Association between subjective voice Assessment and psychological distress after thyroidectomy

概要

ARTICLE IN PRESS
Journal of PeriAnesthesia Nursing 000 (2021) 1−4

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Journal of PeriAnesthesia Nursing
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Research

Association between subjective voice Assessment and psychological
distress after thyroidectomy
Mahoko Taito, RNa,b, Takao Hamamoto, MD, PhDc, Nobuyuki Chikuie, MDc,
Manabu Nishida, MDc, Sachio Takeno, MD, PhDc, Hitoshi Okamura, MD, PhDb,*
a

Department of Nursing, Hiroshima University Hospital, Hiroshima, Japan
Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
c
Department of Otorhinolaryngology, Head and Neck Surgery, Hiroshima University Hospital, Hiroshima, Japan
b

A B S T R A C T
Keywords:
thyroidectomy
voice function
distress
perioperative
postoperative

Purpose: This study aimed to determine the association between postoperative subjective voice function and
psychological distress in patients without laryngeal nerve injury after thyroidectomy.
Design: A prospective cohort study.
Methods: We investigated the factors associated with subjective voice function in patients who underwent
thyroidectomy without laryngeal nerve injury between October 2018 and July 2020. The Voice Handicap
Index was used to assess subjective voice function, the GRBAS (grade, roughness, breathiness, asthenia,
strain) scale to assess objective voice, and the Hospital Anxiety and Depression Scale to assess psychological
distress.
Findings: Among 39 patients who underwent thyroidectomy, 32 had no postoperative laryngeal nerve injury.
Postoperative Voice Handicap Index was significantly associated with Hospital Anxiety and Depression
Scale-Anxiety score after surgery (rs = 0.448, P = .010).
Conclusions: In this study, an association was observed between subjective voice function and anxiety following surgery. The finding suggested that nurses and medical practitioners need to consider postoperative anxiety when evaluating patients’ voice function after thyroidectomy.
© 2021 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

Psychological distress occurs during the perioperative period,1
and anxiety is associated with patients’ subjective ratings of physical
functioning. Zemla et al reported that surgery-related anxiety was
related to patients' subjective ratings of physical functioning.2 It has
also been reported that the greater the patient’s perioperative anxiety, the lower the postoperative quality of life score.3 The assessment
of perioperative anxiety and its management is important because
anxiety regarding surgery affects the assessment of postoperative
subjective physical functioning, and interventions for perioperative
anxiety reduce postoperative pain.4
Voice disturbance associated with superior and recurrent laryngeal nerve injury is a complication that may occur following thyroidectomy.5 Although this usually occurs when the superior and
recurrent laryngeal nerves are injured, it has also been reported to
Conflict of Interest: None to report.
Funding: This research received no specific grant from any funding agency in the
public, commercial, or not-for-profit sectors.
* Address correspondence to Hitoshi Okamura, Graduate School of Biomedical and
Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima 7348551, Japan.
E-mail address: hokamura@hiroshima-u.ac.jp (H. Okamura).

occur in the absence of nerve injury.6,7 Postoperative voice disorders
that are not a result of nerve injury are temporary and often improve
after several months. However, some cases of long-term voice disorders have been reported.8 Previous studies have also reported the
occurrence of speech dysfunction without neurological damage
related to age9 and sex.10
However, the association between perioperative psychological
distress, including anxiety and subjective voice function, has not
been elucidated as a somatic symptom. Perioperative psychological
distress is often assessed and managed by nurses,11 and clarifying the
relationship between psychological distress and subjective voice
assessment may lead to improved patient care. This study aimed to
determine whether perioperative psychological distress after
thyroidectomy is associated with postoperative subjective voice
function.
Methods
This single-center prospective observational study included 39
adult patients admitted to Hiroshima University Hospital to undergo
total or unilateral thyroidectomy for thyroid tumors between October

https://doi.org/10.1016/j.jopan.2021.11.012
1089-9472/© 2021 American Society of PeriAnesthesia Nurses. Published by Elsevier Inc. All rights reserved.

Please cite this article as: M. Taito et al., Association between subjective voice Assessment and psychological distress after thyroidectomy,
Journal of PeriAnesthesia Nursing (2021), https://doi.org/10.1016/j.jopan.2021.11.012

ARTICLE IN PRESS
Journal of PeriAnesthesia Nursing 00 (2021) 1−4

M. Taito et al.

separately for patients with benign and malignant tumors to examine
the difference between benign and malignant tumors. P-values for all
tests were two-sided, and the significance level was set at .05. Statistical Package for the Social Science 25 was used for the analysis.

