Running Head: RADIOTHERAPY

Voice rehabilitation and functional outcomes following radiotherapy for laryngeal cancer

[Name of Student]

[Name of Instructor]
Radiotherapy 2
 Radiotherapy 3

Table of Contents

CHAPTER ONE: INTRODUCTION ............................................................................................. 4

CHAPTER TWO: METHODOLOGY ........................................................................................... 7

Inclusion criteria .......................................................................................................................... 7

Exclusion criteria......................................................................................................................... 8

CHAPTER THREE: RESULTS ..................................................................................................... 9

Study design and Patient characteristics ..................................................................................... 9

Instruments ................................................................................................................................ 10

Integrity of results ..................................................................................................................... 10

Speech and Voice outcome ....................................................................................................... 11

Pretreatment speech and voice status (effects of cancer) .......................................................... 12

Short-term posttreatment outcomes .......................................................................................... 14

One year posttreatment outcomes ............................................................................................. 16

Long-term posttreatment outcomes ........................................................................................... 16

Further dimensional assessment ................................................................................................ 18

CHAPTER FOUR: DISCUSSIONS ............................................................................................. 19

CHAPTER FIVE: CONCLUSION............................................................................................... 23

 Radiotherapy 4

CHAPTER ONE: INTRODUCTION

In terms of research on head and neck cancer (HNC) and clinical treatment, it is now

more important to understand the consequences that affect patients after cancer treatment

(Jacobi, 2010). These data are fundamental to direct rehabilitation and to improve understanding

quality of life and psychological health to improve survival after cancer (Krengl, 2004). Within

the subgroup of patients with laryngeal cancer treatment and organ preservation, the negative

impact of chemotherapy treatment (radiotherapy) on performance (Bibby, 2008), health-related

quality of life (HRQoL), and problems with prosperity / psychology have been investigated in

varying degrees (Starmer, 2008).

In terms of communication and voice function after laryngeal cancer treatment,

investigations show that patients will experience changes in vocal ability that vary from mild to

severe (Hocevar-Boltezar, 2009). Regularly presenting as a severe dysphonia, the voice post RT

was described as breathy (van Gogh, 2006), strained, rough and harsh, with guttural fever and a

changed tone that the patient may remain for a long time (Metcalfe, 2014). Patients themselves

report low voice quality, low volume, low volume and voice fatigue after treatment for laryngeal

cancer (Johns, 2012).

Numerous studies have also examined (HRQOL) and outcomes of quality of life

worldwide (QOL) after laryngeal cancer (Cocks , 2011). Treatment results, specific to the

outcomes of non-surgical treatment, show that most HRQL (power scales and side effects)

decrease several months after radiation therapy at that time and improve by 6 per year to reach

standard levels (before radiation therapy), despite the fact that they remain lower than

regularization estimates (Finizia, 2002). Most of the results of HRQoL's ability and side effects
 Radiotherapy 5

present throughout the year remain constant over a long period, up to 5 years after radiation

therapy (Jacobi, 2010).

Although, while the impact on quality of life and beneficial results was fully

investigated, the study of the psychological well-being / problems of the patient after laryngeal

cancer was studied to a lesser extent (Happ , 2004). Studies recommend that up to 41% of

patients experience possible / probable anxiety or depression, which could be more common,

either before radiotherapy, or one year later, and continued for a long time after administration.

Johansson et al (2011) also recognized that psychological adaptation of patients to laryngeal

cancer and their adaptation systems has a fundamental effect on anxiety, depression, HRQoL,

and survival (Metcalfe, 2014).

Given the degree of utility weakness and the decline in the quality of life after laryngeal

cancer treatment, later studies have explored the potential benefits of voice rehabilitation for this

clinical meeting (Sjogren, 2008). Studies show that the rehabilitation of the voice after laryngeal

cancer significantly improves the voice (acoustic and perceptual characteristics), the

understanding of the observations, the consistency and some results of HRQOL compared to a

partner in cancer of the larynx who did not receive voice rehabilitation (Liza , 2017). In addition,

there is a specific relationship between the possibilities, the quality of life and the patient's

prosperity (Bhuta, 2004). Rinkel and co-authors (2014) emphasized that among the population

suffering from laryngeal cancer, obvious problems with voice, correspondence (and swallowing)

after treatment for cancer of the larynx are high and, obviously, are associated with quality of life

and passionate problems. Subsequently, one would assume that patients who receive

rehabilitation for voice disorders after laryngeal cancer and have a positive impact on the use of
 Radiotherapy 6

HRQoL and functionality may also find positive benefits for their psychological well-being

(Rikke, 2017).
 Radiotherapy 7

CHAPTER TWO: METHODOLOGY

The literature systematic search was carried out using the electronic databases Cochrane,

Embase and Medline. The Mesh terms and Keywords(or equivalent imaginable words) include:

“head and neck cancer”, “Voice rehabilitation”, “radiotherapy “, “laryngeal cancer” and terms

that refer to speech and speech problems and their rehabilitation or evaluation. The studies

distributed from 1991 to 2018 were included. Search was limited to studies of adults (over 18

years of age) and was distributed in English.

