International Journal of Phonosurgery & Laryngology

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2018 | January-June | Volume 8 | Issue 1

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Muscle Tension Dysphonia—The Untold Story

[Year:2018] [Month:January-June] [Volume:8] [Number:1] [Pages:1] [Pages No:0 - 0]

   DOI: 10.5005/ijopl-8-1-iv  |  Open Access |  How to cite  | 



Surya Sureshkumar

Comparison of Voice Handicap Index Scores and Treatment Outcomes Between Professional and Non-professional Voice Users with Hoarseness

[Year:2018] [Month:January-June] [Volume:8] [Number:1] [Pages:5] [Pages No:1 - 5]

Keywords: Hoarseness, Microlaryngeal surgery, Professional voice user, Voice handicap index (VHI) 30

   DOI: 10.5005/jp-journals-10023-1150  |  Open Access |  How to cite  | 


Background: Hoarseness can affect the normal day to day life of people, as the ability to speak is one of the factors which makes us humans superior to other living beings. It is essential for effective communication and reflects one's personality. For some, voice forms the mainstay of their profession. Voice handicap index scores (VHI 30) is a self-assessment questionnaire which evaluates the level of handicap caused due to hoarseness. Patients were divided into groups of professional and non-professional voice users, and after appropriate treatment, the VHI scores were compared between the two. It may be assumed that the professional voice user would fare worse at a certain point of time after treatment. Objective: To compare the VHI 30 score and other voice parameters, and the pathological characteristics of laryngeal lesions between professional and non-professional voice users with hoarseness due to benign laryngeal pathologies, at 6 months posttreatment. Materials and methods: Evaluation results including the VHI 30 score were obtained from 46 patients in both the groups (selected as per inclusion-exclusion criteria). These were compared between pretreatment and 6 months posttreatment status. Chi-square test was used to compare between males and females. Independent sample t-test was used to compare the VHI scores, VHI change, shimmer, F0, contact quotient (CQ) and age between groups P and N. Mann–Whitney test was used to compare jitter between groups P and N. Repeated measures analysis of variance (ANOVA) with Bonferroni post hoc correction was used to compare the change in the VHI score at time points in groups P and N. Results: Our study was done in 46 adult patients in each group (professional group–group P and non-professional group–group N). The mean VHI score pretreatment in group P was 52.3 and 25.6 after 6 months of treatment. In group N, the pretreatment value was 52.1 and posttreatment was 22.3. Comparing the mean difference of VHI score between the two groups showed no statistically significant difference (p-value 0.319). Comparison of rest of the voice parameters also showed no statistically significant difference. Maximum phonation duration (MPD) p-value 0.319; Jitter p-value 0.173, Shimmer p-value 0.313, F0 p-value 0.893, CQ p-value 0.225). Vocal nodule was found to be having higher incidence (65.2% and 60.9% in groups P and N respectively), followed by vocal cord polyp (23.9% and 17.4% in sroups P and N respectively), and vocal fold cyst (10.9% and 21.7% in groups P and N respectively) without an statistically significant difference between both the groups (p-value 0.314) Conclusion: There is no statistically significant difference in posttreatment VHI score, other voice parameters and the characteristics of laryngeal pathologies between the two groups, but the non-professional group showed more improvement numerically irrespective of the nature of treatment availed.



Kavita Sachdeva, Tanvi Shrivastava

Dysphonia and its Correlation with Acoustic Voice Parameters

[Year:2018] [Month:January-June] [Volume:8] [Number:1] [Pages:7] [Pages No:6 - 12]

Keywords: Acoustic parameters, Consensus auditory-perceptual evaluation of voice (CAPE-V), Dysphonia, Praat Voice analysis

