Am J Otolaryngol xxx (xxxx) xxxx

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Am J Otolaryngol
journal homepage: www.elsevier.com/locate/amjoto

Objective and subjective changes in voice after endoscopic sinus surgeries in

patients with and without nasal polyps
Eugene Hung Chih Wonga, , Aun Wee Chongb
⁎

a
Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
b
Otorhinolaryngology (ENT) Department, University Malaya Medical Centre, Kuala Lumpur, Malaysia

ABSTRACT

Background: Many studies have looked at the effect of functional endoscopic sinus surgeries (FESS) on nasalance, nasal consonant and nasalized vowels. Only two
studies investigated the effect of FESS on vocal sound quality and have not found statistically significant changes before and after operations. The aim of this study was to
examine the short-term and long-term objective and subjective changes in the vocal quality of patients after FESS, comparing patients with and without nasal polyps.
Methods: Sixteen patients were recruited for voice analysis during pre-operative, within two weeks and at least three months post-operatively. Subjective ques-
tionnaire was used to assess perception of voice changes.
Results: There were no statistically significant changes in the acoustic parameters of patients with nasal polyposis. In patients with CRS without polyps, there was a
statistically significant increase in fundamental frequency (F0) in nasal sound during early follow up. The changes in soft phonation index (SPI) values between the
two groups were statistically significant during early follow-ups. Only patients with nasal polyposis perceived a subjective change in their voice post-operatively.
Conclusions: Clinicians should inform all patients, especially voice professionals about the possible effects of endoscopic sinus surgeries on their voice quality.

1. Introduction functional endoscopic sinus surgeries (FESS), comparing patients with

Voice is an important communication tool and voice disorders can
affect patients' life in many ways [1]. The acoustic characteristics of
voice are determined by the vocal cords and vocal tracts [2]. The
paranasal sinuses, nasal cavity, oral cavity, pharynx and supraglottic
larynx have been considered as a resonator with important roles in
shaping the resonant characteristics of the vocal tract [3,4]. Disorders
and surgeries to the paranasal sinuses and nasal cavity can affect the
resonance of the nasal passage and causes a perception of change in
quality of nasal sound [5] as well as changes in voice quality (both
nasal and oral sounds) [6].
Many studies have looked at effect of sinonasal surgeries [2,3,5,7]
and nasal decongestants [8,9] on nasalance (ratio of nasal acoustic
energy to total (oral and nasal) acoustic energy) using nasometers. Few
studies [6,10,11] also evaluated the effect of sinonasal surgeries on
nasal consonant and nasalized vowels. However only two other studies
[1,7] that have looked at the effect of sinus surgeries on vocal sound
quality such as jitter, shimmer and foundation frequencies and both
studies have not found statistically significant changes in those para-
meters before and after surgeries.
The primary end point of this study was to investigate the short term
(within two weeks) and long term (more than three months) changes in
vocal quality of patients, both for nasal and non-nasal sounds, after
nasal polyposis and patients with chronic rhinosinusitis (CRS) without
nasal polyps. The secondary end point of this study was to investigate
the subjective perception of voice changes post-operatively (both short
and long term), comparing patients with and without nasal polyps.
2. Methods
2.1. Study design
The inclusion criteria for this study was any patients aged above
18 years old, who underwent FESS requiring opening up of at least one
sinus, for either nasal polyposis or chronic rhinosinusitis without
polyps. Patients who had either open sinonasal surgeries or endoscopic
nasal surgeries without involving opening up of at least one sinus were
excluded from the study.
All surgeries were performed in a single centre by different sur-
geons. Other additional clinical information was collected from the
medical case-notes and electronic patient records.
2.2. Acoustic analysis
Voice analysis was conducted on each patient in a quiet room, with
ambient noise level of < 40 dB, in the Speech and Audiology

⁎
Corresponding author at: Department of Surgery, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Jalan UMS, Kota Kinabalu 88400, Sabah,
Malaysia.
E-mail address: eugene.wong.hc@gmail.com (E.H.C. Wong).

https://doi.org/10.1016/j.amjoto.2019.102367
Received 13 September 2019
0196-0709/ © 2019 Published by Elsevier Inc.