One reviewer analyzed the summaries in which everything was the same, and the full

content of those that were considered applicable was restored. Each of the articles was checked

for possible additional research. Studies on speech and speech results after accompanying

radiotherapy and excluding patients until 1990 were considered important, and studies that

focused only on radiation therapy and a medical procedure were avoided. The study population

should include at least ten patients with squamous cell carcinoma and T2-4 tumors of the oral

opening, oropharynx, laryngopharynx, larynx and nasopharynx. Each of the selected ideas

should be based and distributed in the peer-reviewed journal and should contain entries on useful

topics related to speech or voice.

Inclusion criteria

Clinical studies distributed from 1991 to 2018, written in English, were included in this

audit. Different points of incision were people and adults (over 18). The studies were included in

the case where the study was conducted, they were distributed in peer-reviewed journal, and they

showed the use of simultaneous radiotherapy without another method of treatment of head and

neck cancer. Necessary studies were included to inform about useful problems or rehabilitation
 Radiotherapy 8

options associated with quality of life, trisism, nutrition, swallowing, or agony. In addition,

review or upcoming studies were included, in which previous and subsequent measurements

were announced.

Exclusion criteria

The articles with following data were excluded: practice or texts guidelines; studies that

detailed only the results identified with the medical procedure, only radiotherapy, or various

types of drugs used in treatment; studies showing cancers other than essential cancer in the oral

cavity, nasopharynx, oropharynx, larynx, or laryngopharynx; studies that only report results

identified with survival, toxic effects, or general ability (for example, depression). The purpose

of this audit was to provide detailed information on utilitarian results, and, in addition, options

for post-radiotherapy rehabilitation, thus, the subtleties identified with careful mediation, in

addition to the possible impact of neck dissection, were not considered.

 Radiotherapy 9

CHAPTER THREE: RESULTS

The research methodology yielded two hundred and thirty one results, and seventeen out

of thirty seven selected inaccurate articles to agree on the inclusion and exclusion criteria.

Finally, twenty studies were included. In the attached document, first, twenty (20) articles will be

reviewed by their review structure and assessment tools before they become part, as indicated by

their speech and voice result.

Study design and Patient characteristics

Gender, age, treatment, and injury site were taken into account in all studies. The criteria

for the unambiguous inclusion of the patient in a prospective conclusion, a constant history and

physical condition were absent or were reliably available only in nine out of twenty studies. Four

of the twenty articles provide information on the overall organization of the tumor, therefore,

without a clear order of the tumor (Ackerstaff , 2002).

When considering the possibility of replicating studies related to included patient

collections, many studies lacked data. Only information was collected on various patient signs

and was not isolated, for example, regarding the site of tumor / radiation, even in small studies

N. Patients with essential laryngeal cancer were included in sixteen studies, laryngopharyngeal

carcinoma at nine studies, oropharynx at five studies, patients with cancer of depression of the

oral cavity - in four studies, and patients with cancer of the nasopharynx in one research.

Of the twenty studies, eleven clearly indicated the period (range of years) of patient collection.

For nine articles, there was no or no data on the extent of the patient collection phase. Fifteen of

the twenty articles were upcoming studies, five were peer-reviewed (Ackerstaff , 2009). In eight
 Radiotherapy 10

of the fifteen planned studies, information was collected in organized approaches during post-

treatment.

Four of the following studies included standard and post-treatment evaluations, and all

information that was collected in organized data indicates that within 1 year after treatment. The

remaining sixteen studies reported results after treatment. Four of these sixteen were evaluated at

a clear point in time after treatment, and in twelve studies information on (significant) ranges

after treatment was summarized in the announced result (El Deiry, 2005). Five studies covered a

homogeneous treatment group for patients, although fifteen studies examined several patient

groups and treatment.

Instruments

To break or see the changes in voice and speech results that are shown in the letter, it is

important to think about the type of tools that were used. Within the twenty selected studies,

eighteen different tools were used to evaluate speech and speech after a CRT. Fourteen studies

reported voice results and ten in speech. Within these twenty studies, ten silent-mode

instruments, three clinical-based instruments and three recent production instruments were used.

Objective measures were used in 10 studies. There were extensive contrasts in the visuality and

accuracy of tools for assessing speech or speech problems.

Integrity of results

Each of the twenty studies reports their results using information retrieval methods. In

any case, especially in the case of instruments made independently, due to the lack of

unbreakable quality and legitimacy, as well as in instruments based on a clinician, reliability

 Radiotherapy 11

between patients and intraoral materials is not recorded regularly (Hanna , 2004). Only thirteen

studies had adequate data about the patient’s misfortune or information. Due to the lack of

information about the patient’s misfortune and information in upcoming studies of the quality of

the remainder of the meeting on which the outcome is based, it remains unclear about areas or

stages of the tumor. In the three studies, the number of participants in the audience or the number

of patient subgroups was calculated in a controversial manner over the entire content.

Of the twenty selected articles in three studies, speech, speech, or swallowing was

interpreted at their own patient collection, or referred to as something that should be considered

in future studies. As regards alternative research, it is unclear whether treatment with speech or

speech or swallowing techniques was part of the treatment convention or not. In some studies it

was mentioned that (dark numbers) patients underwent a tracheotomy or gastrostomy before or

in the middle of treatment (Meleca , 2003). In any case, none of the investigator in question can

influence the results and assessments of voice and speech, for example, incite changes in the

patient's perception or viability of voice, speech or devour. It is known that in addition to

selective nutrition, hydration affects voice quality and effort; however it has not been mentioned

in any of the important studies.

