ORIGINAL ARTICLE

https://doi.org/10.5005/jp-journals-10023-1252
International Journal of Phonosurgery & Laryngology
Volume 13 | Issue 2 | Year 2023

Unveiling the Harmonics of the Singing Voice: A Comparative Evaluation of Voice Handicap Index-10, Singing Voice Handicap Index-10, and Singer Reflux Symptom Score in Singers: A Cross-sectional Observational Study

Nishigandha V Nehete¹, Anagha A Joshi², Manish A Prajapati³

^1,2Department of ENT, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India

³Department of ENT, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India

Corresponding Author: Manish A Prajapati, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India, Phone: +91 9029387923, e-mail: prajapatimanish5@gmail.com

Received: 26 December 2023; Accepted: 20 January 2024; Published on: 31 January 2024

ABSTRACT

Aims and objectives: The purpose of this study is to compare the Voice Handicap Index-10 (VHI-10) with the Singer’s Voice Handicap Index-10 (SVHI-10) and assess the Singer Reflux Symptom Score (Singer RSS) with the SVHI-10.

Materials and methods: Study design.

Type of study—cross-sectional observational study.

Sample size (n)—69.

Duration of study—4 months.

Period of study—March–June 2020.

Method—The Google Survey Form™ was designed and created by us and circulated to singers through WhatsApp and Email. VHI-10, SVHI-10, and Singer RSS scores are considered for this study.

Results: Comparison of VHI-10 with Singing Voice Handicap Index-10—the mean VHI-10 was 3.03 and that of SVHI-10 was 6.80 with a p-value was <0.001, which signifies that singers have very specific singing voice issues.

Effect of Singer RSS on SVHI-10 score—only the disorder severity scale was considered in the Singer RSS. Singer RSS score was divided into three groups viz 0–15, 16–30, and 31–45 and an average SVHI-10 score was 19.62 in a group of singers having Singer RSS score between 31 and 45, suggesting that laryngopharyngeal reflux (LPR) causes severe singing voice impairment.

Conclusion: Singers have more specific singing voice issues along with a speaking voice that can be adequately addressed by voice surgeons. LPR is one of the major factors contributing to vocal problems in singers. Self-perceptual scales like VHI-10, SVHI-10, and Singers RSS can be efficiently used to assess voice impairment in singers. Singers have more specific singing voice issues along with a speaking voice that can be adequately addressed by voice surgeons.

Clinical significance: The self-perpetual scales viz VHI-10, SVHI-10, and Singers RSS can be used to assess specific singing voice issues so that they can be adequately addressed by voice surgeons.

How to cite this article: Nehete NV, Joshi AA, Prajapati MA. Unveiling the Harmonics of the Singing Voice: A Comparative Evaluation of Voice Handicap Index-10, Singing Voice Handicap Index-10, and Singer Reflux Symptom Score in Singers: A Cross-sectional Observational Study. Int J Phonosurg Laryngol 2023;13(2):24–26.

Source of support: Nil

Conflict of interest: None

Keywords: Laryngopharyngeal reflux, Self-perpetual scale, Singers Reflux Symptom Score, Singing Voice Handicap Index-10, Voice Handicap Index-10

INTRODUCTION

Singing is a beautiful form of expression where a singer produces musical sounds using the larynx and vocal tract to convey the emotions and melody of a song. A singer’s voice is their instrument; hence, it is crucial for the singers to maintain their voice, as even a minor issue can impact performance and income, emphasizing the importance of diligent vocal care routines and professional guidance. To ascertain the influence of voice impairment on a patient’s quality of life and the resulting degree of handicap, it is essential to conduct a thorough clinical voice evaluation that incorporates patient-reported outcomes. Numerous patient-reported outcome tools are commonly employed in clinical settings to assess treatment outcomes. These include the Voice-related Quality of Life questionnaire, Voice Activity and Participation Profile, Voice Outcomes Survey, Voice Symptom Scale, Voice Handicap Index (VHI), and Voice Handicap Index-10 (VHI-10).