Please cite this article as: Eugene Hung Chih Wong and Aun Wee Chong, Am J Otolaryngol, https://doi.org/10.1016/j.amjoto.2019.102367
E.H.C. Wong and A.W. Chong
Table 1
Voice analysis parameters used for statistical analysis in this study with descriptions and normal reference values for both genders.
Parameters Description1,15
Average fundamental frequency (F0) Average number of cycles produced by vocal folds per second
Absolute jiiter (Jita) Ratio of change of timbre in voice within a short period
Shimmer in dB (ShDB) The amount of change in violence between very short-term picks in sound wave
Noise to harmonic ratio (NHR) The amount of non-harmonic energy in the harmonic spectrum
Soft phonation index (SPI) The ratio of the amount of high- and low-frequency energy in voice
Department of the hospital. The Multi-Dimensional Voice Program
(MDVP, Kay Pentax Software-CSL Model 4500, NJ, USA) was used to
measure the parameters of vocal signals.
A standardized protocol was used for each voice assessment
where patients were seated adjacent to a Shire SM58 Microphone
(Shure Brothers Inc., Agua Prieta, Mexico) with the mouth-to-mi-
crophone distance fixed at 2 cm. Patients were then asked to inhale
and vocalize, in their daily speaking voice, and sustain 4 s of nasal
(“mmmm”) and non-nasal (“ahhhh”) sounds where the acoustic
signal data were recorded. The parameters used for analysis in this
study and their reference for male and female speakers are sum-
marized in Table 1.
All patients had their voices analyzed three times; before the op-
eration, within two weeks of operation and at least three months post-
operatively.
2.3. Subjective analysis
Subjective voice changes associated with surgery were evaluated
with a questionnaire modified from Koo et al. [10], consisting of several
questions about the patients' and their friends or relatives' perception of
their voice quality (Table 2).
2.4. Statistical analysis
The Statistical Package for the Social Sciences version 23 (IBM
SPSS Statistics 23) and the Microsoft Excel 2011 version 14.5.2 for
the Macintosh platform were utilized for statistical analysis. The
baseline demographic data were expressed as mean and standard
deviation for continuous data or frequency and percentages for ca-
tegorical data.
The correlations between values obtained in various acoustic
parameters before and after surgeries were analyzed with Wilcoxon
signed-rank test. A value of p < 0.05 was considered significant.
Mann-Whitney U test was used to compare the acoustic parameters
values between patients with and without nasal polyps. A value of
p < 0.05 was considered significant.
Table 2
Questionnaire for subjective evaluation of voice change before and after sur-
gery.
Questions Yes (describe)
Pre-operative:
Do you have any voice change due to the disease?
Do your friends/relatives noticed any voice change due
to disease
Post-operative (within 2 weeks and at least 3 months after
operation):
Do you think your voice changed after the operation?
Do your friends/relatives notice a voice change after
the operation?
Am J Otolaryngol xxx (xxxx) xxxx
Normal values
Male Female
145.223 Hz 243.973 Hz
41.663 μs 26.927 μs
0.219 dB 0.176 dB
0.122 0.112
6.770 7.534
3. Results
3.1. Patient and disease characteristics
Twenty patients who underwent functional endoscopic sinus sur-
gery (FESS) were recruited over an eighteen months period from August
2015. Four patients were excluded from the study due to loss to follow-
up or refusal to participate after surgeries. Data from the remaining
sixteen patients were included in the final analysis of the study results.
The median age of patients (at the time of surgery) was 42.5 years old
(mean 45.3 ± 15.4, range 18–69) where 62% were male and 38%
female. None of the patients were professional voice users, however six
(37%) of the patients (lecturer, supervisor or healthcare workers) re-
quire regular usage of their voices at work. All patients have no pre-
existing vocal cord or voice pathologies.
All patients had computed tomography (CT) scans of paranasal si-
nuses prior to operation and all patients with polyps had biopsies
performed to obtain histopathological confirmation. In terms of diag-
nosis, majority (62%) of the patients had benign inflammatory polyps
while 38% had CRS without polyps. All patients with nasal polyposis in
this study had Stage III (polyps obstructing the nasal cavity completely
or near completely) as described by Lildholdt et al. [12]. Majority of
patients had bilateral FESS (56%) and most of the patients had bilateral
MMA and opening of maxillary and anterior ethmoid sinuses (37.5%),
followed by opening of unilateral maxillary and anterior ethmoid si-
nuses (31.3%) and opening of bilateral maxillary, ethmoid and sphe-
noid sinuses (12.5%).
3.2. Objective analysis of voice changes with MDVP
The mean post-operative voice analysis was at 1.8 weeks for first
evaluation and at 14 weeks for second evaluation.
In patients with nasal polyposis, during early follow-up (within two
weeks), there was an increase in F0, Jita, ShdB and SPI and a reduction
in NHR for nasal sound, and an increase in F0, ShdB and a reduction in
Jita, NHR and SPI for non-nasal speech. On the other hand, during
second follow-up (more than three months post-operatively), there was
an increase in F0, Jita and SPI and reduction in ShdB for nasal speech.
For non-nasal speech, there was an increase in Jita, ShdB, NHR and SPI
and a reduction in F0. However, all of these changes were not statisti-
cally significant. Table 3 and Table 4 illustrate the changes in each
parameter in all the three examinations for nasal and non-nasal speech
respectively in patients with nasal polyposis.
For patients with CRS without polyps, during early follow-up, there
No was an increase in Jita and NHR and a reduction in F0, ShdB and SPI for
nasal sound. The reduction in F0 was found to be statistically significant
(p = 0.043). On the other hand, for non-nasal sound, there was an
increase in NHR but a reduction in F0, Jita, ShdB and SPI during early
follow-up, although none of these were statistically significant. During
the second follow-up, there was an increase in Jita, NHR and SPI and a
reduction in F0 and ShdB for nasal speech. For non-nasal speech, there
was a reduction in all F0, Jita, ShdB, NHR and SPI. However, all of these
changes were not statistically significant. Tables 5 and 6 illustrate the
changes in each parameter in all the three examinations for nasal and
2
E.H.C. Wong and A.W. Chong Am J Otolaryngol xxx (xxxx) xxxx

