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Septorhinoplasty With Spreader Grafts Enhances Perceived Voice Quality Without Affecting Acoustic Characteristics
Septorhinoplasty With Spreader Grafts Enhances Perceived Voice Quality Without Affecting Acoustic Characteristics *Oner Celik, *Zerrin Boyaci, †Kursat Yelken, *Altay Atespare, ‡Saban Celebi, and *Oncel Koca, *zIstanbul, yTokat, Turkey
Summary: Objective. To identify the effect of septorhinoplasty with spreader grafts on patients’ perception of voice and to measure formant frequencies that may be responsible for perceived changes in voice quality. Methods. A total of 20 patients who underwent septorhinoplasty and had spreader grafts placed during the operations were included. All subjects were tested within the week before surgery and 1–3 months postoperatively by means of perceptual assessment (Voice Handicap Index-10 [VHI-10] and self-assessment of hypo/hypernasality), acoustic analysis, and formant frequency analysis. Results. The mean of VHI-10 score was decreased from 9.44 ± 6.1 to 5.1 ± 3.94 postoperatively (P ¼ 0.03). Fifteen patients (75%) perceived their voices to be hyponasal before surgery, but only three perceived the hyponasality to persist after surgery (P < 0.001). No patient perceived the voice to be hypernasal either before or after surgery. Fifteen patients (75%) perceived their overall voice quality to be improved, whereas five patients perceived no change. None of the patients perceived their voice to be worse after surgery. There were no significant differences between pre- and postoperative acoustic analysis and formant frequency analysis (P > 0.05). Conclusion. Septorhinoplasty with spreader grafts significantly improved patients’ perception of voice; however, acoustic analysis and formant frequency analysis of nasalized vowels did not reveal any significant differences after the operation. Key Words: Septorhinoplasty–Spreader graft–Perceptual voice assessment–Acoustic analysis. INTRODUCTION Septorhinoplasty is one of the most commonly performed otolaryngological operations. This procedure alters nasal cavity structures and effects nasal resonance and voice.1,2 In the literature, only a limited number of studies have examined the role of nasal septal surgery on voice. Mora et al2 evaluated changes in acoustic features of voice after septoplasty and found an improvement in all of the acoustic parameters and a normalization of nasalance 1 month after surgery. Behrman et al1 assessed patient perception and acoustic characteristics of voice before and after upper airway surgery. They established that postoperative changes in relative amplitude of selected formants were statistically significant, but there was no difference in any of the perceptual voice assessments.1 The nasal valve area constitutes the narrowest part of the nose and poses the greatest resistance to nasal airflow; therefore, the internal nasal valve plays a key role in the regulation of the airflow and formation of the nasal resonance. Several operations have been developed to widen the nasal valve angle and prevent it from narrowing during inspiration. The most widely used of these operations involves placing spreader grafts (subperichondral linear strips of cartilage) between the septum and the upper lateral cartilage.3–5 Pre- and postoperative rhinometric analysis Accepted for publication March 15, 2011. From the *Department of Otolaryngology, Maltepe University Medicine Faculty, Istanbul, Turkey; yDepartment of Otolaryngology, Gaziosmanpasa University Medicine Faculty, Tokat, Turkey; and the zDepartment of Otolaryngology, Lutfiye Nuri Burat State Hospital, Istanbul, Turkey. Address correspondence and reprint requests to Kursat Yelken, Department of Otolaryngology, Gaziomanpasa University Medicine Faculty, Tokat, Turkey. E-mail: [email protected] Journal of Voice, Vol. 26, No. 4, pp. 493-495 0892-1997/$36.00 Ó 2012 The Voice Foundation doi:10.1016/j.jvoice.2011.03.005
