Journal of Laryngology and Voice

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 11  |  Issue : 1  |  Page : 7--11

Effect of paan masala on voice parameters


K Sandhya1, N Priyanka2, C Chethan2,  
1 Department of Speech Language Pathology, JSS Institute of Speech and Hearing, Dharwad, Karnataka, India
2 All India Institute of Speech and Hearing, Mysuru, Karnataka, India

Correspondence Address:
K Sandhya
Assistant Professor, Department of Speech Language Pathology, JSS Institute of Speech and Hearing, Dharwad, Karnataka
India

Abstract

Introduction: Ingestion of paan masala (a mixture of areca nut with catechu, slaked lime, and added flavoring agents) is one of the means of smokeless tobacco usage which can also have adverse effect on voice such as dryness in vocal folds which in turn may result in depletion of mucosal layer of the vocal folds. Aim: Aim of the study was to investigate the consequence of paan masala usage on voice parameters and to compare the acoustic parameters amid two groups who were paan users and non paan users respectively. Method: A total of 120 samples (3 trials of phonation of sustained vowel /a/) were obtained from male participants between age ranges of 18 – 40 years. 60 recordings were taken from 20 individuals who indulged in intake of paan masala from past 5-10 years. Another 60 recordings were from 20 individuals who were non paan masala users. The recorded samples were subjected to two types of analysis viz. perceptual evaluation was carried out by 10 qualified speech language pathologists based on standardized voice rating scale and acoustic analysis was done using clinically acceptable software. Results: Results of perceptual analysis indicated increased breathiness which was supported by acoustical NNE. Greater values in jitter, shimmer and Normalized Noise Energy (NNE) in paan users indicates of being at risk of having vocal pathologies. These parameters of voice had a significant difference between paan users and individuals who do not consume paan. Conclusion: The results do indicate that consumption of paan poses an impending threat to voice which is evident in abnormal acoustical findings and it is essential for people to be aware of the consequences of devouring paan for mere pleasure of minutes.



How to cite this article:
Sandhya K, Priyanka N, Chethan C. Effect of paan masala on voice parameters.J Laryngol Voice 2021;11:7-11


How to cite this URL:
Sandhya K, Priyanka N, Chethan C. Effect of paan masala on voice parameters. J Laryngol Voice [serial online] 2021 [cited 2021 Dec 3 ];11:7-11
Available from: https://www.laryngologyandvoice.org/text.asp?2021/11/1/7/320562


Full Text



 Introduction



Smokeless tobacco consumption, which is widespread throughout the world, leads to oral submucous fibrosis (OSMF), which is a long-lasting and devastating condition of the oral cavity with the potential for malignancy. The common components of paan are tobacco, seeds, quenched lime, spices, and areca nut enfolded in betel quid.[1] The continuous chewing of paan (paan is a mixture of chopped areca nut with lime, catechu and other ingredients often includes tobacco) and swallowing of gutkha trigger progressive fibrosis in the submucosal tissue.[1] The term smokeless tobacco to the consumption of unburned tobacco, in the form of chewing, spitting, dipping, and snuff. Consumers chew the tobacco in the mouth and spit out the juice that builds up. Nicotine and other constituents are absorbed in the lining of the oral cavity.[1] People of many regions, including India, Pakistan, other Asian countries, and North America, have a long history of smokeless tobacco use.[2] According to the National Report of Global Adult Tobacco Survey conducted in India and Bangladesh, the current prevalence of smokeless tobacco use is 25.9 and 27.2%, respectively.[3] Paan masala causes other effects such as chest pain, either high or low blood pressure, raised skin temperature, and irregular heartbeat, according to the National Institute of Health.[4] Addiction to paan masala may be related to acute cardiovascular risks, such as increase in heart rate and blood pressure, and that longer use may contribute to the onset of coronary artery disease. Chewers have poor dental hygiene, burning sensation, decreased mouth opening, and precancerous spots, which have high chance of converting to oral cancer.[4] Paan and gutkha are considered as fourth most common psychoactive substance in the world.[4] In India, oral cancer is the common type of cancer with the cause of chewing smokeless tobacco. Paan and gutkha chewers also have been found to exhibit reduced salivation and mucous formation, thereby reducing the oral cavity and exposing the mouth to pathogens such as Aspergillus species.[5] Excessive gutkha eventually lead to loss of appetite, promote unusual sleep patterns, and loss of concentration.

