Voice function and quality of life in laryngectomees

Sammanfattning: Individuals who undergo laryngectomy, surgical removal of the larynx, loose their normal voice. The breathing pattern is altered to permanent tracheostomal breathing. A new voice can be established by use of a segment in the lower part of the pharynx and the most upper part of the esophagus, the pharyngo-esophageal (PE) segment. This is the voice source in tracheoesophageal (TE) speech and esophageal (E) speech). Electrolaryngeal (EL) speech is an alternative speaking technique. The overall aim of this thesis was to describe the function and effects of the PE-segment with the use of endoscopic and radiological methods, to make acoustical and audio-perceptual analyses of laryngectomees voice and speech, and to investigate the laryngectomees self-evaluations of voice function and quality of life. Fifty-four laryngectomees participated in the four studies, all in all 45 TE-speakers, four E-speakers and five EL-speakers. The function of the PE-segment was studied with high-speed imaging recordings and videoradiography. Analyses were made of the vibratory pattern, the shape, the placement and the size of the PE-segment. Recorded speech samples were perceptually and acoustically analysed. Voice problems were evaluated by the use of Voice Handicap Index (VHI) and health-related quality of life was investigated by use of questionnaires from the European Organization for Research and Treatment of Cancer (EORTC). Volitional control of the musculature in the PE-segment was seen in high-speed imaging recordings (study I). In voiceless consonants the vibrations ceased and an opening gesture in the PE-segment was observed during closure duration. In voiced consonants, the vibrations in the PE-segment continued, although with decreased amplitude compared to the surrounding vowels. These findings should be useful in a therapeutic intervention of the coordination of phonation and articulation. Videoradiographical analyses of changes in shape, size and placement of the PE-segment showed predominant placement of the segment in the pharyngeal posterior wall (study II). The physiological measurements of the PE-segment showed inter-individual variations during both phonation and silence. Both TE- and E-speakers were able to make a good closure between the segment and the anterior wall of the pharynx during phonation. Placement of the segment in relation to the cervical column varied from C4 to C7. There were no significant relationships between radiological measurements of the PE-segment, perceptual analyses of voice quality, and acoustical measurements of fundamental frequency and voice intensity. In study IV, mean values of fundamental frequency and voice intensity for TE-speakers were close to normative data, however with wide inter-speaker ranges. Speaking rate for TE-speakers was slow, phrase lengths were short and the number of pauses high, likely due to deviant breath control and manual stoma occlusion. Protocols using visual analogue scales for perceptual ratings of TE-speech and voice proved to be reliable for carefully designed speech-language pathologist ratings. Low pitch, deviant voice quality, low speaking rates and short phrase lengths affected assessments of overall degree of deviation, and these parameters were significantly related to the perceptual assessments. The functional and physical subscales of VHI showed significant relationship with voice intensity, total reading time, phrase length and percent pause time. The emotional subscale of VHI showed no relation with acoustical measurements. Perceptual assessments of TE-speech and voice showed no relationship with the speakers self-reported voice handicap. In study III, self-rated voice handicap (VHI) was moderate for more than 50 percent of the patient group. About one third of the group rated their voice handicap as severe. Scores for the physical and functional subscales were somewhat higher compared to the emotional scale. For TE-speakers, functional and physical voice problems were significantly related to voice intensity, total reading time, phrase length and percent pause time. No other significant relationships were found. Ratings on the functional scales in the EORTC-questionnaire showed mean scores in agreement with normative data. The Global quality of life-scale (Global QOL) showed considerably lower scores as compared to normative data. The EORTC-questionnaire also revealed problems with smell and taste, speech, coughing, and xerostomia. Voice handicap scores showed significant relationship with the participants scoring of Global QOL and the functional scales in the EORTC-questionnaire. VHI-scores were also significantly related to EORTC-scores regarding breathing problems, problems with speech, social contact, pain from the head and neck area, smell and taste, and meal situations. These relationships confirm that the perceived degree of voice handicap affects the individual s participation in social activities. As a conclusion, a combination of the EORTC-questionnaires and the VHI-questionnaire is recommended. Additional questions on tracheostomal breathing, mucus production and coughing is needed for a complete documentation of handicap and health-related quality of life for laryngectomees.