Evaluation of voice handicap and emotional status among dysphonic and non-dysphonic individuals: A cross-sectional survey

Auwal Adamu; Yasir Nuhu Jibril; Emmanuel Sara Kolo; AbdulAkeem Adebayo Aluko; Nafisatu Bello-Muhammad; Abdulrazak Ajiya; Iliyasu Yunusa Shuaibu

doi:10.4103/AMJM.AMJM_40_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 18 | Issue : 4 | Page : 117-122

Evaluation of voice handicap and emotional status among dysphonic and non-dysphonic individuals: A cross-sectional survey

Auwal Adamu¹, Yasir Nuhu Jibril², Emmanuel Sara Kolo², AbdulAkeem Adebayo Aluko², Nafisatu Bello-Muhammad², Abdulrazak Ajiya², Iliyasu Yunusa Shuaibu³
¹ Department of Otorhinolaryngology, Head and Neck Surgery, Abubakar Tafawa Balewa University Teaching Hospital/ Abubakar Tafawa Balewa University, Bauchi, Nigeria
² Department of Otorhinolaryngology, Aminu Kano Teaching Hospital/Bayero University, Kano, Nigeria
³ Department of Surgery, Division of Otorhinolaryngology, Faculty of Clinical Sciences, Ahmadu Bello University, Zaria/ Ahmadu Bello University Teaching Hospital, Zaria, Nigeria

Date of Submission	23-Oct-2022
Date of Acceptance	30-Nov-2022
Date of Web Publication	20-Feb-2023

Correspondence Address:
Dr. Auwal Adamu
Department of Otorhinolaryngology, Head and Neck Surgery, Abubakar Tafawa Balewa University Teaching Hospital/Abubakar Tafawa Balewa University, Bauchi
Nigeria

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/AMJM.AMJM_40_22

Abstract

Background: Dysphonia impairs verbal communication of the sufferer, which can lead to social isolation, depression, and reduced quality of life. Evaluation of voice handicap and emotional impact of dysphonia are not routinely consider in our laryngology and voice clinics, despite the fact that about 50% to 60% of patients with dysphonia have social and psychological problems. Aims: The aim of this study is to investigate the voice handicap and emotional status among dysphonic and non-dysphonic individuals in our environment. Materials and Methods: It was a cross-sectional study that included dysphonic patients and non-dysphonic individuals matched for age and gender. A detailed clinical history was obtained, and the Voice Handicap Index (VHI) questionnaire was used to assess the voice handicap and emotional status of the participants. The mean VHI score of dysphonic and non-dysphonic participants was compared. Results: Ninety dysphonic patients and equal number of non-dysphonic controls completed the study. The mean VHI score dysphonic patients was higher (46.8 ± 17.7) than that of the controls (5.2 ± 3.9), and there was a statistical significant difference between the two groups (P = 0.000). Most of the dysphonic patients 69(77.8%) had poor emotional status, while most of the controls had good emotional status 83(92.3%). Conclusion: This study found high Voice Handicap Index and poor emotional status among dysphonic patients compared to controls. Therefore, patients with dysphonia should be reviewed by a psychologist in order to address the emotional aspect of their problem.

Keywords: Dysphonia, emotional status, voice handicap index score

How to cite this article:
Adamu A, Jibril YN, Kolo ES, Aluko AA, Bello-Muhammad N, Ajiya A, Shuaibu IY. Evaluation of voice handicap and emotional status among dysphonic and non-dysphonic individuals: A cross-sectional survey. Amrita J Med 2022;18:117-22

How to cite this URL:
Adamu A, Jibril YN, Kolo ES, Aluko AA, Bello-Muhammad N, Ajiya A, Shuaibu IY. Evaluation of voice handicap and emotional status among dysphonic and non-dysphonic individuals: A cross-sectional survey. Amrita J Med [serial online] 2022 [cited 2023 Mar 30];18:117-22. Available from: https://ajmonline.org.in/text.asp?2022/18/4/117/370007

