Qualidade de vida em voz de pacientes no pré-operatório de tireoidectomia

Objetivo: avaliar a qualidade de vida em voz de individuos encaminhados a tireoidectomia, antes da realizacao do procedimento. Metodos: participaram do presente estudo pacientes do sexo feminino de um hospital de referencia encaminhados para cirurgia de tireoide ou colelitiase. Os individuos foram subdivididos em: Grupo Estudo - 30 mulheres (media de 44,26 anos), encaminhadas para cirurgia de tireoidectomia parcial ou total; Grupo Controle - 30 mulheres (media de 45,3 anos), encaminhadas para cirurgia de colelitiase. Os participantes responderam um questionario de triagem e ao protocolo Qualidade de Vida em Voz. Os dados foram analisados estatisticamente por meio dos testes Fisher Two Tailed, Teste T de Student e coeficiente de correlacao de Pearson, adotando-se nivel de significância de 5%. Resultados: houve maior ocorrencia de queixa vocal (48,3%), e escores inferiores de qualidade de vida em voz em todos os dominios no grupo estudo, que no grupo controle. Na analise exclusiva ao grupo estudo, observou-se que o dominio fisico foi o mais afetado, com diferenca em relacao ao dominio socioemocional (p=0,002), havendo ainda correlacao positiva forte entre os escores dos dois dominios (r=0,047; p=<0,001). Conclusao: conclui-se que o grupo de mulheres com doencas tireoidianas pre-tireoidectomia estudado apresenta impacto negativo na qualidade de vida em voz, principalmente no que se refere ao dominio fisico, sendo que a medida que os acometimentos fisicos relacionados a voz acontecem, ha acometimento do dominio socioemocional.


INTRODUCTION
Thyroidectomy, the surgery to partially or total removing the thyroid, may cause voice deviations 1,2 with the manipulation of the larynx nerves close to thyroid, or other factors as the used technique in surgery and intubation 3 . But, in Speech-Language clinic practice, before the surgery procedure, is already observed the diseases associated to thyroid causing complaints of voice of endocrine etiology 1,4,5 .
These complaints are due to several factors: for instance, in hypothyroidism the increase of hyaluronic acid in vocal folds lamina propria may lead to fluid retention and thickening of vocal folds 6 ; in hyperthyroidism the results are believed to be resultant of the decrease in sub-glottic pressure caused by the weakness of breathing muscles, 7 and in diseases with the abnormal growth of thyroid the dysphonia may be caused by pressing the larynx nerve 8,9 . Some researches were already developed to evaluate the voice disorders faced by adult patients with thyroid disorders. In general, roughness, low voice, weak voice, strain while speaking, and deviated acoustic measures were observed 10-12 . However, there are still few information about the voice self-assessment and quality of life of subjects with dysphonia caused by thyroid disease, even before thyroidectomy 5,13 . This result may have big importance to designing clinic actions to this population, whether necessary.
Therefore, the purpose to the current study was to assess the voice-related quality of life of patients with indication of thyroidectomy, before the surgery procedure. The target-population was female, from 18 to 59 years, patients of reference hospital placed in Curitiba/ Paraná-Brazil. The subjects were divided in two groups: Experimental Group (EG) -30 women with indication of partial or total thyroidectomy; Control Group (CG) -30 women with indication of cholelithiasis (gallstones). The option for the gallstones disease to CG was made due to lack of injury or symptoms related to phonation in literature 14,15 .

METHODS
The participants were invited to join the research at the hospital, in the booking surgery department, when identifying one of the two surgeries, quoted above, besides the invitation, an explanation of the research purposes and clarifying doubts were made, followed by the informed consent signed by the patient.
Were exclusion criteria for both groups: smoking history (past or present), benign or malign lesion in vocal folds history, hearing complaint, neurologic or psychiatric disorders history, professional voice use in the elite voice professional categories and speaking voice professional 16 . To EG were excluded yet the participants that have already had partial thyroidectomy or previous iodotherapy, or voice complaint for a long time before the thyroid disease diagnosis. Were admitted, for both groups, participants just having co-morbidities without direct relation to voice disorders (arterial hypertension -n=1 in CG and n=1 in EG; diabetes -n=1 in CG; and rheumatoid arthritis -n=1 in CG).
In order to apply the inclusion and exclusion criteria, the subjects answered to a screening questionnaire made by the researchers with the following data: identification, general health, presence or absence of vocal complaint, physician diagnosis of thyroid disturbance. After the screening, the subjects were addressed the Voice-Related Quality of Life questionnaire (V-RQOL). The questionnaire has ten questions divided in three domains: socio-emotional, physical, and total. The patients were guided to read each question and sign, using Likert scale of five point, how the sentence negatively impact the quality of life, as one stating "not a problem" and five stating "problem is 'as bad as it can be'". The calculus is performed using a specific algorithm and maximum punctuation is 100 points 17 . The most sensitive and specificity cohort point is 91.25 18 to detect subjects with and without health voices, and as higher the punctuation higher the voice-related quality of life 17 .
Data were charted and the variables were statistically analyzed. To compare the groups regarding voice complaint the Two Tailed Fisher test was used. The t-student test was used in the comparison of groups regarding the mean scores in three domains, after normality distribution. Regarding the analysis performed exclusively to EG, the t-student Test was used to compare the physical and socio-emotional domains means of V-RQOL, and the Pearson correlation coefficient was used to correlate the scores of these domains. The significance level adopted to all analysis was 5%.
The results showed more voice complaint in EG than CG (p=<.001) - Table 1. In addition, the voice-related quality of life scores were lower in EG to all domains: physical (p=<.001), socio-emotional (p=.002), and total (p=<.001) - Table 2.  Analyzing exclusively the EG, it was observed the physical domain was the most impaired compared to the socio-emotional domain (p=.002) - Table 3.
There was yet the positive and strong correlation of the physical and socio-emotional domains scores of V-RQOL (r=.847, p=<.001) - Figure 1.  24 . It is believed the big occurrence of voice complaint in subjects' pre thyroidectomy happens because, according to literature, regardless the thyroid disease type, it may have physiologic disturbances related to phonation system, whether in voice or breathing level [5][6][7][8][9] . Among the main voice disorders present in thyroid diseases, the most common are: decrease of loudness, vocal fatigue, decrease of fundamental frequency (especially in women), roughness, instability, and breathiness 25 .
A research looking to characterize the communication disorders associated to thyroid diseases in 48 subjects, with indication of thyroid surgery in a public hospital of Curitiba city, showed the most frequent signs and symptoms were: nodule or lump in the neck (78.13%), troubles to swallow (56.25%), voice disturbances (40.63%), and breathlessness (34.38%). Furthermore, the subjects reported the disease cause limitations in work and daily activities. This study highlights the importance to investigate the voice related features of patients with thyroid disease before surgery 4 .
In the current study, the EG subjects had worst scores of voice-related quality of life to all domains,

