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Letter to Editor on “Changes in Acoustic Aspects of Voice Function in Children After Adenotonsillectomy”

      We read with great interest the article by Brkic et al on changes in Acoustic Aspects of Vocal Function in Children After Adenotonsillectomy.
      • Brkic FF
      • Liu DT
      • Campion NJ
      • et al.
      Changes in acoustic aspects of vocal function in children after adenotonsillectomy.
      They have reported significant differences in the fundamental frequency, jitter, shimmer and harmonic noise ratio immediately after surgery.
      • Brkic FF
      • Liu DT
      • Campion NJ
      • et al.
      Changes in acoustic aspects of vocal function in children after adenotonsillectomy.
      Of these the fundamental frequency was the earliest to return to normal in one month. This finding is used to allay the concerns of the parents regarding voice change. We commend the authors for sharing their valuable experience with voice change after adenotonsillectomy. However, we believe that nasalance is an important component of voice and change in nasalance can affect voice quality perceived by the parents. This has not been commented by the authors. We would like to share our preliminary experience with 27 children who underwent adenotonsillectomy for chronic adenotonsillitis at our center. Pre and 1 month postoperative nasalance was measured in these children with the Nasal View (Tiger Electronics Inc, Seattle, Washington).The children were asked to repeat six standardized sentences (two oral, two nasal and two oro-nasal sentences) in their normal pitch, rate and loudness and the mean of three readings was calculated.
      • Pokharel A
      • Naina P
      • Sebastain S
      • Syed KA
      • John M
      • Varghese AM
      Normative nasalance scores in Tamil-speaking Indian children.
      The average age of children in our study was 6.4 years (5.2-7.6 yrs) and the male female ratio was 1.25:1. Analysis of the pre and post op scores by paired t test showed a significant increase change in nasalance after surgery in oral, oronasal and nasal sentences with p values highly significant for nasal and oronasal sentences(P = <0.001) (Table 1). While an increase in nasality has been reported after adenoidectomy, the results after tonsillectomy are conflicting.
      • Subramaniam V
      • Kumar P.
      Impact of tonsillectomy with or without adenoidectomy on the acoustic parameters of the voice: a comparative study.
      • Williams RG
      • Preece M
      • Rhys R
      • et al.
      The effect of adenoid and tonsil surgery on nasalance.
      • Maryn Y
      • Van Lierde K
      • De Bodt M
      • et al.
      The effects of adenoidectomy and tonsillectomy on speech and nasal resonance.
      Adenotonsillectomy is a common surgery in childhood .Parents often have major apprehensions about its post-operative complications especially regarding voice change.
      • Inja RR
      • Paul RR
      • Varghese L
      • et al.
      Voice change following adenotonsillectomy in pediatric population: myth or reality?-A pilot study.
      A study with similar objectives as the authors published by Inja et al from our center found no objective changes in voice parameter after surgery but subjective assessment by the Pediatric Voice Outcome Score questionnaire showed significant change in voice quality.
      • Inja RR
      • Paul RR
      • Varghese L
      • et al.
      Voice change following adenotonsillectomy in pediatric population: myth or reality?-A pilot study.
      Our preliminary results demonstrate that there is a change in nasalance after adenotonsillectomy which could explain the change in subjective measures of voice change. Liu et al also did not note any change in voice acoustic index after surgery but noted positive changes in the aerodynamic function.
      • Liu X
      • Zheng Y
      • Tian P
      • et al.
      The impact of tonsillectomy with or without adenoidectomy on voice: acoustic and aerodynamic assessments.
      Voice is a function of sound generators, sound vibrators and sound resonators. We recommend that including nasalance in voice evaluation will help the ENT fraternity to better address the concerns of parents regarding voice change after adenotonsillectomy.
      TABLE 1Nasalance Values Before and After Adenotonsillectomy
      Pre-op Mean nasalance Post-op Mean Nasalance 95% Confidence Interval
      Sentences Lower Upper t P value
      Oral 1 35.47 36.92 -2.42497 -.48293 -2.980 0.004(<0.05)
      Oral 2 36.61 37.40 -1.51813 -.07100 -2.185 0.032(<0.05)
      Nasal 1 56.25 61.45 -6.06439 -4.33932 -12.002 <0.001
      Nasal 2 54.93 60.96 -6.92572 -5.12094 -13.283 <0.001
      Oronasal 1 45.27 51.35 -6.76264 -5.38896 -17.604 <0.001
      Oronasal 2 44.91 50.91 -6.78758 -5.21686 -15.209 <0.001
      This change in nasalance was found to be statistically significant for all oral, oronasal and nasal sentences.
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      REFERENCES

        • Brkic FF
        • Liu DT
        • Campion NJ
        • et al.
        Changes in acoustic aspects of vocal function in children after adenotonsillectomy.
        J Voice. 2020; (S0892-1997(20)30239-3. https://doi.org/10.1016/j.jvoice.2020.06.022)
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        • Naina P
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        Normative nasalance scores in Tamil-speaking Indian children.
        Logoped Phoniatr Vocol. 2020; 3: 1-6
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        • Kumar P.
        Impact of tonsillectomy with or without adenoidectomy on the acoustic parameters of the voice: a comparative study.
        Arch Otolaryngol Head Neck Surg. 2009; 135: 966-969
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        • Preece M
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        Clin Otolaryngol Allied Sci. 1992; 17: 136-140
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        The effects of adenoidectomy and tonsillectomy on speech and nasal resonance.
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        • Paul RR
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        Voice change following adenotonsillectomy in pediatric population: myth or reality?-A pilot study.
        Indian J Otolaryngol Head Neck Surg. 2019; 71: 574-579
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        The impact of tonsillectomy with or without adenoidectomy on voice: acoustic and aerodynamic assessments.
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