© Borgis - New Medicine 2/2003, s. 30-32
Małgorzata Dębska1, Danuta Chojnacka-Wądołowska2, Mieczysław Chmielik1, Eliza Brożek1, Anna Bielicka1, Ryszard Gubrynowicz2
Assessment of vocal function in patients after papillotomy
1Department of Paediatric Otorhinolaryngology, Medical University of Warsaw, Poland
Head: Prof. Mieczysław Chmielik M.D.
2Phoniatric Clinic, Children´s Memorial Health Centre, Warsaw: Audiology, Phoniatrics and Laryngology Department
Head: Marzanna Radziszewska-Konopka M.D.
Summary
Recurrent laryngeal papillomatosis in children is a disease of viral aetiology. The main method of surgical treatment is classical papillotomy using the Kleinsasser operating laryngoscope. The larynx is a very sensitive organ, so any surgical intervention may increase the risk of scar appearance and intralaryngeal adhesions. All operations should seek to spare the tissue as much as possible. The aim of this study was voice assessment in a group of patients after papillotomy. The group consisted of children suffering from recurrent laryngeal papillomatosis, who were treated in the Department of Paediatric Otorhinolaryngology in Warsaw from 1990 to 2001, now being in a period of remission.
INTRODUCTION
Voice disorders are fairly common in the child population, occurring in from 6 to 9% of children (1). Overload and inappropriate emission of voice are the main reasons for child dysfonia (85-90%), and may provoke secondary organic lesions in the larynx (2). Noduli vocales are good examples of this situation. Primary organic lesions are another important reason for child dysfonia. Laryngeal papillomas belong to this group, and in 45% of voice disorders they are the first symptom of this disease (7).
The study mentioned below is dedicated to the problem of laryngeal papillomatosis.It is also a test of voice assessment in patients after surgical treatment, on the basis of subjective estimates, and chosen parameters for acoustic analysis.
USA epidemiological data inform us that the average number of surgical interventions is 19.7 for one child and near 4.4 for one year. Children who had the disease diagnosed before the third year of life need more than four operations, three times as frequent as patients who fall ill above the fourth year.The possibility of lesion appearance in two or more anatomical regions in this first group of children is also twice as high.
The voice changes connected with the disease are non-specific, but some symptoms can provide a suspicion about the location of lesions. A slow, rough voice may suggest abnormalities in the subglottic region, and dysphonia or "breathy voice” is often connected with lesions within the glottis.The high pitch of stridor suggests glottic or subglottic lesions.
Clardsical microsurgery with a Kleinsasser set and laser technique, allowing the vapourising of minimising the excess tissue, and thus minimising haemorrhage are two important methods in papillotomy. The currently – preferred CO2 lasers are unfortunately associated with a risk of scarring in the area of removal, as a result of the uncontrolled transfer of heat energy. The most common complications are anterior glottal webs (4). The surgical treatment of laryngeal papillomas consists of the total removal of lesions without damaging the normal anatomical structures. If lesions are located in the region of the comissura anterior or posterior, or there is an aggresive increase of papilloma, incomplete removal is suggested to avoid constriction of the air tract by glottic scarring and glottal and subglottal stenoses.
Acoustic voice analysis is a method which allows us to estimate the physical parametres of the voice as pitch, loudness, and quality. Important elements in acoustic analysis are: fundamental frequency F0 (Hz), the level of voice pressure during speech (dB),maximum phonation time(s), maximum frequency range (Hz), the level of disturbances – jitter, shimmer (%), and HNR (harmonic/noise ratio) (5).
MATERIAL
Microsurgical removal of papilloma in the respiratory tract, using a Kleinsasser set under general intratracheal anaesthesia is performed in the Department of Paediatric Otorhinolaryngology in Warsaw. Patients below 10 years are admitted for classical papillotomy, to minimalize the risk of postoperative complications (6). When lesions are located not only in the larynx, but also in the area of the trachea and bronchi the two-step procedure is performed. The first part is tracheobronchoscopy, to remove lesions from the lower respiratory tract, and the second step is classical papillotomy under intratracheal anaesthesia.
A group of 39 children from 1 to 17 years old (average 6.6) suffering from recurrent respiratory papilloma were admitted more than once to the Department of Paediatric Otorhinolaryngology in Warsaw from 1990 to 2000. Some children had already undergone papillotomy in other medical centres. Twenty-five patients without any symptoms of recurrence during recent years were chosen from this group, and invited to a phoniatric consultation in 2002 and 2003. Seven persons came for the examination and for complex subjective and objective voice evaluations to the Phoniatric Clinic, in the Children´s Memorial Health Centre in Warsaw.
