Brazilian
Journal
of
OTORHINOLARYNGOLOGY
www.bjorl.org
ORIGINAL
ARTICLE
Larynx
cancer:
quality
of
life
and
voice
after
treatment
夽
,
夽夽
Vaneli
Colombo
Rossi
a,∗,
Fernando
Laffitte
Fernandes
b,
Maria
Augusta
Aliperti
Ferreira
b,
Lucas
Ricci
Bento
b,
Pablo
Soares
Gomes
Pereira
b,
Carlos
Takahiro
Chone
baSpeechTherapyRehabilitationafterHeadandNeckSurgery,UniversidadeEstadualdeCampinas(UNICAMP),Campinas,SP,Brazil bDisciplineofOtorhinolaryngology,HeadandNeck,UniversidadeEstadualdeCampinas(UNICAMP),Campinas,SP,Brazil
Received1September2013;accepted15April2014 Availableonline22July2014
KEYWORDS
Laryngealneoplasms; Voice;
Squamouscell carcinoma
Abstract
Introduction:Treatmentsforpatientswithlaryngealcanceroftenhaveanimpactonphysical,
social,andpsychologicalfunctions.
Objective: Toevaluate quality oflife andvoice inpatients treatedfor advancedlaryngeal
cancerthroughsurgeryorexclusivechemoradiation.
Methods:Retrospectivecohortstudywith30patientsfreefromdisease:tentotallaryngectomy
patientswithoutproductionofesophagealspeech(ES);tentotallaryngectomypatientswith
tracheoesophagealspeech(TES),andtenwithlaryngealspeech.Qualityoflifewasmeasured
by SF-36,Voice-RelatedQualityofLife(V-RQOL),andVoice HandicapIndex(VHI)protocols,
appliedonthesameday.
Results:TheSF-36showedthatpatientswhoreceivedexclusivechemoradiotherapyhadbetter
qualityoflifethantheTESandESgroups.TheV-RQOLshowedthatthevoice-relatedquality
oflifewaslowerintheESgroup.IntheVHI,theESgroupshowedhigherscoresfor overall,
emotional,functional,andorganicVHI.
Discussion: Qualityoflifeandvoiceinpatients treatedwithchemoradiotherapy wasbetter
thaninpatientstreatedsurgically.
Conclusion: Thetypeofmedicaltreatmentusedinpatients withlaryngealcancercanbring
changesinqualityoflifeandvoice.
© 2014Associac¸ãoBrasileira de Otorrinolaringologiae CirurgiaCérvico-Facial. Publishedby
ElsevierEditoraLtda.Allrightsreserved.
夽
Pleasecitethisarticleas:RossiVC,FernandesFL,FerreiraMA,BentoLR,PereiraPS,ChoneCT.Larynxcancer:qualityoflifeandvoice aftertreatment.BrazJOtorhinolaryngol.2014;80:403---8.
夽夽Institution:DisciplineofSpeechTherapyandOtorhinolaryngology,HeadandNeck;FaculdadedeCiênciasMédicas(FCM)Hospitaldas
Clínicas(HC)---UniversidadeEstadualdeCampinas(UNICAMP),Campinas,SP,Brazil. ∗Correspondingauthor.
E-mail:vanelicolombo@ig.com.br(V.C.Rossi).
http://dx.doi.org/10.1016/j.bjorl.2014.07.005
PALAVRAS-CHAVE
Neoplasiaslaríngeas; Voz;
Carcinomadecélulas escamosas
Câncerdelaringe:qualidadedevidaevozpós-tratamento
Resumo
Introduc¸ão:Tratamentosparapacientescomcâncerdelaringepodemtergrandeimpactona
func¸ãofísica,socialepsicológica.
Objetivo:Avaliarqualidadedevidaevozdepacientestratadosdecânceravanc¸adodelaringe
pormeiocirúrgicoouquimioradioterapiaexclusiva.
Métodos: Estudocoorteretrospectivocom30pacienteslivresdadoenc¸a:sendo10
laringec-tomizadostotaissemproduc¸ãodevoz esofágica(SVE);10 laringectomizadostotaiscomvoz
traqueoesofágica(VTE)e10comvozlaríngea.Aqualidadedevidafoimensuradapelos
proto-colosSF-36;QualidadedeVidaemVoz(QVV)eÍndicedeDesvantagemVocal(IDV),aplicados
nomesmodia.
