Original Paper

Folia Phoniatr Logop 2011;63:269272

DOI: 10.1159/000324214

Published online: March 3, 2011

Assessment of the Voice Handicap Index

as a Screening Tool in Dysphonic Patients
Ewa Niebudek-Bogusz a Anna Kuzaska b Ewelina Woznicka a
Mariola Sliwinska-Kowalska a
a

Department of Audiology and Phoniatrics, Nofer Institute of Occupational Medicine, Lodz, and
of Otolaryngology, Province Hospital Zgierz, Zgierz, Poland

b Department

Key Words
Subjective assessment of voice pathology Screening tool
for voice dysfunction

Abstract
Objective: The aim of the study was to assess the applicability of the Voice Handicap Index (VHI) in the screening diagnostics of voice dysfunction and in the evaluation of the level of handicap due to dysphonia. Patients and Methods: A
total of 165 patients with voice disorders (vocal paresis, benign vocal fold masses, and functional dysphonia) and 65
healthy controls completed the VHI questionnaire. All the
participants were subjected to maximum phonation time
(MPT) assessment, the patients also to laryngovideostroboscopy. Results: The VHI scores for the patients and controls
differed significantly (p ! 0.001). A significant correlation
(p ! 0.05) was found when MPT and VHI were compared.
The cutoff point, at which VHI sensitivity (for distinguishing
between subjects with voice dysfunction and with vocal
health) reached its maximal value (98%) at the highest level
of specificity (95%), was assumed to be 12. Conclusions: The
study revealed that the VHI is a reliable tool for identifying
patients who experience vocal dysfunction and should be
used in multidimensional diagnostics of voice disorders. The

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level of 12 points in the VHI test should be considered to

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Introduction

Diagnosing larynx pathologies usually requires a multidimensional approach. According to the current recommendations of the European Laryngological Society,
a complex assessment of voice dysfunctions should cover
laryngovideostroboscopy, objective voice measurement
with acoustic analysis and/or aerodynamic parameters,
perceptual examination of voice, and self-assessment of
the influence of voice-related problems on the patients
quality of life [1]. Voice disorders have been shown to exert a significant impact on the patients communication
abilities, thus having numerous psychological, social,
physical and occupational implications. Accordingly, the
clinical laryngeal examinations alone were found to be
inadequate for assessing the level of handicap of a dysphonic patient [2, 3]. One of the most common instruments used to evaluate self-perceived voice problems is
Jacobsons Voice Handicap Index (VHI) [4], the Polish

Ewa Niebudek-Bogusz, MD, PhD

Department of Audiology and Phoniatrics
Nofer Institute of Occupational Medicine, ul. Teresy 8
PL91-348 Lodz (Poland)
Tel. +48 42 631 4545, E-Mail ebogusz @ imp.lodz.pl

version of which was developed by Pruszewicz et al. [5] in

2004. Recent international projects have demonstrated
that VHI results obtained from studies conducted in different countries are comparable [6].
It is believed that VHI scores are not diagnosis-bound,
but reflect the subjective assessment of a handicap due to
voice disorders perceived by the subject. However, some
studies have demonstrated not only that VHI scores evaluate the biopsychosocial impact of dysphonia, but also
that they could be considered as a screening tool for distinguishing between individuals with vocal health and
vocal dysfunction [7, 8].
The present study is focused on the application of the
Polish version of the VHI in the assessment of voice function in subjects with and without voice disorders.

60
56
52
48
44
VHI40
scores
36
32
28
24
20
16
12
8
4
0

p < 0.01

Females
Males
p < 0.00

p < 0.05

Functional

p < 0.01

Emotional

Physical

Total

VHI

Fig. 1. Total and subscale (functional, emotional and physical)

VHI scores among male and female patients with voice disorders.