Introduction

Dysphonia is defined as roughness of voice characterized by altered vocal quality, pitch and/or loudness. It has significant public health implications as patients suffer from social isolation, depression, and reduced disease-specific and general quality of life.^[1],[2] It has been reported that dysphonia affects nearly one-third of the population at some point in their lives and the prevalence ranges between 0.65% - 29.9% in the United States (US).^[2] Dysphonia may be associated with impairment of social and professional communications, and subsequent reduction in voice-related quality of life. It has been estimated that approximately 28 million US workers have occupations that require the use of voice, and 7.2% of the individuals surveyed missed work for one or more days within a year because of problem with voice, culminating to about $2.5 billion dollar loss annually.^[2],[3]

Evaluation of dysphonia is often inadequate, laryngoscopy is a common method usually employed. However, the evaluation of voice handicap and emotional impact are often overlooked, despite the fact that about 50% to 60% of patients with dysphonia have associated psychological problems.^[4] According to the European Laryngological Society, comprehensive evaluation of dysphonia should include assessment of clinical status, functional disability, level of handicap and overall emotional status of the patient.^[5] As a result, several assessment tools have been developed for the evaluation of level of handicap, emotional status, and quality of life related to dysphonia. These tools include; the Voice Symptom Scale, the Voice Related Quality of Life, the Vocal Performance Questionnaire, and the Voice Handicap Index (VHI) Questionnaire.^[6],[7] Of these assessment tools, the VHI has been widely accepted and used for research as well as for clinical purposes. VHI was developed by Jacobson et al.^[6] as a measure of perception of voice handicap, they referred to the World Health Organization’s definition of handicap, which was defined as social, economic, or environmental disadvantage resulting from an impairment or disability. The score is a voice-specific measurement, which provides useful information about voice handicap and the emotional impact of dysphonia on the quality of life. The VHI has been tested during its development and demonstrated internal consistency, and test-retest reliability.^[6] Furthermore, several authors have recommended the use of VHI as the gold standard in the assessment of physical, functional, and emotional aspects of dysphonia.^[8],[9],[10] Since then, it has been validated and adapted into many languages, such as Portuguese,^[4] Croatian,^[7] Chinese,^[11] Greek,^[12] Arabic,^[13] and Japanese.^[14] Similarly, some studies have demonstrated that the VHI score evaluates not only the emotional impact of dysphonia, but also serves as a screening tool for distinguishing between individuals with healthy voice and those with dysphonia.^[10],[15] Against this background, this study aimed at evaluating the voice handicap and emotional status among dysphonic and non-dysphonic individuals using the VHI questionnaire.

Materals and Methods

Study setting and design

This was a cross-sectional study conducted between March 2019 and February 2020 at the ENT Clinic of Aminu Kano Teaching Hospital (AKTH), a 700 bed tertiary healthcare facility located in Kano, Nigeria. The hospital serves as a training institution for medical students of the College of Health Science, Bayero University Kano (CHS-BUK). It is also a major referral center in the Northern Nigeria, with an average of 800 patients seen every month.

Ethical principles

Ethical approval to conduct this research was obtained from the Research and Ethics Committees of institution with code number: NHREC/21/08/2008/AKTH/EC/2467. Informed consent was obtained from each participant.

Inclusion and exclusion criteria

This study included adult patients aged ≥18 years who presented with dysphonia at the institution’s otolaryngology clinic. The study also included healthy individuals as controls (age and gender matched) from students of CHS-BUK and staff of AKTH. Individuals excluded from the study were those with history of previous laryngeal surgery or tracheostomy, patients with impending upper airway obstruction, and patients with nasal, nasopharyngeal, or oropharyngeal tumors.

Sample size estimation

Sample size was calculated using Fisher’s formula for estimating minimum sample size for cross sectional study.^[16] n = z²pq/d² where n = minimum sample size required, z = the standard normal deviate obtained from Z-table (1.96), p = prevalence of hoarseness from a previous study,^[17] conducted in our environment = 5.6% = 0.056, q = complementary probability = 1 − P = 1 − 0.056 = 0.944 and d = degree of precision at 95% confidence interval = 0.05. Thus, by substituting these values into the formula; n = [(1.96)² × 0.056 × 0.944] ÷ [(0.05)²] = 81. This was increased by about 10% to cover for attrition. The sample size was approximated to 90. An equal number (90) of age- and gender-matched controls were also recruited given a total of 180 participants.