Table 3 Table 5
Comparison of pre-operative (preop) and post-operative (postop) Comparison of pre-operative (preop) and post-operative (postop)
(postop1 = within 2 weeks, postop 2 = more than 3months) voice analysis (postop1 = within 2 weeks, postop 2 = more than 3 months) voice analysis
(nasal speech) for patients with nasal polyposis. Both postop comparisons were (nasal speech) for patients with CRS without polyps. Both postop comparisons
done with the preop values. * = p < 0.05. were done with the preop values. * = p < 0.05.
Parameters Min Max Mean SD p-Value (+/−) Parameters Min Max Mean SD p-Value (+/−)
F0 (Hz)
F0 (Hz) • Preop 134.96 241.80 187.26 48.69
• Preop 83.98 240.35 148.69 48.55 • Postop1 137.90 252.46 186.15 54.62 0.043*
• Postop1 104.09 255.04 161.85 66.14 1.000 • Postop2 138.00 238.13 171.63 57.60 0.109
• Postop2 119.54 178.39 149.64 27.76 0.273 Jita (μs)
Jita (μs) • Preop 17.22 139.11 53.99 40.84
• Preop 37.76 94.92 60.93 21.25
• Postop1 51.46 120.27 87.01 31.87 0.138
• Postop1 33.44 174.68 97.32 69.74 0.273
• Postop2 29.96 120.30 68.33 46.66 0.593
• Postop2 22.42 165.03 103.41 61.93 0.465 ShdB (dB)
ShdB (dB) • Preop 0.06 0.81 0.28 0.25
• Preop 0.10 0.66 0.29 0.17 • Postop1 0.20 0.32 0.25 0.05 0.893
• Postop1 0.07 0.84 0.40 0.38 0.465 • Postop2 0.09 0.31 0.22 0.12 0.593
• Postop2 0.08 0.57 0.23 0.23 0.068 NHR
NHR • Preop 0.08 0.20 0.12 0.04
• Preop 0.11 0.15 0.13 0.01
• Postop1 0.13 0.15 0.13 0.01 0.893
• Postop1 0.08 0.14 0.11 0.03 0.109
• Postop2 0.11 0.15 0.13 0.02 1.000
• Postop2 0.10 0.14 0.13 0.02 0.715 SPI
SPI • Preop 12.41 42.69 26.15 12.45
• Preop 10.23 92.84 28.31 23.28 • Postop1 11.63 44.68 21.31 13.47 0.345
• Postop1 14.99 38.25 29.38 10.05 0.068 • Postop2 18.74 44.70 29.00 13.79 0.593
• Postop2 11.99 46.62 28.73 14.17 0.273

