Journal of Laryngology and Voice

ORIGINAL ARTICLE
Year
: 2022  |  Volume : 12  |  Issue : 1  |  Page : 5--10

Application of Voice Handicap Index score and flexible laryngoscopy in the evaluation of patients with laryngeal disorders


Auwal Adamu1, Abdulrazak Ajiya2, Yasir Nuhu Jibril2, Abdullahi Musa Kirfi1, Iliyasu Yunusa Shuaibu3, Sabiu Abdu Gwalabe4,  
1 Department of Otorhinolaryngology-Head and Neck Surgery, Abubakar Tafawa Balewa University Teaching Hospital/Abubakar Tafawa Balewa University, Bauchi, Nigeria
2 Department of Otorhinolaryngology, Aminu Kano Teaching Hospital/Bayero University, Kano, Nigeria
3 Department of Surgery, Division of Otorhinolaryngology, Faculty of Clinical Sciences, Ahmadu Bello University, Zaria/Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
4 Department of Medicine, Abubakar Tafawa Balewa University Teaching Hospital/Abubakar Tafawa Balewa University, Bauchi, Nigeria

Correspondence Address:
Auwal Adamu
Department of Otorhinolaryngology-Head and Neck Surgery, Abubakar Tafawa Balewa University Teaching Hospital/Abubakar Tafawa Balewa University, Bauchi
Nigeria

Abstract

Background: Laryngeal disorders are common in our environment, and a number of studies have been carried out. However, there is a paucity of literature with regard to the evaluation of voice-related handicap, and Voice Handicap Index (VHI) score for specific laryngeal disorders. Aim: The aim of this study was to apply the VHI score and flexible laryngoscopy in the evaluation of patients with laryngeal disorders and to determine the mean VHI score for specific laryngeal disorders in our environment. Methodology: A cross-sectional study was conducted among patients with the clinical diagnosis of laryngeal disorder who presented at the otolaryngology clinic of our institution. Patients who had previous laryngeal surgery or tracheostomy were excluded. Data was collected on sociodemographic variables, clinical history, and flexible laryngoscopic findings. The VHI score, which comprised of functional, physical, and emotional subscales was also collected and analyzed. Results: A total of 90 patients completed the study; 56.7% of them were males, whereas 43.3% were females. The mean VHI was highest in patients with laryngeal tumor (68.8 ± 14.8) followed by patients with vocal cord palsy (58.2 ± 5.7), but it was lowest in patients with acute laryngitis (27.1 ± 5.3). There was a statistically significant difference in mean VHI for each laryngeal disorder (P = 0.000). Conclusion: The patients with laryngeal tumor and those with vocal cord palsy had the highest VHI score, which affected their functional and emotional well-being. Therefore, applying VHI score and flexible laryngoscopy is important in the holistic evaluation of patients with laryngeal disorders.



How to cite this article:
Adamu A, Ajiya A, Jibril YN, Kirfi AM, Shuaibu IY, Gwalabe SA. Application of Voice Handicap Index score and flexible laryngoscopy in the evaluation of patients with laryngeal disorders.J Laryngol Voice 2022;12:5-10


How to cite this URL:
Adamu A, Ajiya A, Jibril YN, Kirfi AM, Shuaibu IY, Gwalabe SA. Application of Voice Handicap Index score and flexible laryngoscopy in the evaluation of patients with laryngeal disorders. J Laryngol Voice [serial online] 2022 [cited 2022 Nov 27 ];12:5-10
Available from: https://www.laryngologyandvoice.org/text.asp?2022/12/1/5/360574


Full Text



 Introduction



The larynx is a complex anatomical structure that serves the functions of respiration, vocalization, and lower airway protection.[1] Diseases of the larynx compromise these important functions, and therefore, the patients may present with dysphonia, cough, dyspnea, or even life-threatening upper airway obstruction. Disorders of the larynx are common, they constitute about 39% of otorhinolaryngological surgeries in our environment.[2] Laryngeal disorders have significant public health implications because they can result in impairment of communication, social isolation, depression, and an overall reduction in a patient's quality of life.[3]

