Clinical research

Voice evaluation following endoscopic laser

CO2 cordectomy and conventional cordectomy

Magdalena Lachowska, Ewa Osuch-Wójcikiewicz, Antoni Bruzgielewicz

Department of Otolaryngology, Medical University of Warsaw, Poland Corresponding author:

Magdalena Lachowska MD, PhD
Submitted: 4 October 2009 Department of Otolaryngology
Accepted: 28 October 2009 Medical University
of Warsaw
Arch Med Sci 2011; 7, 1: 143-153 Banacha 1a
DOI: 10.5114/aoms.2011.20621 02-097 Warsaw, Poland
Copyright © 2010 Termedia & Banach Phone: +48 22 599 25 21
Fax: +48 22 599 25 23
E-mail: magdalena.lachowska@
Abstract wum.edu.pl

Introduction: An analysis of long term voice quality outcomes of two different

types of surgical intervention for Tis and T1 glottic carcinoma: laryngofissure
conventional cordectomy and endoscopic laser CO2 cordectomy, with or without
additional radiation therapy.
Material and methods: Total of 46 patients with Tis and T1 glottic carcinoma
served as subjects. All have been treated surgically with laryngofissure
conventional cordectomy (32.61%) or endoscopic laser CO2 cordectomy (67.39%).
The surgeries were performed in the Department of Otolaryngology at the
Medical University of Warsaw (1990-2004). The presented voice assessments
were made at least 3 years following the surgery, in between January 2006 and
February 2007.
Results: In patients after the endoscopic laser CO2 cordectomy the following
findings are more often observed: the unrestrained voice production, wider range
of Fo in a spoken sentence, longer maximum phonation time, better intensity
of phonation for normal and loud speaking, lower degree of hoarseness based
on the Yanagihara’s classification, and the lower VHI. No significant influence
of the performed additional radiotherapy on voice parameters was found.
Conclusions: Patients after endoscopic laser CO 2 cordectomy, compared to
laryngofissure conventional cordectomy, present better voice quality. The amount
of the excised vocal fold tissue, which in our study was slightly larger in case
of the conventional cordectomy, could account for the results mentioned above.
This may also be explained by the necessity of the anterior thyrotomy, which is
required for conventional cordectomy via external approach, and often results
in anterior synechia and level difference between the neocord and the
contralateral vocal fold.

Key words: glottic carcinoma, voice quality, spectrography, acoustic analysis of

voice.

Introduction
A surgical intervention on the vocal folds may lead to their structural
changes mainly due to damaged mucous membrane, whose thickness,
mass, stiffness and elasticity play the main role in voice production. Post-
surgical changes of the vocal folds’ structure may lead to dysphonia [1].
The term dysphonia is used to define multiform voice disorders, affecting
all acoustic components such as frequency, intensity, timbre and phonation
time, exclusively or in groups. Hoarseness may be one of the elements of
dysphonia [2, 3].
Magdalena Lachowska, Ewa Osuch-Wójcikiewicz, Antoni Bruzgielewicz