Resultados: NoSF-36,observou-sequepacientesquereceberamquimioradioterapiaexclusiva
apresentammelhorqualidadedevidadoqueogrupodeVTEeSVE.NoQVVobservou-seque
aqualidadedevidarelacionada àvozémenornogrupoSVE.NoIDVgrupo,SVE apresentou
escoremaiorparaIDVtotal,emocional,funcionaleorgânica.
Discussão: Qualidadedevidaevozdospacientestratadoscomquimioradioterapiaémelhordo
queospacientestratadoscirurgicamente.
Conclusão:Otipodetratamentomédicoutilizadoempacientescomcâncerdelaringepode
trazeralterac¸õesnaqualidadedevidaevoz.
©2014Associac¸ãoBrasileira deOtorrinolaringologiaeCirurgiaCérvico-Facial.Publicadopor
ElsevierEditoraLtda.Todososdireitosreservados.
Introduction
The World Health Organization defines quality of life as completephysical, social,andmentalwell-being,andnot justabsenceof disease.1The voice,asamajorvehicleof
communication, plays a key role in the quality of life of patients,andshouldbeconsideredasanindicatorofhealth ordisease.2
Treatmentsforpatientswithlaryngealcancercanhave amajorimpactonphysical,social,andpsychological func-tion,thusalteringtheirqualityoflife.3Toknowtheimpact
thattreatmentcanhaveonqualityoflifeofpatientswith laryngealcancerisofutmostimportanceforcliniciansand researcherswhoaimnotonlytocuretheirpatients,butalso toachievetheircompletewell-being.
Laryngeal cancer is one of the most common types toaffect the upper airways.4 It represents 25% of
malig-nant tumors of the head and neck, and affects mainly men.5Althoughsurvivalisthemaininterestconcerningthe
patient’s treatment, other parameters such as quality of life,speech,voicefunction,andcomplicationsoftreatment areimportantwhentherapiesarecompared,suchassurgery andchemoradiation.6
Two types of treatment are used when patients are diagnosed with advanced laryngeal cancer: exclusive chemoradiationor totallaryngectomy.When theselected option is total laryngectomy, the patient’s voice is com-pletely lost,with consequent problems in communication andpersonalinteractions.6
Communication is an essential part of social life.7
Although it appears that patients with laryngeal preser-vation have better quality of life, the toxic effects of chemoradiationand scarringaftertreatments canlead to
hoarseness,dysphagia,orpain,whichcanaffectqualityof life.8
Bothchemoradiationandtotallaryngectomyaffect qual-ity of life, although in different ways.9 For patients
who undergo total laryngectomy as treatment modal-ity, there are three possibilities for vocal rehabilitation: esophageal speech (ES), tracheoesophageal speech (TES), and electronic larynx. The first two are the most often used.10 Patients who were rehabilitated with
tracheoe-sophageal prosthesis have a significantly higher speech patternwhencomparedtopatientswhousedothermethods of communication.11 Total laryngectomy brings functional
limitations totheindividual,andthesedonot necessarily translateintopoorerqualityoflife.Inasurveyconducted in2010,theauthorsobservedsignificantchangesinspeech anddeglutitionfunctions in patientstreated forlaryngeal cancer.5
Several questionnaires have been developed to assess the health and quality of life of patients with chronic diseases, and may be used in patients with laryngeal cancer. These questionnaires have been used in previous studies,7,12---16 such as: SF-36 --- this is a multidimensional
indailyactivitiesorwork;andmentalhealth(MH),onthe generalmentalhealthstatus,includinganxiety,depression, andmood.Ithasafinalscorerangingfrom0to100,where 0 corresponds totheworst general health status and100 to the best health status. This questionnaire has been translatedandvalidatedforBrazilianPortuguese.17
Voice-relatedQualityofLife(V-RQOL)---theV-RQOLhas been translated and validated for Brazilian Portuguese.18
This questionnaire contains ten questions covering two domains: social---emotional and physical functioning. The scorefor each question ranges from1 to5,where 1 rep-resents ‘‘not a problem’’ and 5 ‘‘a very big problem.’’ The calculation of the final score is made based on the rulesemployedinseveralquestionnairesonqualityoflife. A standard scoreis calculatedfrom theraw score, and a highervalueindicatesthatthequalityoflifeaspectsarenot impairedbythevoicefunctionality.Themaximumscoreis 100(bestqualityoflife),andtheminimumscoreis0(worst qualityof life),both for a particular domain,and for the overallscore.