Evaluation of laryngeal disorders is generally difficult due to the multiplicity and complexity of factors involved in their pathomechanism and a multidimensional concept that incorporates physical, mental, and psychosocial issues of the patients. Laryngoscopy assesses only the physical component of laryngeal disease and does not encompass the measurement of voice handicap, disability, and quality of life-related issues. As a result, patient-based specific instruments that provide more information on the psychological and functional aspects of laryngeal disorders have been developed. Of these instruments, the Voice Handicap Index (VHI) questionnaire is the most psychometrically robust,[4] and it has been acknowledged by the Agency for Healthcare Research and Quality as a reliable and validated instrument.[5],[6]

A number of studies have been carried out on laryngeal disorders in our environment, but there is a paucity of literature with regard to the evaluation of voice-related handicaps in patients with laryngeal disorders, and the mean VHI score for specific laryngeal disorders has not been well documented. Furthermore, most of the researchers used indirect laryngoscopy and/or direct laryngoscopy for the evaluation of laryngeal disorders, but very few used flexible laryngoscopic examination.[7],[8] Therefore, this study applied the VHI questionnaire and flexible laryngoscopy in the evaluation of patients with laryngeal disorders to determine the mean VHI score for specific laryngeal disorders.

 Methodology



Ethical consideration

The study followed the protocol of the Helsinki Declaration of 1975. Ethical approval was obtained from the institutional research and ethics committee, and consent was obtained from each participant.

Participants

The study was conducted at the otolaryngology clinic of our institution. The study included adult patients (≥18 years) who presented with a clinical diagnosis of laryngeal disorder within the study period. Patients excluded from the study were those with a history of previous laryngeal surgery or tracheostomy, patients with impending upper airway obstruction, patients with nasal, nasopharyngeal, oropharyngeal or hypopharyngeal tumors, patients with bleeding disorders, and uncooperative patients.

Study design

This research was a cross-sectional study.

Study instrument

A structured proforma was used to collect the data. The proforma was categorized into sections: sociodemographic variables, clinical history, VHI score, and flexible laryngoscopic findings. The VHI score was obtained using the standard VHI-30 questionnaire[9] which is a validated instrument and is comprised of functional, physical, and emotional subscales. The physical subscale reflected the self-perceptions of laryngeal disorder and the voice output characteristics. The functional subscale revealed the impact of a person's voice disorders on his or her daily activities whereas the emotional subscale demonstrated the patient's affective and psychological responses to a voice disorder. Each of the three subscales comprised 10 questions that were scored using a five-point Likert scale (0 = never, 1 = seldom, 2 = sometimes, 3 = almost always, and 4 = always). Each subscale had a maximum score of 40 and the total VHI score had a maximum of 120.

Procedure

All the participants underwent ear, nose and throat (ENT) examinations and flexible laryngoscopy, and the findings were documented. The flexible laryngoscopy was carried out according to a standard procedure.[10] Nasal secretions and crusts were suctioned out. A nasal examination was carried out to identify the most capacious nasal cavity, and to exclude gross nasal pathology. Topical nasal drops (10% xylocaine spray ± 0.5% xylometazoline) were applied into the nasal cavity and the throat to ease the procedure. A sterile flexible laryngoscope (Medtronic Xomed, FL, USA; model no: 68E3566M, diameter: 2.7 mm) was used for the procedure. The laryngoscope was lubricated using KY jelly and defogged by wiping the tip of the scope with cotton wool soaked with Savlon. The tip of the scope was passed into the nasal cavity along the flour, and it was advanced gently to visualize the laryngeal structures. The mobility of the vocal cords during respiration and phonation was also examined, and the findings were recorded.

Data analysis

Data collected was filtered using Microsoft Excel, and Statistical Products and Service Solution (SPSS) version 20 for Windows (IBM Inc. Chicago, Illinois, USA) was used for analysis. For quantitative variables, mean and standard deviation were calculated, and for qualitative data, frequencies as well as percentages were obtained. Analysis of variance (ANOVA) was used to compare the relationships between the variables. The level of statistical significance was set at P ≤ 0.05, with a 95% confidence interval.