Endoscopic laser cordectomy and laryngofissure was inaccessible due to equipment failure. The
conventional cordectomy are surgical methods study presents the voice quality outcomes following
applied to the treatment for Tis and T1N0M0 glottic the operations that were made in the past; this fact
carcinoma. The goal of those two types of surgery limits the possibility of randomization. However,
is to achieve the best possible functional outcome the coordination of the patients with the two
including voice quality, while not compromising groups (laser cordectomy or conventional cordec-
oncological principles. The oncological goal is always tomy) depended on access to the laser. That made
the most important in the case of cancer [4-7]. the patient allocation to the two groups in a way
In 1982 in the Department of Otolaryngology at random and gave us the possibility to compare the
the Medical University of Warsaw, for the first time functional results of those two different surgical
in Polish clinical practice, the CO2 laser was used methods.
as a surgical knife in treatment for benign and The endoscopic laser excision of the vocal fold
malignant lesions of the larynx. Since then surgical was comparable to the classification of endoscopic
methods of treatment using the CO2 laser have cordectomies presented by the European Laryn-
continued to be developed and improved [8-10]. gological Society (ELS) in 2000 [11]. Three types of
While performing the operation on the vocal folds, endoscopic laser CO2 cordectomy were performed:
surgeons of our department always paid attention 1. Removal of the mucosa, the intermediate and
to the functional outcomes; this also concerns deep layers of the lamina propria including the
the quality of voice. Unfortunately, until now very superficial fibres of the adjacent vocal muscle
a summary of the long-term results of our work – subligamental cordectomy or type II according
concerning voice quality after cordectomy has not to the ELS classification;
been made or published. Performing all the 2. Removal of the medial portion of the vocal
research and statistics presented in this article gave muscle – transmuscular cordectomy or type III
us the possibility to critically sum up the outcomes according to the ELS classification;
of surgical treatment methods applied for Tis and 3. Extended cordectomy involving the entire vocal
T1N0M0 glottic carcinoma. fold and the anterior commissure extended to
This paper is an analysis of long-term voice the contralateral vocal fold – type Va according
quality outcomes of two different types of surgical to the ELS classification.
intervention for Tis and T1 glottic carcinoma: In the present study, two types of laryngofissure
laryngofissure conventional cordectomy and conventional cordectomy can be distinguished
endoscopic laser CO2 cordectomy, with or without according to the amount of the excised tissue:
additional radiation therapy (using 60Co). 1. Removal of the vocal fold with part of or the
entire anterior commissure;
Material and methods 2. Removal of the vocal fold with part of or the
A total of 46 patients with Tis and T1 glottic entire anterior commissure and vocal process of
carcinoma, 43 men (93.48%) and 3 women (6.52%), the arytenoid cartilage.
served as subjects. All have been treated surgically Comparison of the amount of resected tissue
with laryngofissure conventional cordectomy shows slightly larger resection through conventional
(15 patients, 32.61%) or endoscopic laser CO2 cordectomy than laser cordectomy.
cordectomy (31 patients, 67.39%). The operations The voice evaluation was focused on the manner
were performed over a 14-year period in the of voice production, phonation time, fundamental
Department of Otolaryngology at the Medical frequency, range of the fundamental frequency in
University of Warsaw, between November 1990 and a spoken sentence, analysis of hoarseness based
February 2004. on Yanagihara’s classification, intensity of
The presented voice assessments were phonation, and the Voice Handicap Index (VHI).
performed at least 3 years following the surgery, The patients were divided into homogenous
between January 2006 and February 2007. It is groups according to the treatment method –
a retrospective study. The voice evaluation was surgery alone or surgery with additional radio-
conducted to analyse long-term functional results therapy. The number of patients in groups was
of the two different types of surgical interventions sufficient to perform the statistical analysis.
for Tis and T1 glottic carcinoma mentioned above. Moreover, it allowed for evaluation of the influence
The patients’ age at the time of the primary of the additional radiological treatment on the
