Evaluation of the Effects of Electrostimulation Therapy on the Swallowing and Voice in Patients with Partial Laryngectomy

Evaluation of the Effects of Electrostimulation Therapy on the Swallowing and Voice in Patients with Partial Laryngectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of the Effects of Electrostimulation Therapy on the Swallowing and Voice in Patients with Partial Laryngectomy MRS SAYGILI, PROF EYIGOR, Prof OGUT This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7712359/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Introductıon Partial laryngectomies are surgical procedures performed by removing part of the larynx. As a result of this surgery, aspiration, dysphagia and various voice disorders may occur in patients. These symptoms reduce the life quality of patients and may even result in death. Conventional swallowing and voice rehabilitation can progress slowly after partial laryngectomy, so speech and language pathologist are looking for new methods. There are some studies in the literature using neuromuscular electrical stimulation (NMES) for dysphagia and voice therapy, but there isn’t enough information about whether this method is useful or not for the treatment of patients with partial laryngectomy. Methods Due to the lack of this subject in the literature; in this study, NMES was applied to 20 patients with swallowing problems after partial laryngectomy surgery. The swallowing functions were evaluated by fiberopticendoscop (FEES), voice quality was evaluated by acoustic voice analysis and Voice Handicap Index (VHI). These results were compared before and after treatment. Functional oral intake scale (FOIS), functional outcome swallowing scale (FOSS), penetration aspiration (PAS) and residual scales were compared before and after treatment. FOIS is a scale that explains the current nutritional status of patients and classifies them at 7 levels. According to their stage in FOSS, symptoms are numbered from 0 to 5. PAS determines penetration or aspiration severity and residual scales determine the residual location and severity in patients. Results As a result of our study, patients with partial laryngectomy were evaluated before and after NMES treatment; and these changes were statistically significant in functional oral intake scale (FOIS), functional outcome swallowing scale (FOSS), penetration aspiration scale (PAS) and residual scales (p < 0.05). In addition to this, voice quality was evaluated before and after NMES treatment, and significant improvements were also observed in acoustic parameters of voice such as vibration, luminosity, and noise-to-match ratio (NHR) and VHI scores. However, changes in the fundamental frequency were not significant (p > 0.05). Conclusion The results of this study showed that NMES make progress in swallowing and voice and is a reliable method for treatment. partial laryngectomy neuromuscular electrical stimulation voice handicap index acoustic voice analysis swallowing disorders Figures Figure 1 Figure 2 Figure 3 Figure 4 1. Introduction Partial laryngectomies are surgical procedures performed by removing part of the larynx for patients with carcinoma. The surgical resection includes the vocal cords, ventricular folds, paraglottic space, epigolottis preepigolottis space, arytenoid cartilage and thyroid cartilage. As a result of this surgery, aspiration, dysphagia and various voice disorders may occur in patients. Compared to total laryngectomy, the advantages of this treatment are the absence of permanent tracheostoma and retention of physiologic voice and swallowing. These symptoms reduce the life quality of patients and may even result in death. Considering the studies, voice and swallowing evaluations were made before and after partial laryngectomy and it was observed that both voice, and swallowing were changed 15 (Webster et al., 2010;. Dysphagia causes malnutrition, increases morbidity and mortality, decreases life quality and increases health expenses. For treatment of dysphagia; making collective dietary changes in patients’ eating habits, thermal tactile stimulation, postural changes, special techniques, airway protection maneuvers and oral-motor exercises can be performed. In addition to these treatments, neuromuscular electrical stimulation therapy (NMES) can be used 7 . In the studies of NMES are thought to be effective for muscle size increase, muscular power improvements, muscular aerobic capacity increase and sensory and motor recovery. NMES is dysphagia therapy stimulating the muscles that are active during the swallow 1 , 7 . When we look at the literature, there are some studies about the improvement of swallowing functions after NMES treatment in different patient groups 6 , 8 , 20 . However, there are few studies using NMES in head and neck cancer cases 1 , 23 . There is only one reported case in which the effectiveness of NMES therapy was specifically evaluated after partial laryngectomy. A 64-year-old male patient was applied NMES therapy after partial laryngectomy and an improved in dysphagia levels, penitration aspirasyon score and residual scales 5 . The studies conducted in patients with nasopharyngeal carcinoma and vocal cord paralysisit also mentions that NMES therapy creates positive changes on voice 11 , 25 . In a study where NMES was used for swallowing treatment of patients with dysphagia due to stroke; voice analysis was performed to examine the change in voice after treatment and it was stated that NMES increased the loudness, and stabilization of vocal cord vibration periodicity 16 . The study evaluating the acoustic and perceptual parameters of voice after NMES therapy in partial laryngectomy patients isn’t available in the literature. Therefore, our study in patients with partial laryngectomy is planned to investigate the voice and swallowing functions before and after NMES therapy. 2. Methods The research is a multidisciplinary study conducted in a single center. The sample of the prospective study consists of patients with partial laryngectomy between the ages of 18–75 who were admitted to our hospital's otolaryngology (ENT) and physical therapy and rehabilitation departments. The study was approved by the Research Ethics Committee of our hospital. The research began in February 2019 and ended in November 2019. Our inclusion criteria were being between the ages of 18–75, having undergone partial laryngectomy surgery, not having any psychological and neurological diagnosis, getting rid of cancer, and finding evidence of swallowing disorder. Patients who over the age of 75 and with a psychological and neurological diagnosis, had a history of dysphagia due to any other reason other than laryngectomy surgery and had undergone total laryngectomy surgery, were excluded from the study. Patients over the age of 75 weren’t included because they wouldn’t be able to come to the clinic for treatment on their own. Evaluation Patients who had applied to the ENT Department with complaint of swallowing disorder after partial laryngectomy surgery were directed to the Department of Physical Therapy and Rehabilitation. Before starting electrostimulation therapy, the clinical examination of the patients with swallowing disorders was done by a Physiotherapy and Rehabilitation specialist. Then, the patients were evaluated with fiberoptic endoscopic swallowing study (FEES) by a ENT doctor. The test protocol involves the twice application of 3, 5, 10 ml of water and nectar colored with food coloring (green) with injectors. Similarly, swallowing tests were performed twice with a dessert spoon of yogurt (5 ml) and fish crackers. Fish crackers were used as solid food to obtain standard data. When the residue was detected during the test, the patients were given water to clean the food. FEES made with Kay Pentax swallowing signals lab model 7120, synchronization model 7127E, Light Source 7153, Kay Pentax 7245C Computer (Powers Up – Screen). In every step during the procedure, an otolaryngology and physiotherapy and rehabilitation specialist doctor was there, and all procedures were recorded by a camera. All test results were evaluated by the same otolaryngology and physiotherapy and rehabilitation specialists. In the evaluation of FEES; it was investigated whether there was penetration-aspiration or not. The pharyngeal wall, postcricoid region, vallecula, piriform sinuses, tongue base, true and false cords were examined for residues. It was noted that where and how much of the bolus remained as residual. It was determined in which consistency had pathology and with which consistency was safest to swallow. Functional oral intake, functional swallowing, penetration-aspiration scale, and Yale Pharyngeal Residual Severity Scale were completed for each patient by Physiotherapy and Rehabilitation specialist doctor. All evaluations were made before and after treatment. FOIS (Functional Oral Intake Scala) FOIS scale, which classifies oral intake in 7 categories, was used to level the oral intake status. It is a scale that explains the current nutritional status of patients and classifies them at 7 levels. While the first three levels express tube-dependent enteral feeding status, levels 4 and 7 also explain the oral feeding status 4 . FOSS (Functional Outcome Swallowing Scale) Symptoms are numbered from 0 to 5 according to their stage (between normal function and non-oral nutrition) 21 . Penetration Aspiration Scale (PAS) : It what rated 1 from 8 is a valid and reliable scale. Accordingly, “1” point means that there is no penetration and aspiration, “2–5” point means penetration, “6–8” point means aspiration. Increased numbers determine the severity of dysphagia, depending on whether the bolus is expelled from the airway 24 . Yale Pharyngeal Residue Severity Rating Scale Yale Pharyngeal Residual Severity Scale was used to determine the residual location and severity in patients. It is a scale scored between 1–5 as none (0%), trace (1–5%), mild (5–25%), moderate (25–50%) and severe (> 50) 18 . Voice recording samples; in the ENT Department Phonetics Laboratory, in a soundproof