Study tool

A pretested profoma was used to collect the data. The profoma was categorized into sections. Section A: Socio-demographic variables. Section B: Clinical history. Section C: Voice Handicap Index Questionnaire. The VHI questionnaire is a validated instrument which measure voice-specific information [Table 1].^[6] The VHI score comprised of functional, physical and emotional subscales. Each of the three subscale had a maximum score of 40, and the total VHI score ranged from minimum of 0 to maximum of 120. The score obtained was further categorized as normal (score ≤10), mild voice handicap (score of 11 - 30), moderate voice handicap (score of 31 - 60), and severe voice handicap (score of 61 - 120). Those with normal emotional sub-score (≤10) were considered to have good emotional status, while those with abnormal emotional sub-score (11–40) were considered to have poor emotional status.

Table 1: Voice handicap index questionnaire

Click here to view

Statistical analysis

The data was analyzed using Statistical Product and Service Solution (SPSS) version 20.0 (IBM Inc., Chicago, Illinois, USA). Quantitative data was presented using mean and standard deviation. While qualitative variables were presented using frequencies, percentages and charts. The mean VHI score for the dysphonic and non-dysphonic individuals was calculated. Chi-square and T-test were used to compare the relationship between the variables. The level of statistical significance was set at p-value ≤ 0.05.

Results

One hundred and eighty participants completed the study, they comprised of 90 dysphonic patients (study group) and equal number of non-dysphonic individuals (control group). Patients with dysphonia also presented with other symptoms such as dyspnea in 21 (23.3%), cough in 21 (23.3%), dysphagia in 13 (14.4%), and neck swelling in 12 (13.3%), history of regurgitation at night in 16 (17.9%), while 7 (7.8%) of the patients had no other symptom. The total Voice Handicap Index score among patients with dysphonia ranged between 2–93 with a mean of 46.8 ± 17.7, and that of the non-dysphonic individuals ranged between 0 –14 with a mean of 5.2 ± 3.9 [Table 2]. The severity of voice handicap among dysphonic patients was shown in [Figure 1]. The mean VHI score of dysphonic and non-dysphonic individuals were compared [Table 3], and there was statistically significant difference between the two groups (P = 0.000). The mean VHI scores of dysphonic patients have been compared based on age group and gender [Table 4]. The mean VHI scores of the older patients (>40 years) was statistically significantly higher than those of the younger patients (P = 0.000). Furthermore, the mean VHI of male patients with dysphonia was statistically significantly higher than that of females (P = 0.012). [Table 5] showed comparison of emotional status of dysphonic and non-dysphonic individuals. Most of the dysphonic patients 69(76.7%) had poor emotional status, while most of the non-dysphonic individuals had good emotional status 83(92.3%), and there was statistical significant difference between the two group.

Table 2: Voice handicap index score of dysphonic and non-dysphonic individuals

Click here to view

Figure 1: Severity of voice handicap among dysphonic patients

Click here to view

Table 3: Comparison of mean VHI score of patients with dysphonia and controls

Click here to view

Table 4: Comparison of mean VHI scores of patients with dysphonia based on age group and gender

Click here to view

Table 5: Comparison of emotional status of dysphonic and non-dysphonic individuals

Click here to view

Discussion

Traditionally, assessment of voice disorder is generally believed to be difficult due to multiplicity and complexity of factors that involved physical, functional and emotional status of the patients. In this study, the VHI score of dysphonic and non-dysphonic individuals were assessed, and the result showed that dysphonic individuals had high mean VHI score (46.8 ± 17.7). This is similar to the findings of other authors who reported a mean VHI score of 44.1 ± 21 and 44 ± 15 respectively.^[7],[15] However, a lower mean VHI score of 34.4 ± 3.2 and 37 ± 21.3 were reported among Portuguese and Greek patients with dysphonia respectively.^[4],[12] Higher VHI score in our patients may be due to the late presentation to the hospital or presence of longstanding disease condition. Patients with longstanding diseases were reported to have poor emotional status and tend to have high VHI score.^[18],[19] Furthermore, among the dysphonic patients we studied, severe voice handicap was seen in 23.4% of them, moderate in 54.4% while mild voice handicap in 22.2% of the patients. The proportion of VHI seen in these patients were similar to the findings of Helidoni et al.^[12] where 19% of their patients perceived their voice as being severely impaired, 43% moderately impaired, and 33% mildly impaired. Similarly, another study in Poland reported that 62% of their patients were found to have moderate voice disability, while 18% had a severe disability.^[15]