Patients and Methods

The study group comprised 165 patients with benign larynx
pathologies, including 147 females and 18 males, with a mean age
of 45.4 8 10 years. The controls (volunteers) were 65 persons with
normal voice and no larynx pathologies (54 females and 11 males,
mean age 43.3 8 10.6 years). The study protocol included administration of the Polish version of the VHI questionnaire [5], perceptual voice evaluation, assessment of the objectively measured
aerodynamic voice parameter, maximum phonation time (MPT)
as well as laryngological examination, followed by laryngovideostroboscopy (in the study group only). On the basis of the laryngovideostroboscopic results, the patients were classified into
three subgroups: 88 patients with benign vocal fold masses, e.g.
nodules, polyps, cysts (subgroup I), 25 patients with unilateral or
bilateral vocal paresis (subgroup II), and 52 patients with functional (nonorganic) dysphonia (subgroup III).
The self-administered VHI questionnaire consists of 30 questions and measures the physical, emotional and functional aspects of voice problems on respective subscales. The total VHI
score ranges from 0 to 120, with a low VHI value, i.e. of 030
points denoting the absence of voice problems or only slight voice
problems, a score of 3060 points indicating a moderate handicap level, while that of 61120 points indicates severe voice disorders [4].
Statistical analysis was performed using SPSS (version 12.0)
software. Comparison of mean VHI scores between particular
subgroups of the study group was analyzed using the t test. The
VHI scores in the controls were not normally distributed, so the
differences between the study and the control group were analyzed by nonparametric Mann-Whitney U test. The correlation
between VHI scores and other parameters (e.g. MPT) in the study
group was calculated using Pearsons coefficient and Spearmans
coefficient, and in the controls Spearmans coefficient only. The
evaluation of the screening value of the VHI in subjects with and
without voice pathology consisted in calculating the sensitivity
and specificity of the method and setting the cutoff point on the
receiver operating characteristic (ROC) curve.

270

Folia Phoniatr Logop 2011;63:269272

Results

The VHI exceeded the 30-point level in 81% of patients

and in none of the controls (p ! 0.001). Sixty-two percent
of patients had results ranging from 31 to 60 points, indicating moderate vocal disability, and 18% had a score
above 61 points, indicating a high degree of vocal disability. In the control group, the VHI value ranged between
0 and 18 points. The mean VHI score was significantly
higher in the study group (44 8 15 points) than in the
control group (3 8 3 points, p ! 0.001).
In the study group, the highest mean VHI score was
noted on the physical subscale (21 points) and the lowest
one on the functional subscale (11 points). The mean VHI
scores were significantly higher for females than males;
this referred both to the total VHI and its subscales (p !
0.05; fig. 1). The highest total and subscale VHI scores
were found among the patients with vocal fold paresis,
and the lowest score among patients with benign vocal
fold masses. However, the between-subgroup differences
were statistically significant only with regard to the functional subscale (p ! 0.05). Mean phonation time was 11 s
in the study group, compared to 18 s in the controls (p !
0.001). An inverse correlation was observed between the
VHI score and MPT in the study group (p ! 0.05; fig. 2),
but not in the control group. Moreover, the appearance of
a correlation between the subjective VHI score and the
objective parameter (MPT), observed only in the study
group, confirms the existence of larynx pathologies in
this group. Figure 3 displays the ROC curve for the sensitivity and specificity of the VHI test for distinguishing
between subjects with and without voice dysfunction.

Niebudek-Bogusz /Kuzaska /Woznicka /

Sliwinska-Kowalska

Study groups r = 0.185, p < 0.05; Controls r = 0.057, p > 0.05

100
80
Total VHI score
60
40
20

1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0

0
0

10

15

20 25
MPT

30

35

40

Study groups
Controls

Fig. 2. Correlation between the VHI score and MPT.

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90

Sensitivity
Specificity

Total VHI score (points)

Fig. 3. Sensitivity and specificity of VHI for distinguishing be-

tween subjects with voice dysfunction and with vocal health.

The cutoff point, at which VHI sensitivity reached its

maximal value (98%) at the highest level of specificity
(95%), was assumed to be 12. This means that in a group
of 100 subjects with voice disorders, 98 would receive a
positive result from the VHI test, while among 100
healthy people, 95 would have a negative result from the
VHI test. At the cutoff point of 12, the sensitivity of the
test was higher than for the cutoff point of 30, which is
commonly regarded as the upper limit value. In the present study, at the cutoff point of 30, the sensitivity and
specificity of the VHI tests were 83 and 100%, respectively.