IDV--- aprotocolthatevaluatestheVoiceHandicapIndex (VHI),translatedandvalidatedforBrazilian Portugueseas IDV.19 It consists of 30 items that assesses three areas:
functional, organic, and emotional, with ten items each, aimedtotheconceptofdisadvantage.Thescores are cal-culated using simple summation, and may vary from 10 to120; thehigherthe value, thegreater thevoice hand-icap. Scores from 0 to 30 are considered low, indicating that there is a probable alteration associated with voice inadequacy;31---60,moderatechange invocalinadequacy; 61---120,asignificantlyseveredeteriorationofavoice prob-lem.
Thus,theaimofthisstudywastoevaluatequalityoflife andvoiceofpatientstreatedforadvancedlaryngealcancer, andtocorrelateitwiththetreatmentmodalitiesusedfor thesepatients.
Materials
and
methods
Participants
This study was submitted and approved under number 528/2011 by the institution’s ResearchEthics Committee. Patient recruitment was conducted through the Hospital Cancer Registry. The data collection was performed from Januaryof2000toJanuaryof2008.Duringthisperiod,257 patientswerediagnosedwithlaryngealcancer.Theinclusion criteriawere:patientswithtumorstageT3andT4;patients treatedforlaryngealcancer;withnoassociated neurologi-calalterations;patientswithoutevidenceofdiseaseforat leastfouryears.
Patientswithmetastases,tumorrecurrence,tumorstage T1andT2,presenceof residualdisease,tracheostomy,or requiringfeedingthroughanasogastricorgastrostomytube were excluded from the study. Of the 257 patients with laryngealtumors,only153(59.53%)hadtumorstageT3and T4.OfthetotalsampleofT3andT4stages,only73(47.71%) werealiveatthetimeofthestudy.Patientsincludedinthe studywerecontactedbytelephoneinJanuaryof2012.
Of the 73 patients invited,only 36 (49.31%) agreed to participate.Inordertohavegroupswiththesamenumber
ofpatients,thefirst30patientswhoansweredthecallwere enrolled.Ofthese,28(80%)weremenandtwo(20%)were women, agedbetween 45 and 85 years (mean65 years). Patientsweregroupedbytypeoftreatment:thefirstgroup (G1)consistedoftenpatientssubmittedtototal laryngec-tomy(sixwithradiotherapyandfourwithoutradiotherapy) and who communicated by writing or gestures; the sec-ondgroup(G2)consistedoftenpatientssubmittedtototal laryngectomy(fivewithradiotherapyandfivewithout radio-therapy) andwho usedtracheoesophageal prosthesis; the thirdgroup(G3)consistedoftenpatientswhoweretreated withexclusivechemoradiationandhadpreservedlarynx.
Theproceduresperformedwere:applicationoftheSF-36 protocoltomeasurequalityoflifeofindividuals;application oftheVR-QOLtoverifythequalityoflifeandvoice; appli-cationof theVHI toassess thevoicehandicap index;and alsovocal self-evaluationandauditoryperceptionanalysis ofindividuals’generallevelofthevocalquality.
The SF-36, VR-QOL, and VHI protocols were applied on the same day in all participating subjects. Question-naire applications and voice analyses were performed by four speech therapists specialized in vocal rehabilitation of patients withhead and neck malignancies. Data inter-pretationwasperformed byateamcomprisingtwoofthe speechtherapistsandtwootorhinolaryngologistsspecialized inheadandnecksurgery.
Forvocal self-assessment, subjects were instructed to assess what they thought of their own voice, through a three-point scale: (1) good; (2) moderate; and (3) poor. At the auditory perception analysis (APA), the individuals had their voices recorded in a laptop (Samsung Intel®
AtomTM CPUN455@1.66Hz 1.67GHz), using the software
SoundForge® (Sony Creative Software Inc.), release 4.5.
Recordings were performed with a headset microphone (Bright®)positionedatafixeddistance offivecentimeters
fromthemouth, inanacoustically treatedroom.The fol-lowingsamples werecollected: sustained‘‘A’’ voweland countingnumbersfrom1to10,attheusualfrequencyand intensity.