The human vocal system includes the lungs and the lower airway that function to supply air pressure.[6] The vocal folds are set into vibration by continuous airflow which acts as a source and with many other modifications in the vocal tract. The role of human larynx is obviously more complex and more subtle than the way the larynx functions as an airway protector in most other mammals. Using the five aspects such as loudness, hygiene, pleasantness, flexibility, and representation, the area of normal voice can be addressed.[7] Caring of voice is a lifelong process which requires alertness to protect a very personal part of a person. Vocal folds need moisture to work efficiently. From various drugs to any number of drying environments may dry them out. Smokeless tobacco consumption is one of the driving forces, which leads to Oral Submucous Fibrosis (OSMF), which is a long-lasting and destructive condition of the oral cavity with the potential for malignancy.[8] Ingestion of paan masala is one of the means of smokeless tobacco usage, which can also have adverse effect on voice such as dryness in vocal folds which in turn may result in the depletion of the mucosal layer of the vocal folds. Improper lubrication of the vocal folds prevents them from vibrating and functioning as they should. Tobacco can cause laryngeal epithelial changes as reported.[9] When one or more aspects of voice such as loudness, pitch, quality, or resonance are outside of the normal range for the age, gender, or geographic background of the speaker, we say a voice disorder exists.[10]

Majority of the studies focus on direct tobacco inhalation such as smoking and seldom discuss indirect ingestion such as consumption of paan masala. Some studies discuss the effects of paan masala intake on general health aspects and oral cancer but fail in describing the vocal aspects such as changes in voice parameters such as frequency, perturbation, and noise parameters and also fails in describing the voice quality of an individual who intakes paan masala. Voice disorders in adolescents and adults often have a negative impact on their lives because they may interfere with life interactions and employment. According to the previous study,[11] the highest incidence of paan masala usage was found in the northern part of Karnataka, and hence, the present study considers subjects from this particular region. Therefore, the current study is very much essential not only to know the effects of paan masala on voice but also to create alertness among general public about harmful and implied effects of paan consumption. Appropriate Counselling and treatment plan can be made if any paan chewer reports of voice problems.

Objective

To recognize the consequence of paan masala usage on voice.To understand the difference of acoustic parameters amid paan and non paan users.

 Method



Participants

A total of 120 samples were obtained from participants aged between 18 and 40 years. Two groups of participants were considered, in which Group I included paan masala users and Group II individuals who did not consume paan masala. Sixty recordings were taken from 20 individuals (all males) who indulged in intake of paan masala from past 5 to 10 years, with a frequency of 5–6 packets every day. Remaining 60 samples were obtained from 20 individuals who had no history of paan intake. The time required to collect the data was approximately 5 min per subjects. Individuals with a history of vocal pathology, breathing difficulty, and other associated problems were excluded from the study. Subjects were asked to sit in front of the recording system on an armed chair with back support. They were instructed to phonate vowel/a/for about 5–8 s after a deep inhalation and the objective method of conducting the test procedure was priory informed to all the subjects.

Recording

Three phonation samples of sustained vowel /a/for 5–8 s at a comfortable pitch and loudness were obtained using a sensitive Panasonic boom microphone at a distance of 1 foot from the subject's mouth. The best sample out of the three with less background noise, better stability, and good-quality sample, i.e., 60 samples from each group were considered for further detailed analysis.

Perceptual analysis

This analysis describes voice quality solely by listening to it that is by using auditory perception. In auditory perceptual analysis of voice, hoarseness, breathiness, and roughness are considered as the most common signs, indicating changes in the larynx. Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) rating scale[12] was recommended as it includes all the major domains. The recorded samples were perceptually evaluated by 10 qualified speech language pathologists based on the clinically acceptable GRBAS perceptual four-point voice rating scale. G (Grade) represents severity of hoarseness and also the overall quality of voice. B (Breathiness) is seen if there is air leakage through an insufficient glottic closure, resulting in audible turbulence of air, which can include short unvoiced segments (aphonic moments). R (Roughness or harshness) gives information about the uneven glottic pulses and irregular fluctuations in mean pitch. A (Asthenicity) indicates weakness in the spontaneous phonation and hypokinetic or hypofunctional voice. S (Strain, vocal tension) gives idea of extreme force or tension connected with phonation.

Four-point rating ranges from 0 to 3 where rate 0 – normal, 1 – mild, 2 – moderate, and 3 – severe abnormality in voice quality under the above-mentioned GRBAS sections. The results were converted to percentage and were tabulated.

