Journal of Regional Section of Serbian Medical Association in Zajecar

Year 2020     Vol 45     No 1-2
     
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      UDK 613-056.24:616-006
616.22-089.85
COBISS.SR-ID 16485129

Page 25

     
   
Original paper

Subjective assessment of the quality of life of laryngectomized patients before and after speech rehabilitation

Mila Bunijevac (1,2), Neda Milošević (1, 3), Gordana Čolić (1), Dragan Čauševac (1,3),
Ivana Ristić (4)


(1)HIGH SCHOOL OF SOCIAL WORK, DEPARTMENT OF SPEECH THERAPY, BELGRADE, SERBIA; (2) PHI HOSPITAL "SVETI VRAČEVI", REPUBLIC OF SRPSKA, BIH; (3) CENTER FOR SPEECH PATHOLOGY - LOGOMEDIC, BELGRADE, SERBIA; (4) HIGH SCHOOL OF SOCIAL WORK, OCCUPATION THERAPY DEPARTMENT, BELGRADE, SERBIA
     
 
 
     
 

 

         
  Download in pdf format   Abstract: Introduction: Total laryngectomy exposes the patient to a great deal of psychological stress, both because of the underlying disease and the loss of a very important organ in the overall functioning of the organism and organs, which enables an adequate communication process. Objective: The aim of this study is to conduct a subjective assessment of the quality of life of laryngectomized patients before and after vocal rehabilitation. Methods: The study involved 50 patients after total laryngectomy, ranging in age from 51 years to 83 years. A subjective assessment of speech and voice was conducted with the University of Michigan Quality of Life Instrument — HNQOL and Voice Handicap Index — VHI. These instruments provide information from the patient about the treatment or treatment applied, as well as the impact that vocal rehabilitation has on the quality of his or her life before and after treatment. Results: Prior to vocal rehabilitation of the HNQOL scale, patients experienced pronounced difficulties on all subscales, especially when it came to communication ( E(x)= 5.75 ± 8.64) and emotions ( E(x)= 16.66 ± 15.17); expressed, while chewing/food ingestion ( E(x)= 53.91 ± 26.45) and pain ( E(x)= 50.50 ± 17.71) had mean values. VHI scale (physical subscale E(x)= 36.6 ± 2.93; emotional subscale E(x)= 34.96 ± 3.79; functional subscale E(x)= 35.64 ± 3.37) before vocal rehabilitation, all subjects (100%) belonged to the third category (severe handicap), which was a problem when it came to psychosocial functioning. After vocal rehabilitation, the mean values on the HNQOL scale were very highly expressed and statistically highly significantly improved (communication E(x)= 93.37 ± 10.28; emotions E(x)= 90.58 ± 8.23; chewing/swallowing food E(x)= 96.66 ± 5.77; pain E(x)= 92.25 ± 6.98) which indicated a good quality of life. On the VHI scale of low value (physical subscale E(x)= 10.84 ± 4.41; emotional subscale E(x)= 4.42 ± 4.63; functional subscale E(x)= 21.32 ± 13.29) shows a statistically high significant improvement, ie good psychophysical and functional condition patient. Conclusion: Subjective assessment after vocal rehabilitation resulted in improvement of all parameters tested, especially in the domain of communications and emotions.Vocal rehabilitation has had a positive effect on improving the quality of life of these patients, integrating them into the family and the environment, as well as performing daily activities that we observe through their physical, emotional and functional state.
Keywords: Larynx tumor, Total laryngectomy, Quality of life, HNQOL scale, VHI scale.
 