Theauditoryperceptionanalysiswasperformedbyfour speechtherapists,whowereawarethatthestudy popula-tionconsistedofindividualstreatedforadvancedlaryngeal cancer,butwereunawareofthetreatmentoptionused,as thevoiceswererecordedandtheydidnothaveeyecontact withpatients.Thespeechtherapistswereinstructedto clas-sifyvoices throughathree-pointscale byselectingoneof thefollowingalternatives:(1)good;(2)moderate;and(3) poor. The voices were recorded and then played through speakersinanacousticallytreatedroom.
Thechi-squaredtestorFisher’sexacttest(forexpected values <5) were used to compare categorical variables betweenthethreegroups,whereastheKruskal---Wallistest was used to compare numerical variables between the three groups, due to the absence of normal distribution of variables. Concordance analysis of the assessment of patients’ voices between speech therapists was assessed with the intraclass correlation coefficient (ICC). The Wilcoxon’stest for related sampleswas used tocompare theassessmentofthespeechtherapistsandpatient’s self-evaluation.
Table1 ComparisonoftheitemsoftheSF-36questionnaireaccordingtostudygroup.
G1(novoice) G2(TES) G3(laryngealvoice) pa
Age 65.8 65.10 61.60 0.534
Functionalcapacity 85.0 84.50 88.50 0.970
Physicalaspects 65.0 100 77.50 0.100
Pain 68.6 81.80 90.10 0.035
Overallhealthstatus 84.10 87.50 88.30 0.847
Vitality 90.0 81.50 74.50 0.054
Socialaspects 95.0 100 83.50 0.152
Emotionalaspects 63.33 93.33 80.0 0.230
Mentalhealth 86.80 83.60 76.40 0.199
SF-36questionnaireonqualityoflife,whereascorecloserto100indicatesbetterqualityoflifeandscoreclosertozero,poorerquality oflife;Novoice,patientssubmittedtototallaryngectomy,withoutvoice;TES,patientssubmittedtototallaryngectomyrehabilitated withvoiceprosthesis,withtracheoesophagealspeech.
aKruskal---Wallistest.
Table2 ComparativestatisticalanalysisoftheQVVquestionnaireitemsaccordingtothestudygroup.
G1(novoice) G2(TES) G3(laryngealvoice) pa
TotalQVV 43.45 78.0 93.50 0.001
Totalphysical 48.13 84.38 96.25 0.031
Totalemotional 41.63 73.73 90.83 0.001
QVV,qualityoflifeandvoicequestionnaire,wherescorescloseto100indicatebetterqualityoflifeandvoice;Novoice,patients submittedtototallaryngectomy,withoutvoice;TES,patientssubmittedtototallaryngectomy,rehabilitatedwithvoiceprosthesis,with tracheoesophagealspeech.
aKruskal---Wallistest.
Results
The overall quality of life of patients wasassessed using theSF-36.InTable1,it wasobserved thatallgroups pre-sentedchanges in qualityof life,but theonly items with significantdifferenceswerepainandvitality.G1complained moreoftenofpainthanG3,whichhadascorecloserto100. Regardingvitality,G3complainedofhavinglessvitality.
The results of SF-36 questionnaire demonstrated that patientstreatedsurgicallyandwhocommunicatedthrough gestures or writing complained more often of pain when compared with patients with tracheoesophageal prosthe-sisor treatedexclusivelywithchemoradiation.Itwasalso demonstrated that patients with total laryngectomy with tracheoesophagealprosthesisandexclusivechemoradiation therapyhadbetterqualityoflife,butvitalitywashigherin G1(Table1).
Data on Table 2 demonstrates that patients with tra-cheoesophagealprosthesishadbetterqualityoflifescores whencomparedwithG1(withoutvocalrehabilitation),but worsethanthegroupwithpreservedlarynx.
InTable3,regardingtheVHI,itcanbeobservedthatthe G1(withoutvoice)hadahigherscoreinallitems,showing thatpatients withnovoiceperceivethemselvesashaving amajorvocaldisadvantagecomparedtotheothergroups, whilepatientswithlaryngealvoicehadthelowestscoresin allitems.