indicated significant improvement in nasal valve obstruction.4,5 Spreader grafts enlarge the nasal cavity and have the potential to influence the resonance characteristics and perceived quality of nasally produced sounds. The purpose of this study was to identify the effect of septorhinoplasty with spreader grafts on patients’ perception of voice and to measure acoustic resonance (formant) frequencies that may be responsible for perceived changes in voice quality after surgery. MATERIALS AND METHODS A total number of 20 patients who underwent septorhinoplasty from September 2009 through September 2010 were included in this study. All operations were performed by the first author (O.C.), and all of the patients had spreader grafts placed during the operations. Patients with a history of previous voice pathology and laryngeal or nasal surgery were excluded. Endoscopic examination revealed normal laryngeal findings. All subjects were tested within the week before surgery and 1–3 months postoperatively. The study protocol was reviewed and approved by the Maltepe University Ethics Committee. Perceptual assessment Patient self-assessment of perceived voice quality was obtained in three ways. First, each patient was asked to complete the Voice Handicap Index-10 (VHI-10) at the pre- and postoperative testing sessions.6 This index includes 10 items on the impact of the voice disorder on daily life. The scores range from 0 to 4 according to the frequency of the problem (0 ¼ never, 1 ¼ almost never, 2 ¼ sometimes, 3 ¼ almost always, and 4 ¼ always). Second, each patient answered questions regarding nasality at the pre- and postoperative testing sessions. To avoid any
494 misunderstanding and confusion, the terms ‘‘hypernasality’’ and ‘‘hyponasality’’ were not preferred, instead, the following true/false questions were used: 1. When I speak, it usually sounds like I have a stuffed nose (representing hyponasal speech); 2. When I speak, it seems as if a lot of the sound usually comes from my nose instead of my mouth (representing hypernasal speech).1 Third, at the postoperative testing session, patients were asked to answer the question, ‘‘Compare your voice now to the way your voice was just before the surgery.1 Overall, your voice is now (circle one) Worse, Unchanged, Better.’’ Acoustic assessment Patients were asked to phonate /a/ vowel at the most available pitch and loudness for themselves while a microphone was placed 5 cm from the mouth. Digitally recorded data were transferred to a computer at a sampling rate of 44.1 kHz. The recordings of /a/ vowel were used to evaluate the standard acoustic analysis parameters, including fundamental frequency (F0); perturbation measurements (jitter, shimmer); and harmonic to noise ratio. Patients were then asked to phonate a speech sample consisting of three consonant vowel (CV) monosyllables (nasal consonant /m/ and vowels /a/, /i/, and /u/). Each monosyllable (/ma/, /mi/, and /mu/) was repeated three times at a comfortable speaking pitch and loudness to assess the consistency of the data. As vowels become nasalized when produced adjacent to nasal consonants, these nasalized vowels were used for formant frequency analysis. All acoustic assessments were made by means of online-available Praat program (Paul Boersma, 2001. Version 5.2.21, http://www. praat.org/). Praat is an easy to use, noninvasive computer program that measures various aspects of voice. Spectrograms in Praat were used for the evaluation of formant frequencies. Statistical analysis was performed with SPSS 13.0.0 (SPSS Inc., Chicago, IL). Paired sample t test was used for comparison of acoustic and perceptual voice parameters between pre- and postoperation sessions. McNemar’s test was used for the comparison of responses to the true/false questions of hypernasality and hyponasality. Statistical significance was assumed at P < 0.05. RESULTS The mean age of the patients was 27 years and male to female ratio was 1.22. All comparisons were made between preoperative (1 week before surgery) and postoperative evaluations (1–3 months after surgery). VHI-10 was not changed in three patients and was increased in one patient, whereas the remaining 16 patients had a decreased postoperative VHI-10 score. Overall, the mean value of VHI-10 was decreased from 9.44 ± 6.1 to 5.1 ± 3.94 postoperatively (Table 1). The difference was statistically significant (P ¼ 0.03). Subjective normalization of hyponasality was noted in most of the patients at their postoperative clinical controls as
Journal of Voice, Vol. 26, No. 4, 2012
TABLE 1. Pre- and Postoperative VHI-10 Scores and Acoustic Analysis Parameters (F0, Jitter, and Shimmer)
VHI-10 F0 Jitter Shimmer
Preoperation
Postoperation
P
9.44 ± 6.1 148 ± 55 0.9 ± 0.6 5.4 ± 3.5