room, with a high quality and 24-bit sound card (Creative Audigy; Creative Labs Inc, Milpitas, California) and an omnidirectional microphone (Sennheiser Electronic Corporation, Old Lyme, Connecticut) received. The distance between microphone and the mouth was approximately 15 centimeters. Patients were asked to voice / a / vocal in a comfortable tone and the longest time as much as possible. MultiDimensional Voice Program (MDVP Advanced for Multispeeech, Kay Elemetrics®) was used to analyze the voice recordings. The fundamental frequency, frequency perturbation (jitter), amplitude perturbation (shimmer) and noise-harmonization ratio (NHR) were examined with MDVP program. Each patient completed the voice handicap index form after voice recording. Voice Handicap Index (VHI) is a scale developed by Jacobson et al. It consists of three groups of 10 items, each in the form of functional (F), physical (Fi) and emotional (E). Each item is given a value between 0–4 by the patients, the maximum total score is 120. The higher the score is the greater the problem with the voice. VHI was translated into Turkish and shortened to 10 items because it was a long and time-consuming questionnaire. Validity-reliability study was carried out by Kılıç et al. (2008) 14 .Patients filled the shortened and Turkish translated version. Treatment There are no widely accepted protocols for when and how NMES can be applied for swallowing and voice therapy. In the previously mentioned studies conducted by Fowler et al. and Gorham-Rowan et al. (2016) some changes in vocal function were found in non-dysphonic speakers following 30–60 minutes of a single session of an electrical stimulation applied to the laryngeal area 17 .However, some of these individuals showed either hyperfunctional or hypofunctional phonation following this single session (Fowler et al., 2011). In another study, no significant changes were found in the acoustic sound measurements performed after 15 minutes NMES therapy 17 . Totally, 24 sessions of electrostimulation therapy were applied to patients, twice a week. Each therapy took over 20 minutes. Two pairs of electrodes were used. Every pair of electrodes was aligned horizontally. The upper electrodes were placed just above the hyoid bone and the lower electrodes were placed at the level of the thyroid notch. It was started to be given electricity to patients at the level where they felt muscle contraction in the anterior neck areas. In case, there might be adaptation to the current, the current intensity level was increased at the point where they did not feel the current (sensory stimulation). During the therapy, patients were given only electrostimulation and no exercise. It was suggested to some patients to change their consistency and oral hygiene against the risk of aspiration. Electrostimulation was performed with the VitalStim electrotherapy unit (DJO Global, Vista, CA). This unit provides electrical stimulation with a phase duration of 300 ms during a two-phase pulse wave time at a frequency of 80 Hz. A continuous pulse is applied for 57 seconds (Heijnen et al., 2012). Statistics Descriptive statistics for continuous variables in our study; While expressing mean, standard deviation, minimum and maximum values; It is expressed as number (n) and percentage (%) for categorical variables. Whether the continuous variables in our study were normally distributed or not was examined with the ShapiroWilk test (n < 50) and non-parametric were applied because the variables weren’t normally distributed. Wilcoxon test was used to compare two dependent variables and Friedman test was used for more than two dependent variables. SPSS 22 (Statistical Package for Social Sciences) program was used for statistical analysis and p < 0.05 was used for statistical significance level. 3. Results 24 patients were observed for our study, 2 patients were excluded because they didn‘t meet our inclusion criteria and 1 patient didn‘t want to participate in the study. The therapy had to be abandoned in half due to the infection that occurred while one patient was still on therapy. As a result, our study was completed with 20 cases. 3 of the patients are female and 17 of them are male. The average age is 65.8 ± 7.65. Demographic information of the patients can be seen in Table 1 . Table 1 Demographic Information of Patients Age (Mean ± SD) 65.8 ± 7.65 Male (n, %) 17, %85 Female 3, %15 Smoking History (n, %) Never Smoked 1, %5 50 Years 8, %40 Larengectomy - Horizantovertical Larengectomy (3/4) (n, %) 4, %20 - Supragloctic Larengectomy (n, %) 16, %80 Chemothreapy (n, %) 14, %70 Radiation Therapy (n, %) 3, %15 Time Since Completition of Surgery (months) (Mean, SD) 28 ± 6.6 Table 2 shows the numbers of patients with penetration / aspiration and residues at all food concentrations before and after NMES therapy. There is a statistically significant decrease in residual, penetration and aspiration evaluations for the nutrient concentrations of 3, 5, 10 ml of water, nectar, yogurt and crackers in FEES performed after NMES therapy (p < 0.05). Table 2 Comparison of Penetration-Aspiration, Residue, FOSS and FOIS Scales Before and After Therapy According to the Nutrient Density of the Patients Before Therapy (n %) After Therapy (n %) p Value 3 ml Water Aspiration 17 (%85) 9 (%45) p = 0.005 Penetration 17 (%85) 9 (%45) p = 0.005 Vallecular residue 14 (%70) 7 (%35) p = 0.003 Priform sinüs residue 11 (%55) 6 (%30) p = 0.003 5 ml Water Aspiration 17 (%85) 11 (%55) p = 0.003 Penetration 17 (%85) 11 (%55) p = 0.003 Vallecularresidue 14 (%70) 7 (%35) p = 0.003 Priformsinüsresidue 11 (55) 6 (%30) p = 0.003 10 ml Water Aspiration 17 (%80) 11 (%55) p = 0.003 Penetration 17 (%80) 11 (%55) p = 0.003 Vallecularresidue 10 (%50) 3 (%15) p = 0.003 Priformsinüsresidue 7 (%35) 3 (%15) p = 0.001 3 ml Nectar Aspiration 17 (%85) 9 (%45) p = 0.005 Penetration 17 (%85) 9 (%45) p = 0.005 Vallecularresidue 14 (%70) 7 (%35) p = 0.003 Priformsinüsresidue 11 (55) 6 (%30) p = 0.003 5 ml Nectar Aspiration 17 (%85) 11 (%55) p = 0,003 Penetration 17 (%85) 11 (%55) p = 0.003 Vallecular residue 14 (%70) 7 (%35) p = 0.003 Priform sinüs residue 11 (55) 6 (%30) p = 0.003 10 ml Nectar Aspiration 17 (%85) 11 (%55) p = 0,003 Penetration 17 (%80) 11 (%55) p = 0.003 Vallecular residue 10 (%50) 3 (%15) p = 0.003 Priform sinüs residue 7 (%35) 3 (%15) p = 0.001 Yoghurt Aspiration 8 (%40) 4 (%20) p = 0,00 Penetration 2 (%10) 0 p = 0,00 Vallecular residue 14 (%70) 8 (%40) p = 0,001 Priform sinüs residue 19 (%95) 12 (%60) p = 0,001 Cracher Aspiration 6 (%30) 3 (%15) p = 0,001 Penetration 1 (%5) 0 p = 0,001 Vallecular residue 10(%50) 7 (%35) p = 0,001 Priform sinüs residue 12(%60) 7 (%35) p = 0,001 FOIS(Mean ± SD) 3.3 ± 2.1 4.75 ± 4.4 p = 0.003 FOSS(Mean ± SD) 3.55 ± 1.3 2.1 ± 3.1 p = 0.001 Table 2 shows the comparison of the mean scores of FOIS and FOSS scores before and after NMES treatment. After treatment, there were improvements in FOIS and FOSS scores. These changes were statistically significant in FOIS and FOSS scores before and after NMES treatment (p < 0.05). The total VHI score averages, emotional VHI score, physical VHI score averages, functional VHI score averages before and after therapy are shown in Fig. 1. When comparing the meaning of VHI score before and after therapy for each, a statistically significant difference was found (p < 0.05). All patients participating in the study have improved VHI scores. Figure 2 shows the fundamental frequency averages of patients before surgery, before the therapy, at the end of the 12th therapy and at the end of the 24th therapy. When averages were compared, no statistically significant difference was found (p > 0.05). Figure 3 shows the average of jitter and shimmer patients before the therapy, at the end of the 12th therapy and at the end of the 24th therapy. A statistically significant difference was found when the averages were compared (p < 0.05). Figure 4 shows the mean NHR value of patients at the end of therapy. A statistically significant difference was found when the averages were compared (p < 0.05). 4. Discussion As a result of our study, in patients who had undergone partial laryngectomy, before and after NMES therapy, swallowing evaluation was made and improvement was seen in FOSS, FOIS, PAS and residual scales compared to the pre-therapy, and these changes were found statistically significant. In addition, voice assessment was made before and after NMES therapy. Significant improvement was observed in the VHI scores and acoustic parameters of the voice, such as jitter, shimmer and NHR, but changes in the fundamental frequency weren’t significant. Dysphagia and voice changes appear as an important problem in patients after partial laryngectomy. Chronic aspiration can occur, as it results in resection of the vocal folds and airway protection zones. Furthermore, the voice quality is pale, hoarse, rough and tense 3 , 13 (Webster, et al., 2010;). Among the factors that increase the risk of aspiration; there is low laryngeal position and delayed oropharyngeal transition time. Lingual laryngeal closure is important for effective swallowing and can be acquired with rehabilitation. Rehabilitation can be a slow process after partial laryngectomy. Therefore, NMES has been used in addition to other treatments by speech and language catalogs to treat patients with oropharyngeal dysphagia 22 . Freed et al. (2001) they compared NMES with thermal tactile stimulation therapy and reported that NMES gave better results with swallowing functions in patients with stroke-related dysphagia 8 . Darwish et al. (2017) of the 73 patients who underwent 12 sessions of NMES in a patient with neurological dysphagia, 52 (71%) experienced complete recovery and 21 (29%) had a slight improvement 6 .Sabet et al. (2005) a patient with dysphagia associated with stroke was administered 6 sessions of NMES and it is stated that the patient switched from a pure diet to a solid diet with solidified liquids 20 . 