Table 6
Table 4 Comparison of pre-operative (preop) and post-operative (postop)
Comparison of pre-operative (preop) and post-operative (postop) (postop1 = within 2 weeks, postop 2 = more than 3 months) voice analysis
(postop1 = within 2 weeks, postop 2 = > 3 months) voice analysis (non-nasal (non-nasal speech) for patients with CRS without polyps. Both postop com-
speech) for patients with nasal polyposis. Both postop comparisons were done parisons were done with the preop values. * = p < 0.05.
with the preop values. * = p < 0.05.
Parameters Min Max Mean SD p-Value
Parameters Min Max Mean SD p-Value
F0 (Hz)
F0 (Hz) • Preop 126.20 241.19 177.08 48.56
• Preop 100.08 234.68 140.98 44.16 • Postop1 128.18 236.28 167.24 47.63 0.225
• Postop1 99.69 252.08 153.54 68.13 0.465 • Postop2 130.53 197.16 163.85 47.12 0.180
• Postop2 106.19 153.14 133.29 19.66 0.273 Jita (μs)
Jita (μs) • Preop 21.73 99.13 60.31 27.15
• Preop 23.94 201.67 92.23 57.07 • Postop1 23.14 64.73 41.92 19.75 0.080
• Postop1 24.96 132.11 63.54 48.69 0.144 • Postop2 23.14 60.34 41.74 26.30 0.200
• Postop2 27.30 248.91 108.92 101.66 0.715 ShdB (dB)
ShdB (dB) • Preop 0.15 0.48 0.34 0.12
• Preop 0.20 0.77 0.35 0.17 • Postop1 0.13 0.55 0.27 0.17 0.080
• Postop1 0.16 0.83 0.38 0.31 0.715 • Postop2 0.13 0.23 0.18 0.72 0.180
• Postop2 0.25 0.74 0.44 0.24 0.715 NHR
NHR • Preop 0.11 0.16 0.13 0.02
• Preop 0.11 0.21 0.15 0.03 • Postop1 0.11 0.16 0.14 0.02 0.893
• Postop1 0.11 0.19 0.14 0.03 1.000 • Postop2 0.11 0.13 0.12 0.01 0.180
• Postop2 0.14 0.20 0.17 0.03 0.715 SPI
SPI • Preop 7.52 21.20 12.46 5.77
• Preop 6.76 43.73 20.81 12.08 • Postop1 7.62 17.59 12.17 4.72 0.345
• Postop1 10.34 33.82 18.30 10.62 0.715 • Postop2 7.89 16.62 12.26 6.17 1.000
• Postop2 10.63 40.43 23.97 15.39 0.068

described their voice as “more nasally”, “less clear” or “worse than

non-nasal speech respectively in patients with CRS without polyps.
It was also found that the post-operative changes in SPI values for
nasal sounds during early follow-up between patients with nasal poly-
posis and CRS without polyps were statistically significant (p = 0.032).
Comparisons of changes in other acoustic parameters' values between
patients with both pathologies were not statistically significant
(Table 7).
3.3. Subjective analysis of voice changes by questionnaire
Pre-operatively, 30% of the patients and 40% of their friends or
relatives noticed a change in their voice due to nasal polyposis, whereas
33.3% of patients and 16.7% of their friends or relatives noticed a
change in their voice from CRS without polyps. Majority of the patients
usual”.
During the immediate post-operative period (within two weeks), the
rates of subjective change in voice were 20% according to patients
themselves and 40% according to their friends or relatives for those
with nasal polyps. Most patients described their voice as “less nasally”
or “back to normal”. On the other hand, there were no subjective
changes or improvements noticed by patients or their friends or re-
latives in patients with CRS without polyps.
The rates of subjective change in voice after three months were 30%
according to patients and 30% according to others in patients with
nasal polyposis. Majority of patients described their voice as “im-
proved” or “back to normal” but one patient described his voice as
“became more nasally after surgery”. Again, no subjective change was
noticed in patients or others in those with CRS without polyps.