5.1 ± 3.94 168 ± 54 0.7 ± 0.6 3.5 ± 1.4
0.03 0.05 0.53 0.78
15 patients (75%) perceived their voices to be hyponasal before surgery, but only three perceived the hyponasality to persist after surgery. No patient perceived the voice to be hypernasal either before or after surgery. The difference between preand postoperative responses to the true/false questions of hypernasality and hyponasality was statistically significant (P < 0.001). In response to the question about overall change in voice postoperatively, 15 patients (75%) perceived their voice to be improved, whereas five patients perceived no change. None of the patients perceived their voice to be worse after surgery. Results of acoustic analysis are shown in Table 1. The mean of F0 slightly increased, and the mean of jitter and shimmer slightly decreased. The results of acoustic analysis indicated a postoperative improvement of voice; however, none of the parameters reached a statistically significant level (P > 0.05). Frequency analysis of the first four formants (F1, F2, F3, and F4) was made on the nasalized vowels /a/, /i/, and /u/ (Table 2). This analysis showed that there were no significant differences between pre- and postoperative frequency values in any of the vowels investigated (P > 0.05). DISCUSSION Septorhinoplasty has the potential to affect vocal quality by altering the nasal cavity resonance characteristics. The results TABLE 2. Pre- and Postoperative Frequency Analysis of the First Four Formants (F1, F2, F3, and F4) Made on the Nasalized Vowels /a/, /i/, and /u/ Preoperation
Postoperation
P
929 ± 113 1321 ± 220 2983 ± 338 3786 ± 256
969 ± 112 1344 ± 221 2851 ± 288 3693 ± 243
0.65 0.73 0.1 0.1
F1 F2 F3 F4
890 ± 255 2182 ± 400 2966 ± 272 3825 ± 261
817 ± 166 2189 ± 394 2931 ± 271 3679 ± 264
0.23 0.94 0.62 0.09
/u/ F1 F2 F3 F4
815 ± 76 1728 ± 440 2992 ± 278 3825 ± 283
804 ± 72 1713 ± 359 2914 ± 315 3848 ± 341
0.43 0.89 0.13 0.69
Formants /a/ F1 F2 F3 F4 /i/
Oner Celik, et al
495
Septorhinoplasty With Spreader Grafts
of this study clearly demonstrate that patients’ perception of the voice quality improved after surgery. Our most important perceptual data appear to be the VHI-10 scores. This index is a dysphonia-specific quality-of-life questionnaire with good content validity and reliability. The usefulness of the VHI as an outcome measure is not in the absolute value of the score but rather in the change in score after treatment. The mean of VHI significantly decreased in our patients. Mora et al2 found the mean of VHI to be decreased after septoplasty. Behrman et al1 also examined the effects of upper airway surgery, including septoplasty, turbinectomy, and tonsillectomy, and reported that the mean scores of VHI decreased after surgeries; however, the difference did not reach statistical significance. Patients’ self-evaluation of voice is an important treatment outcome measure. On the basis of true and false questions, most of the patients emphasized preoperative hyponasal voice and the disappearance of hyponasality after surgery. It is also clinically significant that 75% of the patients perceived their voice to be improved after surgery, and none perceived the voice to be worse. A previous study examined patients’ selfperception of voice change after surgery, obtained by a questionnaire, and stated that most of the patients did not notice a change in their voice until others pointed it out to them, usually over the telephone.7 Another study also found no significant difference between pre- and postoperative responses to the true/false questions of hypernasality and hyponasality.1 In response to the question about overall change in voice postoperatively, only 20% of the patients perceived their voice to be improved; the remainder perceived no change, and none of the patients perceived the voice to be worse after surgery.1 Spreader grafts further widen the nasal cavity, most remarkably the internal nasal area, which is the narrowest part in the nose. Placing spreader grafts in addition to septal surgery may have resulted in the improvement seen in our patients. Acoustic analysis is a simple and noninvasive method that can be used for objective voice evaluation. On the basis of acoustic analysis, F0 was found to be slightly increased, and jitter and shimmer were slightly decreased. Although those changes indicated an improvement