9 out of 10 patients with neurological dysphagia given NMES, and traditional therapy by Frost et al. (2018) had a significant improvement with swallowing functions 10 . Bhatt et al. (2015) gave NMES therapy to 44 of 95 patients with head and neck cancer who received chemoradiotherapy and then compared the swallowing functions of these groups with the groups of patients who hadn’t received NMES therapy. They found a significant decrease in FOIS mean scores between the two groups in the group receiving therapy 1 . Langmore et al. (2017) gave NMES and traditional therapy to 116 patients who completed radiotherapy with moderate dysphagia and head and neck cancer and to 54 patients sham NMES and traditional swallowing exercises. Then compared PAS scores and found that the active NMES group had significantly worse PAS scores than the sham group had. In this study, it is revealed that current therapies are limited for patients with head and neck cancer with moderate to severe dysphagia caused by radiation therapy 23 . However, in both studies, only, a special group such as partial laryngectomy aren’t included, all head and neck cancers are included in the study. In a case report, a 64-year-old male patient was given NMES therapy after partial laryngectomy and on the DOSS (Dysphagia Outcome and Severity Scale) was improvement with sensory and motor stimulation. In the PAS, improvement was for both the sensorial and motor stimulus in the honey consistency, but the worsening of the motor stimulus for the pudding consistency was observed. There was reduction of the residues in the base of the tongue with sensorial and motor stimulus for the consistency of pudding and honey; worsening motor stimulus in the posterior wall of the pharynx for honey consistency. In this study; NMES at the sensory and motor levels improved the degree of dysphagia in a patient after the treatment of laryngeal cancer, with higher benefits of the sensory level over the motor in regard to the presence of penetration and residues 5 . In our study; improvements were observed in FOSS, FOIS, PAS and residual scales compared to the pre-therapy, these changes were found statistically significant. When NMES efficiency is evaluated, we think that there is evidence that NMES is a useful therapy for swallowing in these studies and in our study. In the Vocal Fold Bowing patient group, NMES applied in addition to behavioral voice therapy was found to be effective on increasing the loudness and balancing the vocal cord vibration periodicity; improved glottal closure during phonation, reduced supraglottic compression and improved VHI scores during phonation 12 . In a study conducted by Webster et al. with 14 patients with partial laryngectomy; patients started to receive voice therapy after surgery, and VHI was applied at the 2nd and 12th months after surgery. They saw a decrease in VHI total scores between the 2nd and 12th months, but this change wasn’t statistically significant. At the end of the 12th month, half of the patients evaluated their voices better than before (Webster et al., 2010). In our study, VHI scores of 20 patients with partial laryngectomy were examined before and after NMES treatment. Emotional, physical, functional and total VHI scores were found to have been decreased after therapy compared to before therapy period and this change was statistically significant. If we compare two studies; we can interpret that electrostimulation and traditional voice therapy techniques improve the handicap of the patients' own voice perception, but the effect of electrostimulation is more significant. Thomas et al. applied 12 sessions of NMES therapy to 29 of 57 patients who had undergone head and neck cancer surgery, and 12 sessions of traditional voice therapy to 28 of them. They periodically evaluated the VHI scores of patients, before the therapy, after the therapy, in the 6th and 12th months. In both groups, these scores remained constant over the four evaluation periods without statistically significant differences. When they compared the two groups statistically, they found a significant difference in physical, functional and total VHI scores. They didn’t find significant difference in emotional VHI. As a result of the research, they commented that traditional voice therapy had limited effect on vocal functions 25 . In our study, VHI scores were evaluated before and after therapy, and contrary to the study of Law, the scores weren’t fixed, decreased and a statistically significant change was found. Since all patients in our study had partial laryngectomy, their complaints about the voice and the benefit they received from the treatment were similar. Patients in the study group of Law include patients who have undergone any head and neck surgery. The difference between the results of the two studies may have resulted from this 25 . In the study of Kraszewska et al. (2016), electrostimulation was performed in 40 patients with vocal cord paralysis and VHI total scores were examined and acoustic voice analysis was performed before and after therapy. The results were compared with another group receiving routine voice therapy. Compared to the group receiving voice therapy at the end of the therapy, an improvement in the quality of the voice was observed and the mobility of the vocal folds increased; this resulted in improved voice quality parameters in the acoustic evaluation. In this study, the effectiveness of NMES treatment on the function of vocal cord vibration was revealed 11 . In another study, NMES was found to have a positive effect on the loudness and fundamental frequency of the voice (Heijnen et al.,2012). In our study, acoustic analysis was performed four times in all patients who participated in the study, including preoperative, postoperative, 12th and 24th therapy. When we look at the changes in fundamental frequencies, we couldn’t achieve a statistical significant. The patients in our study are various in terms of partial laryngectomy area. Perhaps we could have achieved significant results if we had selected patients who only had surgery on a particular area of the larynx. However, one point that caught our attention was that the distorted voice of the patients approached to the fundamental frequency of their voices before the surgery after 24th therapy. A similar result hasn’t been reported in other available studies. HaewonByeon and SungHyounCho applied 40 sessions of NMES for 15 of 30 patients with dysphagia due to stroke and traditional swallowing therapy to 15 of them. They found a significant difference between jitter and shimmer when they compared the two groups by performing acoustic voice analysis after the therapies. They found the jitter and shimmer decreased 0.3% and the loudness of the voice was increased 2 dB in the NMES group compared to the other group 16 . If we look at the jitter, shimmer and NHR changes in our study, we see that the therapy decreased the values gradually at the end of the 12th and 24th therapy sessions compared to the before therapy values and the values approached very close to normal. We found Jitter averages were decreased 2.33%, shimmer averages 9.63% and NHR averages 0.38 dB after the therapy. These changes were statistically significant. Ptok and Strack (2009), Lagorio et al.(2010) and Guzman et al.(2013) in their studies, they reported that NMES was more effective when applied with other therapy techniques 9 , 12 , 19 .Making an efficient comment on this issue seems to be difficult because we didn’t give treatment other than NMES. The results of our study was similar to other studies investigating the utility of NMES in voice rehabilitation. After NMES therapy, there is great improvement in both perceptual and acoustic parameters of the voice. The only difference of this study from other studies is that changes in fundamental frequencies aren’t statistically significant. The reason for this may be that the patients we included in the study were operated on different parts of the larynx and the time after surgery. As a result of our study, the utility of NMES for voice and swallowing rehabilitation was investigated for patients with partial laryngectomy, and significant contribution was made to the literature about the usefulness of NMES in patients with partial laryngectomy. Our study is important in terms of the absence of studies evaluating the utility of NMES therapy in voice and swallowing therapy in patients with partial laryngectomy. One of the limitations of our study is that the patients we included in the study were operated from different areas of the larynx. Another limitation is that we didn’t have a control group. The strengths of our study are; the application procedure was standard, and the expert team was the same for each patient. In addition, it is important to include only the patients with partial laryngectomy, not all the patients with head and neck cancer. The effects of only one treatment method,not the combined one, is discussed there. According to our study, NMES therapy is a useful therapy method for voice and swallowing therapy in patients with partial laryngectomy. The literature needs much more study to support the results of our study. Declarations Funding This research did not receive any specific grants from funding agencies in the public, commercial, or nonprofit sectors. Acknowledgments None. Competing interest The authors declare that they have no financial conflicts of interest. Ethics approval and consent to parcipate An application was submitted to the ethics committee for approval of the research ethics. In accordance with the decision of the ethics committee (decision number: 19-2T / 28), the research was deemed to be appropriate. The research was conducted ethically, adhering to the requirements of the Declaration of Helsinki. Written informed consent was obtained from each participant for study participation and data publication. Consent for publication All forms and scales were completed by hand by the patient. The first page contains the informed consent form and demographic information. The tests, therapies, and procedures to be performed were clearly explained to the volunteers. Volunteers who agreed were included in the study. Availability of data and materials The datasets generated and/or analyzed during the current study are not publicly available because they contain personal information, but are available from the corresponding author upon reasonable request. References Bhatt AD, Goodwin N, Cash E, Bhatt G, Silverman CL, Spanos WJ, Bumpous JM, Potts K, Redman R, Allison WA, Dunlap NE (2015) Impact of transcutaneous neuromuscular electrical stimulation on dysphagia in patients with head and neck cancer treated with definitive chemoradiation. 