with the VHI score.

Conclusions

At present, the VHI cannot be regarded as a reliable measure to evaluate benefit derived from completing a voice rehabilitation program on an inpatient basis. Apparently, numerous prior treatment regimens constitute a negative prognostic criterion for rehabilitation success as measured subjectively by the VHI.