of voice in our patients, the difference was not significant between pre- and postoperative assessments. A single study compared acoustic analysis parameters before and after septoplasty and suggested an improvement in the parameters and a normalization of nasalance as F0, jitter, and shimmer were all found to be decreased 1 month after surgery.2 The formant frequencies and amplitudes characterize the vowel produced and contribute to overall voice quality. Formants are defined by the size and shape of the oral, nasal, and pharyngeal cavities. Septorhinoplasty with spreader grafts considerably alters the size and shape of the nasal cavity. The changes in nasal resonance characteristics after surgery would be expected to be measured via formant frequency analysis. The nasal sounds are produced by opening the velopharyngeal port, and during normal vowel production, the velopharyngeal port is generally closed to prevent airflow into the nasal cavity.1,7 When the vowel is adjacent to a nasal consonant,
the soft palate remains lowered and vowel becomes nasalized. Therefore, three nasalized vowels were used to measure the formant frequencies. In the literature, a detailed clarification of the acoustic characteristics of nasalization has not been well documented.8,9 Postoperative changes in relative formant amplitudes were found to be statistically significant in patients who underwent several procedures, including septoplasty, turbinectomy, sinus surgery, and tonsillectomy.1,7 Unfortunately, direct relationship between a specific surgery and acoustic changes cannot be determined from these reports because each patient underwent more than one procedure. The study presented here seems to be more accurately designed and might reach a more definitive conclusion, as we assessed potential changes in acoustic characteristics after septorhinoplasty alone. However, our results failed to identify formant frequency alterations underlying the perceived improvement in the patients. Formant frequency is a single invariant property of the acoustic signal, and according to our data, it does not seem to properly identify nasalization. As a conclusion, septorhinoplasty with spreader grafts significantly improved patients’ perception of voice. The perceptual improvement noted postoperatively cannot be attributed with certainty to the spreader grafts, and the same results might be obtained after septoplasty alone. Therefore, a further study that compares septoplasty and septorhinoplasty with spreader grafts would be required to see if the grafts make a difference. In addition, it is possible that the study subjects were looking for improvement and their responses were biased by their surgery, as acoustic improvement was noted only in perceptual measures. Acoustic assessments, including standard acoustic analysis and formant frequency analysis of nasalized vowels, did not reveal any significant differences after the operation. Patients and particularly professional voice users should be informed about potential voice resonance changes that may seriously influence their professional and social life before undergoing a septorhinoplasty.
REFERENCES 1. Behrman A, Shikowitz MJ, Dailey S. The effect of upper airway surgery on voice. Otolaryngol Head Neck Surg. 2002;127:36–42. 2. Mora R, Jankowska B, Dellepiane M, Mora F, Crippa B, Salami A. Acoustic features of voice after septoplasty. Med Sci Monit. 2009;15:CR269–CR273. 3. Andre RF, Paun SH, Vuyk HD. Endonasal spreader graft placement as treatment for internal nasal valve insufficiency. No need to divide the upper lateral cartilages from the septum. Arch Facial Plast Surg. 2004;6:36–40. 4. Ozturan O. Techniques for the improvement of the internal nasal valve in functional-cosmetic nasal surgery. Acta Otolaryngol. 2000;120:312–315. 5. Boccieri A, Macro C, Pascali M. The use of spreader grafts in primary rhinoplasty. Ann Plast Surg. 2005;55:127–131. 6. Murry T, Rosen CA. Outcome measurements and quality of life in voice disorders. Otolaryngol Clin North Am. 2000;33:905–916. 7. Chen MY, Metson R. Effects of sinus surgery on speech. Arch Otolaryngol Head Neck Surg. 1997;123:845–852. 8. Titze IR. Acoustic characteristics of resonant voice. J Voice. 2001;15: 519–528. 9. Dang J, Honda K. Morphological and acoustical analysis of the nasal and paranasal sinuses. J Acoust Soc Am. 1994;96:2088–2100.