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Arch Phys Med Rehabil 86(8):1516–1520. https://doi.org/10.1016/j.apmr.2004.11.049 Costa DR, Silva-Arone MMAD, Rubira CMF, Santos PSDS, Berretin-Felix G (2019) Immediate effect of neuromuscular electrical stimulation on deglutition after treatment of laryngeal cancer: a case report. Efeito imediato da estimulação elétrica neuromuscular na deglutição após tratamento do câncer de laringe: relato de caso. CoDAS 31(3):e20180100. https://doi.org/10.1590/2317-1782/20182018100 Darwish H, Kamel H, Jeady M, Habash M (2017) Role of modified Barium Swallow Pre and Post VitalStim therapy In the rehabilitation of the swallowing mechanism. Medical Imaging and Radiology. 5. 1. 10.7243/2054-1945-5-1 Eyigor S (2015) Neuromuscular Electrical Stimulation in Dysphagia: Alone or Combine? Türkiye Fiziksel Tip ve Rehabilitasyon Dergisi. 61:195–196. 10.5152/tftrd.2015.84453 Freed ML, Freed L, Chatburn RL, Christian M (2001) Electrical stimulation for swallowing disorders caused by stroke. Respir Care 46(5):466–474 Guzman M, Rubin A, Cox P, Landini F, Jackson-Menaldi C (2014) Neuromuscular electrical stimulation of the cricothyroid muscle in patients with suspected superior laryngeal nerve weakness. J voice: official J Voice Foundation 28(2):216–225. https://doi.org/10.1016/j.jvoice.2013.09.003 Frost J, Robinson HF, Hibberd J (2018) A comparison of neuromuscular electrical stimulation and traditional therapy, versus traditional therapy in patients with longstanding dysphagia. Curr Opin Otolaryngol Head Neck Surg 26(3):167–173. https://doi.org/10.1097/MOO.0000000000000454 Kraszewska A, Kosztyła-Hojna B, Łobaczuk-Sitnik A, Moskal D, Falkowski D, Biszewska J, Berger G (2016) Effects of electrostimulation therapy in selected cases of vocal fold paralysis. Polski Merkuriusz Lekarski:organ Polskiego Towarzystwa Lekarskiego 41(241). s:19–25 Lagorio LA, Carnaby-Mann GD, Crary MA (2010) Treatment of vocal fold bowing using neuromuscular electrical stimulation. Archives otolaryngology–head neck Surg 136(4):398–403. https://doi.org/10.1001/archoto.2010.33 Litton WB, Leonard JR (1969) Aspiration after partial laryngectomy: cineradiographic studies. Laryngoscope 79(5):887–908. https://doi.org/10.1288/00005537-196905000-00009 Kiliç MA, Okur E, Yildirim I, Oğüt F, Denizoğlu I, Kizilay A, Oğuz H, Kandoğan T, Doğan M, Akdoğan O, Bekiroğlu N, Oztarakçi H (2008) Ses Handikap Endeksi (Voice Handicap Index) Türkçe versiyonunun güvenilirliği ve geçerliliği [Reliability and validity of the Turkish version of the Voice Handicap Index]. Kulak burun bogaz ihtisas dergisi: KBB = J ear nose throat 18(3):139–147 Lewin JS, Hutcheson KA, Barringer DA, May AH, Roberts DB, Holsinger FC, Diaz EM Jr (2008) Functional analysis of swallowing outcomes after supracricoid partial laryngectomy. Head Neck 30(5):559–566. https://doi.org/10.1002/hed.20738 Byeon H, Cho S (2015) Voice change after Neuromuscular Electrical Stimulation to laryngeal muscles. Advanced Science and Technology Letters, ; 105(6), (s.28–31) Gorham-Rowan M, Morris R (2016) Exploring the effect of laryngeal neuromuscular electrical stimulation on voice. J Laryngol Otol 130(11):1022–1032. https://doi.org/10.1017/S0022215116009038 Neubauer PD, Rademaker AW, Leder SB (2015) The Yale Pharyngeal Residue Severity Rating Scale: An Anatomically Defined and Image-Based Tool. Dysphagia 30(5):521–528. https://doi.org/10.1007/s00455-015-9631-4 Ptok M, Strack D (2009) Therapeutische Beeinflussung von Schwingungs-irregularitäten durch Elektrostimulationstherapie [Therapeutic effects of electrical stimulation therapy on vocal fold vibration irregularity]. HNO 57(11):1157–1162. https://doi.org/10.1007/s00106-008-1828-5 Sabet F, Williams J, Tolat (2005) Raj. Poster Board 110: Electrical Stimulation For Dysphagia: A Case Study And Review. Lippincott Williams and Wilkins. 84;23 Salassa JR (1999) A functional outcome swallowing scale for staging oropharyngeal dysphagia. Dig Dis (Basel Switzerland) 17(4):230–234. https://doi.org/10.1159/000016941 Schweinfurth JM, Silver SM (2000) Patterns of swallowing after supraglottic laryngectomy. Laryngoscope 110(8):1266–1270. https://doi.org/10.1097/00005537-200008000-00008 Langmore SE, McCulloch TM, Krisciunas GP, Lazarus CL, Van Daele DJ, Pauloski BR, Rybin D, Doros G (2016) Efficacy of electrical stimulation and exercise for dysphagia in patients with head and neck cancer: A randomized clinical trial. Head & neck , 38 Suppl 1 (Suppl 1), E1221–E1231. https://doi.org/10.1002/hed.24197 Butler SG, Markley L, Sanders B, Stuart A (2015) Reliability of the penetration aspiration scale with flexible endoscopic evaluation of swallowing. Ann Otol Rhinol Laryngol 124(6):480–483. https://doi.org/10.1177/0003489414566267 Law T, Lee KY, Wong RW, Leung Y, Ku PK, Wong EW, Li HN, Ng LK, van Hasselt CA, Tong MC (2017) Effects of electrical stimulation on vocal functions in patients with nasopharyngeal carcinoma. Laryngoscope 127(5):1119–1124. https://doi.org/10.1002/lary.26243 Webster K et al (2010) Supracricoid partial laryngectomy swallowing voice and speech outcomes. Annals of Otology, Rhinology and Laryngology, ; 119(1), (s.10–16) Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7712359","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":544167836,"identity":"766f00d6-2ab5-4533-8536-5e10ef84c80d","order_by":0,"name":"MRS 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12:15:43","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":96842,"visible":true,"origin":"","legend":"","description":"","filename":"de8b105a95df4970b34f8520a7675dc81enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7712359/v1/d232424ac8614e253c9b7305.xml"},{"id":96251830,"identity":"24e360c3-8b6d-424b-ab48-1d4bf9f53e81","added_by":"auto","created_at":"2025-11-19 07:40:06","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":95102,"visible":true,"origin":"","legend":"","description":"","filename":"de8b105a95df4970b34f8520a7675dc81structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7712359/v1/1c5f0a69c7a03bd3acb976db.xml"},{"id":96249857,"identity":"6638aa86-9fa1-4553-a80f-d6e727ce297f","added_by":"auto","created_at":"2025-11-19 07:36:27","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":104754,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7712359/v1/deeb4a5cbb4836862696b3d4.html"},{"id":96249952,"identity":"65b540d2-061c-4937-966c-fd723cdb407a","added_by":"auto","created_at":"2025-11-19 07:36:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":31589,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChart 1: Total, Emissions, Physical and Functional VHI Scores Before and After Therapy\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7712359/v1/3d8836c0aa653e1fbb66a4fc.png"},{"id":96179074,"identity":"a5cc64bf-89dc-456a-b450-312ebeac9ab5","added_by":"auto","created_at":"2025-11-18 12:15:43","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":29654,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChart 2: Fundemental Frequency Means Before Therapy, After The 12th And 24th Therapy\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7712359/v1/9c0f354ad02886a313cbe2bc.png"},{"id":96251408,"identity":"b52a6366-7a88-4a29-b007-e8eab1410907","added_by":"auto","created_at":"2025-11-19 07:39:42","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":30585,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChart 3: Averages of Pre-Therapy, 12th Therapy and 24th Therapy Jitter and Shimmer % Averages\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7712359/v1/d4299f5850f590b5e8ca24dc.png"},{"id":96179079,"identity":"44e878f9-0f26-4583-a98d-86a82583faf1","added_by":"auto","created_at":"2025-11-18 12:15:43","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":16803,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eChart 4: Pre-Therapy, The 12th Therapy and 24th Therapy NHR Averages\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7712359/v1/c11ecf5dfa705b270134c60a.png"},{"id":96491586,"identity":"8cfdd9da-eb0c-4761-ae10-0314c1d9eb69","added_by":"auto","created_at":"2025-11-21 17:53:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":988650,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7712359/v1/d6771b9b-ef1a-44de-82b2-c25e1eb18854.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of the Effects of Electrostimulation Therapy on the Swallowing and Voice in Patients with Partial Laryngectomy","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePartial laryngectomies are surgical procedures performed by removing part of the larynx for patients with carcinoma. The surgical resection includes the vocal cords, ventricular folds, paraglottic space, epigolottis preepigolottis space, arytenoid cartilage and thyroid cartilage. As a result of this surgery, aspiration, dysphagia and various voice disorders may occur in patients. Compared to total laryngectomy, the advantages of this treatment are the absence of permanent tracheostoma and retention of physiologic voice and swallowing. These symptoms reduce the life quality of patients and may even result in death. Considering the studies, voice and swallowing evaluations were made before and after partial laryngectomy and it was observed that both voice, and swallowing were changed\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e (Webster et al., 2010;.