surgery ranged from 35 to 79 with an average age functional results in patients after cordectomy.
of 61.02 (SD 9.54, median 59). The average age was The linguistics used in the presented study are
similar in both compared groups. the ones used in everyday work in the Phoniatric
Nowadays the indications for conventional Outpatient Department, which is a part of the
cordectomy are limited. In our department this kind Diagnostic, Treatment and Rehabilitation Centre of
of surgery was performed in cases when laser CO2 Hearing and Voice Disorders of the Department of

144 Arch Med Sci 1, February / 2011

 Voice evaluation following cordectomy

Otolaryngology at the Medical University of Warsaw. Phonation time

The linguistics consists of the vowel set, single
A shorter phonation time was observed in
spoken words, simple sentences and read texts.
patients after conventional cordectomy; in group D
The Voice Handicap Index (VHI) introduced by the average was 8.30 s and in group E 11.00 s
Jacobson, in the modification made by Pruszewicz (SD 3.80 and 8.34 respectively). In patients after
et al. [12], was also used. The VHI consists of endoscopic laser CO2 cordectomy it was 13.68s in
3 groups of questions, each having 10 elements. group A and 14.27s in group B (SD 4.07 and 5.92
The acoustic analysis was conducted using respectively). The average maximum phonation
Computerized Speech Lab (CSL) with a 4150 time in all groups together was 12.50s, and ranged
External Module of KAY Elemetrics Corporation. from 3 to 27 (SD 5.50).
The recordings of voice for the acoustic analysis
were carried out in a quiet room with a microphone Fundamental frequency
placed 15 cm from the patient’s mouth. The inten-
To establish whether the fundamental frequency
sity of voice was measured with the microphone at is within normal limits, the gender of the patients
a distance of 30 cm from the mouth. must be taken into account. In our study only
3 females underwent cordectomy, and for that
Statistical analysis reason they were not included in the statistical
A versatile statistical analysis using appropriate analysis (insufficient number for reliable analysis).
methods was carried out. StatSoft Inc. 2005 Statistica The presented results are valid for male patients.
software version 7.1 (data analysis software system),
and literature on statistics in medicine were used [13].
Table I. Patients grouping scheme according to the
Appropriate methods were selected for the proper treatment method – the surgery alone (laser or
statistical analysis. P-values of < 0.05 were considered conventional cordectomy) or the surgery with
significant. Basic and detailed statistics were additional radiotherapy (n = 46)
performed. The normality of the distribution for Group Treatment method Number
quantitative variables was verified. The Student-t test, of patients
variation tests and detailed tests were used. The A laser cordectomy 19
analysis of correlation, independence test, chi-square
B laser cordectomy + radiotherapy 11
test, and Fisher’s test were also used.
C laser cordectomy + radiotherapy 1
Results + conventional cordectomy
D conventional cordectomy or 10
Patient grouping scheme according to surgical conventional cordectomy following
methods and additional radiotherapy laser surgery
The patients (n = 46) were divided into groups E conventional cordectomy 5
A, B, C, D and E according to the treatment method + radiotheratpy
– surgery alone (laser or conventional cordectomy)
or surgery with additional radiotherapy. The number
of patients in groups A, B, D, E was sufficient to Table II. Manner of voice production while speaking
in free conversation, according to the method of the
perform the statistical analysis. Group C was surgical treatment (conventional or laser cordectomy)
excluded from the analysis due to the small number with or without additional radiotherapy (n = 46)
of patients in that group (1 patient) in order to
Group Voice production
obtain reliable statistical results. Group C was
included in the tables for a full picture (Table I). Unrestrained Strained with visible
(number hyperfunction of the
of patients) laryngeal and neck muscles
Manner of voice production
(number of patients)
The manner of voice production was evaluated A 9 10
according to the observation and palpation of the
B 4 7
patients’ neck while speaking in free conversation.
Most of the patients presented strained voice C - 1
production with visible hyperfunction of the D 1 9
laryngeal and neck muscles. Almost all patients with E - 5
unrestrained voice production belonged to the laser
ABCDE 14 32
cordectomy groups (A and B). The results are
presented in Table II. % of n 30.43% 69.57%

