Voice Quality After Supracricoid Laryngectomy and Total Laryngectomy With Insertion of Voice Prosthesis

Voice Quality After Supracricoid Laryngectomy and Total Laryngectomy With Insertion of Voice Prosthesis *Gabriela Torrejano and †Isabel Guimara˜es *Lisbon and yAlcoita˜o, Portugal Summary: Vocal quality was analyzed in 20 subjects who underwent total laryngectomy with insertion of voice prosthesis (TL with VP) and in 10 subjects who underwent supracricoid laryngectomy (SCL). Acoustic analysis was carried out using Lingwaves and Praat, for sustained vowels and conversation to obtain the fundamental frequency (F0) and jitter parameters. Perceptual evaluations and self-assessment of voice impact on the quality of life were also performed. Results showed statistically significant differences between TL + VP and SCL individuals for the mean F0 during conversation, for Roughness, Grade of voice quality, and self-assessment of speech, with worst results in the SCL group. Key Words: Voice–Total laryngectomy–Supracricoid laryngectomy–Acoustic analysis–Perceptual evaluation–Voicerelated quality of life. INTRODUCTION Until 1970, patients with glottic and supraglottic carcinomas were always submitted to total laryngectomy (TL) but since then, a surgical technique called supracricoid laryngectomy (SCL) has become possible. In SCL, patients with early glottic tumors are submitted to cricohyoidoepiglottopexy (CHEP), whereas for those with supraglottic/glottic tumors, cricohyoidopexy (CHP) is applied.1,2 SCL achieves maintenance of the essential functions of larynx: phonation, deglutition, and breathing. However, the voice quality is rough with difficulties in vocal inflections and intensity variation and without gender distinction. These alterations are irreversible even after vocal therapy.2,6 In TL patients, the most obvious consequence is voice loss requiring rehabilitation. In the past, these patients needed to develop the use of an artificial larynx or esophageal voice (EV). In 1978, Blom et al. introduced the first voice prosthesis (VP) which functions as a unidirectional valve, preventing aspiration, but enabling tracheoesophageal voice (TEV) by taking advantage of the pulmonary respiratory source.3 The Blom-Singer technique marked a major milestone in the evolution of restoration techniques of this type. Currently, TEV is the most frequently used rehabilitation process after TL. Several authors4,5 showed that TEV has more advantages than EV in oral communication because it is more similar to laryngeal voice in terms of fundamental frequency (F0), intensity, fluency, and in gender distinction on mean F0.6 Moreover, TEV rehabilitation is faster and more successful, anticipating the improvement of the patient’s quality of life (QoL). Due to the scarce published data concerning voice quality in individuals with TL + VP as opposed to SCL individuals, it is not possible to establish which voice performs better. Accepted for publication August 15, 2007. The paper was presented at the IV Congress of the Portuguese Association of Speech Therapists held in Lisbon, 2005. From the *Otorhinolaryngology Department-Voice and Communication Disorders, Hospital Santa Maria, Epe, Lisbon, Portugal; and the yEscola Superior de Sau´de do Alcoita˜o, Alcoita˜o, Portugal. Address correspondence and reprint requests to Gabriela Torrejano, Rua Dr. Fe´lix Alves Pereira, n 11, 1 Dto. 2710-554 Sintra, Lisbon, Portugal. E-mail: gabriela.torrejano@ gmail.com Journal of Voice, Vol. 23, No. 2, pp. 240-246 0892-1997/$36.00 Ó 2009 The Voice Foundation doi:10.1016/j.jvoice.2007.08.005