\u003c/p\u003e\u003cp\u003eDysphagia causes malnutrition, increases morbidity and mortality, decreases life quality and increases health expenses. For treatment of dysphagia; making collective dietary changes in patients\u0026rsquo; eating habits, thermal tactile stimulation, postural changes, special techniques, airway protection maneuvers and oral-motor exercises can be performed. In addition to these treatments, neuromuscular electrical stimulation therapy (NMES) can be used\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. In the studies of NMES are thought to be effective for muscle size increase, muscular power improvements, muscular aerobic capacity increase and sensory and motor recovery. NMES is dysphagia therapy stimulating the muscles that are active during the swallow\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. When we look at the literature, there are some studies about the improvement of swallowing functions after NMES treatment in different patient groups\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. However, there are few studies using NMES in head and neck cancer cases\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. There is only one reported case in which the effectiveness of NMES therapy was specifically evaluated after partial laryngectomy. A 64-year-old male patient was applied NMES therapy after partial laryngectomy and an improved in dysphagia levels, penitration aspirasyon score and residual scales\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe studies conducted in patients with nasopharyngeal carcinoma and vocal cord paralysisit also mentions that NMES therapy creates positive changes on voice\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. In a study where NMES was used for swallowing treatment of patients with dysphagia due to stroke; voice analysis was performed to examine the change in voice after treatment and it was stated that NMES increased the loudness, and stabilization of vocal cord vibration periodicity\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. The study evaluating the acoustic and perceptual parameters of voice after NMES therapy in partial laryngectomy patients isn\u0026rsquo;t available in the literature.\u003c/p\u003e\u003cp\u003eTherefore, our study in patients with partial laryngectomy is planned to investigate the voice and swallowing functions before and after NMES therapy.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eThe research is a multidisciplinary study conducted in a single center. The sample of the prospective study consists of patients with partial laryngectomy between the ages of 18\u0026ndash;75 who were admitted to our hospital's otolaryngology (ENT) and physical therapy and rehabilitation departments. The study was approved by the Research Ethics Committee of our hospital. The research began in February 2019 and ended in November 2019.\u003c/p\u003e\u003cp\u003eOur inclusion criteria were being between the ages of 18\u0026ndash;75, having undergone partial laryngectomy surgery, not having any psychological and neurological diagnosis, getting rid of cancer, and finding evidence of swallowing disorder. Patients who over the age of 75 and with a psychological and neurological diagnosis, had a history of dysphagia due to any other reason other than laryngectomy surgery and had undergone total laryngectomy surgery, were excluded from the study. Patients over the age of 75 weren\u0026rsquo;t included because they wouldn\u0026rsquo;t be able to come to the clinic for treatment on their own.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEvaluation\u003c/b\u003e\u003c/p\u003e\u003cp\u003ePatients who had applied to the ENT Department with complaint of swallowing disorder after partial laryngectomy surgery were directed to the Department of Physical Therapy and Rehabilitation. Before starting electrostimulation therapy, the clinical examination of the patients with swallowing disorders was done by a Physiotherapy and Rehabilitation specialist. Then, the patients were evaluated with fiberoptic endoscopic swallowing study (FEES) by a ENT doctor. The test protocol involves the twice application of 3, 5, 10 ml of water and nectar colored with food coloring (green) with injectors. Similarly, swallowing tests were performed twice with a dessert spoon of yogurt (5 ml) and fish crackers. Fish crackers were used as solid food to obtain standard data. When the residue was detected during the test, the patients were given water to clean the food. FEES made with Kay Pentax swallowing signals lab model 7120, synchronization model 7127E, Light Source 7153, Kay Pentax 7245C Computer (Powers Up \u0026ndash; Screen). In every step during the procedure, an otolaryngology and physiotherapy and rehabilitation specialist doctor was there, and all procedures were recorded by a camera. All test results were evaluated by the same otolaryngology and physiotherapy and rehabilitation specialists.\u003c/p\u003e\u003cp\u003eIn the evaluation of FEES; it was investigated whether there was penetration-aspiration or not. The pharyngeal wall, postcricoid region, vallecula, piriform sinuses, tongue base, true and false cords were examined for residues. It was noted that where and how much of the bolus remained as residual. It was determined in which consistency had pathology and with which consistency was safest to swallow. Functional oral intake, functional swallowing, penetration-aspiration scale, and Yale Pharyngeal Residual Severity Scale were completed for each patient by Physiotherapy and Rehabilitation specialist doctor. All evaluations were made before and after treatment.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFOIS (Functional Oral Intake Scala)\u003c/strong\u003e\u003cp\u003e FOIS scale, which classifies oral intake in 7 categories, was used to level the oral intake status. It is a scale that explains the current nutritional status of patients and classifies them at 7 levels. While the first three levels express tube-dependent enteral feeding status, levels 4 and 7 also explain the oral feeding status\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFOSS (Functional Outcome Swallowing Scale)\u003c/strong\u003e\u003cp\u003eSymptoms are numbered from 0 to 5 according to their stage (between normal function and non-oral nutrition)\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePenetration Aspiration Scale (PAS)\u003c/b\u003e: It what rated 1 from 8 is a valid and reliable scale.\u003c/p\u003e\u003cp\u003eAccordingly, \u0026ldquo;1\u0026rdquo; point means that there is no penetration and aspiration, \u0026ldquo;2\u0026ndash;5\u0026rdquo; point means penetration, \u0026ldquo;6\u0026ndash;8\u0026rdquo; point means aspiration. Increased numbers determine the severity of dysphagia, depending on whether the bolus is expelled from the airway\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eYale Pharyngeal Residue Severity Rating Scale\u003c/strong\u003e\u003cp\u003eYale Pharyngeal Residual Severity Scale was used to determine the residual location and severity in patients. It is a scale scored between 1\u0026ndash;5 as none (0%), trace (1\u0026ndash;5%), mild (5\u0026ndash;25%), moderate (25\u0026ndash;50%) and severe (\u0026gt;\u0026thinsp;50)\u003csup\u003e18\u003c/sup\u003e.\u003c/p\u003e\u003c/p\u003e\u003cp\u003eVoice recording samples; in the ENT Department Phonetics Laboratory, in a soundproof room, with a high quality and 24-bit sound card (Creative Audigy; Creative Labs Inc, Milpitas, California) and an omnidirectional microphone (Sennheiser Electronic Corporation, Old Lyme, Connecticut) received. The distance between microphone and the mouth was approximately 15 centimeters. Patients were asked to voice / a / vocal in a comfortable tone and the longest time as much as possible. MultiDimensional Voice Program (MDVP Advanced for Multispeeech, Kay Elemetrics\u0026reg;) was used to analyze the voice recordings. The fundamental frequency, frequency perturbation (jitter), amplitude perturbation (shimmer) and noise-harmonization ratio (NHR) were examined with MDVP program. Each patient completed the voice handicap index form after voice recording. Voice Handicap Index (VHI) is a scale developed by Jacobson et al. It consists of three groups of 10 items, each in the form of functional (F), physical (Fi) and emotional (E). Each item is given a value between 0\u0026ndash;4 by the patients, the maximum total score is 120. The higher the score is the greater the problem with the voice. VHI was translated into Turkish and shortened to 10 items because it was a long and time-consuming questionnaire. Validity-reliability study was carried out by Kılı\u0026ccedil; et al. (2008)\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e.Patients filled the shortened and Turkish translated version.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTreatment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThere are no widely accepted protocols for when and how NMES can be applied for swallowing and voice therapy. In the previously mentioned studies conducted by Fowler et al. and Gorham-Rowan et al. (2016) some changes in vocal function were found in non-dysphonic speakers following 30\u0026ndash;60 minutes of a single session of an electrical stimulation applied to the laryngeal area\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.However, some of these individuals showed either hyperfunctional or hypofunctional phonation following this single session (Fowler et al., 2011). In another study, no significant changes were found in the acoustic sound measurements performed after 15 minutes NMES therapy\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTotally, 24 sessions of electrostimulation therapy were applied to patients, twice a week. Each therapy took over 20 minutes. Two pairs of electrodes were used. Every pair of electrodes was aligned horizontally. The upper electrodes were placed just above the hyoid bone and the lower electrodes were placed at the level of the thyroid notch. It was started to be given electricity to patients at the level where they felt muscle contraction in the anterior neck areas. In case, there might be adaptation to the current, the current intensity level was increased at the point where they did not feel the current (sensory stimulation). During the therapy, patients were given only electrostimulation and no exercise. It was suggested to some patients to change their consistency and oral hygiene against the risk of aspiration. Electrostimulation was performed with the VitalStim electrotherapy unit (DJO Global, Vista, CA). This unit provides electrical stimulation with a phase duration of 300 ms during a two-phase pulse wave time at a frequency of 80 Hz. A continuous pulse is applied for 57 seconds (Heijnen et al., 2012).