Klaske van Sluis

Voice outcomes following total laryngectomy 57 studies showing patient-reported voice problems as a result of tumour presence, tracheostomy and earlier organ sparing oncologic treatment, as well as after total laryngectomy [2, 32, 33]. It is acknowledged that the VHI and VHI-10 are not specifically validated for use after total laryngectomy. A study of Moerman et al. has introduced a corrected VHI score (30 item version) specifically to use after TL, which copes with unanswered items [34]. This is useful, since not all questions apply after TL. Future studies could develop this corrected score for the VHI-10, validate the instrument for use after TL, and determine a cut-off score. The acoustic voice outcomes, measured with AVQI, are impaired at all time- points. However, we found a significant deterioration after total laryngectomy. Both t-test (pre- to 6 months post-surgery) and Linear Mixed Effect modelling showed statistical significance (both p<.001 resp.) Earlier research showed a strong correlation between AVQI and perceptual rated voice quality [35]. This study again shows strong correlation between AVQI and perceptual rated voice quality, as well as between AVQI and VHI-10, indicating that these tools mea- sure the same construct. With the confirmation of the AVQI correlating to perceptual outcomes, as well as detecting differences over time, there is justifi- cation for AVQI use in tracheoesophageal speech samples [4, 36]. In this study, an AVQI score of ≥ 6 correlates with a VHI-10 score >11. This cut-off should be validated in a larger study. We find a statistically significant effect of time in perceptual outcome evalu- ations of voice quality by the clinician as well as the participant (LME model). There is a clear deterioration in perceptual rated voice quality and intelligibility after surgery followed by a gradual improvement over 12 months. No effect is found for the investigated oncologic treatment variables a) pri- mary surgical treatment vs. salvage surgical treatment and b) primary closure vs. major reconstruction. It is known that oncological history of CRT nega- tively influences complication rates including fistula, and stricture [37, 38], but we found no influence on QoL or voice outcomes. Earlier literature showed in- ferior voice quality in patients with total laryngectomy who received a major reconstruction of the neopharynx [39]. Previously, Jacobi et al. also reported optimal voice characteristics in tubed flap reconstructions [40]. This shows that the voice after flap reconstruction can be comparable as after primary closure. However, we could not confirm that, the low number of patients did not allow us to look at specific reconstruction techniques. 3.4.1 Strengths and limitations To our knowledge, this is the first study prospectively assessing a combination of acoustic, patient rated, and clinician rated voice outcomes from pre- up to twelve months post-surgery. The prospective character of the study aims to overcome a selection bias of including only excellent speakers. The unique approach with assessing acoustic, self-reported and perceptual outcomes over time provides information about the course of voice outcome and QoL. With