A comparison of voice quality following radiotherapy or transoral laser microsurgery of T1a laryngeal carcinomas

Introduction: Patients with laryngeal carcinoma often present early due to the change in their voice. The treatment for T1aN0M0 carcinoma varies throughout the world, but whether radiotherapy (RT) or endolaryngeal laser excision is performed both result in excellent local control of the tumour and five year survival rates. There are advantages and disadvantages of either treatment but there are no appropriately powered randomised controlled trials comparing them. Over recent decades external beam RT has become the more popular choice and this is partly due to a perception of poor voice outcomes from surgical excision. However with the development of technology allowing surgical precision, transoral laser microsurgery (TLM) has resulted in low morbidity and good voice outcomes. Objective: This research has three main objectives: a. To describe acoustic parameters of ‘normal’ voice; b. To compare voice outcomes in patients treated with TLM with those treated with radiotherapy for T1a SCC of the glottis; c. To investigate longitudinal changes in voice quality in patients undergoing TLM for T1a SCC of the glottis. Methods: The research was divided into three main parts. The first part was to analyse the acoustic parameters of ‘normal’ voice. To describe the parameters of ‘normal’ voice, adults with no history of voice disorders who scored zero on the voice questionnaire (Voice Handicap Index - 10) were included. The second part comprised a comparative cohort study of 40 patients with T1aN0M0 laryngeal carcinoma, treated with either TLM (20 patients) or RT (20 patients) to compare voice outcomes at least one year following treatment. The third part involved a prospective cohort study of 30 patients with T1aN0M0 laryngeal carcinomas who were treated with TLM, comparing voice qualities before and after treatment. All patients were recruited from those attending the regional Head and Neck centre in Aintree University Hospital. The same methodology was adopted for voice recordings for all three parts of the study. Participants were asked to read a phonetically balanced passage and produce a prolonged vowel sound. In a sound proof room the voice recording included simultaneous audio and electrolaryngograph readings. The voice recordings were scored according to the GRBAS voice scale by an experienced rater. Acoustic analysis was performed form the electrolaryngograph recording using the SpeechStudioTM software. Several objective acoustic parameters were calculated from both sustained vowels and connected speech. These include: fundamental frequency (Fx), jitter, shimmer, harmonics to noise ratio (HNR) and normalized noise energy (NNE). In the comparative study of TLM versus RT and the prospective TLM study, patients were asked to complete voice-specific and quality of life questionnaires. The voice-specific questionnaires were the Voice Symptom Scale (VoiSS) and the Voice Handicap Index-10 (VHI-10). The quality of life questionnaire adopted was the University of Washington Quality of Life (UWQoL) version 4. Results: In the acoustic analysis of sustained vowels in normal speech, females have a statistically significantly higher Fx than males (adjusted p=<0.05). There is no other statistically significant difference across the domains for sustained vowels in normal speech. In the analysis of connected speech, Fx is again higher in females (p<0.001). There is no statistically significant difference in amplitude (Ax) or contact quotient (Qx). In the comparison of voice post TLM and RT, there is no statistical difference in voice-specific questionnaires between the groups. The UW-QoL4 found a statistically significantly higher QoL score in the TLM compared with the RT group for appearance (p=0.003), recreation (p=0.048), chewing (p=0.015) and saliva (p=0.016), however these are not statistically significant when adjusted for age. Overall for QoL, the RT group have a statistically significantly lower median score compared to TLM in physical function (p=0.004) and this remains statistically significant when adjusted for age (p=0.036). There is no statistically significant difference for social function (p=0.441). There is no statistically significant difference in perceptual rating (GRBAS score) between RT and TLM groups (total mean 5.49 vs. 5.12, p=0.254). Most domains as part of the acoustic analysis of sustained vowels show no statistically significant difference between RT and TLM. The mean Fx analysis on connective speech is statistically significantly higher in the TLM group (161.2Hz vs. 131.1Hz, adjusted p=0.001). Coherence of frequency is statistically significantly higher in the TLM group (48.6% vs. 36.0%, adjusted p=0.027) and pitch irregularity is statistically significantly higher in the RT group (26.7% vs. 14.9%, adjusted p=0.013). There is no statistically significant difference in mean amplitude between the two groups. Coherence of amplitude is statistically significantly higher in the TLM group (adjusted p=0.006) and amplitude irregularity is statistically significantly higher in the RT group, (12.4% vs. 6.3%, adjusted p=0.005). There is no statistically significant difference in mean contact quotient (p=0.368), coherence (p=0.236) or irregularity (p=0.125) when comparing TLM and RT. In the comparison of voice pre and post TLM, there is no statistical difference in voice-specific questionnaires between the groups. There is no statistically significant difference in the UW-QOLv4 domain scores or composite scores in patients pre- and post- TLM. There was no statistically significant difference in mean score for ‘G’,’R’,’B’ and ‘S’ indicators as part of perceptual rating between pre and post TLM patients, although asthenia was statistically significantly lower post-TLM (0.97 vs. 0.94, adjusted p=0.015). There is no statistically significant difference in any of the domains in the acoustic analysis of sustained vowels pre and post TLM. In the acoustic analysis of connected speech, the mean DFx is statistically significantly higher in the post TLM group (adjusted p=0.001). There is no statistically significant difference in the coherence of frequency or pitch irregularity when comparing pre and post TLM. There is no statistically significant difference in the mean DAx (p=0.121), coherence (p=0.472) or irregularity of amplitude (p=0.184) when comparing pre and post TLM. There is no statistically significant difference in the mean DQx (adjusted p=0.904), coherence (adjusted p=0.293) or irregularity of the contact quotient (adjusted p=0.400) when comparing pre and post TLM. Conclusion: The treatment of T1a laryngeal carcinoma with either TLM or RT has been shown to have comparably good local control. There are advantages and disadvantages of both treatments, however TLM is often preferred by patient and clinician as it is a day case procedure, can provide histological clearance and leaves the option to use RT in the future. However voice outcomes of the procedures have been debated with various reports in the literature. There are challenges when comparing the two treatment modalities due to a number of tumour, patient and surgical factors. It is not surprising that the voice is affected by whatever treatment is performed to treat the glottic carcinoma. This study shows that voice quality is good, however it is measured, for after both TLM and RT