Speech and Voice outcome

Only two studies have made an assessment between the effect of the tumor and the

treatment on the voice, as well as the result of speech. Kazi et al. referred to the fact that tumors

of the larynx change the quality of the voice, because they prevent the passage of wind through

the glottis, they prevent the development of normal lines and they are united by a huge swelling.

The effects of treatment may be caused by radiation fibrosis or disintegration due to the
 Radiotherapy 12

imposition of voice and edema of the larynx and pharynx. Meleca et al. announced that vocal

overlap, neuromuscular insufficiency and paresis can be a side effect of the intrusive effects of

the tumor, while fibrosis, mucous membranes of the delicate laryngeal tissues and vocal overlap

cause atrophic changes as a result of treatment (LoTempio, 2005).

As mentioned above, sixteen out of twenty studies did not collect speech or speech

information prior to treatment, but they reported only the results of subsequent treatment (Meleca

, 2003). In twelve of these studies, the result depended on the accumulation of information

between several months and up to twelve years after treatment ( Knab , 2008). Overall, the

results were taken into account when little attention was paid to (extensive) contrasts in the dates

of collection of information after the treatment of patients, with the exception of the survey

conducted by Fung et al. Here information was included at least 8 months after treatment, an

average of 36.9 months. A critical ratio was found in the time elapsed since the treatment and the

VRQoL scores (Orlikoff , 1999).

Given the standard information that is missing and the time elapsed since treatment, it is

difficult to translate the results of studies that describe higher ranges after treatment. Thus, the

attached sections will focus only on the results of the studies, which included standard

information and assessed the voice and speech of their patients working on organized approaches

during post-treatment (Ackerstaff , 2009).

Pretreatment speech and voice status (effects of cancer)

Four studies included pre-treatment evaluations. In a study by Mittal et al. which

included laryngeal and non-laryngeal tumors, attention was focused on contrasts between two

treatments, one with or without tissue payment, and huge changes between previous results and 3
 Radiotherapy 13

months after treatment (Psyrri , 2004). In a speech, two out of twenty six patients whose

indicators exceeded 50 years, and at the age of fifty years - less than fifty points, made

preliminary estimates of performance indicators on the scale of the head and neck condition (PSS

H & N) months after treatment. As for the voice, eight patients in the previous treatment had no

or minor problems that changed to direct or serious problems 3 months after treatment (Head and

Neck Radiotherapy Questionnaire McMaster, HNRQ) (Boscolo-Rizzo, 2008). Speech and voice

evaluations of different patients prior to treatment were not detailed . In Kazi et al.,

Electroglography (EGG) showed that the estimates of nervousness before treating patients were

not basically the same as expected qualities. At the CRT-tolerant meeting (N = 14), moreover,

the “words in each moment” parameter preceding the treatment was completely lower than that

of normal subjects (N = 21). The collection of CRT knowledge included patients with cancer of

the larynx, larynx and laryngopharynx. In the study of Orlikoff et al., All of them, except for 2 of

12 patients, demonstrated irregular forms of EGG (Dietz , 2002). The most noticeable were

extended contact inconsistency, extended intermediate contact, and interruption of vocal overlap

separation. In addition, from the point of view of the functioning and state of the organs of

speech and speech, it should be noted that eight patients could not be damaged by stroboscopy,

since they did not support endoscopic examination (Samant , 1999). The level of dysphonia was

expressed in both the patient and the speech pathologist in accordance with the altered degree of

roughness, sweating, asthenia, voltage scale (GRBAS). Before treatment, it was found that seven

patients had moderate, and five patients had extreme dysphonia (Dietz , 2002).

In Ackerstaff et al., “Questionnaire of the European Organization for Research and

Treatment of Cancer Quality of Life: Head and Neck (EORTC H & N35)” of patients with CRT

(intra-arterial RTIs (IA) n = 60; intravenous CRT (IV) N = 66) Oral, laryngopharyngeal or
 Radiotherapy 14

oropharyngeal, or carcinoma cancers detected 18.4 / 18.3 marks for speech with a secondary

effect from 0 to 100 (Ackerstaff , 2002). Probably the “speech” here included two consultations

on speaking and requests for piracy and hooliganism, along with voice these lines are related to

things. While the creators focus was associated with changes after treatment, information about

the speech structure, which was assessed using an explicit survey, was not disclosed (Mittal ,

2001).

The reference patient status (N = 39) with cancer of the larynx, gold, nose, or

hypopharynx in Mittal et al. They were difficult to decipher, because of the information obtained

through the EGG and patient interviewing, it is usually believed that before treatment, voice and

speech were disconnected at that time, unlike typical control subjects (Worden , 2009 ).

Short-term posttreatment outcomes

One review, Ackerstaff et al. provided detailed information on the initial results, assessed

on the 7-week treatment period’s last day (Ackerstaff , 2009). The average size of speech

symptoms scale was 18.4 / 18.3, with symptoms ranging from 0 to 100 before treatment,

significantly increased to 45.3 for the “group of AI (N = 88)” and “33.7 (N = 95) for group of IV.

The voice quality, analyzed by methods for an explicit survey of the company for clarity, noise,

tone and familiarity, also deteriorated.

Four studies reported results, approximately several months after treatment, with a range

from 1 to 2 months for Orlikoff et al. moreover, Kazi et al. concentrated one year after the results

of treatment, but their ECG tables on jitter, and per minute the number of words shows

insignificant changes a few months after treatment, as compared to the values before treatment

(Kazi , 2008). The values before treatment were not the same as normal people. In Orlikoff et al.
 Radiotherapy 15

work, when linked with the normal controls, the phonation remained abnormal 1-2 months after

treatment, when it was tested, and phonation of normal controls. In any case, 9 out of 12 patients

indicated a “generous improvement” in voice quality (Orlikoff , 1999).