Table4presentsthecomparativeanalysisofthe evalua-tionofspeechtherapistsandpatientself-assessment.There wasasignificantdifferencebetweentheself-assessmentof thepatient andthatmade byspeechtherapists1, 3,and 4,whosemeanassessmentswerelowerthanpatients’ self-assessment. There wasnosignificant correlation between theevaluationsof thefourspeechtherapists(ICC=0.108;
Table3 ComparativestatisticalanalysisoftheVHIquestionnaireitemsaccordingtothestudygroup.
G1(novoice) G2(TES) G3(laryngealvoice) pa
Totalhandicap 40.30 10.80 4.90 0.001
Emotionalhandicap 11.90 3.40 0.80 0.001
Functionalhandicap 19.60 5.20 2.10 0.001
Organichandicap 9.30 2.20 1.40 0.002
VHI,voicehandicapindex,wherescorescloserto100indicategreaterperceptionofvoicehandicap;novoice,patientssubmittedtototal laryngectomy,withoutvoice;TES,patientssubmittedtototallaryngectomy,rehabilitatedwithvoiceprosthesis,withtracheoesophageal speech.
Table4 Comparativestatisticalanalysisbetweenspeech
therapistsandpatient.
n Mean pa
Self-assessment 20 1.95
---ST1 20 1.55 0.021
ST2 20 1.95 1.000
ST3 20 1.50 0.003
ST4 20 1.50 0.003
MeanSTs --- 1.62
---ST,speechtherapist.
ThemeanassessmentbySTs1,3,and4waslowerthanpatients’ self-assessment(1.95).
a Wilcoxontest.
95%CI:−0.066to0.373;p=0.127).Therewasnosignificant
agreementbetweenexaminers.
Patientstreatedwithexclusivechemoradiationtherapy presentedsimilarresultstopatientswithtracheoesophageal prosthesisattheself-assessment(p=1.000).
Discussion
Itisdifficult toassess qualityoflife andvoiceofpatients treatedforadvancedlaryngealcancer,assessingthe medi-cal, psychological, and social impact on the life of each patientisdifficult, butit isessentialin ordertoestablish parametersofrehabilitationandsupport.5
TheSF-36isoneofthemostpopulartoolstoassess qual-ityoflifeincancerpatients,duetoitshighspecificityand reliability.17
Theresultsofthepresentstudysupportpreviousfindings thatthequalityoflifeofpatientsaftertotallaryngectomy forlaryngealcancersubmittedtovocalrehabilitationwith tracheoesophageal prosthesis may be similarto the qual-ityoflifeofpatientswhoreceivedchemoradiationtherapy, despitethe differentqualitiesofvoice.Inthese patients, notonlythetreatmentchoiceis relevantforagood qual-ityoflife,butalsothemethodofvoicerehabilitationafter surgery.6Thus,itwasobservedthatqualityoflifeofpatients
with tracheoesophageal voice was closer to the quality of lifeof patients whoreceived exclusivechemoradiation therapy,whereaspatientssubmittedtototallaryngectomy withoutvocalrehabilitationhadworsequalityoflife.This findingiscorroboratedbythestudyofClementsetal.,which observed a worse qualityof life in total laryngectomized patients who communicated through gestures.3
Success-fulspeechrehabilitationwithtracheoesophagealprosthesis aftertotallaryngectomy canbeaseffectiveastreatment withchemoradiationtherapyforlaryngealcancer,regarding psychosocialreintegrationandfunctionalability.20
Therefore, as demonstrated in the study by Giordano etal.,patientswithtracheoesophagealprosthesishad bet-terquality oflife whencompared withG1(without vocal rehabilitation), butworse when comparedwiththe group withpreservedlarynx.