Acoustic analysis does not confirm if there is a difference in mean F0 between the referred individuals. Moreover, these data are mostly for sustained tasks1,7–11 with the exception of Globlek et al’s12 study with measures for oral reading. Results obtained from sustained tasks are not so representative as those obtained from oral reading and conversation.13 Some of the published studies researched F0 on laryngectomee voice sources in both sexes and that could have disturbed the data. Data on jitter are also inconsistent; however, it looks like SCL individuals show higher values (Table 1). Perceptual voice analysis using the GRBAS scale22 carried out only in SCL patients2,7,11 revealed values of moderate to severe alterations in Roughness and Grade, slight to moderate alterations in Breathiness, slight or practically absent alterations in Asthenicity, and slight or moderate alterations in Strain (Table 2). The only study comparing TEV and SCL voice was done by Dworkin et al1 who analyzed acoustic and perceptual voice parameters. They concluded that the SCL and TL surgical procedures resulted in equivalent speech in the studied groups. In perceptual voice evaluation, none of the evaluated parameters differed significantly. However, in acoustic analysis, jitter values were more normalized in TL individuals. Reports on patients’ self-assessment of voice impact on QoL show that either the new method of communication does not appear to have a significant impact on the patients’ QoL14 or it affects them moderately.1,15 No significant differences between SCL and TL + VP individuals’ QoL were found.1 In our clinical practice, we have observed that TEV has better voice quality than SCL. Few and conflicting data exist in this area, so we feel that a new study must be implemented. The present study intends to analyze voice quality of SCL and TL + VP individuals, to verify if significant differences exist between the two groups and if TL with VP patients have a better voice quality than SCL patients. METHODOLOGY Subjects were selected among patients diagnosed, treated, and followed for laryngeal carcinoma in the ENT Department of Hospital de Santa Maria, in Lisbon. Thirty males with squamous cell carcinoma underwent TL or SCL and were

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TABLE 1. Acoustic Voice Analysis of Sustained Vowels in TL + VP and SCL Individuals Study

Dworkin et al1

Surgery

TL + VP

Sample Sex

10 7 M, 3 F

Age (y)

Mean: 52 M, 58 F F0 mean (Hz) 117 Jitter (%) 3.3

Van As8

Dworkin et al1 Bron et al7 Pastore et al9 Zacharek et al10 Makeieff et al11

TL + VP Provox SCL (CHP) 30 10 39 patients 7 M, 3 F (29 M, 10 F) 47–82 Mean: 52 M, 58 F 103 (46–229) 109 6.8 6.6

SCL (CHEP) 17 15 M, 2 F

SCL 14 14 M

SCL (CHEP and CHP) 10 7 M, 3 F

SCL (CHEP and CHP) 61 58 M, 3 F

36–68

48–73

39–72

43–80

70 (38–123) 109 (80–130) 109 (89–138) — — 6.6

123 (69–230) 7.8

M, males; F, females.

rehabilitated in Speech Therapy Department between January 1997 and December 2004. As adjuvant treatment, 16 TL patients performed postsurgical radiotherapy and one presurgery. Three SCL patients underwent postsurgical radiotherapy. Two groups of subjects were studied: 10 patients were supracricoid laryngectomees (eight CHEP and two CHP) and 20 total laryngectomees were exclusively tracheoesophageal speakers with Provox VP.23 In the SCL group, mean age was 64 years (range 55–78 years) and in the TL + VP group, it was 59 years (range 44–73 years). All cases in the SCL group were in stage II, whereas in TL, six were in stage III and 14 in stage IV-A, staging according to American Joint Committee on Cancer.16 Time elapsed since the term of speech therapy was significantly lower (U ¼ 52, P < 0.05) in the TL + VP group (a mean of 23 months) than in the SCL group (a mean of 46 months). Acoustic analysis Voices were recorded in a quiet room, directly into the computer, using a hand-held microphone (Philips unidirectional, electret condenser type, with a frequency response of 50– 18 000 Hz and impedance of 600 U, Netherlands), placed 10 cm away from the source, at a 50 angle. The patients were instructed to produce sustained vowels— /a/ and /u/—and 1 minute of conversation in comfortable intensity and pitch. These two vowels were chosen because they represent the articulatory extremities of vocal space and include the most-studied physiological tongue dimensions (anterior/ posterior and height).