If compared with the previous treatment values of ECG, the contrast and previous

treatment, vocal safety from the point of view of jitter, was completely improved, as well as the

range of pitch and wind current measurements, the latter was demonstrated to improve the glottal

capacity and air in the board. The third study with information 1 month after treatment Newman

et al. the score is explained by the methods for proposing in the form of a joint Fisher-

Laugemann competency test (F-LTOAC) (correct / erroneous) in patients with AI compared to

IV with CRT (Newman , 2002). The result shows estimates in general terms for the level of

consonants, explained with an accuracy of 79.9% and 96.6%, with the most commonly known

poor estimates for alveolar fricative factors. The authors referred to the fact that the differences

were balanced for standard contrasts between groups. Therefore, the explanation information

before processing appeared to be available, but was not disclosed. The most unfortunate

consequences of the AI meeting were clarified by the way the meeting included those organised

in T levels, which were refined, progressively contained oral cancer and edentulous patients,

which was a CRT meeting. In the last study, five weeks after the end of treatment, the average

speech score improved and exceeded the levels before treatment. Thus, speech and voice lost

consciousness in the middle of treatment, and, given the three studies that compared results after

treatment and previous measures of treatment, speech and voice seem to improve one to two

months after treatment, exceeding previous treatment levels (Newman , 2002).

 Radiotherapy 16

One year posttreatment outcomes

One year after the start of treatment at patient meetings Ackerstaff et al. Speech score has

also improved. Eighty percent of patients announced a decent and sensitive voice at the same

time, due to the lack of sensitivity and dry mouth, only thirty three percent of their voices and

conversations were as they were before (Hutcheson, 2012). In a previous study, Ackerstaff et al.

1 year after the start of treatment, patients with a long term who did not undergo a medical

procedure, 61% explained a normal voice, twenty seven percent a fairly normal voice, andtwelve

pertcent explained a voice that was far from the previous one (Ackerstaff , 2009). No

information was available prior to treatment in this investigation.

In Kazi et al. in the main year after treatment, the vowel parameters HUE and associated

speech measurements indicated a dynamic improvement with respect to normal sizes. One year

after treatment, the speech frequency in the group of CRT was restored and was proportional to

that of normal control subjects (List, 2004). Be that as it may, although some (as a whole) evolve

towards the norm, some parameters of voice quality, for example, “circulation of laryngeal

relapses” (EGG share from the main relapse in Hz), remain. not normal. Thus, speech and speech

are thus improved in the second half of the year after treatment, although no normal assessment

of speech quality was obtained (Kazi , 2008).

Long-term posttreatment outcomes

Long-term results obtained 1 year after treatment are comprised in 9 studies. However, in

four of them, the results of the early and late evaluations were found in the mean, while the

information was evaluated from the early stage as 1 month after treatment. Three studies wrote

evaluations about a year after treatment. Although in two of these investigations, the end of the
 Radiotherapy 17

evaluation of information was confusing, the other two exams provided post-treatment

evaluation periods, apparently demarcated. Since there were no studies of effects on long

distances that included information on pretreatment, there were no reliable results from the

effects of treatment on long distances (Fung , 2005). However, the assessment of information

obtained as a result of these investigations began no less than 2 years after treatment, therefore,

in any case, the early effects of treatment were prohibited and, if insured, a more intense look at

the two exams with demarcated assessment periods may give some insight the end.

Consequences of treatment: In Boscolo-Rizzo et al. the effects of EORTC QLQ-H & N35, when

they met with 28 patients with cancer of the larynx or laryngopharynx, accumulated two to three

years after treatment (Boscolo-Rizzo, 2008). As a result of the survey, an average speech score

of 0.0 was found with a range from 0 to 78, which thus showed most of the fact that speech was

not weakened, presumably with a couple of anomalies with real speech problems. Since EORTC

QLQ-H & N35 includes only one thing in voice, probably as a whole, voice quality was also not

surprisingly abnormal for most patients. In the second study, Psyrri et al. Personal satisfaction

information (PSS H & N) was available 7-11 years after treatment (Psyrri , 2004). The authors

revealed a constant noise in 2 of 18 patients, while 3 patients reported that their voice quality

improved. Since PSS H & N has a question about speech and nothing in the voice, the place of

birth of the voice remains unclear.

In long-term evaluations, the effect of treatment appears to have diminished. Speech and

voice quality seems to be higher than short-term information. Be that as it may, there still seem

to be cases of severe speech and speech disorders. In the record of missing counter data, these

results over a long distance must be deciphered with a warning (LoTempi, 2005).
 Radiotherapy 18

Further dimensional assessment

In more than single dimension four investigations assessed their data. All focused on

voice results. In Carrara-de Angelis study, acoustic assessments were related to the perceived

level of dysphonia accepted by clinicians (Carrara-de Angelis, 2003). Conversely, Woodson

study suggested that acoustic measurements do not really reflect the way patients look at

correspondence in everyday life (Woodson , 1996). The decisions of their patients about vocal

function, again, correlated with the observation of clinicians. This again is inconsistent with the

findings in Meleca study legally looked at the result of three dimensions (Meleca , 2003). While

members of the main audience coincided with the results of acoustic and optimized ratings, the

solutions for understanding disappeared. Regarding the increasingly sizeable assessment,

Orlikoff et al. in their conversation, they stressed that there is a mismatch between acoustic

information based on data from a clinician and information that is silent (Orlikoff , 1999).