   DOI: 10.5005/jp-journals-10023-1151  |  Open Access |  How to cite  | 


Aim: To evaluate the laryngeal causes of dysphonia, correlation of acoustic voice analysis with Indirect laryngoscopic/ endoscopic findings in various voice disorders. Study design: Hospital based prospective observational study. Materials and methods: Forty patients attending the ear nose throat (ENT) outpatient department (OPD) at a Tertiary Care Government Hospital in one year, with dysphonia for more than 15 days were selected. History, examination, endoscopy, voice analysis was done. For consensus auditory-perceptual evaluation of voice (CAPE-V), the voice was analyzed under the following parameters: roughness, breathiness, strain, pitch, loudness, overall severity. Scores were given out of 100. For acoustic analysis, a computer-based software Praat was used based on jitter, shimmer, noise-harmonic ratio and mean pitch. Result: Benign lesions were most common in adults of age group 21 to 40 years, and malignancy in 41 to 50 years and 61 to 70 years; with male preponderance (4.7:1). Isolated vocal cord palsy (32.5%) was the most common lesion presenting with dysphonia, followed by malignancy (25%). Out of benign lesions, vocal polyp (10%) and nodule (10%) were the commonest, with equal incidence. On analyzing the voice, jitter and shimmer were found to be important parameters depicting the perturbation in frequency and amplitude, respectively. These parameters, indirectly, gave an idea about the vibratory motion of the vocal cords. On statistical analysis, jitter and shimmer showed significant direct correlation with the severity of dysphonia (jitter>shimmer). Noise to harmonic ratio (NHR) was raised in a significant number of dysphonic patients, with direct correlation with an increase in jitter. Although a significant relationship between the variation in mean pitch and CAPE V could not be established in this study; instrumental analysis was still useful in documentation and quantification of mean pitch in various dysphonic samples. Conclusion: Acoustic measurement of voice is a simple yet powerful tool to analyze the patients with dysphonic voice.



Amitabha Roychoudhury, Bhaskar Dey, Samriddha Kumar, Arpita C Shahi

Effect of Age on Swallowing Parameters in an Electroglottographic Study

[Year:2018] [Month:January-June] [Volume:8] [Number:1] [Pages:6] [Pages No:13 - 18]

Keywords: Age, Dry swallow, Electroglottograph (EGG), Percentage amplitude, Pure swallow, Solid swallow, Swallowing, Time, Water swallow

   DOI: 10.5005/jp-journals-10023-1152  |  Open Access |  How to cite  | 


Aim: To establish age as an essential factor in the assessment of swallowing Materials and methods: Sixty subjects were divided into two age groups (18 to 33 years and 55 to 70 years) and were further divided into males and females. Each subject was made to swallow four times each with different food consistency (dry, water, puree, and solid). The electroglottograph (EGG) was done during the swallowing process, and each swallow was depicted by a peak and a trough in the EGG. The X-axis in the EGG showed time while the Y-axis shows percentage amplitude. With the help of web plot digitizer software, the change in time and the change in percentage amplitude were obtained from the point of onset and offset of the peak and trough in the graph and the highest and lowest point on the peak and trough in the graph respectively. Results: A significant effect of age on dry swallow time and percentage amplitude, water swallow time and percentage amplitude, puree swallow time and percentage amplitude, solid swallow time and percentage amplitude was obtained. Conclusion: The results indicated that as age increased there was a significant increase in the change in time and a significant decrease in the change in percentage amplitude parameter. Clinical significance: Age should be considered as an important factor in the process of assessment of swallowing. The altered physiology with an increase in age should influence the clinician's perception of normalcy and prognostic predictions.



Sushant Joshi, Hemendra Bamaniya, Shiv K Vaishnav, Harbinder S Bhuie

Comparison between Voice Handicap Index and Voice Symptom Scale by Subjective Analysis of Voice Disorders

[Year:2018] [Month:January-June] [Volume:8] [Number:1] [Pages:7] [Pages No:19 - 25]

Keywords: Dysphonia, Quality of life, Voice handicap index (VHI), Voice disorders, Voice symptom scale (VoiSS)