     
      INTRODUCTION
Total laryngectomy is a radical procedure that results in the permanent loss of the generator and part of the resonator of the voice, the larynx in which the underlying laryngeal tone is created [1]. Total laryngectomy is performed in advanced cases of laryngeal cancer with signs of deep laryngeal infiltration (T3) or in tumors that have spread to adjacent organs (T4), ie when all the potential for partial surgery is exhausted (2, 3). The patient is exposed to a great deal of psychological stress, both because of the underlying illness and the loss of a very important organ in the overall functioning of the organism and the organ participating in the exercise of communication [4]. Total laryngectomy leads to physical and functional changes that can affect the emotional state and some of the most basic life functions, including breathing, swallowing and communication [5].
Speech rehabilitation is a complex and active process that requires the involvement and cooperation of a laryngectomized person and speech therapist. Speech is an expression of social activity because it is realized in communication with other people. Rehabilitation of laryngeomized patients modifies the anatomy of the upper aerodigestive pathways, creating new anatomical conditions on which breathing, swallowing and phonation functions will have to be organized [3]. It is a very important form of rehabilitation, which in addition to successfully mastering one of the methods of speech increases confidence, creates a better sense of security and improves quality of life [6],
The basic possibilities of speech rehabilitation after total laryngectomy are the development of esophageal speech skills, treoesophageal puncture with the use of a vocal prosthesis, and the use of electrolarynx.
Quality of life has been conceptualized as a multidimensional concept in which health, well-being, health comprehension, functional status and life choices overlap [7, 8]. Some define quality of life in cancer patients as the difference between patient expectations and low achievement that affect quality of life improvement [9]. Quality of life is a general well-being that encompasses objective factors and a subjective evaluation of physical, material, emotional and social well-being, including personal development and purposeful activities [10].

Basic aspects of quality of life are health, functional ability, life satisfaction and independence [11]. It can be measured using a variety of questionnaires, which are mostly completed by patients and thus gives an opinion on the experience of their speech and voice when it comes to physical, emotional and functional state. The quality of life of patients after total laryngectomy is studied within the oncology of head and neck tumors, because of all malignant tumors of the head and neck, laryngeal cancer is the most common cause of oral cancer and oropharynx.
The aim of this study is to examine the quality of life of laryngectomized patients before and after vocal rehabilitation.

METHODS
The study involved 50 patients after total laryngectomy, ranging in age from 51 years to 83 years. The research was conducted at SWU "SvetiVračevi" Hospital in Bijeljina and the Military Medical Academy in Belgrade from April 2014 to November 2015. Data on gender, age, education, smoking experience, time when rehabilitation was initiated, vocal rehabilitation model, and length of treatment were collected through a questionnaire and interview with a patient.
A subjective voice assessment was conducted with University of Michigan Quality of Life Instrument instruments - HNQOL, Terrell et al. [12] and the Voice Handicap Index - VHI, Jacobson et al. [13]. University of Michigan Quality of Life Instrument -HNQOL scale is used to evaluate the quality of life of patients with head and neck cancer. It has been translated into many languages and adapted to different cultures. It was adapted for our speech area by Petrovic-Lazic, Bunijevac in 2014. The scale contains 30 questions, 20 of which are used to score four domains of quality of life assessment: communication (4 points), chewing/swallowing food (6 points), pain (4 points) and emotions (6 points). Respondents were tasked with selecting the answer given for each of these questions, expressing their feelings and opinions about the possibility or success of communication, the possibility of chewing / swallowing food, pain and emotional state. The HNQOL scale can also be used to assess a patient's satisfaction with treatment or treatment, as well as the impact of speech rehabilitation on the quality of his or her life before and after treatment.
Voice Handicap Index - The VHI scale is used to measure the therapeutic outcome of vocal rehabilitation as well as to evaluate the severity of a voice problem. The VHI scale covers three areas, namely: P — physical, E — emotional, F — functional. Each area contains 10 questions. Respondents were tasked with selecting the answer given for each question: "never", "almost never", "sometimes", "almost always", "always". In this way, they expressed their opinions about the experience of their voice and speech when it comes to physical, emotional and functional state. The VHI scale can provide information about the degree of speech disability experienced by the patient himself and the impact that vocal rehabilitation has on the quality of his or her life before and after treatment. Data were collected on two occasions. Patients completed the questionnaire the first time they came to the speech therapist, before starting treatment and the second time after completing the treatment.
Descriptive measures, arithmetic mean with associated standard deviation, as well as minimum and maximum were used in the statistical data processing. Frequency and percentages, and t-test for dependent samples were used. Statistical analysis and analysis were done in the SPSS version 20 (Statistical Package for the Social Sciences) computer program.