Although emotional information at a great distance seems to indicate that the voice has

improved, the assessments made by the doctors show constant gain. There were no tests that

tended to progressive dimensional assessment of speech functioning.

 Radiotherapy 19

CHAPTER FOUR: DISCUSSIONS

The purpose of this revision was to identify the effect of the tumor and the

chemoradiation effect on the voice and, moreover, speech in patients with advanced head and

neck cancer. A search in the literature that was completed for this survey revealed only a couple

of concentrates of this voice, deliberately or potentially speaking. This shows that voice and

speech results were an optional enthusiasm for the previous conventions on the protection of

organs, recommending that after preserving organs, the protection of impeccable ability was

underestimated. It seems that only in the very last decade, clinicians realized that the protection

of organs and abilities is not really a synonym (Samant , 1999).

Most studies among the retrieved hits, focused on overall survival or adverse effects,

most often not in contrast to the protection of organs and careful treatment. It was believed that it

was not actually intended to focus on discoveries or variations within a homogeneous meeting of

patients with CRT, and regular meetings of patients included patients who also underwent a

medical procedure (List, 2004). Of the 20 studies included, 14 wrote about the voice and 10

about the speech - a significant clarification, which is also done only here and there. Patients

with CRT had a lower score for speech and speech evaluation than normal larynx loudspeakers,

but better than patients who received cautious treatment. When all is said, the propensity of CRT

in relation to a medical procedure in combination with radiation therapy in this regard is

confirmed by all the data, despite the fact that there were extremely negative effects (LoTempi,

2005). In general, tests showed that voice and speech deteriorated in the middle of a CRT

treatment and improved again 1-2 months after treatment, exceeding previous treatment levels 1

year or more. In any case, speech and speech measurements did not indicate normal qualities,

either before or after treatment (Tuomi, 2014).

 Radiotherapy 20

It is expected that more information and concentrates, which will be gradually accurate

and will include assessments before treatment, will allow us to evaluate the quality of voice and

speech after long-term treatment. Considering the unexplained remains, entangled follow-up

meetings, the lack of reliability and legitimacy of the devices, internal and external monitoring is

not carried out, there are no counter measurements, there are a number of different and modest

patients, the time of dark collection and the lack of consistency between investigations and

results were not reliable. Along with this, the potential for replication was meager (Parkin, 2005).

Just one study reviewed in this review had a pronounced effect between tumors due to

depression of the oral cavity and laryngeal tumors and pharyngeal region (Knab , 2008). The

combined side effects in patients with non-laryngeal cancer and laryngeal cancer (and the lack of

data on irradiation of lymphatic centers) make it possible to understand changes in speech and

speech caused by cancer and treatment with various CRTs. problematic. Only two exams

allowed to clarify the effect of the tumor and treatment (van der Molen, 2012).

In laryngeal cancer, it can be expected that the tumor should prevent the development of

vocal overlap, causing a deterioration in voice quality. It can be expected that in cancer without a

larynx, the tumor should have a negative effect on verbalization and, consequently, speech.

When reducing the tumor, speech and speech caused by treatment, they should be improved

individually, and long-term negative effects will be explained by congenital anatomical changes

(eg, scars), radiation edema and fibrosis (Mittal , 2001). One of the objectives of this study was

to deliberately assess and identify these effects of the tumor and its treatment with CCRT in

voice and speech. Be that as it may, due to contradictory data in studies, for example, the area of

a tumor, this point cannot be met.

 Radiotherapy 21

Some elements were not mentioned, for example, the effect of speech, swallowing,

tracheotomy, gastrostomy or radiation therapy on the salivary glands or lymphatic centers. In

addition, not only was there a wide range of observation periods, in some studies the

measurement of the subsequent time began from the beginning of treatment, although in various

studies the measurement began from the end of treatment, which makes differentiation more

cumbersome (Worden , 2009 ).

There were 18 different assessment tools, and most of these tools are personal satisfaction

measures that analyze speech and speech results quite outwardly. In particular, approved and

institutionalized surveys are “ineffectively prepared” with elements of speech and speech, which

emphasizes the importance of (additionally) the use of explicit reference / research surveys .

Similarly, when all is said, the phrases and evaluation of speech and speech problems are not

completely isolated. This review emphasizes that the 18 tools used not only demonstrated a wide

variety (acoustic / EGG evaluations and patient examinations, as well as clinical consultations),

but also some of these devices were not institutionalized, and their quality was consistently

stable. and legitimacy has not been declared (LoTempi, 2005).

Virtually all studies combine their results with information from a single survey; The

most supported method of assessment was the patient survey (Knab , 2008). Given the pre-

determined number of patients, this is apparently the “easiest” method for assessing the quality

of speech and speech, since neither the doctor nor the team should be included. Despite the fact

that these surveys provide a relevant picture of the patient’s apparent personal satisfaction, they

do not actually reflect the patient’s actual physical condition, organ function, or the judgment of

the physician (El Deiry, 2005). There are no concentrates that analyze the result of the voice and,

in particular, the speech in several evaluative dimensions in order to check the degree or
 Radiotherapy 22

practicality of each measurement of emotional evaluation or purpose and its clinical sign (El

Deiry, 2005).
 Radiotherapy 23

CHAPTER FIVE: CONCLUSION

This review showed that the requirement of an increasingly dimensional assessment of

the functioning of organs was almost never mentioned, despite the fact that it is obvious that

multidimensional evaluation is mandatory.

