10 Evaluation of Voice Outcome and Quality-of-Life Measures

Beginning the consultation with an open question such as “tell me what is the problem with your voice” will allow patients to explain the problem in their own words and will allow the clinician to pick up on aspects of the problem that are important to the patient. It is also important to watch and listen closely to patients while they explain their problems in the way in which they comport themselves, the words they use in describing their ailments, and the emotions with which they speak.1 This may also aid in judging the perceived severity of the problem for the patient and may help the clinician explain the problem to the patient in appropriate language. Highly stressed or emotional patients may need far more reassurance and a simplistic plan than those patients who present in a more considered manner when an explanation of the anatomy and physiology of their condition will allow them to feel that they have some measure of control and understanding of the problem.

Vocal Hygiene

The health of the vocal tract relies on maintenance of the pliability of the mucosal surfaces. Hydration is key to this, and it is recommended that patients should drink around 2 L of water per day to ensure adequate hydration of the vocal tract. Avoiding caffeine intake (tea, coffee, and soft drinks) is also important in this regard. The use of steam inhalations can help maintain laryngeal hydration. Smoking cessation is imperative as is the avoidance of excessive alcohol intake. Throat clearing is profoundly irritating to the laryngeal mucosa and should be avoided. Vocal behaviors that are considered “abusive”, including screaming and yelling and talking above background noise for prolonged periods, should be avoided..

Reflux History

There is often a degree of laryngopharyngeal reflux (LPR) present in patients who present with dysphonia. Although there is still debate about whether silent reflux is a quantifiable diagnosis, what is certain is that the presence of gastric fluid will cause dehydration in the hypopharynx and larynx. To this end, a reflux scoring system is often used. “The two most popular evaluation scales LPR are the Reflux Symptom Index (RSI)² and the Reflux Finding Score (RFS) (Table 10.1).³ Both these scales are brief questionnaires that may help assess whether the treatment of LPR has been beneficial.

LPR can be limited with some lifestyle modifications: these include the avoiding eating meals late in the evening, avoiding spicy foods, and eating and drinking nothing (except water) for 3 hours before going to sleep.

General Medical History

Laryngeal dysfunction may be caused by an intrinsic laryngeal problem. However, it may be due to surrounding structures affecting the larynx indirectly. Problems with the lower respiratory tract, stomach and oesophagus, and nose and paranasal sinuses may all cause extraneous material to bathe the larynx, affecting its function.

Table 10.1 Evaluation Scales for Laryngopharyngeal Reflux

Lower respiratory tract pathology may cause chronic cough (asthma, bronchitis) or may include the expectoration of infected mucus (emphysema). Bacterially infected material is acidic and may directly damage the vocal tract or indirectly cause dysphonia due to drying of the laryngeal epithelium. Treatment of chronic lower respiratory tract problems often includes steroid inhalers that may dry and thin the laryngeal mucosa.

Professional voice users can be divided into performers (singers, actors) and those with professions that demand voice use (lecturers, teachers, call center workers), and the common theme being that voices are crucial to their careers. As such, changes in the voice can be seen as a catastrophic event even if the cause is fairly benign such as an upper respiratory tract infection.4

Specific questions concerning the role they are currently performing, the range of the role, how often and for how long they are performing, and the environment in which they practice and perform should be asked. Many theaters have dusty wings scenery and curtains, and artificial smoke can be an irritant.

At the end of taking a history, one should ascertain what the patient wishes to get from the consultation and possible treatment. This will ensure that both patient and clinician are aiming for the same goals and have realistic aims.

Subjective Evaluation of Voice

Evaluation of the voice is divided into subjective and objective measures. Under the umbrella term of subjective measures lie both perceptual evaluation and patient questionnaires measuring quality of life. In the modern voice clinic, both of these should be routinely used. In the authors’ practice, the patients are asked to fill in a questionnaire in the waiting room before the appointment—a patient-centered evaluation. This is followed by the doctor’s assessment while listening to the patient—a clinician-centered evaluation. Often these two evaluations give similar overall pictures. However, if there is a large discrepancy, for example, if the clinician hears very little wrong with the voice but the patient questionnaire suggests a terrible condition impinging on the patient’s life, the aims of the appointment and treatment must be carefully addressed and any psychological overlay should be examined.