Arch Med Sci 1, February / 2011 145

Magdalena Lachowska, Ewa Osuch-Wójcikiewicz, Antoni Bruzgielewicz

The average fundamental frequency in the The average range of Fo in patients after laser
groups after laser cordectomy (groups A and B) was cordectomy (groups A and B) was 13.37 semitones
150.29 Hz and 152.50 Hz respectively (SD 23.23 and and 11.50 semitones respectively (SD 2.54 and 2.55
35.85 respectively) (for groups A and B together respectively). In patients after conventional cor-
the mean Fo was 151.11 Hz). In groups after dectomy (group D and B) it was 10.80 semitones
conventional cordectomy (groups D and E) it was and 11.67 semitones respectively (SD 3.19 and 1.15
124.40 Hz and 119.80 Hz respectively (SD 33.56 and respectively).
33.85 respectively) (for groups D and E together the
mean Fo was 122.87 Hz). There were 2 patients Analysis of hoarseness based on Yanagihara’s
after conventional cordectomy who presented classification
phonation at the level of the vestibular folds The spectrographic analysis of the vowels /i/ /e/
(1 patient in group D and 1 in group E) with the /a/ was used for evaluation of the degree of
fundamental frequency at 58 Hz and 70 Hz. hoarseness. The analysis revealed that the patients
after endoscopic laser cordectomy (groups A and B)
Range of the fundamental frequency in presented less hoarse voice than the patients after
a spoken sentence using semitones laryngofissure conventional cordectomy (groups D
The range of Fo in a spoken sentence was and E). The results are presented in Table III, and
examples in Figures 3, 4, 5, 6 and 7.
evaluated using spectrographs of the Polish sentence
“Ten dzielny żołnierz był z nim razem” (The brave
Intensity of phonation – normal speaking and
soldier stayed together with him) (Figures 1
and 2). It was impossible to establish the range of
loud speaking
the fundamental frequency in 3 patients due to a lot The intensity of phonation, both in normal
of noise components in the spectrographs (1 patient speaking and loud speaking measured at a distance
in group B and 2 in group E). of 30 cm from the patient’s mouth, was higher

Figure 1. Narrowband spectrograph of the sentence Figure 2. Narrowband spectrograph of the sentence
“Ten dzielny żołnierz był z nim razem” (The brave soldier “Ten dzielny żołnierz był z nim razem” (The brave
stayed together with him) in a patient after endoscopic soldier stayed together with him) in a patient after
laser CO2 cordectomy of the right vocal fold conventional cordectomy of the left vocal fold

Table III. Degree of hoarseness based on the Yanagihara’s classification according to the method of the surgical
treatment (conventional or laser cordectomy) with or without additional radiotherapy (n = 46)
Group Degree of hoarseness based on the Yanagihara’s classification
I II III IV
(number of patients) (number of patients) (number of patients) (number of patients)
A 1 10 7 1
B – 7 1 3
C – – – 1
D – – 4 6
E – – 4 1
ABCDE 1 17 16 12
% of n 2.17% 36.96% 34.78% 26.09%