The proposed standards are available for the voice test, for example, Dejonckere, Meleca,

Leeuw, and Verdonck studies agreed with the recommendation of a multidimensional summary

and research goals. Recommendations for speech assessment conventions for cancer patients are

not yet available, but they are absolutely necessary, since articulation disorders clearly associated

with a tumor or treatment strongly influence speech intelligibility. In general, clinical tools and

additional insights are used to examine the patient's clarity and articulation abilities. Be that as it

may, human recognition reliably conveys the abstract, and clinical examination with the

participation of various members of the audience is quite expensive and impossible in a clinical

setting. As a result, almost identical to the multidimensional conventions proposed for voice

testing, a comparable speech research tool should include something like a patient survey on

speech and clarity, along with acoustic studies and, for example, F-LTOAC. In the future, if they

are prevalent in terms of duplicating the behavior of a regular agent audience or a clinician, the

planned speech coherence studies, which are less exorbitant in time, may help. this respect.

The study mentioned in this deliberate review provides insight into the effects of cancer

and CRT on speech and speech in patients with advanced head and neck cancer. Thinking about

the progression of speech and speech quality after treatment requires more and more precise and

ideally inevitable research, including caliber estimates and an institutionalized evaluation

agreement covering all relevant utilitarian parts of voice and speech.

 Radiotherapy 24

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 Radiotherapy 25

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outcomes of chemoradiation for advanced head and neck cancer: a systematic review.

Eur Arch Otorhinolaryngol; 267:1495–1505.

Jacobi I, van der Molen L, Huiskens H, van Rossum MA, Hilgers FJ. (2010)Voice and speech

outcomes of chemoradiation for advanced head and neck cancer: A systematic review.

Eur Arch Otorhinolaryngol ;267:1495–505.

Johns MM, Kolachala V, Berg E, Muller S, Creighton FX, Branski RC. (2012), Radiation

fibrosis of the vocal fold: From man to mouse. Laryngoscope;122:SS107–SS125.

Krengli M, Policarpo M, Manfredda I, et al. (2004), Voice quality after treatment for T1a glottic

carcinoma radiotherapy versus laser cordectomy. Acta Oncol;43:284–289

List, M. A., & Bilir, S. P. (2004, April). Functional outcomes in head and neck cancer.

In Seminars in radiation oncology (Vol. 14, No. 2, pp. 178-189). WB Saunders.

Liza Bergström, Elizabeth C Ward and Caterina Finizia, (2017), Voice rehabilitation after

laryngeal cancer: Associated effects on psychological well-being, Supportive Care in

Cancer, 10.1007/s00520-017-3676-x, 25, 9, (2683-2690).

Metcalfe CW, Lowe D, Rogers SN. (2014), What patients consider important: Temporal

variations by early and late stage oral, oropharyngeal and laryngeal subsites. J

Craniomaxillofac Surg;42:641–7.

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55:74–108

Rikke Daugaard, Trille Kjaer, Christoffer Johansen, Jane Christiansen, Elo Andersen, Anni L.

Nielsen and Susanne O. Dalton, (2017), Association between late effects assessed by
 Radiotherapy 26

physicians and quality of life reported by head-and-neck cancer survivors, Acta

Oncologica, 56, 2, (342).

Rinkel RN, Verdonck-de Leeuw IM, van den Brakel N, de Bree R, Eerenstein SE, Aaronson N,

et al. (2014), Patient-reported symptom questionnaires in laryngeal cancer: Voice, speech

and swallowing. Oral Oncol ;50:759–64.

Sjogren EV, van Rossum MA, Langeveld TM, et al. (2008), Voice outcome in t1a midcord

glottic carcinoma: laser surgery vs radiotherapy. Arch Otolaryngol Head Neck

Surg;134:965–972

Starmer HM, Tippett DC, Webster KT. (2008), Effects of laryngeal cancer on voice and

swallowing. Otolaryngol Clin North Am;41:793–818.

Tuomi, L., (2014). Voice Rehabilitation and Functional Outcomes Following Radiotherapy for

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Hilgers, F. J. (2012). Pre-and posttreatment voice and speech outcomes in patients with

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 Radiotherapy 27

Articles Reviewed

Ackerstaff AH, Tan IB, Rasch CR, Balm AJ, Keus RB, Schornagel JH, Hilgers FJ (2002)

Quality-of-life assessment after supradose selective intra-arterial cisplatin and

concomitant radiation (RADPLAT) for inoperable stage IV head and neck squamous cell

carcinoma. Arch Otolaryngol Head Neck Surg 128:1185–1190

Ackerstaff AH, Balm AJ, Rasch CR, de Boer JP, Wiggenraad R, Rietveld DH, Gregor RT,

Kroger R, Hilgers FJ (2009) First-year quality of life assessment of an intra-arterial

(RADPLAT) versus intravenous chemoradiation phase III trial. Head Neck 31:77–84

Boscolo-Rizzo P, Maronato F, Marchiori C, Gava A, Da Mosto MC (2008) Long-term quality of

life after total laryngectomy and postoperative radiotherapy versus concurrent

chemoradiotherapy for laryngeal preservation. Laryngoscope 118:300–306

Carrara-de Angelis E, Feher O, Barros AP, Nishimoto IN, Kowalski LP (2003) Voice and

swallowing in patients enrolled in a larynx preservation trial. Arch Otolaryngol Head

Neck Surg 129:733–738

Dietz A, Nollert J, Eckel H, Volling P, Schroder M, Staar S, Conradt C, Helmke B, Dollner R,

Muller RP, Wannenmacher M, Weidauer H, Rudat V (2002) Organ preservation in

advanced laryngeal and hypopharyngeal carcinoma by primary radiochemotherapy.