The most commonly used questionnaire for patient self-assessment is VHI-10. However, singers have very specific singing voice complaints. So VHI-10 is insufficient in revealing how voice problems truly affect singers. Consequently, the Singing Voice Handicap Index (SVHI) was developed by Cohen et al. in English in 2007.¹ The original SVHI index consisted of 36 questions related to physical, emotional, and social aspects of voice impairment. As it increased the cognitive load on singers during follow-up, a shorter version of the 10 questionnaires was developed and validated.²

Laryngopharyngeal reflux (LPR) is an inflammatory disease that can cause voice disorders. LPR is prevalent among professional voice users, often attributed to frequent travel, reliance on outside food consumption, and extended stage performances, which can result in irregular dietary habits. So, the Singers Reflux Symptom Score (Singer RSS), a singers-reported outcome instrument, is developed to assess specific LPR symptoms in singers.³

AIMS AND OBJECTIVES

The purpose of this study is to compare the VHI-10 with the Singer’s Voice Handicap Index-10 (SVHI-10) and assess the Singer RSS with the SVHI-10.

MATERIALS AND METHODS

Study Design

Type of study—Cross-sectional observational study.

Sample size (n)—69.

Duration of study—4 months.

Period of study—March–June 2020.

Method

The Google Survey Form™ was designed and created by us and circulated to singers through WhatsApp and e-mail.⁴

Voice Handicap Index 10 (VHI-10), SVHI-10, and Singer RSS scores are considered for this study.

Materials

Self-designed Google survey form.⁴
Voice Handicap Index-10 (VHI-10) (Table 1).⁵
Singing Voice Handicap Index-10 (SVHI-10) (Table 2).⁵
Singers Reflux Symptom Score (singers RSS) (Table 3).³

**Table 1:** Voice handicap index-10 (VHI-10)
Number	Index	Scale
1.	F1, my voice makes it difficult for people to hear me	0 1 2 3 4
2.	F2, people have difficulty understanding me in a noisy room	0 1 2 3 4
3.	F8, my voice difficulties restrict personal and social life	0 1 2 3 4
4.	F9, I feel left out of conversations because of my voice	0 1 2 3 4
5.	F10, my voice problem causes me to lose income	0 1 2 3 4
6.	P5, I feel as though I have to strain to produce a voice	0 1 2 3 4
7.	P6, the clarity of my voice is unpredictable	0 1 2 3 4
8.	E4, my voice upsets me	0 1 2 3 4
9.	E6, my voice makes me feel handicapped	0 1 2 3 4
10.	P3, people ask “What is wrong with your voice?”	0 1 2 3 4

E, emotional; F, functional; P, physical

**Table 2:** Singing Voice Handicap Index-10 (SVHI-10)
Number		Index	Scale
1.	P	It takes a lot of effort to sing	0 1 2 3 4
2.	F	I am unsure of what will come out when I sing	0 1 2 3 4
3.	P	My voice “gives out” on me while I am singing	0 1 2 3 4
4.	E	My singing voice upsets me	0 1 2 3 4
5.	F	I have no confidence in singing voice	0 1 2 3 4
6.	P	I have trouble making my voice do what I want it to	0 1 2 3 4
7.	P	I have to “push it” to produce my voice when singing	0 1 2 3 4
8.	P	My singing voice tires easily	0 1 2 3 4
9.	E	I feel something is missing in my life because of my inability to sing	0 1 2 3 4
10.	P	I am unable to use my “high voice”	0 1 2 3 4

E, emotional; F, functional; P, physical

**Table 3:** Singer Reflux Symptom Score (Singer RSS). Within the last month, I suffered from one/several followed symptoms
Number	Index	Scale for disorder frequency, disorder severity, quality of life impact each
1.	I suffer from hoarseness	0 1 2 3 4 5
2.	I suffer from voice breathiness	0 1 2 3 4 5
3.	I have difficulties reaching high notes	0 1 2 3 4 5
4.	I must make an additional effort during the singing	0 1 2 3 4 5
5.	I have lack of power	0 1 2 3 4 5
6.	I have a lack of vocal resistance and vocal fatigue	0 1 2 3 4 5
7.	I have excess of mucus	0 1 2 3 4 5
8.	I have excessive dryness of the throat	0 1 2 3 4 5
9.	Others	0 1 2 3 4 5

0, no effect; 5, highest effect

RESULTS

Comparison of Voice Handicap Index-10 with Singing Voice Handicap Index-10

The mean [standard deviation (SD)] of VHI-10 was 3.03 (5.18) and that of SVHI-10 was 6.80 (8.77) with SE of VHI-10 and SVHI-10 being 0.625 and 1.057, respectively. The mean difference (SD) between the two was –0.3768 (6.939). By using an unpaired t-test, p-value was <0.001 (Table 4).

