Voice disorders

- Committee

➡️Chair of the Panel:

Usama Abdel Naseer

➡️Scientific Group Members:

Abdalla Anayet, Abdelrahman Eltahaan, Ahmed Mostafa, Alaa Gaafar, Amr Taha, Ashraf Lotfy, Athar Reda Ibrahim, Bahaa Eltoukhy, Haytham Elfarargy, Hazem Dewidar, Ihab Sifin, Loay Elsharkawy, Mai Mohammed Salama, Mina Esmat, Rania Abdou, Reda Sharkawy, Saad Elzayat, Samir Halim.

➡️Abbreviations

VD: voice disorders

➡️Glossary:

Dysphonia:  Altered vocal quality, pitch, loudness, or vocal effort that impairs communication as assessed by a clinician and/or affects quality of life

Patient-reported  outcome  measures: subjective  evaluation  by patients  with  voice  disorders,  the  Voice  Handicap  Index  (VHI) and  Voice-Related  Quality  of  Life  (V-RQOL)  were  developed  from  the  viewpoint  of  the  disorders’  effects  on patient  quality  of  life. 

Stroboscope: Advanced laryngeal imaging designed to visualize vocal fold vibratory abnormalities that cannot be appreciated with continuous light laryngoscopy. It uses a synchronized flashing light that passes through a laryngoscope

The aerodynamic  assessment  :  is  defined  as  “individual  or  combined  measurements  of  voice  strength,  pitch, expiratory  flow  in  phonation  and  maximum  phonation  time (MPT)” .  This  method  enables  examiners  to  understand  the pathological  conditions  related  to  vocal-fold  vibration,  and  it  is useful  to  compare  the  patient’s  voice  before  and  after  treatment

Acoustic  analysis  is  an  objective  evaluation  of  voice disorders  that  analyzes  speech  signals  and  provides  quantitative evaluations.

Voice therapy: is provided for dysphonia with no morphological abnormality.  Voice  therapy  is  also  applicable  to  motor diseases,  such  as  vocal-fold  paralysis,  Parkinson’s  disease,  or psychogenic  vocal  disorders.  Voice  therapy  has  a  long  history both  in  direct  and  indirect  therapy,  and  methodologies  of  the therapies  based  on  various  theoretical  systems  have  been developed,  but  its  classification  or  application  has  not  been established  adequately

➡️Scope

This Guideline is concerned with diagnosis and treatment decision of voice disorders affecting children and adults

- Executive Summary

·  In the GRBAS Scales, four grades of scale are recommended because of their high reproduction rate and sufficient resolution

·  Using the VHI and V-RQOL as patient-reported outcome measures They  are,  strongly recommended  as  subjective  evaluation  tools  for  voice  disorders as they are highly  reliable  and  validated

·  Laryngoscopy is an essential tool for visualization of the larynx to diagnose the cause of dysphonia

·  Laryngostroboscopy is useful for diagnosis of voice disorders. It is also useful for the diagnosis and monitoring. Laryngostroboscopy was useful for the diagnosis of patients with voice disorders in 27.2% of cases

·  Acoustic analysis is useful in objective evaluation of voice disorders, especially for evaluating effectiveness of treatment. 

·  measurement  of  voice  strength, measurement  of  pitch,  measurement  of  expiratory  flow  in phonation, measurement  of  MPT,  measured  individually  or combined

·  clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy

·  Clinicians should inform patients with dysphonia about control/preventive measures

·  Clinicians should document resolution, improvement, or worsened symptoms of dysphonia or change in QOL among patients with dysphonia after treatment or observation.

➡️Purpose

Appraisal of the research evidence that exists to support the use of voice measures in the clinical assessment of patients with voice disorders. And outline the measures used in the management of Functional voice disorders.

Specifically,  the  goals  are  to  improve  diagnostic  accuracy,  identify  cases  who  are  most  susceptible  to  voice disorders,  and  educate  clinicians  and  patients  regarding  voice disorders   

➡️The target audience    

The guideline is intended for all clinicians who are likely to diagnose and manage voice disorders

- Methods

A comprehensive search for guidelines was undertaken to identify the most relevant guidelines to consider for adaptation.

inclusion/exclusion criteria followed in the search and retrieval of guidelines to be adapted: 

·  Selecting only evidence-based guidelines (guideline must include a report on systematic literature searches and explicit links between individual recommendations and their supporting evidence) 