DISCUSSION
Quality of life study in subjects before thyroidectomy surgery is extremely relevant and has already been highlighted in literature as parameter of social, physical, and emotional context perception, and it is considered important factor to assess the survival conditions, especially in long term 19 .
Voice-related quality of life deviations may be present due to voice and larynx diseases there are many times detected before the surgery procedure 20 . Therefore it is important before the surgery to perform a laryngoscope, and, in some cases which the immobility is observed, is also recommended to perform larynx electromyography, seeking to distinguish immobility cases from palsy using electric activity monitoring 21,22 . Vocal fold immobility may be present before surgery due to neural commitment or vocal fold mechanic fixation, which may be finding in cases with tumor invasion of lamina propria and vocal muscle, or by muscle fixation 20 .
The voice complaint was significantly higher in subjects' pre thyroidectomy (Table 1). These findings corroborates other studies that show high levels of voice complaint in subjects with thyroid diseases 1,5,23 ,   (Figure 1). The results show despite the physical domain to be more affected, while physical is impaired, the limitation also influence emotionally the subject.
The study analyzing dysphonia patients in general pointed out the most influence in subject's quality of life is physical symptoms, but the dysphonic subjects have the perception about their voices no to be sounding as should be, whether due to troubles in production, whether to troubles in voice daily use, which also impacts the other domains 26 .
Other studies about thyroid diseases whether in treatment definition stage or assessing before and after treatment 19 also highlight the negative voice self-assessment of this population. In addition, the literature 1,19,21,29 point out the importance of speech language pathologist in the multi-professional team following this population, starting before the surgery, helping in the voice symptoms control and decreasing the effects of voice complaint in quality of life using guidance, long term following, and, in cases which already have the indication, therapy pre and post surgery.

CONCLUSION
It is concluded, from the obtained results, the studied women group with thyroid disease pre thyroidectomy has negative impact in voice-related quality of life, mainly in physical domain, and as the physical symptoms regarding voice begin, there is socioemotional impairment.
physical, socio-emotional, and total (Table 2). Beyond statistically different, it was observed the all the scores domains in EG are lower than recommend by literature to health voices, and all CG scores domains are higher than expected, which is higher than 91.25 18 .
The scores to physical, socio-emotional, and total domains in the present study were 74.44, 83.54, and 78.75, respectively. The index are similar to a study analyzing the voice-related quality of life of 67 women with benign thyroid disease diagnose, and mean age of 44.7±14.8 years, as follow: 76.25, 77.72, and 73.09 to the physical, socio-emotional domain, and total, respectively. The study also concluded the patients with benign thyroid disease have high frequency of voice complaints and their voices have negative impact on quality of life 5 . Yet in studies analyzing patients with suspicion of thyroid cancer the index found were slight higher of 84.21, 92.86, and 85.00 to physical, socioemotional, and total domain respectively 23 .
Furthermore, it is observed these indexes are similar to the ones found in studies analyzing other dysphonic population 26,27 . Other research comparing dysphonic and health subjects of primary health service had mean of total domain of 93.6 in health subjects and 83 in dysphonic patients, also finding significant difference between groups 28 , corroborating the results of the current study regarding the comparison between EG and CG.
The difference between the studied groups may be attributed to the choice of a control group with a disease that do not compromise or cause symptoms related to the phonation system or voice, 14,15 and, therefore, do not impair the voice-related quality of life due to the disease.
Analyzing exclusively the EG it was observed the physical domain was the most affected (Table 3). This result corroborates the conclusion of studies with thyroid benign disease patients 5 , and suspicion of thyroid cancer 23 . Probably the results are original from the physical discomfort related to the symptoms and the voice features of this population [10][11][12] , which are perceptible regardless the subjects' voice demand and profession, and lately the subject perceives the interference in social and daily activities, and the amount these limitations impact emotionally. But the voice deviation do not impact the social and emotional components (socio-emotional domains), because they do not incapacitate the development of daily activities.
A positive strong correlation was found between the physical and socio-emotional domains scores in