|Year : 2013 | Volume
| Issue : 1 | Page : 26-28
Effect of surgery and radiotherapy on voice characteristics following glottic cancer
Niloofer Binth Nizar, Priyanka Vasnaik, Geethu Mohan, Jensy Gangan Kuniyil
Department of Speech and Hearing, Father Muller College of Speech and Hearing, FMCI, Mangalore, India
|Date of Web Publication||20-May-2013|
Department of Speech and Hearing, Father Muller College of Speech and Hearing, FMCI, Mangalore - 575 002
Source of Support: None, Conflict of Interest: None
To gain a better insight into voice characteristics and various contributing factors causing voice problem of patients who have undergone surgical treatment and radiation therapy for glottic cancer. A detailed voice assessment was carried out. Various acoustic, aerodynamic and perceptual measures were evaluated following the surgery and radiation therapy for glottic cancer. Results of acoustic and perceptual analysis indicated a severe hoarse voice. From the current study, it is inferred that the extent of tumor/site of lesion, modality of treatment and type of surgery also contribute to the deviation in voice characteristic in patient with glottic cancer. The glottic cancer can have several effects on an individual's daily living as it affects voice, which becomes a major hindrance for communication. The affected individuals should be evaluated by a speech language pathologist to identify the exact nature of voice impairment at the earliest in order to plan a comprehensive management strategy that could restore voice to give a good quality of life.
Keywords: Glottic cancer, radiation therapy, speech language pathologist, voice impairment
|How to cite this article:|
Nizar NB, Vasnaik P, Mohan G, Kuniyil JG. Effect of surgery and radiotherapy on voice characteristics following glottic cancer. Muller J Med Sci Res 2013;4:26-8
|How to cite this URL:|
Nizar NB, Vasnaik P, Mohan G, Kuniyil JG. Effect of surgery and radiotherapy on voice characteristics following glottic cancer. Muller J Med Sci Res [serial online] 2013 [cited 2022 Jan 29];4:26-8. Available from: https://www.mjmsr.net/text.asp?2013/4/1/26/112273
| Introduction|| |
Squamous cell cancer is the most common cancer of head and neck and accounts for 80% of head and neck cancers.  Laryngeal carcinoma is the 14 th most common form of malignancy in India and worldwide. Glottic tumors arise from the true vocal folds, including the anterior and posterior commissures. Persistent hoarseness is the usual presenting symptom of glottic carcinoma. Early stage glottic cancers, (i.e., T1 and T2) are managed with a single modality, such as radiation, endoscopic excision, or conservation laryngeal surgery. Advanced lesions, (i.e., T3 and T4) are typically treated with a combination of radiation and chemotherapy.
| Case Report|| |
An 80-year-old male was brought to the hospital on 01.08.12 presented with a history of change in voice since 1 year. The patient has a history of tobacco consumption for about 35 years. The biopsy report was done on 17.04.11, which revealed well differentiated squamous cell carcinoma of keratinizing type involving right vocal cords. Site of lesion: Proliferative growth involving right vocal cords extending just in front of vocal process posterior and lateral end of true cords laterally, lower end of the true cord inferiorly involving anterior commissure and extending to anterior one-third of the left vocal cords. T 2b N 0 M 0 (carcinoma in right vocal cord).
Following the cancer, the patient underwent micro laryngeal surgery with wide excision of right vocal folds and anterior one-third of left vocal folds on 3.10.11. Flexible nasopharyngoscopy done on 5.12.11 revealed normal nasal, nasopharynx, and oro pharynx and a small proliferation lesion near anterior commissure. Following this the patient underwent radiation therapy for 35 sittings from 27.12.11 to 22.2.12 for a period of 2 months. Oto-rhinolaryngology evaluation was done on 1.8.12. Bilateral vocal folds and arytenoid were edematous (post-radiotherapy edema) on indirect laryngoscopy.
During the initial visit demographic data and detailed case history which includes information regarding specific voice complaints, changes in voice quality, pitch, intensity, fatigability and other precipitating factors were documented. The patient reported change in voice following surgery for glottis carcinoma which was gradually progressive and persisting. Detailed perceptual, aerodynamic and acoustic evaluation of voice was carried out.
The test for perceptual evaluation included grade, roughness, breathiness, asthenia, strain (GRBAS) voice rating scale. This scale rates the voice quality along five parameters. The parameter are: Grade (the overall degree of voice abnormality), roughness, breathiness, asthenia (voice weakness), and strain. Each parameter is quantified on a 4-point scale, where each score represents the degree of voice quality as follows: 0 = normal, 1 = mild, 2 = moderate, and 3 = severe.
Maximum phonation duration, a test for aerodynamic measures to assess respiratory efficiency was done. The patient's task was to phonate the vowels (/a/), (/i/), and (/u/) for as long as possible after maximal inspiration at a comfortable pitch and loudness.
