Page 109 - HHR-HNR 2.0

Radiation treatment may result in changes in voicing. This is especially the case when the larynx is within the radiated area. Known negative effects of radiation are vocal fatigue, reduced voice dynamics and range, vocal fold atrophy, oedema, scarring, changes in hydration and xerostomia (Fung, Yoo et al. 2001, Fung, Lyden et al. 2005, Starmer, Tippett et al. 2008). Depending on the dose and fractionation, radiation first causes inflammation of the radiated area, subsequently resulting in ulceration of the skin and/or tissue (Ward and van As-Brooks 2007). In extreme cases atrophy or even necrosis may occur. Radiation with concomitant chemotherapy increases the negative effects and in addition causes further side effects, such as nausea, vomiting and/or changes in taste (Allal, Bieri et al. 1997). Effects on voice and speech are seen up to a year after combined chemoradiation treatment (Van der Molen, Van Rossum et al. 2012).\u000DWhen a tumour is surgically removed, this may impair the physiology of voicing. Surgical resection may cause nerve damage or alter the mass of the vocal folds, which may disrupt the voice and the swallowing function. When, for instance, the vocal folds have been damaged or the vocal fold movement is limited or jittery, this may lead to a glottal gap. This may in turn lead to voicelessness, hoarseness, limitations in loudness and pitch, pain, and problems with phonation (Starmer, Tippett et al. 2008). Larger tumours in the laryngeal area can be surgically treated with a laryngectomy, a removal of the larynx (Ward and Van As 2014). A laryngectomy has severe consequences for quality of life, since the patient loses their natural vocal source (Singer, Merbach et al. 2007, Ward and Van As 2014).\u000DIn addition to the direct impact of the surgical resection on the anatomy of the larynx, voice disorders may also arise from a tracheotomy or gastrostomy. This may for instance be caused by changes in the climate of the lungs and/or vocal tract or disruptions in the swallowing mechanism.\u000DOther effects on voicing after treatment of head and neck tumours may be limitations in physical condition and/or lung function. Changes in lung function that may indirectly influence voicing can be measured using spirometry. The most important and reliable measurement of lung function is forced vital capacity (Garcia-Rio, Pino et al. 2004). This allows for the measuring of changes in lung volume between maximum inhale and exhale.\u000D5.3.2.2 Voice quality assessment techniques\u000DThe quality of the voice and changes in voicing can be measured along multiple dimensions. Recommended is a multidimensional assessment, allowing for both subjective and objective assessment of the voice (Orlikoff, Kraus et al. 1999, Dejonckere, Bradley et al. 2001, Meleca, Dworkin et al. 2003, Friedrich and Dejonckere 2005, Jacobi, van der Molen et al. 2010). In order to determine the impact of the tumour and the treatment, the timing of measurement points is important; in particular, the collection of pretreatment data (Jacobi, van der Molen et al. 2010). In addition to more objective measurement tools such as acoustic measurements (Jacobi, van der Molen et al. 2010), electroglottography, and aerodynamic or stroboscopic measurements, the voice is often assessed subjectively through patient-centred questionnaires such as the Voice Handicap Index VHI; (Jacobson, Johnson et al. 1997, Van Gogh, Mahieu et al. 2007), the V-RQoL (Hogikyan and Sethuraman 1999), or standardised quality of life questionnaires (e.g. EORTC;(Aaronson, Ahmedzai et al. 1993, Bjordal, Hammerlid et al. 1999), the FACT H&N (Cella, Tulsky et al. 1993), the HNCI (Funk, Karnell et al. 2003), the LENT-SOMA (Denis, Garaud et al. 2003)). Most of the quality of life questionnaires are, however, poorly equipped to assess components of voice, and they often do not differentiate between voice and speech (Jacobi, van der Molen et al. 2010). In addition to these patient questionnaires the voice can be assessed perceptually through the use of, for instance, GRBAS (Hirano and McCormick 1981),\u000D108\u000D