**Table 4:** Comparison of VHI-10 and SVHI-10
	VHI-10	SVHI-10
Mean (SD)	3.03 (5.18)	6.80 (8.77)
SE	0.625	1.057
Correlation	0.613
Mean difference (SD)	–0.3768 (6.939)
p-value	<0.001

Effect of Singer Reflux Symptom Score on Singing Voice Handicap Index-10 Score

Only the disorder severity scale was considered in the Singer RSS.

Singer RSS score was divided into three groups viz 0–15, 16–30, and 31–45 and an average SVHI-10 score was compared as 1.8, 9.76, and 19.62, respectively. Singers with high RSS scores had high SVHI-10 scores suggesting that LPR causes singing voice impairment (Table 5).

**Table 5:** Effect of Singer RSS on SVHI-10
Number	Singers RSS groups	Average SVHI-10 score
1.	0–15	1.8
2.	16–30	9.76
3.	31–45	19.62

DISCUSSION

The p-value was <0.001 when VHI-10 was compared with SVHI-10. It states that there is a significant difference between VHI-10 and SVHI-10. When singers participated in the SVHI-10 assessment, they tended to characterize their voice issues as more pronounced compared to their responses in the VHI-10 survey. Specifically, they assign a severity score of 6.80 in the SVHI-10, contrasting with a milder score of 3.03 in the VHI-10.

Renk et al. had similar results stating that the SVHI-10 score of 20.4 and the VHI-10 score of 12.1, identifying their voice problem as more severe.⁵

Singing Voice Handicap Index-10 (SVHI-10) score was 19.62 in singers who had RSS scores between 31 and 45. It signifies that singers having LPR have severe singing voice impairment. The LPR study group of Young Otolaryngologists of International Federation of Oto-rhino-laryngological Societies (YO-IFOS) has innovatively crafted a novel tool for the accurate evaluation of symptoms associated with LPR specifically within the realm of singing voice.³

CONCLUSION

Significant differences in VHI-10 and SVHI-10 scores indicate that singers have more specific singing voice issues along with a speaking voice that can be adequately addressed by voice surgeons. LPR is one of the major factors contributing to vocal problems in singers.

Self-perceptual scales like VHI-10, SVHI-10, and Singers RSS can be efficiently used to assess voice impairment in singers.

Clinical Significance

The self-perpetual scales viz VHI-10, SVHI-10, and Singers RSS can be used to assess specific singing voice issues so that they can be adequately addressed by voice surgeons.

DISCLOSURE

Informed and valid consent was taken from all patients.
Permission from the ethics committee of the institution was taken before commencing the study.

REFERENCES

1. Cohen SM, Jacobson BH, Garrett CG, et al. Creation and validation of the singing voice handicap index. Ann Otol Rhinol Laryngol 2007;116(6):402–406. DOI: 10.1177/000348940711600602

2. Cohen SM, Statham M, Rosen CA, et al. Development and validation of the singing voice handicap-10. Laryngoscope 2009;119(9):1864–1869. DOI: 10.1002/lary.20580

3. Lechien JR, Schindler A, Robotti C, et al. Laryngopharyngeal reflux disease in singers: Pathophysiology, clinical findings and perspectives of a new patient-reported outcome instrument. Eur Ann Otorhinolaryngol Head Neck Dis 2019;136(3S):S39–S43. DOI: 10.1016/j.anorl.2018.08.008

4. https://docs.google.com/forms/d/1Pu9jG_OiansStjVEHyGJQ_OJom9prVsjbVWcYKKGF8A/edit

5. Renk E, Sulica L, Grossman C, et al. VHI-10 and SVHI-10 differences in Singers’ self-perception of dysphonia severity. J Voice 2017;31:383.e1–383.e4. DOI: 10.1016/j.jvoice.2016.08.017

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