 Results



A total of 90 patients completed the study. Most of the patients were males (56.7%), whereas the rest were females (43.3%), with a male–female ratio of 1:0.8. The age of the patients ranged between the ages of 18 and 70 years, with the majority of them 40 (44.4%) between 31 and 50 years [Table 1]. In addition to dysphonia, the participants also presented with other symptoms such as dyspnea in 21 (23.3%), cough in 21 (23.3%), dysphagia in 13 (14.4%), neck swelling in 12 (13.3%), and history of regurgitation at night in 16 (17.8%) patients. Most of the participants did not smoke (70.0%) or ingest alcohol (88.9%) and were of Hausa ethnicity [Table 1]. The distribution of laryngeal disorders based on occupation is shown in [Table 2]. The laryngeal tumor was the most common 20 (22.2%); it was more frequent among nonteachers (85.0%) than among teachers (15.0%), whereas vocal cord nodules were more common in teachers (70%) than in nonteachers (30%). [Figure 1] shows a laryngeal polyp at the anterior commissure, narrowing the laryngeal inlet.{Figure 1}{Table 1}{Table 2}

The total VHI score among patients with laryngeal disorders ranged between 21 and 93 with a mean of 46.8 ± 17.7. [Table 3] shows the range, mean, and standard deviation of VHI subscales. [Table 4] shows the mean VHI score for specific laryngeal disorders. The mean VHI was highest in patients with laryngeal tumors (68.8 ± 14.8) followed by patients with vocal cord palsy (58.2 ± 5.7), but it was lowest in patients with acute laryngitis (27.1 ± 5.3). The ANOVA test yielded a statistically significant difference in the mean VHI for each laryngeal disorder (P = 0.000). [Table 5] showed the distribution of the mean VHI based on the occupation of the patients; the mean VHI was high in teachers (49.9 ± 12.2) and preachers (49.5 ± 21.2), but it was low among students (27.0 ± 9.7). The ANOVA test yielded a statistically significant difference in mean VHI for each occupation (P = 0.0086).{Table 3}{Table 4}{Table 5}

 Discussion



Among the patients with laryngeal disorders reviewed in this study, the highest mean VHI score was seen in patients with laryngeal tumors (68.8 ± 14.8). Patients with laryngeal tumors are more likely to have chronic disease progression and chronic voice problems, leading to emotional disturbance, functional disability, and likely physical incapacitation (in the advanced disease stage). These may contribute to a high VHI score in this group of patients. However, Taguchi et al.[11] in Japan and Kasper et al.[12] in Germany reported a relatively lower VHI score of 42.2 and 38.9 ± 26.0, respectively. The low VHI score in their study may be attributed to the early detection of laryngeal cancer in their environment, and/or adequate counselling of patients with laryngeal cancer, which will go a long way toward reducing emotional stress and functional disability.

Similarly, patients with vocal cord palsy were found to have a high VHI score (58.2 ± 5.7) in this study. This is in agreement with the findings of Forti et al.[13] where vocal fold paralysis (61.33 ± 26.56) and other chronic laryngeal lesions had a high VHI score. Taguchi et al.[11] also reported that neuromuscular disorders such as vocal fold paralysis, psychological dysphonia, and spasmodic dysphonia had the highest VHI scores of 53.0, 55.9, and 65.0, respectively.[11] Another author also reported that the highest total VHI and subscores were found among the patients with vocal fold paresis.[14] Furthermore, other workers also reported that patients with neurogenic pathologies had significantly higher VHI scores than all other pathological groups.[6],[15],[16],[17]

This study found that the mean VHI of patients with vocal cord polyps and vocal cord nodules as 38.0 ± 1.4 and 42.1 ± 4.6, respectively. This is in agreement with the findings of Forti et al.[13] who reported 38.43 ± 29.86 and 35.49 ± 17.88 in patients with vocal cord polyps and vocal cord nodules, respectively. A similar study also reported VHI scores of 34.8 and 36.8 among patients with vocal polyps and vocal nodules, respectively.[11] The VHI score of patients with vocal polyps and vocal nodules was among the lowest in the group of patients we studied. This may be due to the fact that vocal cord polyps and nodules are benign lesions, and they tend to have a less emotional impact on the patient's psychological status. Our findings are corroborated by another study where the lowest VHI scores were found among patients with benign vocal fold masses.[14]

The mean VHI scores of various laryngeal disorders were compared, and the result showed that there was a statistically significant difference in mean for each laryngeal disorder, and hence each disease entity had a different voice handicap level (P = 0.000). This is in agreement with the findings of several authors,[6],[15],[16],[17] who reported that the VHI score differed to a statistically significant extent between the various laryngeal diseases (P < 0.05). However, other workers found no statistically significant differences between various laryngeal disorders and the mean VHI scores (P > 0.05).[18],[19] These variations may be due to the use of different versions of VHI, as one of the authors uses the Latvian version of VHI.