Conversation was chosen because results obtained from speech are more representative of F0 compared with those from the production of sustained vowels and reading.13 Oral reading was also excluded because some individuals were unable to read fluently. Lingwaves17 and Praat18 software were used to capture and analyze the acoustic signal. Praat was predefined with a standard frequency response between 50 and 200 Hz for F0 analysis. Lingwaves was also predefined with the same frequency to measure jitter percentage in vowels. This software was chosen because it was the voice analysis program available in our ENT Department. Perceptual evaluation of vocal quality Roughness, Breathiness, Asthenicity, Strain, and Grade of voice quality were evaluated by the first author of this study, during conversation using the terminology of the GRBAS scale. The categorization is based on Likert scale from 0 to 3 (0 ¼ normal, 1 ¼ slight alteration, 2 ¼ moderate alteration, and 3 ¼ severe alteration). The selection of these categories was decided because they were the most frequently cited in the published literature on similar studies.2,7,11 Self-assessment of voice impact on QoL The Portuguese version15 of a questionnaire with two questions and three statements developed by Clements et al19 was used. It is classified according to a Likert scale from 1 to 5 (1 is the worst reply and 5 is the best one for all questions, with the

TABLE 2. Perceptual Voice Analysis

Grade Roughness Breathiness Asthenicity Strain *P > 0.5. * 1–5 Points.

Lallemant et al2

Bron et al7

Makeieff et al11

SCL (n ¼ 37)

SCL (n ¼ 17)

SCL (n ¼ 61)

2.1 2.1 1.4 0.8 1.4

2.8 2.7 1.2 0.1 1.2

2.3 2.1 1.9 1.7 1.8

Dworkin et al1

Overall intelligibility* Speech fluency* Vocal quality*

SCL (n ¼ 10)

TL + VP (n ¼ 10)

4.0* 4.0* 2.8*

4.0* 3.7* 2.9*

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0.004238

0

0

-0.004574

-0.006752 1.15

4.2

0.136041

0 Time (s)

Time (s)

FIGURE 1. Vowel /a/—TL with VP’s wave. exception of question 4 that scores in an inverse way [see Appendix]). Analysis and data processing All statistical data (personal data, self-assessment questionnaire, and perceptual and acoustic analyses) were inserted in the Social Package for Social Sciences version 11.5 (Chicago, IL). The longest period achieved by one patient in the production of vowels was approximately 1000 milliseconds. So, it was only possible for all patients to analyze 900 milliseconds of the most stable part of the wave of mid vowel segments from /a/ and /u/. The same period of wave was selected for the measurement of F0 and relative jitter. Jitter is a valid assessment tool with alternate sound sources. Figures 1 and 2 present the waveforms that exhibit alaryngeal voice sources (which were analyzed in the present study) to be similar to laryngeal voices in their ‘‘quasi-periodic’’ nature. The statistical processing involved descriptive analysis (mean, mode, and dispersion measurements) and the inferential analysis was carried out through the Mann-Whitney test for independent samples. RESULTS From Table 3 one can see that the TL + VP group presents lower values of mean F0 in all speech tasks than the SCL group. The mean F0 difference between groups is 3.77semitones (ST) for

vowel /a/, 1.89 ST for vowel /u/, and 3.95 ST for conversation. Nevertheless, statistically significant differences between groups were only found in mean F0 for conversation (U ¼ 47, P ¼ 0.043). In conversation, the values of maximum and minimum F0 have higher amplitude in the TL with VP group. From Table 4 one can see that the TL + VP group presents lower values of jitter, for both vowels, than the SCL group. There were no confirmed significant differences between groups (TL with VP and SCL) in jitter (P > 0.05). Table 5 shows that perceptual evaluation of Roughness and Grade of voice quality reveals that the most frequent classification used for both groups was moderate alteration. However, the mean values for TL + VP in Grade and Roughness were lower (2—moderate alteration) than the mean values in the SCL group (3—severe alteration). There are very significant differences between the two groups in Roughness (U ¼ 60, P ¼ 0.003) and Grade parameters (U ¼ 60, P ¼ 0.003). The voice perceptual evaluation reveals higher mean values in SCL group even in Breathiness, Asthenicity, and Strain parameters. However, the differences found in these three parameters are not statistically significant. Table 6 shows that the SCL group tends to answer with slightly lower values (less satisfied) than the TL + VP group, even in statement number 4, whose score is analyzed in an inverse way. The differences between the two groups are only statistically significant for question number 2 (U ¼ 57, P ¼ 0.023).