\u003c/p\u003e\u003cp\u003e\u003cb\u003eStatistics\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDescriptive statistics for continuous variables in our study; While expressing mean, standard deviation, minimum and maximum values; It is expressed as number (n) and percentage (%) for categorical variables. Whether the continuous variables in our study were normally distributed or not was examined with the ShapiroWilk test (n\u0026thinsp;\u0026lt;\u0026thinsp;50) and non-parametric were applied because the variables weren\u0026rsquo;t normally distributed. Wilcoxon test was used to compare two dependent variables and Friedman test was used for more than two dependent variables. SPSS 22 (Statistical Package for Social Sciences) program was used for statistical analysis and p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was used for statistical significance level.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e24 patients were observed for our study, 2 patients were excluded because they didn\u0026lsquo;t meet our inclusion criteria and 1 patient didn\u0026lsquo;t want to participate in the study. The therapy had to be abandoned in half due to the infection that occurred while one patient was still on therapy. As a result, our study was completed with 20 cases. 3 of the patients are female and 17 of them are male. The average age is 65.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.65. Demographic information of the patients can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic Information of Patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e65.8 \u0026plusmn; 7.65\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMale (n, %)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17, %85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFemale\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3, %15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSmoking History (n, %)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eNever Smoked\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1, %5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;10 Years\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e10\u0026ndash;50 Years\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11, %55\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e\u0026gt;\u0026thinsp;50 Years\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8, %40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLarengectomy - Horizantovertical Larengectomy (3/4) (n, %)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4, %20\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003e- Supragloctic Larengectomy (n, %)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16, %80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eChemothreapy (n, %)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14, %70\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRadiation Therapy (n, %)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3, %15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTime Since Completition of Surgery (months) (Mean, SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the numbers of patients with penetration / aspiration and residues at all food concentrations before and after NMES therapy. There is a statistically significant decrease in residual, penetration and aspiration evaluations for the nutrient concentrations of 3, 5, 10 ml of water, nectar, yogurt and crackers in FEES performed after NMES therapy (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Penetration-Aspiration, Residue, FOSS and FOIS Scales Before and After Therapy According to the Nutrient Density of the Patients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBefore Therapy (n %)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAfter Therapy (n %)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep Value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003e3 ml Water\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAspiration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (%85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (%45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (%85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (%45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVallecular residue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (%70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (%35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePriform sin\u0026uuml;s residue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (%55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (%30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003e5 ml Water\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAspiration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (%85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (%55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (%85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (%55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVallecularresidue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (%70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (%35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePriformsin\u0026uuml;sresidue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (%30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003e10 ml Water\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAspiration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (%80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (%55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (%80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (%55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVallecularresidue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (%50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (%15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePriformsin\u0026uuml;sresidue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (%35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (%15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003e3 ml Nectar\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAspiration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (%85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (%45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (%85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (%45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.005\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVallecularresidue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (%70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (%35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePriformsin\u0026uuml;sresidue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (%30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003e5 ml Nectar\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAspiration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (%85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (%55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0,003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (%85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (%55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVallecular residue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (%70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (%35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePriform sin\u0026uuml;s residue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6 (%30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003e10 ml Nectar\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAspiration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (%85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (%55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0,003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (%80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11 (%55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVallecular residue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10 (%50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (%15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePriform sin\u0026uuml;s residue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (%35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (%15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eYoghurt\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAspiration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (%40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (%20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0,00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2 (%10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0,00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVallecular residue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (%70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (%40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0,001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePriform sin\u0026uuml;s residue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (%95)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12 (%60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0,001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u003cb\u003eCracher\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAspiration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (%30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3 (%15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0,001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePenetration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (%5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0,001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVallecular residue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10(%50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (%35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0,001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePriform sin\u0026uuml;s residue\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12(%60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7 (%35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0,001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFOIS(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.3\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.75\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFOSS(Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.55\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the comparison of the mean scores of FOIS and FOSS scores before and after NMES treatment. After treatment, there were improvements in FOIS and FOSS scores. These changes were statistically significant in FOIS and FOSS scores before and after NMES treatment (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eThe total VHI score averages, emotional VHI score, physical VHI score averages, functional VHI score averages before and after therapy are shown in Fig.