Summary: Objective. To identify the effect of septorhinoplasty with spreader grafts on patients’ perception of voice and to measure formant frequencies that may be responsible for perceived changes in voice quality. Methods. A total of 20 patients who underwent septorhinoplasty and had spreader grafts placed during the operations were included. All subjects were tested within the week before surgery and 1–3 months postoperatively by means of perceptual assessment (Voice Handicap Index-10 [VHI-10] and self-assessment of hypo/hypernasality), acoustic analysis, and formant frequency analysis. Results. The mean of VHI-10 score was decreased from 9.44 ± 6.1 to 5.1 ± 3.94 postoperatively (P ¼ 0.03). Fifteen patients (75%) perceived their voices to be hyponasal before surgery, but only three perceived the hyponasality to persist after surgery (P < 0.001). No patient perceived the voice to be hypernasal either before or after surgery. Fifteen patients (75%) perceived their overall voice quality to be improved, whereas five patients perceived no change. None of the patients perceived their voice to be worse after surgery. There were no significant differences between pre- and postoperative acoustic analysis and formant frequency analysis (P > 0.05). Conclusion. Septorhinoplasty with spreader grafts significantly improved patients’ perception of voice; however, acoustic analysis and formant frequency analysis of nasalized vowels did not reveal any significant differences after the operation. Key Words: Septorhinoplasty–Spreader graft–Perceptual voice assessment–Acoustic analysis. INTRODUCTION Septorhinoplasty is one of the most commonly performed otolaryngological operations. This procedure alters nasal cavity structures and effects nasal resonance and voice.1,2 In the literature, only a limited number of studies have examined the role of nasal septal surgery on voice. Mora et al2 evaluated changes in acoustic features of voice after septoplasty and found an improvement in all of the acoustic parameters and a normalization of nasalance 1 month after surgery. Behrman et al1 assessed patient perception and acoustic characteristics of voice before and after upper airway surgery. They established that postoperative changes in relative amplitude of selected formants were statistically significant, but there was no difference in any of the perceptual voice assessments.1 The nasal valve area constitutes the narrowest part of the nose and poses the greatest resistance to nasal airflow; therefore, the internal nasal valve plays a key role in the regulation of the airflow and formation of the nasal resonance. Several operations have been developed to widen the nasal valve angle and prevent it from narrowing during inspiration. The most widely used of these operations involves placing spreader grafts (subperichondral linear strips of cartilage) between the septum and the upper lateral cartilage.3–5 Pre- and postoperative rhinometric analysis Accepted for publication March 15, 2011. From the *Department of Otolaryngology, Maltepe University Medicine Faculty, Istanbul, Turkey; yDepartment of Otolaryngology, Gaziosmanpasa University Medicine Faculty, Tokat, Turkey; and the zDepartment of Otolaryngology, Lutfiye Nuri Burat State Hospital, Istanbul, Turkey. Address correspondence and reprint requests to Kursat Yelken, Department of Otolaryngology, Gaziomanpasa University Medicine Faculty, Tokat, Turkey. E-mail: [email protected] Journal of Voice, Vol. 26, No. 4, pp. 493-495 0892-1997/$36.00 Ó 2012 The Voice Foundation doi:10.1016/j.jvoice.2011.03.005
indicated significant improvement in nasal valve obstruction.4,5 Spreader grafts enlarge the nasal cavity and have the potential to influence the resonance characteristics and perceived quality of nasally produced sounds. The purpose of this study was to identify the effect of septorhinoplasty with spreader grafts on patients’ perception of voice and to measure acoustic resonance (formant) frequencies that may be responsible for perceived changes in voice quality after surgery. MATERIALS AND METHODS A total number of 20 patients who underwent septorhinoplasty from September 2009 through September 2010 were included in this study. All operations were performed by the first author (O.C.), and