Methods Setting
3. Evaluation Protocol
The protocol included vocal acoustic evaluation, psychological assessment, self- evaluation of quality of life and the diagnosis and classification of functional voice disorder.
3.1 - Vocal Acoustic Evaluation
The recording took place in the Audiology room of the ENT Department, a Faraday Cage. A digital recorder was used with a unidirectional headset microphone placed at a distance of 5 cm from the mouth.
The voice analysis included the recording of three sustained vowels (/i/, /a/, and /u/) produced at a comfortable level. Besides this, cough recording was also performed.
This procedure occurred before the clinical interview avoiding influences on voice production and consequently on vocal quality.
The vocal signals were analyzed with Praat software (version 5.3.17) in seven acoustic measures, namely fundamental frequency, jitter, shimmer, vocal intensity, harmonic-to-noise ratio (HNR), and the first and second formants.
A more detailed description of this procedure is provided in Study 5.
3.2 - Clinical Data
The patients answered to a semi-structured interview with open and closed questions (Appendix C).
The interview explored the patient’s sociodemographic data (age, education, employment status, marital status, and hobbies); habits (tobacco and alcohol); past and present medical history (acute and chronic diseases; surgical procedures; regular medication; hearing complaints; breathing problems; allergies; swallowing problems); voice use patterns (at home and at work; external comments about the voice); vocal symptoms (onset; type; evolution; current and/or past history of voice therapy; family history of voice disorders); psycological data (current and/or past mental health treatments; family history of psychiatric disorders).
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3.3 - Psychological Evaluation
A set of standardized tests, mostly psychological instruments were applied (clinical and self-assessment tests):
Clinical assessment tests: Mini International Neuropsychiatric Interview (MINI);
Hamilton Depression Rating Scale (HAM-D); and Hamilton Anxiety Rating Scale (HARS) (Study 2).
Self-assessment tests: Millon Clinical Multiaxial Inventory (MCMI-II) (Study 3);
Temperament Evaluation of Memphis, Pisa, Paris and San Diego - Auto questionnaire (TEMPS-A) (Study 4).
The battery of tests was applied respecting the sequence of instruments present on the data collection notebook (Appendix D). Patients completed them in their own time. In case of doubts the researcher could clarify the questions.
The Rating Scales for depression and anxiety (HAM-D and HARS) were filled in at the end of the interview, based on the researcher’s overall perception of the patient.
3.4 - Evaluation of Quality of Life
The self-evaluation of quality of life was assessed through the Voice Handicap Index (VHI-30) (Study 6).
The description of the listed instruments will be developed in Chapter “Results”, in the respective study.
3.5 - ENT Evaluation
Patients were observed and evaluated by an ENT specialist or resident who made a
videoendoscopy with a rigid endoscope (Karl Storz; Germany) or with a
fibronasoendoscope (Olympus; Japan), which permitted the recording of the vocal folds in digital format.
The vocal folds were captured in the abduction and adduction positions, allowing the evaluation of their anatomy and movements.
Two other ENT specialists analyzed the endoscopic findings separately. If disagreement arose, the images were re-analyzed.
The patients were classified and clustered into three groups according to the classification system that was previously described: 39 patients (47%) in PVD group, 16 patients (19%) in MTVD1 group (primary muscle tension voice disorders), and 28 patients (34%) in MTVD2 group (secondary muscle tension voice disorders).
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4. Variables
In the present work, the variables were aggregated into four categories in order to characterize the three study groups. The variables were systematized accordingly: characterization of subjects (Tables 1, 2 and 3), psychological evaluation (Table 4), vocal acoustic evaluation (Table 5), and self-evaluation of quality of life (Table 6).
TABLE 1
Operationalization of the Variables for the Characterization of Subjects (Part I) Characterization of Subjects
Sociodemographic Characteristics
Age: Years.
Education: Incompleted basic education, 1st cycle, 2nd cycle, 3rd cycle, secondary education, higher education, academic degree or master’s degree.
Employment Status: Housewife, employed, sick leave, unemployed or retired. Marital Status: Single, married, divorced or widowed.
Health Behaviors Smoking status: Non-smoker, current smoker or past smoker. Alcohol Consumption patterns: Without, daily or occasionally.