2018 and July 2020. Cases with invasion of surrounding organs, tracheal involvement, the need for tracheostomy for thyroidectomy, distant metastases, cognitive dysfunction, and vocal cord paralysis
before and after surgery were excluded, and patients from whom
consent to participate in the study was not obtained were also
excluded. Mobility of the vocal cords was assessed by an otolaryngologist using a pharyngolaryngoscope before and after the surgery to
exclude nerve damage. Eligible patients undergoing thyroidectomy
participated in questionnaire surveys on subjective voice function,
both preoperatively and 1 week postoperatively.
The Voice Handicap Index (VHI)12 was used to assess subjective
vocal function; this is a self-rating scale that assesses individuals
based on 30 items related to functional (F), physical (P), and emotional
aspects (E), on a 5-point scale ranging from no problem to always. The
total VHI score (from 0 to 120 points) is higher when the patient perceives failure. For each aspect, the score is distributed from 0 to 40
points; the higher the score, the greater the perception of disability.
Psychological distress was assessed using the Hospital Anxiety
and Depression Scale (HADS),13 which was developed as a measure
of general symptoms of anxiety and fear and is a clinically important
screening instrument for anxiety and depressive symptoms in
medical practice. In the present study, the HADS was also used to
measure psychological distress in the perioperative period of
thyroidectomy.14,15 The HADS is a self-rating scale that assesses anxiety (A) and depression (D) on a scale from “not at all” to “often”, with
seven items each for anxiety and depression, for a total of 14 items.
Each item is rated on a scale of 0 to 3, with the highest score for each
factor being 21. For each factor, a score of 0 to 7 was rated as no anxiety or depression, a score of 8 to 10 as suspected diagnosis, and a
score of 11 or higher as confirmed diagnosis.
The GRBAS scale16 was used by medical professionals to examine
the objective and subjective voice evaluations. The GRBAS scale can
perceptually evaluate dysphonia. Voice quality is rated as follows: G
(Grade), R (Rough), B (Breath), A (Asthenic), and S (Strained). The
rating points on the G scale are 0, 1, 2, and 3 for “normal”, “mild”,
“moderate”, and “severe hoarseness”, respectively. The GRBAS assessment was performed by a speech pathologist, physician, or nurse
with experience in GRBAS assessment, and the severity assessment
was based on the consensus of two or more judges.

Results
Summary of the Subjects
The study included 32 of 39 patients who underwent thyroidectomy; 1 patient who could not be evaluated postoperatively, and 6
patients who had postoperative nerve injury were excluded.
The participants included 9 men and 23 women with a mean age
of 57 years (range, 34 to 82 years). For thyroid tumor removal, total
and unilateral resections were performed in 3 and 29 patients,
respectively (Table 1).
Comparison of subjective voice function assessment, objective
voice function assessment, and psychological distress before and
after surgery
The differences in VHI, HADS-A, HADS-D, and GRBAS scores before
and after surgery are shown in Table 2. In terms of changes in psychological anxiety, the HADS-A score increased after surgery, and the
HADS-D score decreased after surgery, but there was no significant
difference in any of them. Additionally, there was a significant change
in the “breathiness” index of the GRBAS, a tool for objective assessment of speech function; however, no significant changes were
observed in other indices. In addition, no significant difference in
VHI, HADS-A, and HADS-D scores was found between benign and
malignant thyroid tumors.

Associated factors with postoperative Voice Handicap Index
Associated characteristics of participants with postoperative subjective voice function are shown in Table 3. The results showed a significant association only between the postoperative VHI, subjective
voice assessment, and the postoperative HADS-A score, a psychological anxiety assessment. There was no significant association between
postoperative VHI and other factors. In addition, subgroup analysis of
benign and malignant tumors showed that there was no significant
association between VHI and benign tumor patients (n = 6)
(rs = 0.609, P = .200); however, there was a significant association
between VHI and Post-HADS-A in malignant tumor patients (n = 26)
(rs = 0.394, P = .047).

Ethical Considerations
This study was conducted with the approval of the Ethical Review
Board of Epidemiological Studies, Hiroshima University (No. E-1377). ...

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