RESULTS
The study involved 50 patients after total laryngectomy, 47 male subjects and three female subjects, as shown in Table 1. All subjects in this study were smokers. The most frequently represented respondents were pensioners, slightly fewer were persons in employment, and these were mostly persons with secondary education. The examiners came from both urban and rural areas.

Table 1.Structure of the sample by gender, smoking status, education and place of residence
f - frequency, % - percentage.

The age of the respondents ranged from 51 to 83 years (Table 2). The length of smoking experience ranges from 20 to 55 years, and the length of treatment ranges from one month to 12 months.

Table 2.Structure of the sample by age of the respondent, length of smokers' time and length of treatment
N - number of subjects, Min. - minimum, Max. - maximum, - arithmetic mean (mean), SD – standard deviation.

Patients mastered two models of speech, namely esophageal and electro-laryngeal speech (Table 3).

Table 3. Structure of the sample according to vocal rehabilitation model
N - number of subjects, % - percentage.

Prior to vocal rehabilitation, the HNQOL subscales had low levels of expression on the HNQOL subscale, especially with regard to communication and emotion subscales, whereas the subscales related to food ingestion and chewing and pain had medium levels. Using the t-test for dependent samples after vocal rehabilitation, statistically significant improvement was found on all subscales of the HNQOL scale (Table 4). A statistically significant difference on the HNQOL scale also exists in the total score before and after treatment, which means that better overall functioning of patients in all examined domains after treatment compared to the pre-treatment period, which also indicated a better quality of life.

Table 4.HNQOL scale — before and after vocal rehabilitation
E(x) - arithmetic mean, SD - standard deviation, t - t-test, p - statistical significance
Statistically significant values are highlighted (bold)

Prior to vocal rehabilitation on all subscales of the VHI scale, subjects had high mean values, which negatively affected their quality of life. Using the t-test for dependent samples after vocal rehabilitation, statistically significant improvement was found on all subscales of the VHI scale, that is, the patients' physical, emotional and functional condition improved after treatment (Table 5).
A statistically significant difference on the VHI scale also exists in the total score before and after treatment, which means that the overall functioning of patients after treatment is better compared to the pre-treatment period.

Table 5.VHI scale — before and after vocal rehabilitation
E(x) - arithmetic mean, SD - standard deviation, t - t-test, p - statistical significance
Statistically significant values are highlighted (bold)