Acoustic analysis

To assess acoustical analysis of voice, Dr. Speech Software (Voice Assessment, Version 3.0) by Tiger Electronics' (Seattle, WA, USA) was used. Dr. Speech voice assessment is a speech analysis program intended for doing speech/voice evaluation for speech language pathologists and for speech/voice scientists. It is comprised of nine integrated software programs to produce a comprehensive window-based assessment and training system. Voice evaluation provides quantitative information to analyze the voice disorders. According to the study,[13] acoustic parameters commonly used in the applications of acoustic analysis as well as the most referenced in the literature are the fundamental frequency (F0), jitter, shimmer, and harmonic-to-noise ratio (HNR). Acoustic analysis was done by selecting a steady vowel phonation of 5 s and by obtaining voice parameters from the selected bit such as frequency measures (F0 gives information about number of times a sound wave produced by the vocal cords repeats during a given time period in terms of Hertz, minimum and maximum frequency, and standard deviation [SD] F0), Perturbation measures (Jitter is a parameter of frequency variation from cycle to cycle and Shimmer relates to the amplitude variation of the sound wave),[14] and noise parameters (normalized noise energy [NNE], signal-to-noise ratio [SNR], and HNR is assessment of the ratio between periodic components and nonperiodic component comprising a segment of voiced speech).[15] This was done for both the groups and attained values were tabulated. The data were subjected to further statistical analysis.

 Results



Descriptive statistics was done to find out the mean and SD of voice parameters between control and experimental groups. Mean and SD for F0 were M = 121.39; SD = 0.65, M = 129.65; SD = 0.98, for jitter M = 0.43; SD = 0.052, M = 0.24; SD = 0.016, Shimmer M = 6.0; SD = 0.12, M = 2.74; SD = 0.15, NNE M = −7.62; SD = 0.25, M = −19.55; SD = 0.97, HNR M = 18.58; SD = 1.10, M = 19.97; SD = 1.92, SNR M = 18.58; SD = 1.10, M = 19.97; SD = 1.92 for Group 1 and Group II respectively [Table 1] and [Figure 1].{Table 1}{Figure 1}

Test of normality was administered and no significant difference was seen (P < 0.05), suggestive of normal distribution. Hence, further parametric test was done. Since there were many dependent variables, MANOVA was done and the results showed a greater mean for voice parameters, namely jitter (F (1, 0.38) = 12.57, P = 0.01) shimmer (F (1, 105.95) = 253.54, P = 0.00), and NNE (F (1, 1424.08) = 707.11, P = 0.00), which had a significant difference between paan users and individuals who do not consume paan. No significant difference was observed for the remaining voice characteristics [Figure 2] and [Figure 3].{Figure 2}{Figure 3}

To establish a correlation between acoustical and perceptual measures, Chi-square test was done and Pearson's Chi-square was attained. The results were found to be significant between perceptual breathy quality rating and acoustical NNE X2 (3, n = 40) =11.61, P = 0.009 and also between jitter, shimmer, and roughness in the perceptual rating X2 (2, n = 40) = 10.35, P = 0.006, hence justifying that there was a good correlation between breathy voice quality and NNE and also rough voice quality with jitter and shimmer.

 Discussion



Reduced F0 was noticed in paan users compared to nonpaan users. It is believed that this reduction in F0 is a result of edema of the vocal folds caused by tobacco smoke.[16] Greater values in jitter, shimmer, and NNE in the experimental group indicates increased noisy component, which might indicate of being at risk of having vocal pathologies.[17] The F0 was lower in smokers, and average jitter and shimmer were higher in smokers comparing to nonsmokers. Significant correlation was observed between the auditory perception of grade, roughness, and breathiness as well as jitter, shimmer, and NNE.[18] The previous study[19] indicated that the mean and SD of jitter, shimmer, and NNE in individuals with vocal pathologies were significantly higher when compared to normal individuals. The study also concluded that there was a high correlation between perceptual ratings of breathy and roughness with acoustical parameters such as NNE, jitter, and shimmer, respectively. Similar study[20] stated moderate-to-high correlation between, respectively, the numbers of voice breaks, jitter (local), shimmer (local), and GRBAS subscales. Larger jitter, shimmer, and NNE in the subjects with alcohol abuse were stated,[21] where in another study the change was found in voice quality in elderly smokers.[22],[23] Mean jitter and shimmer were greater in smokers when compared to nonsmokers. Another research[24] summarized that both perturbation measures and noise-related measures had a significant difference in smokers in comparison with nonsmokers. Paan and paan masala are considered tobacco products as reported by the previous studies,[25],[26] which demand to conduct a studies on regular paan users and its effect on voice parameters.

 Conclusion



The results of the study indicate that the consumption of paan poses an impending threat to voice which is evident in abnormal acoustical findings and it is essential for people to be aware of the consequences of devouring paan for mere pleasure of minutes. Future studies can be done to identify the physical and physiological changes in the larynx and vocal tract due to usage of paan masala and also effect on articulatory and vocal tract functioning for long-term paan masala consumers is also necessary. Adequate measures have to be taken to change the lifestyle and behaviors of high risk in people who all are using paan/gutkha without knowing their effect on vocal mechanism.