146 Arch Med Sci 1, February / 2011

 Voice evaluation following cordectomy

Figure 3. Narrowband spectrograph of the vowels /i/ Figure 5. Narrowband spectrograph of the vowels /i/
/e/ /a/ in a patient after endoscopic laser CO2 /e/ /a/ in a patient after endoscopic laser CO2
cordectomy of the right vocal fold – grade I cordectomy of the left vocal fold – grade III
hoarseness hoarseness

Figure 4. Narrowband spectrograph of the vowels /i/ Figure 6. Narrowband spectrograph of the vowels /i/
/e/ /a/ in a patient after endoscopic laser CO2 /e/ /a/ in a patient after conventional cordectomy
cordectomy of the right vocal fold – grade II of the right vocal fold – grade III hoarseness
hoarseness

in patients after endoscopic laser cordectomy

(groups A and B) compared to the patients after
conventional cordectomy (groups D and E). The
mean values are presented in Table IV.

Voice Handicap Index

The VHI scores indicate that all groups had
subjective voice problems, but the CO2 laser
cordectomy groups (A and B) presented lower
values and the conventional cordectomy groups
(D and E) higher values. The mean values of VHI
are presented in Table V.
Figure 7. Narrowband spectrograph of the vowels /i/
Analysis of correlation
/e/ /a/ in a patient after conventional cordectomy
The analysis of correlation was performed for of the left vocal fold – grade IV hoarseness
the fundamental frequency values, range of Fo in
semitones, phonation time, intensity of phonation
in dB for normal and loud speaking, and the VHI. • intensity of phonation in normal and loud
Significant p-values for correlation (p < 0.05) were speaking (p = 0.000),
found for: • VHI and intensity of phonation in loud speaking
• phonation time and VHI (p = 0.022), (p = 0.000).

Arch Med Sci 1, February / 2011 147

Magdalena Lachowska, Ewa Osuch-Wójcikiewicz, Antoni Bruzgielewicz

Table IV. Mean values of phonation intensity in normal and loud speaking according to the method of the surgical
treatment (conventional or laser cordectomy) with or without additional radiotherapy (n = 46)
Group Mean intensity [dB] SD
Normal speaking Loud speaking Normal speaking Loud speaking
A 66.37 81.00 2.69 3.02
B 67.09 81.91 2.39 3.42
C 64 76 – –
D 64.40 77.30 1.96 3.02
E 64.80 77.20 3.27 4.32
ABCDE 65.89 79.89 2.65 3.73

Table V. Voice Handicap Index (VHI) according to the method of the surgical treatment (conventional or laser
cordectomy) with or without additional radiotherapy (n = 46)

Group VHI Mean SD

points
0-30 pts 31-60 pts 61-120 pts
VHI
Number Mean Number Mean Number Mean
of patients points of patients points of patients points
A 10 12.1 9 42.4 – – 26.47 17.59
B 9 14.1 2 40 – – 18.82 12.07
C 1 22 – – – – 22 –
D 4 19.5 4 47.8 2 66 40.10 20.05
E – – 4 47 1 73 52.20 14.48
ABCDE 24 14.5 19 44.3 3 68.3 30.30 19.23

Variation tests for evaluation of the influence vs. E) on voice parameters such as the fundamental
of cordectomy type and subsequent frequency values, range of Fo in semitones,
radiotherapy on the acoustic analysis results phonation time, intensity of phonation in dB for
normal and loud speaking, and VHI was carried out.
Comparison of laser cordectomy vs. The analysis revealed significant p-values for
conventional cordectomy the intensity of phonation in loud speaking
The evaluation of the influence of cordectomy (p = 0.0334), and the VHI (p = 0.0003), which
type (laser vs. conventional; group A vs. D) on voice presented better results in patients after laser
parameters such as the fundamental frequency cordectomy (Table VII).
values, range of Fo in semitones, phonation time,
intensity of phonation in dB for normal and loud Comparison of laser cordectomy and laser
speaking, and the VHI was carried out. cordectomy with radiotherapy vs. conventional
The analysis revealed significant p-values for the cordectomy and conventional cordectomy with
range of Fo in semitones (p = 0.0253), phonation radiotherapy
time (p = 0.0018), and intensity of phonation in
The evaluation of the influence of cordectomy
loud speaking (p = 0.0041), which presented better
type with or without additional radiotherapy (groups
results in patients after laser cordectomy. However,
A and B vs. D and E) on voice parameters such as
the fundamental frequency was significantly better
the fundamental frequency values, range of Fo in
in patients after conventional cordectomy
semitones, phonation time, intensity of phonation
(p = 0.0257) (Table VI).
in dB for normal and loud speaking, and the VHI
was carried out.
Comparison of laser cordectomy with
The analysis revealed significant p-values for
radiotherapy vs. conventional cordectomy
the phonation time (p = 0.0050), intensity of
with radiotherapy
phonation in normal speaking (p = 0.0110) and
The evaluation of the influence of cordectomy loud speaking (p = 0.0002), and the VHI
type followed by additional radiotherapy (group B (p = 0.0004), which presented better results in