DISCUSSION

Laryngeal cancer accounts for 1-3% of all malignant tumors and has increased significantly in recent years. About 20% are present in head and neck tumors. They occur more frequently in males (94%) than in females (6%), which has been reported in studies by other authors [14, 15].It has been observed that men consume more alcohol and cigarettes than women.
The age structure influences its frequency, so a sharp increase is observed after the age of 40. The age of the respondents in our study ranged from 51 to 83 years (E(x) = 62.6 ± 7.32). The results in this study are comparative with the results of a number of studies that state that laryngeal cancer occurs from 4 to 7 decades, with most cases occurring in the sixth decade of life [16, 17].
One of the leading causes of laryngeal cancer is smoking. In our study, all subjects were active smokers with an average length of smoking time of 35.8 ± 6.16. years. Other authors also highlight the negative effects of smoking when it comes to the occurrence of laryngeal cancer [18, 19, 15], as well as the combined effect of smoking and alcohol consumption [20].
The length of vocal rehabilitation ranged from one month to one year. In patients who successfully mastered esophageal speech, vocal rehabilitation lasted longer, while patients who successfully mastered electro-laryngeal speech had three to five treatments. According to other researchers, continuous speech rehabilitation lasted from three to eight months [21], and mastering esophageal speech from six to twelve months [15]. Vocal rehabilitation should take as long as necessary to achieve optimal results.
Before vocal rehabilitation based on the results obtained on the HNQOL scale, patients had impaired quality of life in all domains. Neilson et al. [17] state that in patients after total laryngectomy there is a generalized sense of diminished quality of life.
Inability to speak in our study adversely affected the quality of life of patients after total laryngectomy, which is consistent with other studies [22, 23, 24, 15, 25].
Prior to vocal rehabilitation, laryngectomized patients exhibited emotional distress related to their condition. Other authors 'research findings [22, 26, 15] also highlight the negative impact of physical appearance on patients' emotional state, leading to a decline in quality of life.
On the subscale, chewing/ingesting food prior to vocal rehabilitation, subjects experienced moderate interference with taste loss and chewing / ingestion of food, which negatively affected their quality of life, consistent with other studies [27, 28].
Pain is one of the most common symptoms in cancer patients and is a common cause of depression, fear, hopelessness and declining quality of life [29]. In our study, the presence of pain in the subjects was of moderate intensity. They mostly had shoulder pain, which negatively affected their quality of life.
Based on the results obtained on the VHI scale, all subjects belonged to the group of severe speech handicap prior to vocal rehabilitation, which is understandable because laryngeal cancer is a chronic disease that causes emotional and psychological problems in the patient [30]. Multiple studies have shown that total laryngectomy has a negative impact on the physical, emotional and functional state of the patient leading to a decline in quality of life [31, 32]. The physical consequences of total laryngectomy limit the patient in social activities as well [6]. In patients after total laryngectomy, social functions and roles in the environment in which they live are impaired, the disease prevents them from performing family, social and professional activities [6]. Inclusion in different types of treatment has a positive impact on reducing these problems, with vocal rehabilitation being the primary one, as shown in our study.
After completing vocal rehabilitation, mastering one of the methods of speech had the positive effect of neglecting physical appearance, enhancing self-confidence and a sense of security, and thus improving the quality of life. Vocal rehabilitation in patients after total laryngectomy affects their emotional, social and psychological functioning, as well as a better quality of life [33, 26, 15].
Involvement of patients after total laryngectomy in the process of vocal rehabilitation and speech control is one of the important factors for improving quality of life, facilitating return to normal life activities and positively influencing the improvement of emotional state of these patients [34]. Which method will be used in the vocal rehabilitation process varies from patient to patient. Tracheoesophageal speech is one of the most preferred methods [35], with electro-laryngeal speech the most commonly adopted allaringeal phonation [36], while esophageal speech is the best and most natural way of establishing speech function.
The goal of vocal rehabilitation is to enable patients to successfully communicate with the environment using some of the models of alaringeal speech, and thus improve their quality of life. The success of vocal rehabilitation is judged by the patient's subjective experience, that is, his / her self-assessment of how successful he / she is in daily activities and how satisfied he / she is with his/her quality of life.

CONCLUSION
Subjective assessment after vocal rehabilitation led to an improvement in all parameters examined, especially in the domain of communication and emotions.Vocal rehabilitation is of great importance in patients after total laryngectomy and is aimed at successfully mastering one of the speech methods, which is strongly associated with improving quality of life.It allows the return to normal life activities and improves the emotional state of these patients, thus reducing the consequences of total laryngectomy. The positive effect of vocal rehabilitation is achieved by strengthening self-confidence and creating a sense of security. The success of vocal rehabilitation is judged by the patient's subjective experience, that is, their self-assessment of how successful they are in their daily activities and how satisfied they are with their quality of life. In the future, improving the quality of life of laryngectomized patients should be one of the main goals that can be achieved through a multidisciplinary treatment approach and vocal rehabilitation, enabling them to return to the social and work environments more quickly.

Gratitude. The authors thank Prof. Jeffrey Terrel, PhD, an otolaryngologist in Ann Arbor, Michigan, who allowed us to use his scale University of Michigan Head & Neck Quality of Life Instrument (HNQOL).

Conflict of interest: The authors declare that they have no conflict of interest.