   DOI: 10.5005/jp-journals-10023-1153  |  Open Access |  How to cite  | 


Objective: Purpose of the present study was to use and compare two patient-derived scales voice handicap index (VHI) and voice symptom scale (VoiSS) for the assessment of the quality of life in patients of voice disorders and to assess their response to treatment. Design: Longitudinal, cohort comparison study. Setting: Department of Otorhinolaryngology, Maharana Bhupal Government Hospital, Udaipur, Rajasthan Participants: Fifty patients with a complaint of change in voice attended ear, nose and throat outpatient department at Maharana Bhupal Government Hospital and Rabindranath Tagore Medical College, Udaipur from 7th July 2010 to 30th June 2011. Materials and methods: Two self-reported patients derived scale VHI and VoiSS were applied to all 50 patients of voice disorders both before as well as after treatment and compared the effect sizes of both the scales. Result: Out of 50 cases, maximum cases included in the study were of malignant growth larynx (30%) followed by vocal nodule (18%). A total of 60% were male, and 40% were female. Maximum cases were of 41 to 60 years of age group (48%). Both the patient-derived scales VHI and VoiSS were found equally useful in assessing the quality of life in patients of voice disorders. Outcomes were similar in both the scales. The mean scores in both the scales before treatment were reduced to almost half after the respective treatment. Conclusion: The result suggested that both the scales (VHI and VoiSS) are equally important as the results were highly correlated and no strong evidence was found to favor either of the scales. These scales are very useful in the assessment of the impact of voice disorders on patient's life and improvement in the quality of life after respective treatment as well as in assessing response to treatment.



Ashwani Sethi, Awadhesh K Mishra, Deepika Sethi

Endoscopic Laser Cordotomy Versus Coblator Cordectomy: Our Experience in Managing Bilateral Abductor Paralysis

[Year:2018] [Month:January-June] [Volume:8] [Number:1] [Pages:5] [Pages No:26 - 30]

Keywords: Bilateral abductor paralysis, Coblator, CO2 laser, Cordectomy, Cordotomy

   DOI: 10.5005/jp-journals-10023-1154  |  Open Access |  How to cite  | 


Introduction: Bilateral abductor vocal fold paralysis is a potentially challenging surgical entity. Various surgical options have been proposed for managing this condition. The present study aims to share our experience of using two established surgical modalities in managing this condition. Study design: Retrospective review. Setting: Tertiary health care center. Materials and methods: Twenty-three consecutive patients meeting inclusion criteria undergoing posterior cordotomy using CO2 laser (n = 9) and posterior cordectomy using coblator (n = 14) were included in this study. Preoperative subjective voice analysis was done and compared with measurements at 6 months post procedure. Parameters studied included voice handicap index (VHI), the need for repeat procedures, the effect of decannulation and subjective improvement in respiratory distress. Results: In all the patients undergoing these surgical procedures, there was a significant improvement in the airway as adjudged by the postoperative subjective improvement in respiratory distress (in five non-tracheostomized patients) and uneventful decannulation (in 18 tracheostomized patients). However, there was no statistically significant difference in either of the two techniques. The postoperative VHI scores showed no statistically significant difference with the preoperative assessment using either of the techniques. Two of the patients in the CO2 laser group and one patient in the coblator group required the procedure to be repeated owing to recurrence of respiratory distress. Conclusion: Both CO2 laser-assisted posterior cordotomy and coblator assisted posterior cordectomy are safe and efficacious options for the management of compromised airway secondary to bilateral abductor paralysis of vocal folds with comparable outcomes.



Jayanta Roy, Amitabha Roychoudhury, Bhaskar Dey, Rajanikanta Pradhan, Abhijit Das, Susmita Ghosh

Effectiveness of Neuromuscular Electrical Stimulation on Neurological Pharyngeal Dysphagia

[Year:2018] [Month:January-June] [Volume:8] [Number:1] [Pages:5] [Pages No:31 - 35]

Keywords: Endoscopic evaluation of swallowing, Neurological, Neuromuscular electrical stimulation, Penetration-aspiration scale, Pharyngeal dysphagia, videofluoroscopic study of swallowing