0.02072

0.01442

0

0

-0.02256 0

2.5973

-0.01508 1.13

Time (s)

1.28

Time (s)

FIGURE 2. Vowel /a/—SCL’s wave.

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TABLE 3. Fundamental Frequency (Hz) TL with VP

SCL

F0

/a/ (n ¼ 20)

/u/ (n ¼ 20)

Conversation (n ¼ 20)

/a/ (n ¼ 9)

/u/ (n ¼ 10)

Conversation (n ¼ 9)

Minimum Maximum Mean ± SD

65 85 74 ± 27.79

64 89 78 ± 21.37

54 175 82* ± 20.76

82 97 92 ± 40.34

66 100 87 ± 27.5

63 175 103* ± 27.83

*P < 0.05.

DISCUSSION F0 A comparison between the two groups shows that the TP + VP have a lower mean F0 than the SCL individuals for all speech tasks, with statistically significant difference only for conversation. This is not in agreement with previous research1,8–11 where the opposite result was found for vowels. TL with VP group shows a slightly lower minimum F0, in conversation, when compared with SCL group. No data were found for conversation in other studies. In the present study, the mean F0 data for the sustained vowels in both groups are consistently lower than those found in the literature.1,8–11 It is quite conceivable that the differences found may be due to methodological discrepancies between the present study and the published ones: sample (gender and number), chosen speech tasks, and analysis program. In fact, it is possible that one of the confounding variables may be related to gender. In the majority of the analyzed studies (Table 1), data are of both sexes and we should stress the well-known gender dimorphism and the high degree of consensus about female’s voice being generally higher than male’s voice, even in the studied sample.6 On the other hand, most of the samples are smaller than the one used in the present study. Setting aside the methodology differences, can this fact be explained by the lower frequency of the Portuguese male, when compared to voices of populations studied in other countries? We found no studies on laryngectomee voice sources made in Portugal. However, Guimara˜es20 carried out a study in Portuguese population, on normal adult men, in which the average F0 minimum found in sustained vowels was below values found in foreign literature. Jitter Jitter values in TL with VP patients were similar to those cited by Van As8 but lower results were reported by other researchers.1,12 In SCL patients, the results are in accordance with Makeieff et al’s11 research and slightly superior to the