There are several scoring systems for the clinician to assess the voice (Table 10.2). One of the most widely used is the Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scale that marks the overall grade, the roughness, the breathiness, the asthenia (weakness), and the strain of the voice. First described by Hirano,⁵ it is easy to be trained to use, has good inter-user reliability,⁶ and remains one of the most important, reliable, and valid methods of voice evaluation.⁷ Each of the five categories is graded from 0 (no perceived abnormality) to 3 (severe abnormality). Studies have suggested that the GRBAS has a strong inter-user reliability for the grade, roughness, and breathiness but less so for asthenia (weakness) and strain.⁸

The Grade, Roughness, Breathiness, Asthenia, Strain, Instability (GRBASI)⁹ scale is essentially the same but includes an instability score, allowing a score for vocal breaks in an otherwise normal voice.

The Consensus Auditory Perceptual Evaluation of Voice (CAPE V)¹⁰ is a visual analogue score on a 10-cm line and includes measures of pitch and loudness. It was developed as a consensus statement in 2003 by the American Speech-Language-Hearing Association (ASHA).

Table 10.2 Grading Schemes for Evaluation of the Voice

The Vocal Profile Analysis (VPA)11 is a detailed descriptor; however, it is considered by many to be too complex for regular use and its outcomes are not, at the time of going to press, validated.

Patient Questionnaires (Quality-of-Life Measures)

The role of patient-centered questionnaires is to determine the impact of the perceived vocal abnormality on the day-today life of the patient (Table 10.3). If there is no sinister cause for their dysphonia, treatment can be based on the perceived impairment or handicap.¹² To determine the level of disability, several patient-centered questionnaires have been developed.

•The Voice Handicap Index: The Voice Handicap Index (VHI)¹³ is probably the most widely used. It has 30 questions that determine the physical, functional, and emotional impairment that the patient’s dysphonia causes. Each is scored between 0 (never) and 4 (always), giving a maximum total score of 120. It is useful for the clinician and psychologically for the patient to see the change in scores before and after treatment. Such changes have been well documented¹⁴ and are important to record to both justify the treatments used and to be able to assess changes in technique or treatment methods.

•The Voice Handicap Index 10: The Voice Handicap Index 10 (VHI-10)¹⁵ is an adaptation of the VHI (Appendix 10.1). It has been reduced from 30 to 10 questions and has been validated. The personal preference of the authors is to use the VHI-10 questionnaire as it is quick and easy to fill in and patients seem to prefer a shorter questionnaire.

•The Voice Symptom Scale: The Voice Symptom Scale (VoiSS)¹⁶ is also a 30-item questionnaire that examines three main parameters: impairment (15 items), emotional symptoms (8 items), and related physical symptoms (7 items). It has been subject to rigorous psychometric evaluation and is the most extensively validated self-report voice measure available.¹⁷ However, it is not yet widely used.

•The Voice-Related Quality of Life: The Voice-Related Quality of Life (V-RQOL)¹⁸ is a 10-item questionnaire that measures well in validity, reliability, and responsiveness tests. It has not been through the same rigorous validation as the VoiSS but is an easy-to-use questionnaire.

Table 10.3 Patient Quality-of-Life Questionnaires

Appendix 10.1 Voice Handicap Index 10
Instructions: These are statements that many people have used to describe their voices and the effects of their voices on their lives. Circle the response that indicates how frequently you have the same experience.

Each of the above is validated and has its exponents and its detractors. Other than the level of validation, none of these have proven benefit over any of the others and so it is, in large part, the personal preference of the clinician to use any of these. The reason that none of these has any benefit over any of the others is probably in part due to the fact that they measure the patient’s perception of their own voice that may or may not correlate with the clinician’s perception of the patient’s voice. As long as the questionnaire used has good reliability and can be used pre- and post-treatment, any of these may be used.

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