all of the patients had spreader grafts placed during the operations. Patients with a history of previous voice pathology and laryngeal or nasal surgery were excluded. Endoscopic examination revealed normal laryngeal findings. All subjects were tested within the week before surgery and 1–3 months postoperatively. The study protocol was reviewed and approved by the Maltepe University Ethics Committee. Perceptual assessment Patient self-assessment of perceived voice quality was obtained in three ways. First, each patient was asked to complete the Voice Handicap Index-10 (VHI-10) at the pre- and postoperative testing sessions.6 This index includes 10 items on the impact of the voice disorder on daily life. The scores range from 0 to 4 according to the frequency of the problem (0 ¼ never, 1 ¼ almost never, 2 ¼ sometimes, 3 ¼ almost always, and 4 ¼ always). Second, each patient answered questions regarding nasality at the pre- and postoperative testing sessions. To avoid any
494 misunderstanding and confusion, the terms ‘‘hypernasality’’ and ‘‘hyponasality’’ were not preferred, instead, the following true/false questions were used: 1. When I speak, it usually sounds like I have a stuffed nose (representing hyponasal speech); 2. When I speak, it seems as if a lot of the sound usually comes from my nose instead of my mouth (representing hypernasal speech).1 Third, at the postoperative testing session, patients were asked to answer the question, ‘‘Compare your voice now to the way your voice was just before the surgery.1 Overall, your voice is now (circle one) Worse, Unchanged, Better.’’ Acoustic assessment Patients were asked to phonate /a/ vowel at the most available pitch and loudness for themselves while a microphone was placed 5 cm from the mouth. Digitally recorded data were transferred to a computer at a sampling rate of 44.1 kHz. The recordings of /a/ vowel were used to evaluate the standard acoustic analysis parameters, including fundamental frequency (F0); perturbation measurements (jitter, shimmer); and harmonic to noise ratio. Patients were then asked to phonate a speech sample consisting of three consonant vowel (CV) monosyllables (nasal consonant /m/ and vowels /a/, /i/, and /u/). Each monosyllable (/ma/, /mi/, and /mu/) was repeated three times at a comfortable speaking pitch and loudness to assess the consistency of the data. As vowels become nasalized when produced adjacent to nasal consonants, these nasalized vowels were used for formant frequency analysis. All acoustic assessments were made by means of online-available Praat program (Paul Boersma, 2001. Version 5.2.21, http://www. praat.org/). Praat is an easy to use, noninvasive computer program that measures various aspects of voice. Spectrograms in Praat were used for the evaluation of formant frequencies. Statistical analysis was performed with SPSS 13.0.0 (SPSS Inc., Chicago, IL). Paired sample t test was used for comparison of acoustic and perceptual voice parameters between pre- and postoperation sessions. McNemar’s test was used for the comparison of responses to the true/false questions of hypernasality and hyponasality. Statistical significance was assumed at P < 0.05. RESULTS The mean age of the patients was 27 years and male to female ratio was 1.22. All comparisons were made between preoperative (1 week before surgery) and postoperative evaluations (1–3 months after surgery). VHI-10 was not changed in three patients and was increased in one patient, whereas the remaining 16 patients had a decreased postoperative VHI-10 score. Overall, the mean value of VHI-10 was decreased from 9.44 ± 6.1 to 5.1 ± 3.94 postoperatively (Table 1). The difference was statistically significant (P ¼ 0.03). Subjective normalization of hyponasality was noted in most of the patients at their postoperative clinical controls as
Journal of Voice, Vol. 26, No. 4, 2012
TABLE 1. Pre- and Postoperative VHI-10 Scores and Acoustic Analysis Parameters (F0, Jitter, and Shimmer)
VHI-10 F0 Jitter Shimmer
Preoperation
Postoperation
P
9.44 ± 6.1 148 ± 55 0.9 ± 0.6 5.4 ± 3.5
5.1 ± 3.94 168 ± 54 0.7 ± 0.6 3.5 ± 1.4
0.03 0.05 0.53 0.78