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TABLE 2
Operationalization of the Variables for the Characterization of Subjects (Part II) Characterization of Subjects
Vocal Data
Vocal Symptoms: Hoarseness, aphonia, vocal fatigue an/or intensity changes.
Onset of the Vocal Symptoms: Type (progressive or sudden); date knowledge (no or yes); past vocal symptom (no or yes). Time since the Onset of Vocal Symptoms: Less than 1 month, 1 to 3 months, 3 to 6 months, 6 to 12 months, 12 to 18 months,
18 to 24 months, 2 to 5 years, 5 to 10 years or more than 10 years.
Comments made by Others about the Patients’ Voice: Without, speak loud, not understood or not heard.
Family History of Voice Disorders: Prevalence (without or with); etiology of the voice disorder (benign, malignancy,
psychogenic, unknown); identification of the family members with voice disorders with reference to the etiology (Appendix E).
Current History of Speech Therapy: Without or with; current status (keeps, discharged or disengagement) (Appendix E), past
(past history, previously same vocal symptoms); self-perception on future benefits (uncertainly, no or yes) (Appendix E).
Vocal Behavior: Not applied, talk much, talk less, strives voice, abuse of phone, and a combination of one or more; vocal
TABLE 3
Operationalization of the Variables for the Characterization of Subjects (Part III) Characterization of Subjects
Psychological Data
Current Mental Health Treatments: Psychological, psychiatric or both.
Pharmacotherapy: Without or with; Current psychotropic medication (no or yes); psychotropic medication (anxiolytic;
antidepressant, anticonvulsivant, anxiolytic and antidepressant, anxiolytic and anticonvulsivant, antidepressant and anticonvulsivant; anxiolytic, antidepressant and antipsychotic.
Treatments in Mental Health Services: Psychological or psychiatric treatments, or both treatments; self-perception on future
benefits with mental health treatment (uncertainly, no or yes).
Family History of Psychiatric Disorders: Prevalence (without or with).
- Psychiatric Disorders in the Family: Frequency (n); number of family members (1,2,3 or 4) and etiology of
psychiatric disorders (affective disorders, anxiety disorders, psychotic disorders, alcohol dependence, drug dependence, AHDH, epilepsy, dementia, anorexia nervosa, and co-morbidity) of direct family members; number of family members (1,2,3,4,5 or 7) and etiology of psychiatric disorders (affective disorders, anxiety disorders, alcohol dependence, drug dependence, AHDH, epilepsy, dementia, mental retardation, and co-morbidity) of other family members (Appendix E). - Family History of Suicidal Behaviors: Frequency (n) for suicide attempt; frequency (n) on suicides; identification of
family members with suicide attempts (father, mother, uncle and cousin); identification of family members who committed suicide (mother, daughter, brother, uncle, grandfather) (Appendix E).
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TABLE 4
Operationalization of the Variables resulting from the Psychological Evaluation Psychological Evaluation
Psychological Tests
HAM-D: Severity of symptoms of depression. HARS: Severity of symptoms of anxiety.
MINI: Presence or absence of psychiatric disorders (current and past).
MCMI-II: Presence or absence of personality traits and personality disorders, and clinical syndromes. TEMPS-A: Presence or absence of affective temperaments.
TABLE 5
Operationalization of the Variables resulting from the Vocal Acoustic Evaluation Vocal Acoustic Evaluation
Vocal Acoustic Parameters Fundamental frequency (F0); jitter; shimmer; vocal intensity; harmonic-to-noise ratio (HNR); formants: F1 and F2.
TABLE 6
Operationalization of the Variables resulting from the Self-evaluation of Quality of Life Self-evaluation of Quality of Life
Quality of Life in Voice Disorders VHI-30: Self-perception of voice handicap and disability (total score; scores for functional, physical, and emotional subscales).
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5. Statistics
A database was specifically built for the present study using SPSS Statistic v21.0 for Mac OS (IBM Corporation, Chicago, IL).
After introducing the collected data, some variables were reviewed in order to enable better visualization and to assist in their handling.
Descriptive statistics were used to characterize the three groups (PVD, MTVD1 and MTVD2): means, standard deviations (SDs), and minimum and maximum values for continuous variables, and frequencies, percentages and adjusted residuals for categorical variables.
Different statistical tests procedures were applied in the six studies according to their goals and the specificity of the variables under analysis.