3
E.H.C. Wong and A.W. Chong Am J Otolaryngol xxx (xxxx) xxxx

Table 7 late, nasal and non-nasal sounds). In patients with CRS without polyps,
Comparison of pre-operative (preop) and post-operative (postop) there was a statistically significant increase in F0 (p = 0.043) in nasal
(postop1 = within 2 weeks, postop 2 = more than 3 months) voice analysis sound during early follow up. However, at long term follow up, there
(nasal and non-nasal speech) for patients with CRS without polyps. was no significant changes in F0 found. Changes in all other parameters
* = p < 0.05.
for this category were not statistically significant.
Parameters Nasal (p-value) Non-nasal (p-value) For nasal speech, the changes in SPI values were also found to be
statistically significantly different (p = 0.032) between patients with
F0 (Hz)
• Postop1 0.413 0.556
nasal polyposis and CRS without polyps during early follow-ups.
• Postop2
Jita (μs)
0.533 0.533 Sinus surgeries can result in a decrease in mucosal surface area, an
increase in paranasal sinus volume and a widened nasal passages,
• Postop1 0.730 0.905 which in turn decrease the nasal airway resistance [3–5]. This results in
• Postop2
ShdB (dB)
0.800 0.533
a decrease in acoustic damping and an increase in acoustic coupling