\u0026nbsp;1. When comparing the meaning of VHI score before and after therapy for each, a statistically significant difference was found (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). All patients participating in the study have improved VHI scores.\u003c/p\u003e\u003cp\u003eFigure 2 shows the fundamental frequency averages of patients before surgery, before the therapy, at the end of the 12th therapy and at the end of the 24th therapy. When averages were compared, no statistically significant difference was found (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eFigure 3 shows the average of jitter and shimmer patients before the therapy, at the end of the 12th therapy and at the end of the 24th therapy. A statistically significant difference was found when the averages were compared (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003cp\u003eFigure 4 shows the mean NHR value of patients at the end of therapy. A statistically significant difference was found when the averages were compared (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eAs a result of our study, in patients who had undergone partial laryngectomy, before and after NMES therapy, swallowing evaluation was made and improvement was seen in FOSS, FOIS, PAS and residual scales compared to the pre-therapy, and these changes were found statistically significant. In addition, voice assessment was made before and after NMES therapy. Significant improvement was observed in the VHI scores and acoustic parameters of the voice, such as jitter, shimmer and NHR, but changes in the fundamental frequency weren\u0026rsquo;t significant.\u003c/p\u003e\u003cp\u003eDysphagia and voice changes appear as an important problem in patients after partial laryngectomy. Chronic aspiration can occur, as it results in resection of the vocal folds and airway protection zones. Furthermore, the voice quality is pale, hoarse, rough and tense \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e (Webster, et al., 2010;). Among the factors that increase the risk of aspiration; there is low laryngeal position and delayed oropharyngeal transition time. Lingual laryngeal closure is important for effective swallowing and can be acquired with rehabilitation. Rehabilitation can be a slow process after partial laryngectomy. Therefore, NMES has been used in addition to other treatments by speech and language catalogs to treat patients with oropharyngeal dysphagia\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eFreed et al. (2001) they compared NMES with thermal tactile stimulation therapy and reported that NMES gave better results with swallowing functions in patients with stroke-related dysphagia\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Darwish et al. (2017) of the 73 patients who underwent 12 sessions of NMES in a patient with neurological dysphagia, 52 (71%) experienced complete recovery and 21 (29%) had a slight improvement\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e .Sabet et al. (2005) a patient with dysphagia associated with stroke was administered 6 sessions of NMES and it is stated that the patient switched from a pure diet to a solid diet with solidified liquids\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. 9 out of 10 patients with neurological dysphagia given NMES, and traditional therapy by Frost et al. (2018) had a significant improvement with swallowing functions\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eBhatt et al. (2015) gave NMES therapy to 44 of 95 patients with head and neck cancer who received chemoradiotherapy and then compared the swallowing functions of these groups with the groups of patients who hadn\u0026rsquo;t received NMES therapy. They found a significant decrease in FOIS mean scores between the two groups in the group receiving therapy\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Langmore et al. (2017) gave NMES and traditional therapy to 116 patients who completed radiotherapy with moderate dysphagia and head and neck cancer and to 54 patients sham NMES and traditional swallowing exercises. Then compared PAS scores and found that the active NMES group had significantly worse PAS scores than the sham group had. In this study, it is revealed that current therapies are limited for patients with head and neck cancer with moderate to severe dysphagia caused by radiation therapy\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. However, in both studies, only, a special group such as partial laryngectomy aren\u0026rsquo;t included, all head and neck cancers are included in the study.\u003c/p\u003e\u003cp\u003eIn a case report, a 64-year-old male patient was given NMES therapy after partial laryngectomy and on the DOSS (Dysphagia Outcome and Severity Scale) was improvement with sensory and motor stimulation. In the PAS, improvement was for both the sensorial and motor stimulus in the honey consistency, but the worsening of the motor stimulus for the pudding consistency was observed. There was reduction of the residues in the base of the tongue with sensorial and motor stimulus for the consistency of pudding and honey; worsening motor stimulus in the posterior wall of the pharynx for honey consistency. In this study; NMES at the sensory and motor levels improved the degree of dysphagia in a patient after the treatment of laryngeal cancer, with higher benefits of the sensory level over the motor in regard to the presence of penetration and residues\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. In our study; improvements were observed in FOSS, FOIS, PAS and residual scales compared to the pre-therapy, these changes were found statistically significant. When NMES efficiency is evaluated, we think that there is evidence that NMES is a useful therapy for swallowing in these studies and in our study.\u003c/p\u003e\u003cp\u003eIn the Vocal Fold Bowing patient group, NMES applied in addition to behavioral voice therapy was found to be effective on increasing the loudness and balancing the vocal cord vibration periodicity; improved glottal closure during phonation, reduced supraglottic compression and improved VHI scores during phonation\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e. In a study conducted by Webster et al. with 14 patients with partial laryngectomy; patients started to receive voice therapy after surgery, and VHI was applied at the 2nd and 12th months after surgery. They saw a decrease in VHI total scores between the 2nd and 12th months, but this change wasn\u0026rsquo;t statistically significant. At the end of the 12th month, half of the patients evaluated their voices better than before (Webster et al., 2010). In our study, VHI scores of 20 patients with partial laryngectomy were examined before and after NMES treatment. Emotional, physical, functional and total VHI scores were found to have been decreased after therapy compared to before therapy period and this change was statistically significant. If we compare two studies; we can interpret that electrostimulation and traditional voice therapy techniques improve the handicap of the patients' own voice perception, but the effect of electrostimulation is more significant. Thomas et al. applied 12 sessions of NMES therapy to 29 of 57 patients who had undergone head and neck cancer surgery, and 12 sessions of traditional voice therapy to 28 of them. They periodically evaluated the VHI scores of patients, before the therapy, after the therapy, in the 6th and 12th months. In both groups, these scores remained constant over the four evaluation periods without statistically significant differences. When they compared the two groups statistically, they found a significant difference in physical, functional and total VHI scores. They didn\u0026rsquo;t find significant difference in emotional VHI. As a result of the research, they commented that traditional voice therapy had limited effect on vocal functions\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. In our study, VHI scores were evaluated before and after therapy, and contrary to the study of Law, the scores weren\u0026rsquo;t fixed, decreased and a statistically significant change was found. Since all patients in our study had partial laryngectomy, their complaints about the voice and the benefit they received from the treatment were similar. Patients in the study group of Law include patients who have undergone any head and neck surgery. The difference between the results of the two studies may have resulted from this\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. In the study of Kraszewska et al. (2016), electrostimulation was performed