Results of a multicenter phase II study. HNO 50:146–154

Dubois MD, Crevier-Buchman L, Martin C, Prades JM (2006) Epidermoid carcinoma of

piriform sinus after chemo-radiotherapy: acoustic evaluation and voice handicap. Rev

Laryngol Otol Rhinol (Bord) 127:299–304

El Deiry M, Funk GF, Nalwa S, Karnell LH, Smith RB, Buatti JM, Hoffman HT, Clamon GH,

Graham SM, Trask DK, Dornfeld KJ, Yao M (2005) Long-term quality of life for
 Radiotherapy 28

surgical and nonsurgical treatment of head and neck cancer. Arch Otolaryngol Head

Neck Surg 131:879–885

Fung K, Lyden TH, Lee J, Urba SG, Worden F, Eisbruch A, Tsien C, Bradford CR, Chepeha

DB, Hogikyan ND, Prince ME, Teknos TN, Wolf GT (2005) Voice and swallowing

outcomes of an organ-preservation trial for advanced laryngeal cancer. Int J Radiat Oncol

Biol Phys 63:1395–1399

Hanna E, Sherman A, Cash D, Adams D, Vural E, Fan CY, Suen JY (2004) Quality of life for

patients following total laryngectomy vs chemoradiation for laryngeal preservation. Arch

Otolaryngol Head Neck Surg 130:875–879

Kazi R, Venkitaraman R, Johnson C, Prasad V, Clarke P, Rhys-Evans P, Nutting CM,

Harrington KJ (2008) Electroglottographic comparison of voice outcomes in patients

with advanced laryngopharyngeal cancer treated by chemoradiotherapy or total

laryngectomy. Int J Radiat Oncol Biol Phys 70:344–352

Knab BR, Salama JK, Solanki A, Stenson KM, Cohen EE, Witt ME, Haraf DJ, Vokes EE (2008)

Functional organ preservation with definitive chemoradiotherapy for T4 laryngeal

squamous cell carcinoma. Ann Oncol 19:1650–1654

LoTempio MM, Wang KH, Sadeghi A, Delacure MD, Juillard GF, Wang MB (2005)

Comparison of quality of life outcomes in laryngeal cancer patients following

chemoradiation vs. total laryngectomy. Otolaryngol Head Neck Surg 132:948–953

Meleca RJ, Dworkin JP, Kewson DT, Stachler RJ, Hill SL (2003) Functional outcomes

following nonsurgical treatment for advanced-stage laryngeal carcinoma. Laryngoscope

113:720–728
 Radiotherapy 29

Mittal BB, Kepka A, Mahadevan A, Kies M, Pelzer H, List MA, Rademaker A, Logemann J

(2001) Tissue/dose compensation to reduce toxicity from combined radiation and

chemotherapy for advanced head and neck cancers. Int J Cancer 96 Suppl:61–70

Newman LA, Robbins KT, Logemann JA, Rademaker AW, Lazarus CL, Hamner A, Tusant S,

Huang CF (2002) Swallowing and speech ability after treatment for head and neck cancer

with targeted intraarterial versus intravenous chemoradiation. Head Neck 24:68–77

Psyrri A, Kwong M, DiStasio S, Lekakis L, Kassar M, Sasaki C, Wilson LD, Haffty BG, Son

YH, Ross DA, Weinberger PM, Chung GG, Zelterman D, Burtness BA, Cooper DL

(2004) Cisplatin, fluorouracil, and leucovorin induction chemotherapy followed by

concurrent cisplatin chemoradiotherapy for organ preservation and cure in patients with

advanced head and neck cancer: long-term follow-up. J Clin Oncol 22:3061–3069

Orlikoff RF, Kraus DH, Budnick AS, Pfister DG, Zelefsky MJ (1999) Vocal function following

successful chemoradiation treatment for advanced laryngeal cancer: preliminary results.

Phonoscope 2:67–77

Samant S, Kumar P, Wan J, Hanchett C, Vieira F, Murry T, Wong FS, Robbins KT (1999)

Concomitant radiation therapy and targeted cisplatin chemotherapy for the treatment of

advanced pyriform sinus carcinoma: disease control and preservation of organ function.