A Review of Hearing Loss in Cleft Palate Patients

Background. Cleft palate is associated with recurrent otitis media with effusion and hearing loss. This study analysed the way these patients' hearing is managed in Alder Hey Children's Hospital. Method. A retrospective audit was carried out on cleft palate patients in Alder Hey Children's Hospital. Audiology assessment and treatment options were reviewed. Comparisons were made between the use of ventilation tubes (VTs) and hearing aids (HAs). The types of cleft, types of hearing loss, and the management output of the audiology regions were also reviewed. Results. The audiology assessments of 254 patients were examined. The incidence of VT insertion in this group of patients was 18.9%. The hearing aid incidence rate was 10.1%. The VT-related complication rate was 25.5% and the HA related complication rate was 9.1%. Conclusion. The data demonstrates that both treatments are viable, and a new protocol which combines the short term benefit of VT insertion with the lower complication rate of HA is required

Evaluating The Usability And Accessibility Of LMS “Blackboard” At King Saud University

King Saud University is in the process of adopting and implementing the interactive Blackboard Learning Management Systems (LMSs) with features that allow members of staff and teachers from different faculties to access, upload assignments, send quizzes, download content, and evaluate the academic progress of the members of faculty. However, many faculty members complain about the accessibility and usability of the e-learning software because of the perceptions that the interactive features are not user friendly. Little research has been done to evaluate the accessibility and usability of the e-learning software. The current study was conducted to answer the research questions on the accessibility and usability of the blackboard vista e-learning software and the barriers of user experience when interacting with blackboard. The study was based on the hypothesis that Blackboard LMS is highly accessible and usable by teachers in the King Saud University and a hypothesis that stated otherwise. The elements that were evaluated using questionnaires include the design user interface, navigational features, and ease of use to answer the research questions. The results proved the hypothesis that ‘Blackboard LMS is accessible and usable by the teachers from different faculties for the delivery of content in the King Saud University. However, the study recommends that university should customize the e-learning software to the needs of the teachers to offer courses in English and in Arabic to increase and enhance the accessibility and usability of the software.

Dietary analysis and nutritional behaviour in people with and without age-related macular disease

Background and Aims: Consumption of antioxidant nutrients can reduce the risk of progression of age-related macular degeneration (AMD) - the leading cause of visual impairment in adults over the age of 50 years in the UK. Lutein and zeaxanthin (L&Z) are of particular interest because they are selectively absorbed by the central retina. The objectives of this study were to analyse the dietary intake of a group of AMD patients, assess their ability to prepare and cook healthy food, and to make comparisons with people not affected by AMD. Methods: 158 participants with AMD were recruited via the UK charity The Macular Society, and fifty participants without AMD were recruited from optometric practice. A telephone interview was conducted by trained workers where participants completed a 24 hour food diary, and answered questions about cooking and shopping capabilities. Results: In the AMD group, the average L&Z intake was low in for both males and females. Those able to cook a hot meal consumed significantly more L&Z than those who were not able. Most participants were not consuming the recommended dietary allowance of fibre, calcium, vitamin D and E, and calorific intake was also lower than recommendations for their age-group. The non-AMD group consumed more kilocalories and more nutrients than the AMD group, but the L&Z intake was similar to those with AMD. The main factor that influenced participant’s food choices was personal preference. Conclusion: For an ‘informed’ population, many AMD participants were under-consuming nutrients considered to be useful for their condition. Participants without AMD were more likely to reach recommended daily allowance values for energy and a range of nutrients. It is therefore essential to design more effective dietary education and dissemination methods for people with, and at risk of, AMD

Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews

Background Current NHS policy favours the expansion of diagnostic testing services in community and primary care settings. Objectives Our objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community. Review methods We performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion. Results We identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed. Conclusions In the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control. Limitations We have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers. Future work There is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area. Funding The National Institute for Health Research Health Services and Delivery Research programme