• Postop1 0.413 0.190

•
NHR
Postop2 1.000 0.133
• Postop1 0.413 1.000
•
SPI
Postop2 1.000 0.267
• Postop1 0.032* 0.730
• Postop2 0.800 0.133
4. Discussion
Many sinus surgeons have patients reporting voice quality changes
following surgeries to their paranasal sinuses with some patients even
being identified perceptually, based on their specific speech nasality, as
having a long “sinus history” [6]. Even though FESS is a minimally
invasive procedure, it can change the acoustic characteristics of vocal
tract and produce significant increase in nasality of patients [3].
Many studies measuring effects of various pathologies (chronic
rhinosinusitis, adenoid vegetation, velopharyngeal insufficiency and
nasal polyposis) on nasalance have been conducted [3,5,8,9], sug-
gesting that sinuses are important resonator for the voice. Nasalance
scores after application of nasal decongestants have also been assessed
in several studies [8,9]. Many studies have also found significant
changes in nasalance after sinus surgeries [3,5,13]. However, Kim et al.
[2,7] found that even though patients' nasality increased significantly at
one month post-operatively, the nasality returned to pre-operative level
at 3 to 6 months post-operatively after proper healing [7]. Besides that,
there have also been many studies [6,11] that investigated the change
in formants frequency and amplitude before and after endoscopic sinus
surgeries.
Computer-based acoustic analysis is normally used for study of
vocal dysfunction, measuring the acoustic signal properties of a spoken
speech [1]. They provide objective information about human voice
instead of subjective data (such as with perceptual ratings of voice
quality) [1].
From literature review, there were only two other studies that in-
vestigated the change in acoustic parameters before and after endo-
scopic sinus surgeries. Acar et al. [1] evaluated the effect of endoscopic
sinus surgery on acoustic parameters in patients with nasal polyposis
with various stages of nasal obstruction. They found an increase in F0
and reduction in jitter, shimmer and NHR post-operatively for Stage I
and II polyposis, and an increase in F0, jitter, shimmer and NHR post-
operatively in Stage III polyposis. However, these were all not statisti-
cally significant. They have, however, found statistically significant
post-operative changes in shimmer values between Stage III patients
(increased shimmer post-operatively in non-nasal vowel sound) and
Stage I and II patients [1].
Kim et al. [7] studied the change in nasalance, GRBAS scores and
acoustic parameters pre-operative, one month and three months post-
FESS with or without septoturbinoplasty. They found no statistically
significant changes in all the measurements of F0, vF0, jitter, shimmer,
vAM and NHR measured at the three timelines.
In our study, we have not found any statistically significant changes
of the acoustic parameters in patients with nasal polyposis (early and
with the paranasal sinuses, causing an increase in nasal acoustic energy
and nasalance [2,14]. Therefore, even though these surgeries does not
affect the larynx, they can result in changes to the structure of the vocal
tracts and resonance of the voice production, which in turn, change the
quality of the voice [2].
However, the effect of resonance changes on voice production by
the laryngeal glottis and vibrating vocal cords remains unclear where
there might be compensatory mechanisms in patients with nasal poly-
posis on vocal cords and laryngeal glottis due to gain in the phonetic
feature of normal speech that were familiar to the patients [1]. For
example, Acar et al. [1] found that changes in the nasal resonance could
cause development of adaptive mechanisms large enough to affect the
voice in phonatory and resonatory systems. The recovery of post-op-
erative hypernasality may be explained by the recovery of the sinonasal
mucosa, which leads to normalization of the mucosa vibration and
dampening function [2].
Patients' perception of post-operative voice changes is considered an
important component of outcome assessment in voice disorders [15],
especially in benign diseases due to its impact on quality of life [14],
however, it has received limited emphasis when it comes to endoscopic
sinus surgeries. Hosemann et al. [6] found that only 29% of patients or
their relatives noticed a change in their voice quality after endoscopic
sinus surgery. On the other hand, Chen et al. [11] found that most
patients did not notice a change in their voice until others pointed out
to them, usually over the telephone, with some patients described their
voice being “deeper”, “less nasal” or the speech became “more in-
telligible” after surgery. 70 to 95% of patients felt their spoken vowels
of “i” were less nasally, whereas 60 to 80% perceived their spoken
vowels of “ae” to be more nasally after sinus surgery [11]. In our study,
only 20 to 30% of patients with nasal polyposis perceived a subjective
change in their voice post-operatively, which could be explained by the
fact that a single change in the voice production system may not ne-
cessarily cause vocal resonance to be perceived differently [14]. On the
other hand, none of the patients with CRS without polyps noticed any
subjective changes in their voice during both early and late post-op-
erative follow-ups.
Our findings from this study have useful clinical applications.
Professional voice users frequently enquire about possibility of voice
changes after their operations. We demonstrated that vocal quality may
change in the immediate post-operative period in patients with CRS
without polyps, although these changes became insignificant after three
months. Clinicians can therefore inform patients, especially profes-
sional voice users, about this potential effect and at the same time, re-
assure them that their voice quality may return to normal after a period
of time. For subjective perception of voice changes, our study showed
that 20–30% of patients with nasal polyps perceived a change in their
voice post-operatively (both immediate and long-term). However, ma-
jority of these changes were positive ones, where patients or their re-
latives described the change as “improved” or “back to normal”.
Therefore, clinicians can provide this important information during pre-
operative counselling of patients as well.
Limitations of our study include the small sample size; each surgery
being performed by different surgeons and lack of objective quantifi-
cation of size of sinus opening after surgeries. It may be useful to

4
E.H.C. Wong and A.W. Chong
correlate the rate of changes in the voice parameters with the size of
sinus opening post-operatively to guide us on the extent of ostium
widening during operation in the future. Besides that, there were also
no professional voice users in this cohort, where subjective perception
of voice changes is more important. However, we believe this sample of
patients represent the usual group of population we operate on, who
also relies on their voices in their daily work. There is also a need to
establish the normative values of acoustic parameters for local popu-
lation as the normative reference in the MDVP software were adapted
for the Western population [16].
5. Conclusion
Patients with nasal polyposis and CRS without polyps were found to
have changes in acoustic parameters after endoscopic sinus surgeries.
The changes in soft phonation index (SPI) values between the two
groups were statistically significant during early follow-ups. Clinicians
should inform all patients, especially voice professionals as well as
regular voice users about the possible effects of endoscopic sinus sur-
geries on their voice quality. However, more studies with bigger sam-
ples and longer follow-ups are required to further investigate this field.
Funding source
None.
CRediT authorship contribution statement
Eugene Hung Chih Wong:Formal analysis, Investigation, Data
curation, Writing - original draft, Writing - review & editing.Aun
Wee Chong:Conceptualization, Methodology, Resources, Writing -
review & editing, Supervision.
Am J Otolaryngol xxx (xxxx) xxxx
Declaration of competing interest
None.
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