Head Neck 21:595–601

Woodson GE, Rosen CA, Murry T, Madasu R, Wong F, Hengesteg A, Robbins KT (1996)

Assessing vocal function after chemoradiation for advanced laryngeal carcinoma. Arch

Otolaryngol Head Neck Surg 122:858–864

Worden FP, Moyer J, Lee JS, Taylor JM, Urba SG, Eisbruch A, Teknos TN, Chepeha DB,

Prince ME, Hogikyan N, Lassig AA, Emerick K, Mukherji S, Hadjiski L, Tsien CI,
 Radiotherapy 30

Miller TH, Wallace NE, Mason HL, Bradford CR, Wolf GT (2009) Chemoselection as a

strategy for organ preservation in patients with T4 laryngeal squamous cell carcinoma

with cartilage invasion. Laryngoscope 119:1510–1517

 Radiotherapy 31

Appendix 1: Overview of study designs, accrual periods, patient numbers, tumour stages and

sites, treatments and assessment tools of the 20 selected studies

Referen Study Tot CR N CRT + Tumour site Treatment/t Evaluation tool

ces design, al T relevant ype of issue

Evaluati accrual N N outcome

on tool period, T

stage

Ackerst Prospectiv 50 50 Voice, 26 Oropharynx, RADPLAT FACT H&N UW

aff et al. e period oral cavity, , QoL HN QoL

unknown hypopharyn aspects

TIII–IV x, trans-,

supraglottic,

piriformis

sinus

Ackerst Prospectiv 236 207 Voice/spee Oral cavity, IA CRT EORTC QLQ-

aff et al. e 1999– ch, 126 oropharynx, versus IV H&N35 TSQ

2004 hypopharyn CRT

TIII–IV x

Boscolo Retrospect 72 28 Speech, 28 Hypolaryng CRT versus EORTC QLQ-

-Rizzo ive 2001– (67) eal– surgery ± H&N35

et al. 2004 TII– pharyngeal RT

IV larynx
 Radiotherapy 32

Carrara- Prospectiv 43 15 Voice, 15 Pyriform CRT versus Vowel/a/:CRP

de e 1999– (19) sinus, reference (GRBAS) by 2/3

Angelis 2001 TII– transglottic, values trained listeners,

et al. IV supraglottic, acoustics

glottic

Dietz et Prospectiv 30 30 Voice, 28 Hypopharyn Accelerated LENT-SOMA 5-

al. e 1997– x, glottic, CRT— p-scale

2000 TII– supraglottic organ

IV preservatio

Dubois Prospectiv 22 10 Voice, Pyriform CRT vs VHI, GRBAS 3

et al. e period 10/12 sinus normal listeners,

unknown acoustics,

TII–III vowel/a/

El Deiry Retrospect 54 27 Speech, 27 Oropharynx, CRT versus HNCI

et al. ive 1991– hypopharyn surgery ±

2002 TI– x, larynx RT

IV (stages

3–4)

Fung et Prospectiv 56 37 Voice, 37 Larynx CRT vs PSS HN VRQoL

al. e period (97) speech, 27 surgery ±

 Radiotherapy 33

unknown RT

TII–IV

Hanna Retrospect 42 19 Speech, 15 Larynx, CRT vs TL EORTC QLQ-

et al. ive period hypopharyn + pRT H&N35

unknown x

T?(stages

3–4)

Kazi et Prospectiv 42 15 Voice, 14 Hypopharyn Induction Sustained

al. e period x, larynx CT + RT vs vowel/i/,

unknown supraglottic TLE ± RT connected speech

T?(stages vs normals EGG, acoustic

3–4) analysis

Knab et Retrospect 32 20 Voice, 20 Supraglottic CRT, 3 Voice quality

al. ive 1996– , glottic treatment scored by single

2002 regimen radiation

TI0056 oncologist/otolary

ngo–logist,

poorest score if

differing

Lo Prospectiv 49 15 Speech, 15 Larynx CRT versus UW HN QoL

Tempio e period TLE + RT

et al. unknown

T? (stages
 Radiotherapy 34

2–4)

Meleca Retrospect 14 12 Voice, 14 Larynx CRT VHI, acoustics,

et al. ive 1997– aerodynamics 5-

2000 TII– point scale by 3

IV clinicians,

stroboscopy 5-

point scale

Mittal et Prospectiv 39 39 Voice/spee Oropharynx, CRT; FACT H&N, PSS

al. e period ch, 26 nasopharyn tissue/dose H&N, McMaster

unknown x, compensati RQ, F-LTOAC,

T?(stages hypopharyn on versus conversational

3–4) x, larynx no speech recordings

compensati

on

Newma Prospectiv 30 30 Speech, 20 Oral RADPLAT F-LTOAC

n et e pharyngeal versus CRT (correct/incorrect)

unknown larynx

period

TII–IV

Orlikoff Prospectiv 12 12 Voice, 12 Supraglottic CRT versus Acoustics,

et al. e TII–IV vocal fold control aerodynamics,

1994– EGG,

1996 stroboscopy, G
 Radiotherapy 35

from GRBAS

(clinician and

patient)

Psyrri et Prospectiv 48 18 Voice, 15 Nasopharyn CRT versus PSS H&N

al. e, 1992– x induct C

1996 TI–

IV (stage

3–4)

Samant Prospectiv 25 25 Speech/voi Piriform RADPLAT Self-designed 3-

et al. e 1993– ce, 24 sinus point outcome

1995 TII– scale

IV

Woodso Prospectiv 16 16 Voice, 15 Oropharynx, RADPLAT Overall voice

oral cavity,
n et al. e period pharynx, vs controls; quality (mean of
hypopharyn
unknown x, piriform laryngeal 5–7-point scales),
sinus,
TIII–IV glottic versus non- patient interview,
supraglottic
laryngeal acoustics,

aerodynamics

Worden Prospectiv 36 27 Speech, 11 Hypopharyn IC + CRT PSS H&N,

et al. e period x, glottic, for Understandability

unknown supraglottic, responders of speech

TIV