REFERENCES:

  1. Mitrović S. Komunikacija bez larinksa. Med pregl 2008; LXI (3-4);121-2.
  2. Đukić V, Nešić V. Hirurška anatomija i fiziologija larinksa. ActaClin 2008; 8(3): 21-47.
  3. Bunijevac M. Uticaj vokalne rehabilitacije na kvalitet života laringektomiranih pacijenata. Beograd: Visoka škola socijalnog rada; 2019.
  4. Petrović-Lazić M, Kosanović R, Vasić M. Rehabilitacija laringektomiranih bolesnika. Beograd: Nova naučna; 2010.
  5. Attieh AY, Searl J, Shahaltough NH, Wreikat MM, Lundy DS. Voice restoration following total laryngectomy by tracheoesophageal prosthesis: Effect on patients' quality of life and voice handicap in Jordan. Health Qual Life Outcomes 2008;6:26.
  6. Bunijevac M, Petrović-Lazić M, Maksimović S. Quality of life of patients after total laryngectomy. Saarbrücken, Germany: Lambert Academic Publishing; 2017.
  7. Berzon R, Hays RD, Shumaker SA. International use, application and performance of health -related quality of life instruments. Qual Life Res 1993; 2(6): 367-8.
  8. Dolan P. Valuing health-related quality of life. Pharmacoeconomies 1998; 15(2): 119-127.
  9. Calman KC. Quality of life in cancer patients--an hypothesis.J Med Ethics 1984;10(3):124-127.
  10. Felce D, Perry J. Quality of life: its definition and measurement. Res Dev Disabil 1995;16(1):51-74.
  11. Đukić V, Milovanović J, Folić M, Pavlović B, Jotić A, Trivić A, et al. Karcinom larinksa. Beograd: Paratenton; 2017.
  12. Terrell JE, Nanavati KA, Esclamado RM, Bishop JK, Bradford CR, Wolf GT. Head and Neck cancer-specific quality of life: Instrument validation. Arch Otolaryngol Head Neck Surg1997; 123: 1125-1132.
  13. Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benninger MS, et al.. The Voice Handicap Index (VHI): development and validation. Ame J Speech Lange Pathol1997; 6: 66-70.
  14. Rosso M, Kraljik N, Mihaljević I, Sirić L, Sos D, Vranjes Z. Epidemiology of laryngeal cancer in Osijek-Baranja County (eastern Croatia). CollAntropol2012; 36(2): 107-110.
  15. Bunijevac M, Petrović-Lazić M. Značaj rane vokalne rehabilitacije i kvalitet života laringektomiranih pacijenata. Spec edukac rehabilitac 2016; 15(4): 379-393.
  16. Woodward TD, Oplatek A, Petruzzelli GJ. Life after total laryngectomy. A measzreod long-term survival, function and quality of life. Arch Otolaryngol Head Neck Surg 2007; 133(4): 526-532.Neilson K, Pollard A, Boonzaier A, Corry J, Castle JD, Smith D, et al. A longitudinal study of distress (depression and anxiety) up to 18 months after radiotherapy for head and neck cancer. Psychooncology 2013; 22(8): 1843-8.
  17. Duffy SA, Terrel JA, Valenstein M, Ronis DL, Copeland LA, Connors M. Effect of smoking, alcohol and depression on the quality of life of head and neck cancers patients. Gen HospPsychiatry 2002; 24(3): 140-147.
  18. Laccourreye O, Ishoo E, de Mones E, Garcia D, Kania R, Hans S. Supracricoidhemilaryngopharyngectomy in patients with invasive squamous cell carcinoma of the pyriform sinus. Part I: Technique, complications, and long-zerm functional outcome. Ann OtolRhynolLaryngol2005; 114: 25-32.
  19. Vartanian JG, Carvahlo AL, Toyota J, Kowalski IS, Kowalski LP. Socioeconomic effect of and risk factors for disability in long-term survivors of head and neck cancer. Arch OtolaryngolHead Neck Surg 2006;132(1), 32-35.