Parameters of voice evaluated in the group of patients were:
1. Quality
2. Average position of voice (Hz)
3. Maximum frequency range (Hz)
4. Maximum phonation time (s)
5. Attitude of voice
6. Breathing route
7. Status of resonators
8. Jitter and Shimmer –(%)
9. Harmonic /noise ratio (HNR)
Acoustic voice analysis was performed by computer, using the PRAAT system (8). The group of patients (n=7) consisted of 4 males and 3 females aged from 10 to 24 years. The diagnosis was made between the 2nd and 11th years of life. The most common symptom of the disease observed in this group was increased hoarseness. The number of surgical interventions varied s from 3 to 13 (avarage 7.3), and the time from the last operation was from 1 to 9 years (average 3.7 years). The boy, who needed the largest number of operations because of recurrence of lesions is now 14 years old and his voice is coated, with a soft attitude, F0=197 Hz and maximum frequency range 190-406 Hz.
The results of examination are shown in tables 1, 2, 3, 4.
Table 1. Clinical data of group.
| Initials | Sex | Age at the phoniatric examination | Age at diagnosis | First Symptoms | Number of operations | Time after treatment | Methods of treatment | Pharmacological treatment
(Roferon) |
| R.H. | F | 24 | 10 | Hoarseness Stridor | 13 | 1 year | microsurgery laser | + |
| O.A. | F | 12 | 2 | Hoarseness | 3 | 9 years | microsurgery | |
| Ch.M. | M | 16 | 5 | Hoarseness | 7 | 4 years | microsurgery | |
| K.O. | F | 18 | 4 | Hoarseness Stridor | 10 | | microsurgery | |
| S.D. | M | 14 | 5 | Hoarseness Stridor Dyspnoea | 8 | 7 years | microsurgery | + |
| R.K. | M | 19 | 11 | Hoarseness | 7 | 2 years | Microsurgery laser | |
| M.K. | M | 10 | 4 | Hoarseness | 3 | 3 years | microsurgery | |
Table 2. Basic voice parameters of examined group.
| Initials | Fo (Hz) | Maximum frequency range | Maximum phonation time |
| R.H. | 214 | 184-428 | 25´´ |
| O.A. | 277 | 238-420 | 15´´ |
| Ch. M. | 126 | 116-329 | 19´´ |
| K.O. | 210 | 185-280 | 12´´ |
| S.D. | 197 | 146-406 | 13´´ |
| R.K. | 110 | 97-355 | 18´´ |
| M.K. | 260 | 248-685 | 18´´ |
Table 3. Basic voice parameters of examined group.
| Initials | Voice quality | Attitude of voice |
| R.H | dysphonic | Soft |
| O.A. | Rather sonorous | Soft |
| Ch.M. | dysphonic | Soft |
| K.O. | coated | Hard |
| S.D. | Rather sonorous | Soft |
| R.K. | dysphonic | rather hard |
| M.K. | Hoarseness | Hard |
Table 4. Acoustic voice analysis (parameters: Jitter, Shimmer, HNR).
| Initials | Jitter | Shimmer | HNR |
| R.H. | 0.20% | 2.31% | 28.83 |
| O.A. | 0.48% | 4.28% | 19.72 |
| Ch.M. | 0.50% | 5.66% | 18.96 |
| K.O. | 0.48% | 5.50% | 18.89 |
| S.D. | 0.41% | 2.37% | 25.48 |
| R.K. | 0.30% | 2.77% | 23.48 |
| M.K. | 1.05% | 5.53% | 15.89 |
Three patients have values of Jitter, Shimmer, and HNR in the normal range, corresponding with values for a normal voice (8). Only one patient has a Jitter value>1 and an increased value of Shimmer and HNR.
CONCLUSIONS
1. Microsurgical papillotomy gives a chance to have good voice parameters, even after repeated operations.
2. Phoniatric rehabilitation after operations may improve the status of a patient´s voice.
Piśmiennictwo
1. Wilson D.K.: Voice problems in children 1987 (3rd ed.) Baltimore: Wiliams & Wilkins. 2. Johnson T.S.: Child DR Voice disorders in a child. Handbook of speech language pathology and audiology. Toronto: B.C. Decker Inc. 3. Derkay C.S.: Recurrent respiratory papillomatosis. Laryngoscope 2001; 111:57-69. 4. Dedo H.H., Yu K.C.Y.: CO2 laser treatment in 244 patients with respiratory papillomas. Laryngoscope 2001; 111:1639--1644. 5. Hillman R.E. et al.: Appropriate use of objective measures of vocal function in the multidisciplinary management of voice disorders. Curr Opinion Otolaryngol Head Neck Surg 1997; 5(3):172-175. 6. Zawadzka-Głos L. et al.: Laryngeal papillomatosis in children and their surgical treatment. New Med. 2002; 5(9):64-66. 7. Pruszewicz A.: Foniatria kliniczna PZWL 1992. 8. Świdziński P.: Przydatność analizy akustycznej w diagnostyce zaburzeń głosu. Poznań 1998.