148 Arch Med Sci 1, February / 2011

 Voice evaluation following cordectomy

Table VI. Evaluation of the cordectomy type (laser vs. conventional, the group A vs. D) influence on the acoustic
analysis results

Parameter Group A Group D P value P value

Mean n SD Mean n SD of the F test of the
value value Student-t test
Fundamental 150.29 17 23.23 124.40 10 33.56 0.1908 0.0257*
frequency [Hz]
Range of Fo 13.37 19 2.54 10.80 10 3.19 0.3945 0.0253*
[semitones]
Phonation time [s] 13.68 19 4.07 8.30 10 3.80 0.8694 0.0018*
Intensity of 66.37 19 2.69 64.40 10 1.96 0.3282 0.0513
phonation in
normal
speaking [dB]
Intensity of 81.00 19 3.02 77.30 10 3.02 0.9467 0.0041*
phonation
in loud
speaking [dB]
VHI points 26.47 19 17.59 40.10 10 20.05 0.6069 0.0694

*p-values of < 0.05 are significant

Table VII. Evaluation of the cordectomy type followed by radiotherapy (laser cordectomy with radiotherapy vs.
conventional cordectomy with radiotherapy, group B vs. E) influence on acoustic analysis results

Parameter Group B Group E P value P value

Mean n SD Mean n SD of the F test of the
value value Student-t test
Fundamental 152.50 10 35.85 119.80 5 33.85 0.9857 0.1141
frequency [Hz]
Range of Fo 11.50 10 2.55 11.67 3 1.15 0.3635 0.9164
[semitones]
Phonation time [s] 14.27 11 5.92 11.00 5 8.34 0.3459 0.3803
Intensity of 67.09 11 2.39 64.80 5 3.27 0.3811 0.1338
phonation
in normal
speaking [db]
Intensity of 81.91 11 3.42 77.20 5 4.32 0.4977 0.0334*
phonation
in loud
speaking [dB]
VHI points 18.82 11 12.07 52.20 5 14.48 0.5824 0.0003*
*p-values of < 0.05 are significant

patients after laser cordectomy. However, the frequency values, range of Fo in semitones,
fundamental frequency was significantly better phonation time, intensity of phonation in dB for
in patients after conventional cordectomy normal and loud speaking, and the VHI):
(p = 0.0051) (Table VIII). • factor 1 – the type of cordectomy (laser or
conventional),
Variation analysis of two factors • factor 2 – additional radiotherapy (performed or
The variation analysis of two factors evaluated not performed),
whether the following factors have a significant • interaction of factors 1 and 2 – interaction of the
influence on the voice parameters (the fundamental two analysed factors.

Arch Med Sci 1, February / 2011 149

Magdalena Lachowska, Ewa Osuch-Wójcikiewicz, Antoni Bruzgielewicz

Table VIII. Evaluation of the cordectomy type with or without additional radiotherapy (group A and B vs. D and E)
influence on acoustic analysis results

Parameter Group A and B Group D and E P value P value

Mean n SD Mean n SD of the F test of the
value value Student-t test
Fundamental 151.11 27 27.90 122.87 15 32.50 0.4842 0.0051*
frequency [hz]
Range of Fo 12.72 29 2.66 11.00 13 2.83 0.7496 0.0639
[semitones]
Phonation time [s] 13.90 30 4.74 9.20 15 5.56 0.4525 0.0050*
Intensity of 66.63 30 2.57 64.53 15 2.36 0.7578 0.0110*
phonation
in normal
speaking [db]
Intensity of 81.33 30 3.14 77.27 15 3.35 0.7447 0.0002*
phonation
in loud
speaking [db]
VHI points 23.67 30 16.01 44.13 15 18.79 0.4520 0.0004*
*p-values of < 0.05 are significant

The analysis revealed that the type of • intensity of phonation in normal speaking
cordectomy had an influence on the following voice (p = 0.0158),
parameters (Table IX): • intensity of phonation in loud speaking
• fundamental frequency (p = 0.0070), (p = 0.0004),
• phonation time (p = 0.0142), • the VHI (p = 0.0001).