In agreement with the study by Schuster et al., it wasobservedthatpatientswithtracheoesophagealspeech appreciatedtheirnewmethodofcommunication,butnotas muchaspatientswithapreservedlarynx.7Terrelletal.also
reportedthatpatientswhounderwentexclusive chemoradi-ationtendedtohavebetterqualityoflife,withbetterscores attheSF-36,whencomparedwithpatientswhounderwent totallaryngectomy.8
Whenthepatients’self-assessmentiscomparedwiththe evaluationmadeby speechtherapists,itcan beobserved that speech therapists found the voice of patients with tracheoesophagealspeech(Table 4)to betheworst, per-hapsdue toa morecriticalsense regardingvoicequality, astheself-assessmentofpatientsinbothgroupswas simi-lar.Thesefindingsaredifferentfromthoseinthestudyby Finizia et al.,which found a significant difference in the self-assessment of patients, where total laryngectomized patientswithtracheoesophagealprosthesisevaluatedtheir voicesasbeingworsethanpatientswithpreservedlarynx.4
Regardingqualityoflifeandvoice,theresultsindicate thatnot only the methodof treatment usedis important (total laryngectomy vs. chemoradiation), as well as the presence of vocal rehabilitation after total laryngectomy, astherewasa significant differencebetweenG1 andG2. Although patients in both G2 and G3 had a functioning voice,therewasnosignificant differencein vocalquality. G2,whose patientsuse atracheoesophageal prosthesis as amethodofcommunication,hasworsevoice-related qual-ityof life when compared topatients fromG3, whohad the larynx preserved, showing that the natural larynx is irreplaceable.
This finding differs from those by Finizia et al., who reportedthatthequalityoflifeofpatientswith tracheoe-sophagealprosthesiswasbetterthanthatofpatients who receivedradiotherapyalone,butitissimilartotheresultsof thestudiesbyOridateetal.andbyBoscolo-Rizzoetal.6,21,22
InthestudybyTerreletal.,allpatientssubmittedtototal laryngectomyhad, inthe long-term, considerabletime to readjusttotheirnewcondition,andthereforetheirscores couldbehigher, astheywere less worried about difficul-tieswith volume,clarity, andoverall abilityto speak.8 It
is believed that thisis due to thefact that patients sub-mittedtototallaryngectomy,astheylivedfor some time withoutvoice,losttheirauditorymemory;whentheyhave the opportunity of communication, the acquired voice is perceivedbythemasexcellent.
Patientswhoreceivedexclusivechemoradiationtherapy, as they are aware of their pretreatment voices, classify theirpost-treatmentvoicesasmoderatewhencomparedto thepre-treatment. Studiesdemonstratethatpatientswho underwenttotallaryngectomyaremoreconcernedwiththe physicalconsequencesofsurgeryandinterferenceinsocial activitiesthanwithimpairedcommunication.23Inthe
imme-diatepostoperativeperiod,patientsalreadyshowfunctional limitations.However,subsequently,whenthefearofdeath andtheuncertaintyofcurehavebeenovercome,individuals begintoobserveandassessthefunctionallimitations result-ingfromtheirtreatmentbyassigningpositiveandnegative pointsthatwilldirectlyinfluencetheirqualityoflife.
AccordingtoGomesandRodriguesetal.,total laryngec-tomized patients with tracheoesophageal prosthesis have better quality of life as, unlike patients with exclusive chemoradiationtherapy,theyundergospeechtherapy;this closecontactwiththetherapistcanbringapositive influ-encetothepatient’svocalperception.5Robertsonreported
undergospeechanddeglutitiontherapy,andthatthiscan impairtheirqualityoflife,whencomparedwithtotal laryn-gectomizedpatients.24
Whencomparingtheself-assessmentofpatientstreated solelywithchemoradiotherapy,withtotallaryngectomyand tracheoesophagealprosthesis,thepresentstudyobserveda differentresultthatbyFiniziaetal.,6whoreportedthatthe
vocalqualityofchemoradiationtherapyisbetterassessed by patients than total laryngectomized patients. Another importantqualityoflifefactoristheaspectofbeing disease-free,as itspresence influencesthe quality of life due to physical, social, and psychological negative impacts that treatmentfailurebringstothepatient.Ifagroupoftotal laryngectomized patients without voice, with voice, and preserved larynx, but withpersistent had been assessed, perhaps their quality of life would be worse than in the threegroups without the disease. Therefore, the cureof thediseaseitselfmustalsobeconsideredinthequalityof lifeassessment.
Conclusion
Regardingqualityof lifeandvoiceofthepatientstreated foradvancedlaryngealcancerandcurrentlydisease-free,it canbeconcludedthat:
1. Among thosesubmittedtototallaryngectomy,patients withtracheoesophagealprosthesishavebetterqualityof lifeandvoice.
2. Vocal self-assessment is similaramong patients under-going chemoradiation therapy and patients with tra-cheoesophagealprosthesis.However,intheaudiological assessment,thetracheoesophagealvoicehastheworst performance.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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