·  Selecting only national and/or international guidelines 

·  Specific range of dates for publication (using Guidelines published or updated 2013 and later)

·  Selecting peer reviewed publications only 

·  Selecting guidelines written in English  language 

·  Excluding guidelines written by a single author not on behalf of an organization in order to be valid and comprehensive, a guideline ideally requires multidisciplinary input

·  Excluding guidelines published without references as the panel needs to know whether a thorough literature review was conducted and whether current evidence was used in the preparation of the recommendations 

The following characteristics of the retrieved guidelines were summarized in a table:

•  Developing organisation/authors

•  Date of publication, posting, and release

•  Country/language of publication

•  Date of posting and/or release

•  Dates of the search used by the source guideline developers

All retrieved Guidelines were screened and appraised using AGREE II instrument (www.agreetrust.org) by at least two members. the panel decided a cut-off point or rank the guidelines  (any guideline scoring above 50% on the rigour dimension was retained)

Evidence assessment

According to WHO handbook for Guidelines we used the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to assess the quality of a body of evidence, develop and report recommendations. GRADE methods are used by WHO because these represent internationally agreed standards for making transparent recommendations. Detailed information on GRADE is available on the following sites:

■ GRADE working group: http://www.gradeworkingroup.org

■ GRADE online training modules: http://cebgrade.mcmaster.ca/

■ GRADE profile software: http://ims.cochrane.org/revman/gradepro

Table 1 Quality of evidence in GRADE

Table 2 Significance of the four levels of evidence

Table 3 Factors that determine How to upgrade or downgrade the quality of evidence

- The strength of the recommendation

The strength of a recommendation communicates the importance of adherence to the recommendation.

➡️Strong recommendations

With strong recommendations, the guideline communicates the message that the desirable effects of adherence to the recommendation outweigh the undesirable effects. This means that in most situations the recommendation can be adopted as policy.

➡️Conditional recommendations

These are made when there is greater uncertainty about the four factors above or if local adaptation has to account for a greater variety in values and preferences, or when resource use makes the intervention suitable for some, but not for other locations. This means that there is a need for substantial debate and involvement of stakeholders before this recommendation can be adopted as policy.

When not to make recommendations

- Recommendations

Research Needs

1. Evaluate the different modalities of voice therapy

- References

1- Umeno H, Hyodo M, Haji T, Hara H, Imaizumi M, Ishige M, Kumada M, Makiyama K, Nishizawa N, Saito K, Shiromoto O, Suehiro A, Takahashi G, Tateya I, Tsunoda K, Shiotani A, Omori K. A summary of the Clinical Practice Guideline for the Diagnosis and Management of Voice Disorders, 2018 in Japan. Auris Nasus Larynx. 2020 Feb;47(1):7-17. doi: 10.1016/j.anl.2019.09.004. Epub 2019 Oct 4. PMID: 31587820.

2- Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, McCoy SJ, Ouellette DR, Patel RR, Reavis CC, Smith LJ. Clinical practice guideline: hoarseness (dysphonia)(update). Otolaryngology–Head and Neck Surgery. 2018 Mar;158(1_suppl):S1-42.

3- Verdolini K, Rosen CA, Branski RC, editors. Classification manual for voice disorders-I. Psychology Press; 2014 Apr 8.

4- Wuyts FL, De Bodt MS, Van de Heyning PH. Is the reliability of a visual analog scale higher than an ordinal scale? An experiment with the GRBAS scale for information. J Voice 1999;13:508–17.

5- Chang JI, Bevans SE, Schwartz SR. Otolaryngology clinic of North America: evidence-based practice: management of hoarseness/dysphonia. Otolaryngol Clin North Am 2012;45:1109–26.

6- Woo P, Colton R, Casper J, Brewer D. Diagnostic value of stroboscopic examination in hoarse patients. J Voice 1991;5:231–8.

7- Sataloff RT, Spiegel JR, Hawkshaw MJ. Strobovideolaryngoscopy: results and clinical value. Ann Otol Rhinol Laryngol 1991;100:725–7.

8- Petrovic-Lazic M, Jovanovic N, Kulic M, Babac S, Jurisic V. Acoustic and perceptual characteristics of the voice in patients with vocal polyps after surgery and voice therapy. J Voice 2015;29:241–6.

9- Burduk PK, Wierzchowska M, Orzechowska M, Kazmierczak W, Pawlak-Osinska K. Assessment of voice quality after carbon dioxide laser and microdebrider surgery for Reinke edema. J Voice 2015;29:256–9.