There was no significant influence of the

additional radiotherapy on the voice parameters
Table IX. Variation analysis of two factors
(p > 0.05). There was no significant influence of the
Voice parameter Factor F P-value interaction of the two analysed factors on the voice
1 8.142 0.0070* parameters (p > 0.05) (Table IX).
Mean
fundamental 2 0.014 0.9078
frequency
The independence test and Wanke’s excess
12 0.110 0.7421
The statistical analysis revealed that the
1 1.390 0.2458
additional radiotherapy after the surgery did not
Range of Fo 2 0.242 0.6258 significantly influence the functional outcomes
12 1.802 0.1874 (p > 0.05). This allowed us to classify patients into
1 6.558 0.0142* larger groups (group A with B together, and group D
with E together) and perform the independence
Phonation time 2 0.946 0.3364
test. Wanke’s excess was calculated to facilitate
12 0.390 0.5357 interpretation of the results of the independence
1 6.340 0.0158* test (Wanke’s excess is considered valid when it is
Intensity of
> 1, which confirms the analysed feature as
phonation in normal 2 0.440 0.5107
speaking
statistically significant).
12 0.036 0.8498 The manner of voice production and hoarseness
Intensity of 1 14.930 0.0004* degree based on Yanagihara’s classification were
phonation in 2 0.138 0.7120 analysed using the mentioned tests.
loud speaking The independence test showed statistically
12 0.215 0.6453
a considerably higher occurrence of the following
1 17.787 0.0001* parameters in the patients after endoscopic laser
VHI 2 0.159 0.6921 cordectomy (p < 0.05, Wanke’s excess > 1):
12 3.141 0.0838 • unrestrained voice production (p = 0.0164,
Wanke’s excess 1.39),
*p-values of < 0.05 are significant

150 Arch Med Sci 1, February / 2011

 Voice evaluation following cordectomy

• lower degree of hoarseness based on a further decrease of Fo in males (mean value of

Yanagihara’s classification (p = 0.0001, Wanke’s 154 Hz), and increase of Fo in females (mean value
excess 1.50). of 204 Hz) was observed. The maximum phonation
time increased to 15.4 s. The voice characteristics
Discussion changed from hoarse to pure. The authors
concluded that the smooth and straight neocord in
After the removal of the vocal fold invaded by
place of the excised vocal fold creates good
the glottic carcinoma a scar develops and takes
conditions for voice emission [17]. In our study the
over the function of the vocal fold. Krengli et al.
mean value of the fundamental frequency was
evaluated voice outcomes at a minimum of 2 years
higher in the group of patients after laser surgery
after the laser cordectomy to be sure that
(151.11 Hz) compared to patients after conventional
the post-treatment changes were stabilized.
cordectomy (122.87), where the mean value was
The electroacoustic analysis of the voice detected
close to the normal Fo (for males it is taken to be
type II – III hoarseness based on Yanagihara’s
about 128 Hz).
classification in 30% of patients, while severe In their study, Keilmann et al., investigated and
dysphonia (type IV of Yanagihara) was observed in compared voice outcomes in patients after
70%. The mean value of fundamental frequency conventional cordectomy and after laser cordectomy.
was 134.5 Hz [14]. The study revealed that patients after laser surgery
Different results to Krengli et al. were reported more often presented better voice quality in the
by McGuirt et al. In most patients after endoscopic spectrograph classification based on Yanagihara. As
laser cordectomy grade III hoarseness of Yanagihara for the fundamental frequency and the maximum
was detected. The mean value of the voice intensity phonation time there were no statistical differences
was 43 dB, and the maximum phonation time was between the groups of patients [18].
16.01 s. Patients themselves rated their voice as Schindler et al. conducted a comparable study
normal or close to normal [15]. of voice evaluation following conventional
In Remacle et al.’s opinion the debate concerning cordectomy and laser cordectomy in patients
the results of vocal quality after radiotherapy or operated on for early glottic cancer. They analysed
endoscopic laser cordectomy remains open. Some the maximum phonation time, degree of hoar-
authors claim no differences in voice quality after seness based on Yanagihara’s classification, voice
either procedure while others maintain that the perturbation, and the GRBAS scale. The results were
radiotherapy is better. It is difficult to compare slightly better in patients after conventional
treatment methods because of the differences cordectomy. However, the detailed analysis did not
among authors in the extent of the cordectomy, prove any statistical significance indicating the
techniques of radiotherapy, ways of patient superiority of any of the presented surgical
selection and the methods of voice evaluation. methods [19].
Remacle et al. are not in favour of radiotherapy for In our study in patients after endoscopic laser
the treatment of T1 vocal fold carcinoma, even if cordectomy the following findings were more often
there is any doubt with regard to the vocal quality observed: unrestrained voice production and lower
after the surgery [16]. degree of hoarseness based on Yanagihara’s
In the present study no significant influence of classification. Moreover the statistical analysis
the additional radiotherapy, performed in some proved that the following voice parameters depend
patients, on voice parameters was found. This on the surgical treatment method: the range of Fo
allows us to conclude that when it comes to voice in a spoken sentence, maximum phonation time,
quality most important was the method of surgical intensity of phonation for normal and loud
treatment, and the influence of the complimentary speaking, and the VHI. The above-mentioned
radiation therapy was not significant. parameters were found to be better in patients
Betlejewski et al. reported a long-term follow-up after laser cordectomy.
study of patients after laser cordectomy performed Remacle et al. reported that the voice quality
due to glottic carcinoma. The voice evaluation, depended on the extent of resection of the vocal
conducted just after healing of the glottis, revealed fold in patients undergoing laser cordectomy. The
the mean value of the maximum phonation time spectrographic examination revealed better results
at 10 s. The mean fundamental frequency was quite in patients with smaller tissue resection of the vocal
high at 170 Hz in males and quite low at 178 Hz in fold. The values for the maximum phonation time
females. The second voice examination was and vocal intensity did not differ significantly
performed 3 years later and revealed an increase among patients [16]. Modrzejewski et al. analysed
in maximum phonation time up to 11.8 s, lowering acoustically patients after conventional cordectomy
of the males’ voices to 160 Hz, and increase of the and did not find any significant differences in the
fundamental frequency in females to the mean fundamental frequency according to the amount
value of 190 Hz. Eight to ten years after the surgery of excised tissue of the vocal fold [20].