TABLE 4. Jitter (%) TL + VP (n ¼ 20) F0

/a/

/u/

SCL (n ¼ 10) /a/

/u/

Mean ± SD 6.79 ± 1.44 6.08 ± 3.29 8.03 ± 3.18 8.48 ± 4.1

values found in other studies.1,10 Jitter values are more deviated from normal in the SCL group, in both vowels—considering jitter <1% as normal.13 It is important to note that it was not possible to analyze jitter for vowel /a/ in an individual submitted to SCL, because he presented a very modified and breathy voice. Dworkin et al1 relate significant differences in jitter values between TL with VP and SCL, with more pathological results in the SCL group. Although the differences found in the present study are not statistically significant, the results are consistent with Dworkin et al.1 In general, it was difficult to compare acoustics findings in the different studies. It would be very important to standardize internationally the methodology used (such as the researched voice sample and parameters), which would facilitate the comparison between studies, and lead to greater validity of the conclusions. Perceptual evaluation In both groups, perceptual evaluation parameters, ordered from most modified to least modified, are, respectively, Roughness, Asthenicity, Breathiness, and Strain. This is not entirely in accordance with the published data (that studied only SCL groups),7,11 where the order is Roughness, Breathiness, Strain, and, lastly, Asthenicity. There is accordance only in the first parameter (Roughness). One of the possible reasons is related to the degree of subjectivity of this manner of evaluation. The present study was carried out only by the investigator, without inter- and intrajudges reliability as in other studies.1,11 In the current study, there are significant differences in Grade and Roughness parameters between groups indicating that, perceptually, the SCLs’ voice had less quality than the TL with VP voice. No similar study was found comparing these two groups using GRBAS. However, Dworkin et al1 did not find significant differences between TL with VP and SCL (using another scale). Although the correlation with acoustic analysis was not accomplished, jitter values (irregularity) are higher in SCL than in TL with VP, and therefore in accordance with perceptual analysis. Self-assessment of voice impact on QoL The results of the present study are always more positive in the TL with VP group and significant differences were found in reply to statement 2, in which the SCL group considers the voice weaker than the TL with VP group. This is not in agreement with previous research,1 where no significant differences were found, using Voice Handicap Index (VHI). Several authors21

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TABLE 5. Voice Perceptual Evaluation (Using GRBAS Scale)

TL with VP Minimum Maximum Mode Mean ± SD SCL Minimum Maximum Mode Mean ± SD

n

Grade

Roughness

Breathiness

Asthenicity

Strain

20

2 2 2 2.00* ± 0.00

2 2 2 2.00* ± 0.00

0 2 0 0.35 ± 0.587

1 2 1 1.15 ± 0.367

0 2 0 0.25 ± 0.55

10

2 3 2 2.40* ± 0.516

2 3 2 2.40* ± 0.516

0 3 1 0.80 ± 0.919

1 2 1 1.40 ± 0.516

0 2 0 0.60 ± 0.699

*P < 0.01.

have questioned the ability of VHI in assessing the results of this population because TL with VP patients had lower scores (more favorable) in Functional, Emotional, and Physical subscales when compared with patients submitted only to radiotherapy with larynx preservation. In another study,15 the Clements et al’s19 questionnaire was used in TL with VP patients and the results are in accordance with the present study, for the same population. The first three questions of the self-evaluation questionnaire have a direct relation with voice. In the last two questions, it would have been expected that the TL with VP group would obtain more negative answers because of their physical alteration (eg, tracheostoma, the need to use the hand to speak, and modified hygiene cares). Several questions arise from this study. (1) Do, in fact, TL + VP patients have better QoL? (2) Do TL with VP patients (who had a radical change in their form of communication and even in their physical condition) establish a lower expectation in comparison with their past, therefore becoming more positive than SCL patients? (3) Could it be that a longer period after

speech therapy, which is the case of the SCL group, leads to worse adaptation and acceptance of the QoL due to vocal irregularities increase? (4) Have they answered the questions centralizing their reply on vocal quality? (5) And, therefore, is the self-evaluation questionnaire of Clements et al an adequate instrument to measure voice impact on QoL in patients submitted to SCL when compared to TL with VP? Strengths and limitations within the study This study is the first attempt to study the Portuguese TL with VP patients compared with SCL patients. Useful information about these Portuguese population voices has been provided in this study. It must be pointed out that this is a clinical study in a population with very specific characteristics. Nevertheless, attention must be given to the limitations of this study related to: (1) the reduced dimension of the sample (particularly the SCL group), the different characteristics of postsurgery intervention (eg, radiotherapy); (2) time elapsed since speech therapy in both groups; (3) interjudges’ analysis was not feasible in perceptual evaluation; (4) intrajudges’ analysis was not attempted;

TABLE 6. Self-Assessment of Voice Impact on QoL (4) My Current Method of (5) Overall, Communication How Satisfied are (3) My Ability Limits My Interaction You With the to Communicate Over the Telephone is: With Other People Quality of Your Life?

(1) How Satisfied are You With Your Method of Communication?