This study also showed that the majority of the patients with laryngeal disorders were teachers (26.7%). This is logical because teachers are commonly involved in voice abuse, and dysphonia is reported to be more common in them.[20],[21],[22] Furthermore, preachers constituted about 13.3% of patients in our study. This may also be due to voice misuse, as suggested by a study where the authors reported that dysphonia was more common in preachers than in the general population.[23] Analysis of laryngeal disorders based on occupation showed that vocal cord nodules were more common in teachers than in nonteachers in this study (70% vs. 30%, respectively). This is similar to the findings of Hameed et al.[24] who reported that vocal cord nodules were more common in teachers and other professional voice users. Similarly, Lira Luce et al.[25] found that teachers had a higher frequency of laryngeal abnormalities than nonteachers/control group (51.6% vs. 16%, respectively). Other studies in Nigeria also reported that laryngeal abnormalities were more common in teachers than in nonteachers: Nwoargu et al.[26] reported that the prevalence of chronic nonspecific laryngitis (including vocal nodules) was 55.6% with about two-thirds (60.88%) of the abnormalities were found in professional voice users like teachers. However, Alabi et al.[21] reported a lower frequency of laryngeal abnormalities (23.5%) during indirect laryngoscopy among teachers. The lower frequency of laryngeal abnormalities may be due to differences in the examination modalities used. The flexible laryngoscope gives a better and excellent view of the larynx than the laryngeal mirror examination.

This study found that the mean VHI was high in teachers (49.9 ± 12.2) and preachers (49.5 ± 21.2). Moreover, there was a statistically significant difference in the mean VHI for each specific occupation (P = 0.0086). This is similar to the findings of Thomas et al.[27] who reported that student-teachers had significantly greater total VHI scores than the reference group. Teachers were classified among the professional voice users. If a professional voice user experiences a voice disorder, they can have voice handicaps and disabilities in the workplace as they rely on their voice, and they may be at risk of losing their job. This emphasizes the importance of having a healthy voice in this group of people. The significance of this is that teachers with abnormal laryngeal findings tend to have severe perceived voice handicaps, which can affect their physical and psychosocial well-being and may render them handicapped in terms of work-related function, and eventually, they may be at risk of losing their job. Therefore, the attending physician should take into consideration the assessment of voice handicap in addition to laryngoscopy in patients with laryngeal diseases.