In this study, the older patients had a mean VHI score higher than the younger patients, and there was a statistically significant difference between the age groups (P = 0.000). This is similar to the findings of Malik et al.^[13] where older speakers showed higher VHI scores than younger ones. The higher VHI score in the older patient may be due to the fact that older people have been reported to have more serious psychosocial implication of dysphonia.^[20] High prevalence of other comorbidities in older patients may also explain the high VHI in them.^[20] However, a study among Hebrew speakers showed no statistically significant difference between the total VHI score and the respondent’s age (P = 50.156).^[21] Other researchers also reported that VHI and all its sub-scores were not significantly affected by age (P > 0.10).^{[12],[22],[23],[24]} This study also showed that the mean VHI score of male patients with dysphonia was higher than that of females, and there was a statistically significant difference between the two groups (P = 0.012). This is because men with dysphonia may become more emotionally disturbed if the dysphonia affected their job. Some authors also reported that males with dysphonia had higher VHI scores than females,^[13],[25] but other studies have demonstrated contrary results.^{[4],[14],[15]} However, several workers believed that there was no statistically significant difference between the VHI scores of men and women with voice disorder.^{[12],[21],[22],[23]}

The mean VHI score of dysphonic patients was higher than that of non-dysphonic participants of this study, and comparison showed that there was a statistically significant difference between the two groups (P = 0.000). This is similar to the findings of Xu et al.^[11] in China and Helidoni et al.^[12] in Greece who reported that the mean VHI scores were higher for dysphonic patients than controls and there was a statistically significant difference between the two groups (P < 0.001). Similarly, researchers have demonstrated that speakers with voice complaints have significantly higher total VHI scores than speakers without voice complaints. (P < 0.001).^[4],[23] Furthermore, several other studies reported that the dysphonic patients had a higher average VHI score compared to non-dysphonic individuals, and they concluded that subjects with dysphonia had significantly higher voice handicap than non-dysphonic controls (P = 0.000).^{[7],[13],[15],[21],[25],[26],[27]} The similarities of these results and findings of this study may be due to the use of the same assessment tool (VHI score) which was validated and had strong internal consistency and reliability.^{[6],[7],[8],[9],[10],[28]} The clinical significance of the higher VHI score in dysphonic patients, is that these patients have considerable voice handicap which can have an impact on their emotional well-being. As a result, the attending physician should not ignore such a handicap because it has a negative consequences on the patient’s quality of life.