(2) My Speech is:

TL with VP Minimum 20 Maximum Mode Mean ± SD

1 5 3 3.00 ± 1.076

2 4 3 3.30* ± 0.571

2 5 3 3.05 ± 0.887

1 4 3 2.55 ± 0.759

3 4 4 3.55 ± 0.510

SCL Minimum 10 Maximum Mode Mean ± SD

1 3 3 2.80 ± 0.632

2 3 3 2.80* ± 0.422

2 3 3 2.70 ± 0.675

1 5 3 2.70 ± 1.059

2 4 4 3.10 ± 0.876

n

*P < 0.05.

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Voice Quality After SCL and TL

and (5) the validity of the self-assessment questionnaire as an adequate instrument in TL with VP group when compared with SCL group. CONCLUSION The results of the present study indicate statistically significant differences between TL + VP and SCL individuals for the mean F0 during conversation, for Roughness, Grade of voice quality, and self-assessment of speech. All evaluation parameters suggested that vocal quality is better in the TL with VP group, contrasting with major publications. Nevertheless, attention must be given to the limitations of this study. Results of the questionnaire measuring voice impact on the QoL were surprising. In the future, other studies would be useful to clarify this question. SCL was introduced to improve these patients’ QoL. However, with respect to voice quality, this surgery does not appear to be better than TL with VP. Acknowledgments We thank Professor Ma´rio Andrea who made the accomplishment of this study possible in his Department. We also thank the patients who participated in this study. REFERENCES 1. Dworkin P, Meleca R, Zacharek M, et al. Voice and deglutition functions after the supracricoid and total laryngectomy procedures for advanced stage laryngeal carcinoma. Arch Otolaryngol Head Neck Surg. 2000;129: 311-320. 2. Lallemant J, Bonnin P, El-Sioufi I, Bousquet J. Cricohyoepiglottopexy: long-term results in 55 patients. J Laryngol Otol. 1999;113:532-537. 3. Blom E, Singer M, Hamaker R. Tracheostoma valve for post-laryngectomy voice rehabilitation. Annals of Otology, Rhinology and Laryngology. 1982;91:576-578. 4. Robbins J. Acoustic differentiation of laryngeal, esophageal, and tracheoesophageal speech. J Speech Hear Res. 1984;27:577-585. 5. Op de Coul BMR, Hilgers FJM, Balm AJM, Tan IB, Van Tinteren H, Van den Hoogen FJA. A decade of postlaryngectomy vocal rehabilitation in 318 patients: a single institution’s experience with consistent application of indwelling voice prostheses. Arch Otolaryngol Head Neck Surg. 2000;126: 1320-1328.