  20. Sokal W, Kordylewska M, Golusiński W. An influence of some factors on the logopedic rehabilitation of patients after total laryngectomy.Otolaryngol Pol 2011; 65(1): 20-5.
  21. Doyle PC, Keith RL. Contemporary considerations in the treatment and rehabilitation of head and neck cancer: Voice, speech and swallowing. Austin, TX: Pro-Ed; pp. 2005:76-77.
  22. Palmer AD, Graham MS. The Relationship Between Communication and Quality of Life in Alaryngeal Speakers. J Speech Long PatholAudiol2004; 28(1): 6-24.
  23. Saki N, Nikakhlagh S, Araghi S, Khanifer Z. The quality of life of patients after total laryngectomy. Biosci Biotech Res Asia 2015; 12: 103-108.
  24. Mertl J, Žáčková E, Řepová B. Quality of life of patients after total laryngectomy: the struggle against stigmatization and social exclusion using speech synthesis. DisabilRehabil Assist Teechnol 2017; 27: 1-11.
  25. Nemr K, Raquel ACS, Takeshita-Monaretti TK, Pires-Buzanelli E,Simões-Zenari M, Aguiar-Ricz LA. Scientific Evidence Regarding the Quality of Life of Total Laryngectomees. Arch OtolaryngolRhinol2015; 1(2): 034-044.
  26. PernambucoLdeA, Oliveira JHP, Régis RMFL, Lima LM, Araújo AMB, Balata PMM, et al. Quality of life and deglutition after total laryngectomy. Int Arch Otorhinolaryngol 2012; 16(4): 460-465.
  27. Bunijevac M, Petrović-Lazić M, Jovanović-Simić N, Maksimović S. Uticajradioterapijenakvalitetživotalaringektomiranihpacijenata pre iposlevokalnerehabilitacije. Tim med glas2018; 43(2): 41-48.
  28. Simone CB 2nd, Vapiwalo N, Hampshire MK, Metz JM. Palliative care in the management of lung cancer: analgesic utilization and barries to optimal pain management. J Opioid Manag2012; 8(1): 9-16.
  29. Ateşci FÇ, Oğuzhanoğlu NK, Baltalarli B, Karadağ F, Özdel O, Karagöz N. Kanserhastalarindapsikiyatrikbozukluklarveilişkilietmenler. TürkPsikiyatriDergisi 2003; 14(2): 145-152.
  30. Elmiyeh B, Dwivedi RC, Jallali N, Chisholm EJ, Kazi R, Clarke PM, et al. Surgical voice restoration after total laryngectomy: an overview. Indian J Cancer 2010; 47(3): 239-247.
  31. Schindler A, Mozzanica F, Ginocchio D, Invernizzi A, Peri A, Ottaviani F. Voice-related quality of life in patients after total and partial laryngectomy. AurisNasus Larynx 2012; 39(1): 77-83.
  32. Rossi VC, Fernandes FL, Ferreira MA, Bento LR, Pereira PS, Chone CT. Larynx cancer: Quality of life and voice after treatment. Braz J Otorhinolaryngol 2014; 80: 403-408.
  33. Bunijevac M, Petrović-Lazić M, Jovanović-Simić N, Maksimović S. Quality of life of patients after total laryngectomy – SF-36. Early Intervent Spec EducatRehabilit2016;587-598.
  34. El-Sharnobya MK, Behairya EA, Abdel-Fettah AA, Al-Belkasy MA. Voice rehabilitation after total laryngectomy. Menoufia Med J 2015; 28(4): 800-806.
  35. Hanjun L, ManwaLNg. Electrolarynx in voice rehabilitation. AurisNasus Larynx 2007; 34(3): 327-332.
     
     
     
      Corresponding Address:
Mila Bunijevac, Visoka škola Socijalnog rada, Departman za Logopediju, Beograd
E-mail: bunijevacmila@yahoo.com
Paper received: 3.4.2020
Paper Internet issues: 30.6.2020
     
             
             
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