 Conclusion



Applying VHI score and flexible laryngoscopy is important in the holistic evaluation of patients with laryngeal disorders. Each laryngeal disorder had a different mean VHI score, and the highest score was seen in patients with laryngeal tumors and those with vocal cord palsy. Therefore, it is recommended that the VHI score should be used routinely in our clinics to evaluate the level of handicap in these patients to address both the physical and emotional aspects of their problems.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Harkema JR, Carey SA, Wagner JG, Dintzis SM, Liggitt D. 6 – Nose, sinus, pharynx, and larynx. In: Treuting PM, Dintzis SM, editors. Comparative Anatomy and Histology. San Diego: Academic Press; 2012. p. 71-94.
2Lasisi AO. Otolaryngological practice in developing country: A profile of met and unmet needs. East Cent Afr J Surg 2008;13:101-4.
3Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES, Gillespie MB, et al. Clinical practice guideline: Hoarseness (dysphonia). Otolaryngol Head Neck Surg 2009;141:S1-S31.
4Lam PK, Chan KM, Ho WK, Kwong E, Yiu EM, Wei WI. Cross-cultural adaptation and validation of the Chinese Voice Handicap Index-10. Laryngoscope 2006;116:1192-8.
5Biddle AK, Watson LR, Hooper CR, Lohr KN, Sutton SF. Criteria for Determining Disability in Speech-Language Disorders. Evidence Report/Technology Assessment No. 52 (Prepared by the University of North Carolina Evidence-based Practice Center). Rockville: AHRQ Publication; 2002.
6Amir O, Ashkenazi O, Leibovitzh T, Michael O, Tavor Y, Wolf M. Applying the voice handicap index (VHI) to dysphonic and nondysphonic Hebrew speakers. J Voice 2006;20:318-24.
7Isa A, Sandabe MB, Ngamdu YB, Garandawa HI, Kodiya AM. A clinical appraisal of hoarseness in adults at University of Maiduguri Teaching Hospital. Bio Med J 2013;10:36-41.
8Adobamen PO. Causes of hoarseness in Benin City, Nigeria. J Otol Rhinol 2015;4:5-7.
9Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benninger MS, et al. The voice handicap index (VHI): Development and validation. Am J Speech Lang Pathol 1997;6:66-70.
10Adamu A, Kolo ES, Ajiya A, Mahmud A, Shuaibu IY, Nwaorgu OG. Fibreoptic laryngoscopic assessment of patients with hoarseness: A cross-sectional analysis. J West Afr Coll Surg 2022;12:12-6.
11Taguchi A, Mise K, Nishikubo K, Hyodo M, Shiromoto O. Japanese version of voice handicap index for subjective evaluation of voice disorder. J Voice 2012;26:e15-9.
12Kasper C, Schuster M, Psychogios G, Zenk J, Ströbele A, Rosanowski F, et al. Voice handicap index and voice-related quality of life in small laryngeal carcinoma. Eur Arch Otorhinolaryngol 2011;268:401-4.
13Forti S, Amico M, Zambarbieri A, Ciabatta A, Assi C, Pignataro L, et al. Validation of the Italian voice handicap index-10. J Voice 2014;28:263.e17-263.e22.
14Niebudek-Bogusz E, Kuzańska A, Woznicka E, Sliwinska-Kowalska M. Assessment of the voice handicap index as a screening tool in dysphonic patients. Folia Phoniatr Logop 2011;63:269-72.
15Helidoni ME, Murry T, Moschandreas J, Lionis C, Printza A, Velegrakis GA. Cross-cultural adaptation and validation of the voice handicap index into Greek. J Voice 2010;24:221-7.
16Schindler A, Ottaviani F, Mozzanica F, Bachmann C, Favero E, Schettino I, et al. Cross-cultural adaptation and validation of the voice handicap index into Italian. J Voice 2010;24:708-14.
17Moradi N, Pourshahbaz A, Soltani M, Javadipour S, Hashemi H, Soltaninejad N. Cross-cultural equivalence and evaluation of psychometric properties of voice handicap index into Persian. J Voice 2013;27:258.e15-258.e22.
18Trinite B, Sokolovs J. Adaptation and validation of the voice handicap index in Latvian. J Voice 2014;28:452-7.
19Schindler A, Mozzanica F, Vedrody M, Maruzzi P, Ottaviani F. Correlation between the voice handicap index and voice measurements in four groups of patients with dysphonia. Otolaryngol Head Neck Surg 2009;141:762-9.
20Simberg 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.
21Alabi BS, Nwawolo CC, Okeowo PA, Somefun OA. Prevalence of hoarseness and vocal cord abnormalities among school teachers in Surulere local government area of Lagos State. Niger J Surg 2005;11:21-5.
22Johnson KJ, Akinola MA, Okonkwo KC. The prevalence of voice disorders in secondary school teachers in South west Nigeria. IOSR J Dent Med Sci 2017;16:76-9.
23Ibekwe MU. Hoarseness among preachers in Port Harcourt metropolis. Otolaryngol Online J 2019;9:186-94.
24Hameed A, Mushwani M, Sheik SI, Aziz B. Surgical audit of laryngeal disorders examined through flexible fibreoptic nasopharyngocope/laryngoscope. PJMHS 2013;7:456-9.
25Lira Luce F, Teggi R, Ramella B, Biafora M, Girasoli L, Calori G, et al. Voice disorders in primary school teachers. Acta Otorhinolaryngol Ital 2014;34:412-8.
26Nwaorgu OG, Onakoya PA, Ibekwe TS, Bakari A. Hoarseness in adult Nigerians: A University College Hospital Ibadan experience. Niger J Med 2004;13:152-5.
27Thomas G, Kooijman PG, Donders AR, Cremers WR, de Jong FI. The voice handicap of student-teachers and risk factors perceived to have a negative influence on the voice. J Voice 2007;21:325-36.