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6. Bellandese M, Lerman J, Gilbert H. An acoustic analysis of excellent female esophageal, tracheoesophageal, and laryngeal speakers. J Speech Lang Hear Res. 2001;44:1315-1320. 7. Bron L, Pasche P, Brossard E, Monnier P, Schweizer V. Functional analysis after supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Laryngoscope. 2002;112:1289-1293. 8. Van As C. Tracheoesophageal Speech-A Multidimensional Assessment of Voice Quality. Nieuwegein, Holanda: Budde-Elinkwijk Grafische producties; 2001. 9. Pastore A, Yuceturk A, Trevisi P. Evaluation of voice and speech following subtotal reconstructive laryngectomy. Eur Arch Otorhinolaryngol. 1998;255:371-374. 10. Zacharek M, Pasha R, Meleca R, et al. Functional outcomes after supracricoid laryngectomy. Laryngoscope. 2001;111:1558-1564. 11. Makeieff M, Barbotte E, Giovanni A, Guerrier B. Acoustic and aerodynamic measurement of speech production after supracricoid partial laryngectomy. Laryngoscope. 2005;115:546-551. 12. Globlek D, Simunjak B, Ivkic M, Hedjever M. Speech and voice analysis after near-total laryngectomy and tracheoesophageal puncture with implantation of Provox 2 prosthesis. Logoped Phoniatr Vocal. 2004;29:84-86. 13. Baken RJ, Orlikoff RF. Clinical Measurement of Speech and Voice. San Diego, CA: Singular Publishing Group; 2000. 14. Doyle P. Foundations of Voice and Speech Rehabilitation Following Laryngeal Cancer. San Diego, CA: Singular Publishing Group; 1994. 15. Gonc¸alves F. A Qualidade Vocal nos Laringectomizados com Pro´tese Fonato´ria. Monografia final do curso de licenciatura em Terapia da Fala. Alcoita˜o: Escola Superior de Sau´de do Alcoita˜o, 20. 16. American Joint Committee on Cancer. AJCC Cancer Staging Manual [Chapter 5]. 6th ed.). New York, NY: Springer; 2002 [p. 47–57]. 17. Lingcom Gmbh Forchhreim, versa˜o 2.28 Lingwaves 2002. http://www. atmosmed.de/pages; 2002. 18. Boersma P, Weenink D. Institute of Phonetic Sciences. Version 4.3.04 of Praat.http://www.fon.hum.uva.nl/praat/ 2004;; 2004. Accessed March 25, 2005. 19. Clements K, Rassekh C, Seikaly H, Hokanson J, Calhoun K. Communication after laryngectomy. An assessment of patient satisfaction. Arch Otolaryngol Head Neck Surg. 1997;124:493-496. 20. Guimara˜es I. An electrolaryngographic study of dysphonic Portuguese speakers [Tese de Doutoramento]. Londres: Universidade de Londres; 2002. 21. Stewart M, Chen A, Stach C. Outcomes analyses of voice and quality of life in patients with laryngeal cancer. Arch Otolaryngol Head Neck Surg. 1998;124:143-148. 22. Hirano M. Clinical Examination of Voice. New York: Springer-Verlag; 1981. 23. Hilgers F, Schouwvenburg P. A new low-resistance self-retaining prosthesis (Provox) for voice rehabilitation after total laryngectomy. Laryngoscope. 1990;100:1202-1207.

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Appendix ANNEX Satisfaction of Patients Questionnaire Questionário de Auto-avaliação English / Portuguese Instructions: The following set of questions and statements are all followed by a scale of answers. Please mark an “X” on the scale at the point which most closely resembles your answer. Instruções: O seguinte conjunto de perguntas e afirmações é seguido por uma escala de respostas. Por favor marque X na caixa que julgue mais parecida com a sua resposta. Example: Never

Rarely

Sometimes

Often

Always

Nunca

Poucas vezes

Algumas vezes

Muitas vezes

Sempre

1

3

2

4

5

1. How satisfied are you with your method of communication? 1. Está satisfeito com o seu método de comunicação? Extremely Unsatisfied

Somewhat Unsatisfied

Satisfied

Very Satisfied

Extremely Satisfied

Pouco Satisfeito

Satisfeito

Muito Satisfeito

Muito

Extremamente Satisfeito

1 2. My speech is: 2. A minha fala é:

2

3

4

5

Extremely Poor

Poor

Fair

Good

Excellent

Muito Fraca

Fraca

Razoável

Boa

Excelente

1 2 3. My ability to communicate over the telephone is: 3. A minha capacidade para falar ao telefone é:

3

4

5

Extremely Poor

Poor

Fair

Good

Excellent

Muito Fraca

Fraca

Razoável

Boa

Excelente

1 2 3 4. My current method of communication limits my interaction with other people: O meu método actual de comunicação limita a minha relação com os outros:

4

5

Never

Rarely

Sometimes

Often

Always

Nunca

Poucas vezes

Algumas vezes

Muitas vezes

Sempre

1 2 3 5. Overall, how satisfied are you with the quality of your life? Em geral, qual o grau de satisfação com a sua qualidade de vida?

4

5

Extremely Poor

Poor

Fair

Good

Excellent

Muito Fraco

Fraco

Razoável

Bom

Excelente

1

2

3

4

5