Patient-Based Assessment of Effectiveness of Voice Therapy in Vocal Mass Lesions with Secondary Muscle Tension Dysphonia

Document Type: Original


1 Department of Speech Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran.

2 Musculoskeletal Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; Department of Speech Therapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran.

3 Otorhinolaryngology Research Center, Tehran University of Medical Sciences, Tehran, Iran.

4 Department of Physiotherapy, School of Rehabilitation, Tehran University of Medical Sciences, Tehran, Iran; Sports Medicine Research Center, Tehran University of Medical Sciences, Tehran, Iran.


Use of patient-based voice assessment scales is an appropriate method that is frequently used to demonstrate effectiveness of voice therapy. This study was aimed at determining the effectiveness ofvoice therapy among patients with secondary muscle tension dysphonia (MTD) and vocal mass lesions.
Materials and Methods:
The study design was prospective, with within-participant repeated measures. Thirty-three patients with secondary MTD and vocal mass lesions participated in the study, selected on the basis of voice history, laryngeal palpation, and videostroboscopy examination. An experienced otolaryngologist and one experienced speech language pathologist undertook the diagnostic process. Voice therapy included both direct and indirect techniques and lasted approximately 2 months for all included patients. The voice handicap index (VHI) was used to evaluate the effectiveness ofvoice therapy among included patients. Paired t-test, size of the standardized effect (ESI),and mean standardized response (ESII) were used to analyze effectiveness of the target voice therapy.
The findings of this study indicate astatistically significant improvement after the voice therapy protocol (P<0.05; t>1.96). Results of ESI and ESII demonstrate that the VHI scale is sufficiently responsive to detect voice therapy change (ES>0.8).
This study recommends a combination of direct and indirect voice therapy in the vocal rehabilitation of patients with secondary MTD and vocal mass lesions. Furthormore, we recommend use of the VHI scale to show voice therapy changes for both clinical and research purposes.


Main Subjects

1. Dejonckere PH, Clemente P, Cornut G, Crevier Buchman L, Friedrich G, Van De Heyning, et al. A basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques. Eur Arch Otorhinolaryngol. 2001; 258: 77–82.

2. Kreiman J, Gerratt BR, Kempster G, Erman A, Berke G. Perceptual Evaluation of Voice Quality: Review, Tutorial, and a Framework for Future Research. J Speech Hear Res.1993;36:31–2.

3. Helou LB, Solomon NP, Henry LR, Coppit GL, Howard RS, Stojadinovic A. The role of listener experience on Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) ratings of post-thyroidectomy voice. Am J Speech Lang Pathol. 2010; 19:249–53.

4. Zraick RI, Kempster GB, Connor NP, Klaben BK, Bursac Z, Glaze LE. Establishing validity of the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Am J Speech Lang Pathol. 2011;
20: 16–17.

5. Karnell MP, Melton SD, Childes JM, Coleman TC, Dailey SA, Hoffman HT. documentation of voice disorders. J Voice. 2006;21:576–90.

6.Moradi N, Porshahabaz 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.

7. Seifpanahi S, Jalaie S, Nikoo MR, Sobhani-Rad D. Translated Versions of Voice Handicap Index (VHI)-30 across Languages: A Systematic Review. Iran J Public Health. 2015 44(4):458–69.

8. Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benninger MS, et al. The Voice Handicap Index (VHI): Development and Validation.AJSLP. 1997;6:66–70.

9. Rosen CA, Murry T, Zinn A, Zullo T, Sonbolian M. Voice handicap index change following treatment of voice disorders. J Voice. 2000; 14(4): 619-23.

10. Bouwers F, Dikkers FG. A retrospective study concerning the psychosocial impact of voice disorders: Voice Handicap Index change in patients with benign voice disorders after treatment (measured with the Dutch version of the VHI). J Voice. 2009;23:218–24.

11. Stuut M, Tjon Pian Gi RE, Dikkers FG. Change of Voice Handicap Index after treatment of benign laryngeal disorder. Eur Arch Otorhinolaryngol. 2014; 271:1157–62.

12.Craig J, Tomlinson C, Stevens K, Kotagal K, Fornadley J, Jacobson B, Garrett CG, Francis DO. Combining voice therapy and physical therapy: A novel approach to treating muscle tension dysphonia. J Commun Disord. 2015;58:169–78.

13. Tezcaner CZ, Karatayli Ozgursoy S, Sati I, Dursun G. Changes after voice therapy in objective and subjective voice measurements of pediatric patients with vocal nodules. Eur Arch Otorhinolaryngol. 2009;266:1923–7.

14. Thomas G, Mathews SS, Chrysolyte SB, Rupa V.Outcome analysis of benign vocal cord lesions by videostroboscopy, acoustic analysis and voice handicap index. Indian J Otolaryngol Head Neck Surg. 2007;59:336–40.