Acknowledgment

JSS Institute of Speech and Hearing, Dharwad, was acknowledged.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Shah G, Chaturvedi P, Vaishampayan S. Arecanut as an emerging etiology of oral cancers in India. Indian J Med Paediatr Oncol 2012;33:71-9.
2Banerjee SC, Ostroff JS, Bari S, D'Agostino TA, Khera M, Acharya S, et al. Gutka and Tambaku Paan use among South Asian immigrants: A focus group study. J Immigr Minor Health 2014;16:531-9.
3Tricker A, Preussmann R. The occurrence of N-nitro compounds in Zarda tobacco. Cancer Lett 1988;42:113-8.
4Niaz K, Maqbool F, Khan F, Bahadar H, Ismail Hassan F, Abdollahi M. Smokeless tobacco (paan and gutkha) consumption, prevalence, and contribution to oral cancer. Epidemiology and Health 2017;39:e2017009.
5Avasn Maruthit Y, Rao RS, Palivela H, Thakre S. Impact of gutkha chewing & smoking on microbial environment of oral cavity: A case study on slum dwellers of selected areas in Visakhapatnam. J Environ Sci Eng 2004;46:268-73.
6Hixon TJ, Weismer G, Hoit JD. Preclinical speech science: Anatomy, physiology, acoustics, and perception. Choice Reviews Online 2009;46:46-4478-46-4478. doi: 10.5860/choice.46-4478.
7Boone DR. The Voice and Voice Therapy. Englewood Cliffs, NJ: Prentice-Hall; 1977.
8Garg A, Chaturvedi P, Gupta PC. A review of the systemic adverse effects of areca nut or betel nut. Indian J Med Paediatr Oncol 2014;35:3-9.
9Hirabayashi H, Koshii K, Uno K, Ohgaki H, Nakasone Y, Fujisawa T, et al. Laryngeal epithelial changes on effects of smoking and drinking. Auris Nasus Larynx 1990;17:105-14.
10Boone DR. The Voice and Voice Therapy. Upper Saddle River, NJ: Pearson Education; 2010.
11Keluskar V, Kale A. An epidemiological study for evaluation of oral precancerous lesions, conditions and oral cancer among Belgaum population with tobacco habits. Biosci Biotech Res Comm 2010;3:50-4.
12Hirano M, McCormick KR. Clinical examination of voice by Minoru Hirano. J Acoust Soc Am 1986;80:1273. doi: 10.1121/1.393788.
13Teixeira JP, Oliveira C, Lopes C. Vocal acoustic analysis – Jitter, shimmer and HNR parameters. Procedia Technol 2013;9:1112-22.
14Zwetsch I, Fagundes R, Russomano T, Scolari D. Digital signal processing in the differential diagnosis of benign larynx diseases. Scientia Medica 2006;16:109-12.
15Murphy PJ, Akande OO. Cepstrum-Based Estimation of the Harmonics-to-Noise Ratio for Synthesized and Human Voice Signals. International Conference on Nonlinear Analyses and Algorithms for Speech Processing; 2005. p. 150-60.
16Norante JD, Rubin P. Clinical Oncology for Medical Students and Physicians. 5th ed. New York: American Cancer Society; 1979. p. 163-80.
17Damborenea Tajada J, Fernández Liesa R, Llorente Arenas E, Naya Gálvez MJ, Marín Garrido C, Rueda Gormedino P, et al. The effect of tobacco consumption on acoustic voice analysis. Acta Otorrinolaringol Esp 1999;50:448-52.
18Murry T. Vocal tract parameters associated with voice quality and preference. J Voice 1988;2:111-7.
19Uloza V, Saferis V, Uloziene I. Perceptual and acoustic assessment of voice pathology and the efficacy of endolaryngeal phonomicrosurgery. J Voice 2005;19:138-45.
20Sabir B, Tour B, Moussetad M. Correlation between acoustic measures, voice handicap index and GRBAS scales scores among Moroccan students. Curr Pediatr Res 2017;21:243-353.
21Wan P, Huang Z. The effect of smoke and alcohol abuse to voice. J Clin Otorhinolaryngol Head Neck Surg 2008;22:686-7.
22Vasconcelos SV, Mello RJ, Silva SJ, Soares EB. Effects of smoking on the elderly people's vocal cords dimensions. Int Arch Otorhinolaryngol 2009;13:24-9.
23Sommer C, Schultz-Coulon HJ. Long-term results after microlaryngoscopic removal of Reinke's edema. Natl Libr Med 2007;55:365-74.
24Gonzalez J, Carpi A. Early effects of smoking on the voice: A multidimensional study. Med Sci Monit 2004;10:CR649-56.
25Mukherjea A, Modayil MV, Tong EK. Paan (pan) andpaan (pan) masalashould be considered tobacco products: Table 1. Tobacco Control 2014;24:e280-4.
26Brackett IP. Parameters of voice quality. In: Travis LE, editor. Handbook of Speech Pathology and Audiology. Englewood Cliffs, NJ: Prentice-Hall; 1971. p. 441-63.