   DOI: 10.5005/jp-journals-10023-1155  |  Open Access |  How to cite  | 


This study was done to find the effectiveness of neuromuscular electrical stimulation (NMES) over anterior neck muscles. Sixteen patients, age range 50 to 80 years with pharyngeal dysphagia of neurological origin were included for study. A similar age-matched control group of 16 patients was taken from medical records. Detailed history, clinical assessment, investigations that are a flexible endoscopic evaluation of swallowing (FEES) and videofluoroscopic study of swallowing (VFS) was done. Subjective response (percentage of total diet taken orally) and penetration-aspiration scale (PAS) score at the beginning of treatment were noted. NMES was given to the study group along with swallow therapy. The suprahyoid muscles were stimulated regularly for 2 weeks. The reassessment was done after 2 weeks. The control group received only swallow therapy but no NMES. The results of the control group were also noted. Changes in the percentage of the total quantity of diet taken orally were asked. Upgradation in PAS score was assessed using FEES and VFS. The satisfactory improvement was found within 2 weeks in the study group. This took about 2 months in the control group. Hence, NMES was found to be an effective tool for dysphagia management.



Abhishek Gupta, Sukamal Das, Chandan Saha, Baisakhi Bakat, Soumitra Ghosh, Barin K Roychaudhuri

Sulcus Vocalis: Our Experience

[Year:2018] [Month:January-June] [Volume:8] [Number:1] [Pages:5] [Pages No:36 - 40]

Keywords: Sulcus vocalis, Vocal fold, Voice therapy

   DOI: 10.5005/jp-journals-10023-1156  |  Open Access |  How to cite  | 


Aims and objectives: • Evaluate the incidence of sulcus vocalis. • To document and analyze the outcome of treatment of sulcus vocalis. Materials and methods: A prospective observational study, conducted over 1 year, at a tertiary care teaching hospital in the department of ENT and Head-Neck surgery. Patients attending a voice clinic with dysphonia were included in the study. The diagnosis was made by fiberoptic laryngoscopy (FOL) and confirmed by stroboscopy. Patients were classified into types I, II or III according to Ford classification (1996). Conservative management in the form of vocal hygiene and voice therapy was advocated for all patients. No improvement warranted surgery. Subjective voice handicap index-10 (VHI-10) and objective evaluation (FOL) was performed at diagnosis and at 3 and 6 months of follow-up. The minimum follow-up period was 6 months. Results: A total of 167 patients attended the voice clinic for 6 months, of which 23 cases were diagnosed with sulcus vocalis. Of these 10 were females and 13 were males. 10 cases were categorized as type I, 9 as type II and 3 as type III. One patient had type II sulcus on right vocal fold and type I on the left side. All 10 cases of type I were treated satisfactorily by voice therapy. Out of 9 cases of Type II, 8 underwent microlaryngoscopic fat injection following voice therapy whereas 1 case was improved by voice therapy alone. In type III, patients 2 underwent fat implantation whereas 1 case underwent fat injection on one side and fat implantation on the other. All patients underwent post-operative voice therapy for 6 months. The reasonably good vocal outcome was noted during follow-up at 3 and 6 months. Conclusion: Sulcus vocalis is not a very uncommon condition. Fibreoptic laryngoscopy aided with stroboscopy can confirm the diagnosis in all cases. Type I responds well to voice therapy. In case of type II and III sulcus, the reasonably good vocal outcome is achieved with surgical intervention, followed by prolonged voice therapy.



Vicky Khattar, Sohil D Gala, Bachi Hathiram

Vocal Fold Medialization Procedures for 30 Cases of Glottic Insufficiency: Our Experience

[Year:2018] [Month:January-June] [Volume:8] [Number:1] [Pages:5] [Pages No:41 - 45]

Keywords: Glottic insufficiency, Medialization procedures, Medialization thyroplasty