15. Rosen CA, Gartner-Schmidt J, Hathaway B, Simpson CB, Postma GN, Courey M, et al. A nomenclature paradigm for benign midmembra- nous vocal fold lesions. Laryngoscope. 2012; 122:

16. Wang CT, Lai MS, Hsiao TY. Comprehensive Outcome Researches of Intralesional Steroid Injection on Benign Vocal Fold Lesions. J Voice. 2015; 29:578–87.

17. Dailey SH, Spanou K, Zeitels SM. The evaluation of benign glottic lesions:rigid telescopic stroboscopy versus suspension microlaryngoscopy. J Voice. 2007;21:112–18.

18. Cho JH, Choi YS, JOO YH, Park YH, Sun DI. Clinical Significance of Contralateral Reactive Lesion in Vocal Fold Polyp and Cyst. J Voice. 2018; 32:109–15.

19. Van Houtte E, Van Lierde K, D’haeseleer E, Claeys S. The prevalence of laryngeal pathology in a treatment seeking population. J Voice. 2013; 27: 177–86.

20. Verdolini K, Rosen, Branski RC. Classification Manual for Voice Disorders-I.1st Edition. Psychology Press; 2006.

21. Boone D, McFarlane S, Vonberg S. The voice and voice therapy. 7th ed. United States of America: Pearson Education; 2005.

22. Stemple JC, Roy N, Klaben BK. Clinical Voice Pathology. Fifth Edition. Plural Publication; 2014.17.

23. Colton R, Casper J, Leonard R. Understanding voice problems: A Physiological Perspective for Diagnostic for Diagnostic and Treatment. 4th ed. Lippincott Williams & Wilkins; 2006.

24. Aronson AE. Clinical Voice Disorders: An Interdisciplinary Approach, 3rd ed. New York: Thieme Stratton; 1990.

25. Roy N, Leeper HA. Effects of the manual laryngeal musculoskeletal tension reduction technique as a treatment for functional voice disorders: perceptual and acoustic measures. J Voice. 1993;7:242–9.

26. Roy N, Bless DM, Heisey D, Ford CN. Manual circumlaryngeal therapy for functional dysphonia: an evaluation of short- and long-term treatment outcomes. J Voice. 1997;11:321–31.

27. Van Lierde KM, De Ley S, Clement G, Bodt De, Van Cauwenberge P. outcome of laryngeal manual therapy in four Dutch adults with persistent moderate-to-severe vocal hyperfunction: a pilot study. J Voice. 2004;18:467–74.

28. Carding PN, Horsley IA, Docherty GJ. A study of the effectiveness of voice therapy in the treatment of 45 patients with nonorganic dysphonia. J Voice. 1999; 13:72–104.

29. Ruotsalainen JH, Sellman J, Letho L, Jauhiainen M, Verbeek JH. Interventions for treating functional dysphonia in adults. Cochrane Database Syst Rev. 2007; 3:CD006373.

30. Ruotsalainen JH, Sellman J, Lehto L, Verbeek J. Systematic review of the treatment of functional dysphonia and prevention of voice disorders. Otolaryngol Head Neck Surg. 2008;138:557–65.

31. Verdolini Abbott K. Lessac-Madsen Resonant Voice Therapy. Oxfordshire,UK: Plural Publishing Inc; 2008.

32. Van Houtte E, Van Lierde K, and Sofie Claeys Pathophysiology and Treatment of Muscle Tension Dysphonia: A Review of the Current Knowledge. J Voice.2011;25:202–7.

33. Angsuwarangsee T, Morrrison M. Extrinsic Laryngeal muscular tension in patients with voice disorders. J Voice. 2002;16:333–43.

34. Carter R, Lubinsky J, Domholdt E. Rehabilitation Resaerch. 4the ed. United State of America: Elsevier Saunders. 2009.

35. de Yébenes Prous MJ1, Rodríguez Salvanés F, Carmona Ortells L. Responsiveness of Outcome Measures. ReumatolClin. 2008;4:240–7.

36. Beaton DE, Bombardier C, Katz JN, Wright JG. A taxonomy for responsiveness. J Clin Epidemiol. 2001;54:1204–17.

37. Husted JA, Cook RJ, Farewell VT, Gladman DD. Methods for assessing responsiveness: a critical review and recommendations. J Clin Epidemiol. 2000;53:459–68.

38. Stratford PW, Riddle DL. Assessing sensitivity to change: choosing the appropriate change coefficient. Health Qual Life Outcomes. 2005;3:23.

39. Norman GR, Stratford P, Regehr G. Methodological problems in the retrospective computation of responsiveness to change: the lesson of Cronbach. J Clin Epidemiol. 1997; 50:869–79.

40. Deyo RA, Centor RM. Assessing the responsiveness of functional scales to clinical change: an analogy to diagnostic test performance. J Chron Dis. 1986;39: 897–906.

41. Khoramshahi H, Khatoonabadi AZ, Khoddami SM, Dabirmoghaddam P, Ansari NN. Responsiveness of Persian Version of Consensus Auditory Perceptual Evaluation of Voice (CAPE-V), Persian Version of Voice Handicap Index (VHI), and Praat in Vocal Mass Lesions with Muscle Tension Dysphonia. J Voice.2017; article in press.