15 patients (75%) perceived their voices to be hyponasal before surgery, but only three perceived the hyponasality to persist after surgery. No patient perceived the voice to be hypernasal either before or after surgery. The difference between preand postoperative responses to the true/false questions of hypernasality and hyponasality was statistically significant (P < 0.001). In response to the question about overall change in voice postoperatively, 15 patients (75%) perceived their voice to be improved, whereas five patients perceived no change. None of the patients perceived their voice to be worse after surgery. Results of acoustic analysis are shown in Table 1. The mean of F0 slightly increased, and the mean of jitter and shimmer slightly decreased. The results of acoustic analysis indicated a postoperative improvement of voice; however, none of the parameters reached a statistically significant level (P > 0.05). Frequency analysis of the first four formants (F1, F2, F3, and F4) was made on the nasalized vowels /a/, /i/, and /u/ (Table 2). This analysis showed that there were no significant differences between pre- and postoperative frequency values in any of the vowels investigated (P > 0.05). DISCUSSION Septorhinoplasty has the potential to affect vocal quality by altering the nasal cavity resonance characteristics. The results TABLE 2. Pre- and Postoperative Frequency Analysis of the First Four Formants (F1, F2, F3, and F4) Made on the Nasalized Vowels /a/, /i/, and /u/ Preoperation
Postoperation
P
929 ± 113 1321 ± 220 2983 ± 338 3786 ± 256
969 ± 112 1344 ± 221 2851 ± 288 3693 ± 243
0.65 0.73 0.1 0.1
F1 F2 F3 F4
890 ± 255 2182 ± 400 2966 ± 272 3825 ± 261
817 ± 166 2189 ± 394 2931 ± 271 3679 ± 264
0.23 0.94 0.62 0.09
/u/ F1 F2 F3 F4
815 ± 76 1728 ± 440 2992 ± 278 3825 ± 283
804 ± 72 1713 ± 359 2914 ± 315 3848 ± 341
0.43 0.89 0.13 0.69
Formants /a/ F1 F2 F3 F4 /i/
Oner Celik, et al
495
Septorhinoplasty With Spreader Grafts
of this study clearly demonstrate that patients’ perception of the voice quality improved after surgery. Our most important perceptual data appear to be the VHI-10 scores. This index is a dysphonia-specific quality-of-life questionnaire with good content validity and reliability. The usefulness of the VHI as an outcome measure is not in the absolute value of the score but rather in the change in score after treatment. The mean of VHI significantly decreased in our patients. Mora et al2 found the mean of VHI to be decreased after septoplasty. Behrman et al1 also examined the effects of upper airway surgery, including septoplasty, turbinectomy, and tonsillectomy, and reported that the mean scores of VHI decreased after surgeries; however, the difference did not reach statistical significance. Patients’ self-evaluation of voice is an important treatment outcome measure. On the basis of true and false questions, most of the patients emphasized preoperative hyponasal voice and the disappearance of hyponasality after surgery. It is also clinically significant that 75% of the patients perceived their voice to be improved after surgery, and none perceived the voice to be worse. A previous study examined patients’ selfperception of voice change after surgery, obtained by a questionnaire, and stated that most of the patients did not notice a change in their voice until others pointed it out to them, usually over the telephone.7 Another study also found no significant difference between pre- and postoperative responses to the true/false questions of hypernasality and hyponasality.1 In response to the question about overall change in voice postoperatively, only 20% of the patients perceived their voice to be improved; the remainder perceived no change, and none of the patients perceived the voice to be worse after surgery.1 Spreader grafts further widen the nasal cavity, most remarkably the internal nasal area, which is the narrowest part in the nose. Placing spreader grafts in addition to septal surgery may have resulted in the improvement seen in our patients. Acoustic analysis is a simple and noninvasive method that can be used for objective voice evaluation. On the basis of acoustic analysis, F0 was found to be slightly increased, and jitter and shimmer were slightly decreased. Although those changes indicated an improvement of voice in our patients, the difference was not significant between pre- and postoperative assessments. A