Discussion

The study aimed to assess the applicability of the VHI

in the screening diagnostics of voice dysfunction and in
the evaluation of the biopsychosocial impact of voice disorders in laryngological practice. The VHI scores (total
and subscale scores) of the patients with benign larynx
dysfunctions such as benign vocal fold masses, vocal fold
paresis/paralysis and functional dysphonia were compared with respective scores among individuals with no
larynx pathologies. The mean VHI score in the study
group and the control group differed significantly. In our
study group, the mean VHI score (44 points) was slightly
higher than the results obtained by other authors; for example, a score of 40 points was reported by Woisard et al.
[9]. At the same time, some consistency was found between the results obtained by Woisard et al. [9] and our
own with respect to the subscale scores: the highest level

VHI in Dysphonic Patients

of handicap referred to the physical subscale, while the

lowest one to the functional subscale. These results are
also concordant with the findings of Kooijman et al. [10],
who postulated that the physical aspects of voice disorders exert the strongest impact on the VHI score. On the
other hand, comparing the mean VHI scores in subgroups formed on the basis of diagnostic categories, the
between-subgroup differences were significant only with
regard to the functional subscale; the highest functional
VHI score was associated with patients with vocal paresis. Analogically, some authors [11] reported that patients
with vocal fold paresis tended to perceive vocal dysfunction to a larger extent than patients with dysphonia diagnosed from other causes.
The biopsychosocial consequences related to voice
disorders seem to be worse among women than men. Like
in our study, Japanese phoniatricians noted that women
with dysphonia obtained significantly higher VHI scores
than men [12]. This could be explained by some peculiarities that predispose women to the development of
voice problems; these include female glottic configuration that favors glottic bowing, and lower levels of hyaluronic acid in the superficial layers of the mucous membrane of the lamina propria, which controls the elasticity
of the vocal folds [13, 14]. However, as de Jong et al. [15]
reported, women are possibly more concerned about
their voice disorders as compared to males, and (perhaps
because of that) they use more active coping strategies to
solve their voice problems.
An analysis of the correlations between the VHI score
and MPT yielded a significant inverse relationship to the
total VHI score and to subscale scores. The results are

Folia Phoniatr Logop 2011;63:269272

271

consistent with other findings, which indicate that reduced respiratory capacity and decreased MPT have a
negative impact on voice quality and its efficiency, as well
as on the VHI score [16].
In the present study, an evaluation of the applicability
of the VHI questionnaire to the screening of voice disorders was undertaken. The study indicates that a VHI cutoff point of 12 should be used to identify patients with
voice problems in daily life. At this value, the best sensitivity of 98% along with the best specificity of 95% were
reached. These findings are in agreement with the results
obtained by Grassel et al. [7], whose study concerning the
grading of the VHI indicates that a shift exceeding 12
points reflects noticeable self-perceived problems caused
by dysphonia. The cutoff point value of 12 is similar to
the 13 points proposed by Ohlsson and Dotevall [8] in the
Swedish version of the VHI. These authors considered
this level to be clinically relevant and useful for distinguishing patients with voice disorders from controls.
Their conclusion differs only slightly from the one drawn
by Van Gogh et al. [17], who postulated that the level of
15 points should indicate the borderline of the VHI test.

The authors of the latter study obtained a high sensitivity

(97%) and good specificity (86%) from the VHI test,
which are comparable to our findings. It should be underlined that the cutoff levels of 12, 13, or 15 points differ
considerably from the value of 30, which is the upper limit of the range assumed clinically to be corresponding to
mild voice impairment [4].
To conclude, the outcomes of the present study indicate not only that VHI is a reliable tool to assess the biopsychosocial impact of voice disorders, but also that it can
be used as a screening tool to distinguish between subjects with and without voice dysfunction. The value of 12
points in the VHI test should be taken into consideration
as a threshold for rating the handicap due to voice disorders.