Acoustic analysis of voice was done using the software PRAAT by an experienced speech language pathologist in a sound treated room. The client was asked to phonate and sustain/a/. The parameters analyzed were fundamental frequency (minimum and maximum), intensity, frequency and intensity perturbations such as jitter, shimmer and noise related measures.
| Results|| |
Results of perceptual analysis indicated severe hoarseness with predominantly breathy quality. GRBAS scale revealed a rating of 3 for Grade, Rough, Asthenic, Strained and Breathy. Aerodynamic analysis revealed reduced maximum phonation duration indicating respiratory insufficiency (/a/-5 s, /i/-4 s, /u/-4 s). On acoustic evaluation, significantly higher jitter (local) and shimmer (local) values, i.e., 2.488% and 19.83% respectively and decreased harmonic to noise ratio of 8.38 dB were noted. The average intensity was 50.35 dB. The fundamental frequency was found to be 122.50 Hz (min) and 122.50 Hz (max). Results of subjective and objective analysis indicated severe harshness with breathy quality resulting in a severe hoarse voice.
| Discussion|| |
Voice changes can occur as a consequence of any damage to the vocal fold and other intrinsic structures due to the carcinoma. The treatment modality also is an important factor contributing to voice in patients with glottic cancer. Each mode of cancer treatment like radiation therapy, surgery or chemotherapy, presents some or other complications to the voice. Extend of the surgery will depend on the location and extent of the tumor. Surgery can leave a tissue deficit due to the tumor excision and stiffness due to scarring. The tissue deficit may leave a gap in the glottal area during the adduction of vocal folds. This gap may cause wastage of air resulting in breathy quality and inadequate vocal loudness and short phonation duration. The tissue gap and stiffness of the surrounding tissue may lead to impaired mucosal wave motion due to irregular vocal fold vibration.
Early glottic cancers are usually treated with endoscopic surgery, radiation therapy, or partial open surgery. In recent years, with advancement of technology endoscopic CO 2 laser surgery has made headway compared to radiation therapy with reduced morbidity and CO 2 laser treatment has improved voice quality when compared to that obtained following cordectomy.  In the current study, the patient underwent micro laryngeal surgery, the risk of voice impairment would be more in this surgery and may have contributed to a higher degree of voice impairment as compared to voice impairment due to other modalities such as laser CO 2 surgery.
The radiation can cause swelling of the mucosa followed by dryness and stiffness of the vocal folds. The long-term effects of radiation include fibrosis of soft-tissue, which limits the normal range of muscle motion.  The patient in the present study underwent radiation therapy for 35 sittings within 2 months, this can also be a precipitating factor in the voice impairment due to the radiation effects on vocal folds. A study was done on objective evaluation of the quality of voice following radiation therapy for glottic cancer. Acoustic and aerodynamic assessment was done in 12 patients. The vocal quality of these patients treated by radiation therapy has been described to have slight abnormalities in the voice profile. None of the patients studied scored normal values in both the assessment. The study concluded that although radiation therapy cures a high proportion of patients with T1 glottic cancer, the quality of voice doesn't return to normal following treatment. 
Deviant voice quality was negatively affected by increasing age (senescent changes). With increasing age vocal folds undergo various physiological changes such as bowing, atrophy, edema, and posterior glottal gap. Senescent have played only a minimal role in this individual since the individual reported voice problem after surgery and radiation therapy.
It was inferred from the results that acoustic analysis matched with the perceptual analysis. Perturbation measures such as jitter correlated with perceptual roughness and shimmer to hoarseness. Both jitter and shimmer values were increased. Harmonic to noise ratio was found to be reduced. The harmonic to noise ratio below 20 dB is considered to be a measure of noticeable hoarseness.  Reduced intensity can be due to gap in glottal area following surgery which causes inadequate medial compression required for louder voice productions. The result obtained in this study shows a signiﬁcant correlation between the subjective and objective measures.
The voice serves as an important function for communication and the impairment can interfere with daily life activities, hence it becomes important on the part of a speech language pathologist to assess and manage the voice problem at the earliest. Thus early identification and diagnosis of glottis cancer and early voice therapy is important for restoration of voice.
| Acknowledgment|| |
The authors thank the Lord Almighty, for His choicest blessings to carry out this study. The authors are indebted to the management of Father Muller Medical College Hospital, Mangalore for granting permission for the study. The authors thank Mr. Akhlilesh P. M, Principal and all the staff of Father Muller College of Speech and Hearing, Mangalore for their constant support and guidance.
We also thank the ENT department of the College Hospital. The authors acknowledge the co-operation of the participants in the study. The authors are thankful to their parents for the full support and encouragement.
| References|| |
|1.||Gourin CG. First Steps - I've Been Diagnosed with Head and Neck Cancer. Johns Hopkins Patients' Guide to Head and Neck Cancer. London: Jones and Bartlett Publishers; 2010. p. 11. |
|2.||Keilmann A, Bergler W, Artzt M, Hörmann K. Vocal function following laser and conventional surgery of small malignant vocal fold tumors. J Laryngol Otol 1996;110:1138-41. |
|3.||Leonard RJ, Kendall KA. Dysphagia in head and neck surgery patients. In: Dysphagia Assessment and Treatment Planning: A Team Approach, A Volume in the Dysphagia Series. San Diego, Ca: Singular Publishing Group, Inc.; 1997. p. 26. |
|4.||Aref A, Dworkin J, Devi S, Denton L, Fontanesi J. Objective evaluation of the quality of voice following radiation therapy for T1 glottic cancer. Radiother Oncol 1997;45:149-53. |
|5.||Williamson G. Instrumental Measurement of Voice, 2008. Available from: http://www.speech-therapy-information-and-resources.com/instrumental-measurement-of-voice.html. [Last cited 2008 Dec 5]. |