Arch Med Sci 1, February / 2011 151

Magdalena Lachowska, Ewa Osuch-Wójcikiewicz, Antoni Bruzgielewicz

The connection between voice quality and the Re f e r e n c e s

depth of the excision of the vocal fold was proved 1. Krzeski A, Maniecka-Aleksndrowicz B, Lachowska M.
by Delsupehe et al., who evaluated the perceptual Podstawy chirurgicznego leczenia dysfonii [Polish].
voice characteristics in patients after laser Magazyn Otorynolaryngologiczny 2005; 15: 91-8.
2. Maniecka-Aleksndrowicz B, Domeracka-Kołodziej
cordectomy. The authors also noted that there was A. Dysfonia i chrypka [Polish]. Magazyn Otorynolaryn-
clear improvement for most of the voice gologiczny 2004; 9: 17-25.
characteristics over time [21]. As Mendenhall et al. 3. Wiskirska-Woźnica B. Kompleksowa ocena głosu w scho-
reported, in their literature review, most of the rzeniach organicznych i czynnościowych krtani. Rozprawa
studies presented in international articles did not habilitacyjna [Polish]. Akademia Medyczna, Poznań 2002.
4. McWhorter AJ, Hoffman HT. Transoral laser microsurgery
investigate large groups of patients. However, for laryngeal malignancies. Curr Probl Cancer 2005; 29:
analysis of them revealed that voice quality 180-9.
becomes poorer with laser resections of larger 5. Mendenhall WM, Werning JW, Hinerman RW, Amdur RJ,
tumours [5]. Villaret DB. Management of T1-T2 glottic carcinomas.
Like many other authors, Peretti et al. also Cancer 2004; 100: 1786-92.
6. Peretti G, Nicolai P, Redaelli de Zinis LO, et al. Endoscopic
considered that vocal outcomes are strictly related
CO2 laser excision for Tis, T1, and T2 glottic carcinomas:
to glottic competence, which depends on the cure rate and prognostic factors. Otolaryngol Head Neck
amount of resected vocal fold tissue. In their opinion, Surg 2000; 123: 124-31.
the preservation of the anterior commissure and 7. Pukander J, Kerälä J, Mäkitie A, Hyrynkangas K, Virtaniemi J,
most of the vocal muscle plays a key role in obtaining Grenman R. Endoscopic laser surgery for laryngeal cancer.
good and close to normal voice quality [22]. Sittel et Eur Arch Otorhinolaryngol 2001; 258: 236-9.
al. reported that for the vocal result the preservation 8. Janczewski G, Sonnenberg Z, Połubiński R. Laser jako
narzędzie chirurgiczne [Polish]. Otolaryngol Pol 1982; 36:
of the anterior commissure is most important, in 181-6.
contrast to no linear correlation between the amount 9. Połubiński R. Ocena kliniczna wartości lasera CO2
of the removed glottic tissue and postoperative voice stosowanego w mikrochirurgii wybranych schorzeń nieno-
results. In their opinion, the most important factor wotworowych krtani. Praca doktorska [Polish]. Warszawa
is the mechanism of the postoperative phonation 1985.
after laser cordectomy [23]. In our study the reason 10. Sonnenberg Z. Laser CO2 w leczeniu stanów przed-
rakowych krtani. Praca habilitacyjna [Polish]. Warszawa
for the obtained results could be the amount of the
1987.
excised vocal fold tissue, which was slightly larger in 11. Remacle M, Eckel HE, Antonelli A, et al. Endoscopic
the case of conventional cordectomy. This can also cordectomy. A proposal for classification by the Working
be explained by the formation of the anterior Committee, European Laryngological Society. Eur Arch
synechia and the level difference between the Otorhinolaryngol 2000; 257: 227-31.
neocord and the contralateral vocal fold in the 12. Pruszewicz A, Obrębowski A, Wiskirska-Woźnica B,
Wojnowski W. W sprawie kompleksowej oceny głosu –
patients after conventional cordectomy via the
własna modyfikacja testu samooceny niesprawności głosu
external route, which requires an anterior thyrotomy. (Voice Handicap Index) [Polish]. Otolaryngol Pol 2004; 58:
Bertino et al. believed that the postoperative voice 547-9.
quality depends on the shape of the neocord and the 13. Petrie A, Sabin C. Statystyka medyczna w zarysie [Polish].
phonatory mechanism adopted by the patient after Wydawnictwo Lekarskie PZWL 2006.
the cordectomy [24]. 14. Krengli M, Policarpo M, Manfredda I, et al. Voice quality
after treatment for T1a glottic carcinoma – radiotherapy
To conclude, our study revealed that in patients
versus laser cordectomy. Acta Oncol 2004; 43: 284-9.
after endoscopic laser CO2 cordectomy, compared to 15. McGuirt WF, Blalock D, Koufman JA, Feehs RS. Voice
laryngofissure conventional cordectomy, the following analysis of patients with endoscopically treated early
findings are more often observed: unrestrained voice laryngeal carcinoma. Ann Otol Rhinol Laryngol 1992; 101:
production, wider range of Fo in a spoken sentence, 142-46.
longer maximum phonation time, better intensity of 16. Remacle M, Lawson G, Jamart J, Minet M, Watelet JB,
phonation for normal and loud speaking, lower degree Delos M. CO2 laser in the diagnosis and treatment of early
cancer of the vocal fold. Eur Arch Otorhinolaryngol 1997;
of hoarseness based on Yanagihara’s classification,
254: 169-76.
and lower VHI. The amount of excised vocal fold tissue, 17. Betlejewski S, Sinkiewicz A, Mackiewicz-Nartowicz H.
which in our study was slightly larger in the case of Odległe wyniki leczenia raka krtani T1 i T2 w mikrochirurgii
conventional cordectomy, could account for the results laserowej [Polish]. Otolaryngol Pol 2005; 59: 235-7.
mentioned above. This may also be explained by the 18. Keilmann A, Bergler W, Artzt M, Hörmann K. Vocal
necessity of anterior thyrotomy, which is required in function following laser and convenctional surgery of
conventional cordectomy via an external approach, small malignant vocal fold tumours. J Laryngol Otol 1996;
110: 1138-41.
and often results in anterior synechia and a level
19. Schindler A, Palonta F, Preti G, Ottaviani F, Schindler O,
difference between the neocord and the contralateral Cavalot AL. Voice quality after carbon dioxide laser and
vocal fold. No significant influence of additional conventional surgery for T1a glottic carcinoma. J Voice
radiotherapy on voice parameters was found. 2004; 18: 545-50.

152 Arch Med Sci 1, February / 2011

 Voice evaluation following cordectomy

20. Modrzejewski M, Olszewski E, Wszołek W, Reroń E,

Stręk P. Acoustic assessment of voice signal deformation
after partial surgery of the larynx. Auris Nasus Larynx
1999; 26: 183-90
21. Delsupehe KG, Zink I, Lejaegere M, Bastian RW. Voice
quality after narrow-margin laser cordectomy compared
with laryngeal irradiation. Otolaryngol Head Neck Surg
1999; 121: 528-33.
22. Peretti G, Piazza C, Balzanelli C, Cantarella G, Nicolai P.
Vocal outcome after endoscopic cordectomies for Tis and
T1 glottic carcinomas. Ann Otol Rhinol Laryngol 2003; 112:
174-9.
23. Sittel C, Eckel HE, Eschenburg C. Phonatory results after
laser surgery for glottic carcinoma. Otolaryngol Head Neck
Surg 1998; 119: 418-24.
24. Bertino G. Bellomo A, Ferrero FE, Ferlito A. Acoustic
Analysis of voice quality with or without false vocal fold
displacement after cordectomy. J Voice 2001; 15: 131-40.

Arch Med Sci 1, February / 2011 153