single study compared acoustic analysis parameters before and after septoplasty and suggested an improvement in the parameters and a normalization of nasalance as F0, jitter, and shimmer were all found to be decreased 1 month after surgery.2 The formant frequencies and amplitudes characterize the vowel produced and contribute to overall voice quality. Formants are defined by the size and shape of the oral, nasal, and pharyngeal cavities. Septorhinoplasty with spreader grafts considerably alters the size and shape of the nasal cavity. The changes in nasal resonance characteristics after surgery would be expected to be measured via formant frequency analysis. The nasal sounds are produced by opening the velopharyngeal port, and during normal vowel production, the velopharyngeal port is generally closed to prevent airflow into the nasal cavity.1,7 When the vowel is adjacent to a nasal consonant,
the soft palate remains lowered and vowel becomes nasalized. Therefore, three nasalized vowels were used to measure the formant frequencies. In the literature, a detailed clarification of the acoustic characteristics of nasalization has not been well documented.8,9 Postoperative changes in relative formant amplitudes were found to be statistically significant in patients who underwent several procedures, including septoplasty, turbinectomy, sinus surgery, and tonsillectomy.1,7 Unfortunately, direct relationship between a specific surgery and acoustic changes cannot be determined from these reports because each patient underwent more than one procedure. The study presented here seems to be more accurately designed and might reach a more definitive conclusion, as we assessed potential changes in acoustic characteristics after septorhinoplasty alone. However, our results failed to identify formant frequency alterations underlying the perceived improvement in the patients. Formant frequency is a single invariant property of the acoustic signal, and according to our data, it does not seem to properly identify nasalization. As a conclusion, septorhinoplasty with spreader grafts significantly improved patients’ perception of voice. The perceptual improvement noted postoperatively cannot be attributed with certainty to the spreader grafts, and the same results might be obtained after septoplasty alone. Therefore, a further study that compares septoplasty and septorhinoplasty with spreader grafts would be required to see if the grafts make a difference. In addition, it is possible that the study subjects were looking for improvement and their responses were biased by their surgery, as acoustic improvement was noted only in perceptual measures. Acoustic assessments, including standard acoustic analysis and formant frequency analysis of nasalized vowels, did not reveal any significant differences after the operation. Patients and particularly professional voice users should be informed about potential voice resonance changes that may seriously influence their professional and social life before undergoing a septorhinoplasty.
REFERENCES 1. Behrman A, Shikowitz MJ, Dailey S. The effect of upper airway surgery on voice. Otolaryngol Head Neck Surg. 2002;127:36–42. 2. Mora R, Jankowska B, Dellepiane M, Mora F, Crippa B, Salami A. Acoustic features of voice after septoplasty. Med Sci Monit. 2009;15:CR269–CR273. 3. Andre RF, Paun SH, Vuyk HD. Endonasal spreader graft placement as treatment for internal nasal valve insufficiency. No need to divide the upper lateral cartilages from the septum. Arch Facial Plast Surg. 2004;6:36–40. 4. Ozturan O. Techniques for the improvement of the internal nasal valve in functional-cosmetic nasal surgery. Acta Otolaryngol. 2000;120:312–315. 5. Boccieri A, Macro C, Pascali M. The use of spreader grafts in primary rhinoplasty. Ann Plast Surg. 2005;55:127–131. 6. Murry T, Rosen CA. Outcome measurements and quality of life in voice disorders. Otolaryngol Clin North Am. 2000;33:905–916. 7. Chen MY, Metson R. Effects of sinus surgery on speech. Arch Otolaryngol Head Neck Surg. 1997;123:845–852. 8. Titze IR. Acoustic characteristics of resonant voice. J Voice. 2001;15: 519–528. 9. Dang J, Honda K. Morphological and acoustical analysis of the nasal and paranasal sinuses. J Acoust Soc Am. 1994;96:2088–2100.