Conclusion

The dysphonic patients had poorer emotional status and a statistically significant higher voice handicap compared to controls. As a result, routine clinical evaluation of patients with dysphonia should include a voice handicap assessment, as this will highlight any associated emotional problem. Therefore, we recommend that any patient with a high voice handicap should be reviewed by a psychologist.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Mirza N, Ruiz C, Baum ED, Staab JP The prevalence of major psychiatric pathologies in patients with voice disorders. Ear Nose Throat J 2003;82:808-10, 812, 814.
2.	Roy N, Merrill RM, Gray SD, Smith EM Voice disorders in the general population: prevalence, risk factors, and occupational impact. Laryngoscope 2005;115:1988-95.
3.	Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES, Gillespie MB, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg 2009;141:S1-S31.
4.	Guimarães I, Abberton E An investigation of the voice handicap index with speakers of portuguese: preliminary data. J Voice 2004;18:71-82.
5.	Günther S, Rasch T, Klotz M, Hoppe U, Eysholdt U, Rosanowski F Determination of subjective impairment in dysphonia. A methodological comparison. HNO 2005;53:895-900, 902–4.
6.	Jacobson BH, Johnson A, Grywalski C, et al. The voice handicap index (VHI): development and validation. Am J Speech Lang Pathol 1997;6:66-70
7.	Bonetti A, Bonetti L Cross-cultural adaptation and validation of the voice handicap index into croatian. J Voice 2013;27:130.e7-130.e14.
8.	Benninger MS, Gardner GM, Jacobson BH New dimensions in measuring voice treatment outcome and quality of life. In: Sataloff RT, editor. Professional voice. The science and art of clinical care. 3rd ed. Oxford: Plural Publishing;2005. p. 471-7.
9.	Kasper C, Schuster M, Psychogios G, Zenk J, Ströbele A, Rosanowski F, et al. Voice handicap index and voice-related quality of life in small laryngeal carcinoma. Eur Arch Otorhinolaryngol 2011;268:401-4.
10.	Grässel E, Hoppe U, Rosanowski F Grading of the voice-related quality of life index. HNO 2009;57:896-901.
11.	Xu W, Han D, Li H, Hu R, Zhang L Application of the mandarin chinese version of the voice handicap index. J Voice 2010;24:702-7.
12.	Helidoni ME, Murry T, Moschandreas J, Lionis C, Printza A, Velegrakis GA Cross-cultural adaptation and validation of the voice handicap index into greek. J Voice 2010;24:221-7.
13.	Malki KH, Mesallam TA, Farahat M, Bukhari M, Murry T Validation and cultural modification of arabic voice handicap index. Eur Arch Otorhinolaryngol 2010;267:1743-51.
14.	Taguchi A, Mise K, Nishikubo K, Hyodo M, Shiromoto O Japanese version of voice handicap index for subjective evaluation of voice disorder. J Voice 2012;26:668.e15–9.
15.	Niebudek-Bogusz E, Kuzańska A, Woznicka E, Sliwinska-Kowalska M Assessment of the voice handicap index as a screening tool in dysphonic patients. Folia Phoniatr Logop 2011;63:269-72.
16.	Jibril YN, Adamu A, Jalo RI, Farouk ZL, Salisu AD, Nwaorgu OGB Transient-evoked otoacoustic emission findings in children (1-12 years) with cerebral palsy in Kano, Nigeria. Niger Postgrad Med J 2020;27:371-6.
17.	Eziyi JAE, Amusa YB, Akinpelu OV Prevalence of Otolaryngological diseases in Nigerians. East Centr Afri J Surg 2010;15:85-9.
18.	Schneiderman N, Ironson G, Siegel SD Stress and health: psychological, behavioral, and biological determinants. Annu Rev Clin Psychol 2005;1:607-28.
19.	Naylor C, Das P, Ross S, Honeyman M, Thompson J, Gilburt H Bringing together physical and mental health: A new frontier for integrated care. 1st ed. London: The King’s Fund;2016. p. 22-30.
20.	Gregory ND, Chandran S, Lurie D, Sataloff RT. Voice disorders in the elderly. J Voice 2012;26:254-8.
21.	Amir O, Ashkenazi O, Leibovitzh T, Michael O, Tavor Y, Wolf M Applying the voice handicap index (VHI) to dysphonic and nondysphonic Hebrew speakers. J Voice 2012;20:318-24.
22.	Saleem AF, Natour YS Standardization of the arabic version of the voice handicap index: an investigation of validity and reliability. Logoped Phoniatr Vocol 2010;35:183-8.
23.	Ohlsson AC, Dotevall H Voice handicap index in Swedish. Logoped Phoniatr Vocol 2009;34:60-6.
24.	Moy FM, Hoe VC, Hairi NN, Chu AH, Bulgiba A, Koh D Determinants and effects of voice disorders among secondary school teachers in peninsular Malaysia using a validated malay version of Vhi-10. PLoS One 2015;10:e0141963.
25.	Tafiadis D, Kosma EI, Chronopoulos SK, Voniati L, Ziavra N A preliminary receiver operating characteristic analysis on voice handicap index results of the greek voice-disordered patients. Int J Otolaryngology and Head & Neck Surgery 2018;7:98-114.
26.	Schindler A, Ottaviani F, Mozzanica F, Bachmann C, Favero E, Schettino I, et al. Cross-cultural adaptation and validation of the voice handicap index into italian. J Voice 2010;24:708-14.
27.	Moradi N, Pourshahbaz A, Soltani M, Javadipour S, Hashemi H, Soltaninejad N Cross-cultural equivalence and evaluation of psychometric properties of voice handicap index into persian. J Voice 2013;27:258.e15-22.
28.	Adamu A, Ajiya A, Jibril YN, Kirfi AM, Shuaibu IY, Gwalabe SA Application of voice handicap index score and flexible laryngoscopy in the evaluation of patients with laryngeal disorders. J Laryngol Voice 2022;12:5-10.