in 40 patients with vocal cord paralysis and VHI total scores were examined and acoustic voice analysis was performed before and after therapy. The results were compared with another group receiving routine voice therapy. Compared to the group receiving voice therapy at the end of the therapy, an improvement in the quality of the voice was observed and the mobility of the vocal folds increased; this resulted in improved voice quality parameters in the acoustic evaluation. In this study, the effectiveness of NMES treatment on the function of vocal cord vibration was revealed\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. In another study, NMES was found to have a positive effect on the loudness and fundamental frequency of the voice (Heijnen et al.,2012). In our study, acoustic analysis was performed four times in all patients who participated in the study, including preoperative, postoperative, 12th and 24th therapy. When we look at the changes in fundamental frequencies, we couldn\u0026rsquo;t achieve a statistical significant. The patients in our study are various in terms of partial laryngectomy area. Perhaps we could have achieved significant results if we had selected patients who only had surgery on a particular area of the larynx. However, one point that caught our attention was that the distorted voice of the patients approached to the fundamental frequency of their voices before the surgery after 24th therapy. A similar result hasn\u0026rsquo;t been reported in other available studies.\u003c/p\u003e\u003cp\u003eHaewonByeon and SungHyounCho applied 40 sessions of NMES for 15 of 30 patients with dysphagia due to stroke and traditional swallowing therapy to 15 of them. They found a significant difference between jitter and shimmer when they compared the two groups by performing acoustic voice analysis after the therapies. They found the jitter and shimmer decreased 0.3% and the loudness of the voice was increased 2 dB in the NMES group compared to the other group\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. If we look at the jitter, shimmer and NHR changes in our study, we see that the therapy decreased the values gradually at the end of the 12th and 24th therapy sessions compared to the before therapy values and the values approached very close to normal. We found Jitter averages were decreased 2.33%, shimmer averages 9.63% and NHR averages 0.38 dB after the therapy. These changes were statistically significant. Ptok and Strack (2009), Lagorio et al.(2010) and Guzman et al.(2013) in their studies, they reported that NMES was more effective when applied with other therapy techniques\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.Making an efficient comment on this issue seems to be difficult because we didn\u0026rsquo;t give treatment other than NMES.\u003c/p\u003e\u003cp\u003eThe results of our study was similar to other studies investigating the utility of NMES in voice rehabilitation. After NMES therapy, there is great improvement in both perceptual and acoustic parameters of the voice. The only difference of this study from other studies is that changes in fundamental frequencies aren\u0026rsquo;t statistically significant. The reason for this may be that the patients we included in the study were operated on different parts of the larynx and the time after surgery.\u003c/p\u003e\u003cp\u003eAs a result of our study, the utility of NMES for voice and swallowing rehabilitation was investigated for patients with partial laryngectomy, and significant contribution was made to the literature about the usefulness of NMES in patients with partial laryngectomy. Our study is important in terms of the absence of studies evaluating the utility of NMES therapy in voice and swallowing therapy in patients with partial laryngectomy.\u003c/p\u003e\u003cp\u003eOne of the limitations of our study is that the patients we included in the study were operated from different areas of the larynx. Another limitation is that we didn\u0026rsquo;t have a control group. The strengths of our study are; the application procedure was standard, and the expert team was the same for each patient. In addition, it is important to include only the patients with partial laryngectomy, not all the patients with head and neck cancer. The effects of only one treatment method,not the combined one, is discussed there.\u003c/p\u003e\u003cp\u003e According to our study, NMES therapy is a useful therapy method for voice and swallowing therapy in patients with partial laryngectomy. The literature needs much more study to support the results of our study.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grants from funding agencies in the public, commercial, or nonprofit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no financial conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to parcipate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAn application was submitted to the ethics committee for approval of the research ethics. In accordance with the decision of the ethics committee (decision number: 19-2T / 28), the research was deemed to be appropriate.\u003c/p\u003e\n\u003cp\u003eThe research was conducted ethically, adhering to the requirements of the Declaration of Helsinki. Written informed consent was obtained from each participant for study participation and data publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll forms and scales were completed by hand by the patient. The first page contains the informed consent form and demographic information. The tests, therapies, and procedures to be performed were clearly explained to the volunteers. Volunteers who agreed were included in the study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available because they contain personal information, but are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBhatt AD, Goodwin N, Cash E, Bhatt G, Silverman CL, Spanos WJ, Bumpous JM, Potts K, Redman R, Allison WA, Dunlap NE (2015) Impact of transcutaneous neuromuscular electrical stimulation on dysphagia in patients with head and neck cancer treated with definitive chemoradiation. 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Laryngoscope 127(5):1119\u0026ndash;1124. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/lary.26243\u003c/span\u003e\u003cspan address=\"10.1002/lary.26243\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWebster K et al (2010) Supracricoid partial laryngectomy swallowing voice and speech outcomes. Annals of Otology, Rhinology and Laryngology, ; 119(1), (s.10\u0026ndash;16)\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"partial laryngectomy, neuromuscular electrical stimulation, voice handicap index, acoustic voice analysis, swallowing disorders","lastPublishedDoi":"10.21203/rs.3.rs-7712359/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7712359/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroductıon\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePartial laryngectomies are surgical procedures performed by removing part of the larynx. As a result of this surgery, aspiration, dysphagia and various voice disorders may occur in patients. These symptoms reduce the life quality of patients and may even result in death. Conventional swallowing and voice rehabilitation can progress slowly after partial laryngectomy, so speech and language pathologist are looking for new methods. There are some studies in the literature using neuromuscular electrical stimulation (NMES) for dysphagia and voice therapy, but there isn’t enough information about whether this method is useful or not for the treatment of patients with partial laryngectomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDue to the lack of this subject in the literature; in this study, NMES was applied to 20 patients with swallowing problems after partial laryngectomy surgery. The swallowing functions were evaluated by fiberopticendoscop (FEES), voice quality was evaluated by acoustic voice analysis and Voice Handicap Index (VHI). These results were compared before and after treatment. Functional oral intake scale (FOIS), functional outcome swallowing scale (FOSS), penetration aspiration (PAS) and residual scales were compared before and after treatment. FOIS is a scale that explains the current nutritional status of patients and classifies them at 7 levels. According to their stage in FOSS, symptoms are numbered from 0 to 5. PAS determines penetration or aspiration severity and residual scales determine the residual location and severity in patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs a result of our study, patients with partial laryngectomy were evaluated before and after NMES treatment; and these changes were statistically significant in functional oral intake scale (FOIS), functional outcome swallowing scale (FOSS), penetration aspiration scale (PAS) and residual scales (p \u0026lt; 0.05). In addition to this, voice quality was evaluated before and after NMES treatment, and significant improvements were also observed in acoustic parameters of voice such as vibration, luminosity, and noise-to-match ratio (NHR) and VHI scores. However, changes in the fundamental frequency were not significant (p \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe results of this study showed that NMES make progress in swallowing and voice and is a reliable method for treatment.\u003c/p\u003e","manuscriptTitle":"Evaluation of the Effects of Electrostimulation Therapy on the Swallowing and Voice in Patients with Partial Laryngectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-18 12:15:38","doi":"10.21203/rs.3.rs-7712359/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"aad1f1b0-4a09-4e3a-ad33-8e69484afadf","owner":[],"postedDate":"November 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-21T17:53:11+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-18 12:15:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7712359","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7712359","identity":"rs-7712359","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}