Acknowledgment
Part of this study was supported by the project of the Polish
State Committee for Scientific Research, project No. 18.6/07.

References
1 Dejonckere PH, Crevier-Buchman L, Marie
JP, Moerman M, Remacle M, Woisard V: Interpretation of the European Laryngological
Society (ELS) basic protocol for assessing
voice treatment effect. Rev Laryngol Otol
Rhinol 2003;124:279283.
2 Lundstrom E, Hammarerg B, Munck-Wikland E: Voice handicap and health-related
quality of life in laryngectomees: assessments with the use of VHI and EORTC questionnaires. Folia Phoniatr Logop 2009; 61:
8392.
3 Murry T, Medrado R, Hogikyan ND, Aviv
JE: The relationship between ratings of voice
quality and quality of life measures. J Voice
2004;18:183192.
4 Jacobson BH, Johnson A, Grywalski C, Silbergleit A, Jacobson G, Benninger MS, et al:
The Voice Handicap Index (VHI): development and validation. Am J Speech Lang
Pathol 1997; 6:6670.
5 Pruszewicz A, Obrbowski A, WiskirskaWonica B, Wojnowski W: Complex voice
assessment Polish version of the Voice
Handicap Index (VHI) (in Polish). Otolaryngol Pol 2004;58:547549.

272

6 Verdonck-de Leeuw I, Kuik DJ, De Bodt MS,

Guimaraes I, Holmberg EB, Nawka T, Rosen
CA, Schindler A, Whurr R, Woisard V: Validation of the Voice Handicap Index (VHI) by
assessing equivalence of European translations. Folia Phoniatr Logop 2008; 60: 173
178.
7 Grassel E, Hoppe U, Rosanowski F: Grading
of the Voice Handicap Index. HNO 2008;56:
12211228.
8 Ohlsson AC, Dotevall H: Voice handicap
index in Swedish. Logoped Phoniatr Vocol
2009;34:6066.
9 Woisard V, Bodin S, Yardeni E, Puech M:
The Voice Handicap Index: correlation between subjective patient response and quantitative assessment of voice. J Voice 2007;21:
623631.
10 Kooijman P, Thomas G, Graamans K, de
Jong F: Psychosocial impact of the teachers
voice throughout the career. J Voice 2007;21:
316324.
11 Schindler A, Bottero A, Capaccio P, Ginocchio D, Adorni F, Ottaviani F: Vocal improvement after voice therapy in unilateral
vocal fold paralysis. J Voice 2008;22:113118.
12 Taguchi A, Masamitsu H, Kazuyo M, Osamu
S: Japanese version of Voice Handicap Index
(VHI) for subjective evaluation of voice disorders. Jpn J Logoped Phoniatr 2006;47:372
378.

Folia Phoniatr Logop 2011;63:269272

13 Tavares EL, Martins RH: Vocal evaluation in

teachers with or without symptoms. J Voice
2007;21:407414.
14 Butler JE, Hamond TH, Gray SD: Genderrelated differences of hyaluronic acid distribution in the human vocal fold. Laryngoscope 2001;111:907911.
15 de Jong F, Michiel S, Orey K, Decoster W:
Gender and vulnerability to voice problems;
in Obrbowski A (ed): Proceedings of the
Congress of the XXV Union of European
Phoniatricians, 810 May 2008, Poznan, Poland. Med News 2008;77:2425.
16 Schindler A, Mozzanica F, Vedrody M,
Maruzzi P, Ottaviani F: Correlation between
the Voice Handicap Index and voice measurements in four groups of patients with
dysphonia. Otolaryngol Head Neck Surg
2009;141:762769.
17 Van Gogh C, Mahieu HF, Kuik DJ, Rinkel
RN, Langendijk JA, Verdonck-de Leeuw I:
Voice in early glottic cancer compared to benign voice pathology. Eur Arch Otorhinolaryngol 2007;264:10331038.

Niebudek-Bogusz /Kuzaska /Woznicka /

Sliwinska-Kowalska

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