   DOI: 10.5005/jp-journals-10023-1157  |  Open Access |  How to cite  | 


Introduction: Glottic insufficiency which is inability to obtain complete vocal fold approximation during phonation is a common cause for dysphonia. Vocal fold immobility, vocal fold sulcus, presbylaryngis, vocal fold scarring are common causes. Materials and methods: We have studied 30 cases of glottic insufficiency that failed conservative management and underwent surgical intervention. Voice parameters like maximal phonation time (MPT) and voice handicap index (VHI) have been used as assessment parameters along with laryngoscopic examination. Observations and results: Twenty-one cases had vocal fold immobility, while the rest had vocal sulcus (7), vocal fold atrophy (1), vocal fold scarring (1) as the cause. All cases presented with voice change with few having symptoms of aspiration. Patients were subjected to either vocal fold injection or medialization thyroplasty depending on the etiology and severity, and the outcomes assessed. Majority of our cases showed good amount of improvement on videolaryngoscopy and voice analysis (MPT, VHI scores). Mean MPT scores improved from 7.57 seconds (pre-operative) to 18.83 seconds (final post-operative) and VHI scores changed from a mean of 49.6 to 26.57. Few had post operative problems like vocal fold oedema, under correction, implant malposition. Four patients needed revision procedures due to suboptimal results. Conclusion: Selection of the most suitable procedure for each patient, meticulous and precise technique and adequate follow up will promise best results and minimize complications and undesired results in patients of glottic insufficiency.



Sheetal B Radia

Multimodality Treatment for the Contact Granuloma of the Vocal Folds

[Year:2018] [Month:January-June] [Volume:8] [Number:1] [Pages:6] [Pages No:46 - 51]

Keywords: Botulinum toxin type A injection (BTXA), Contact granuloma, Microlaryngeal surgery, Proton pump inhibitor, Voice therapy

   DOI: 10.5005/jp-journals-10023-1158  |  Open Access |  How to cite  | 


Introduction: This study aims to show the response of contact granuloma (CG) to Botulinum toxin type A injection (BTXA), proton pump inhibitors (PPI) and voice therapy (VT). Materials and methods: A non-randomized prospective analytical study was done at a tertiary care hospital, in which 70 patients with CG were seen over a 2 years period. Depending on the size of the CG, the patients were divided into three groups and treated as below: Group A: VT + BTXA+ PPI for farewell grade I and II CG Group B: VT + BTXA + PPI + Microlaryngeal surgery (MLS) for Farewell Grade III and IV CG Group C: VT + PPI (a group which did not agree for BTXA). Statistical analysis: Data were analyzed and stored using Microsoft Excel 2010 file and qualitative data was represented in the form of frequency and percentage. Results: Of the 70 patients in our study, we included 30 patients in group A, 19 in group B and 21 included in group C. All Group A patients (100%) resolved; however 1 patient needed a reinjection of BTXA. In group B, 18 patients (94.7%) resolved,1 patient (5.3%) had recurrence. In Group C, 18 patients (85.7%) resolved, and three patients (14.3%) had persistent CG. Conclusion: In our study, patients of farewell grade I and II treated with BTXA, PPI and VT had a 100% resolution rate. Surgery along with BTXA, PPI and VT is an acceptable treatment modality for farewell grade III and IV CG, as our study indicated a 94.7% success rate and 5.3% recurrence rate. The patients who did not receive BTXA had a decreased rate of resolution (85.7%).



Arundhatee P Sapre, Rahul S Gosavi

Primary Laryngeal Amyloidosis: A Discussion of 10 Cases with a Review of the Literature

[Year:2018] [Month:January-June] [Volume:8] [Number:1] [Pages:9] [Pages No:52 - 60]

Keywords: Benign laryngeal tumor, Larngeal amyloidosis, Primary amyloidosis

   DOI: 10.5005/jp-journals-10023-1159  |  Open Access |  How to cite  | 


Primary laryngeal amyloidosis is rare, accounting for 0.2 to 1.2 % of its benign tumors. However, it is the most common site in the upper aerodigestive tract for isolated primary amyloidosis. The most common symptom is hoarseness of voice, and depending on the extent of involvement, it may present with varying degrees of breathlessness. Diagnosis requires accurate histopathology using special staining by Congo red stain which demonstrates the typical apple-green birefringence when seen under polarized light. Diagnosis is often missed in the absence of special stains. Treatment requires as complete an excision as possible preferably with a laser. Periodic follow-ups are needed for the detection of recurrences. We present a series of 10 patients with primary laryngeal amyloidosis attending the voice clinic from March 2011 to February 2018, with a discussion of their management and a review of literature.


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