The Impact of Voice Disorders Among Teachers: Vocal Complaints, Treatment-Seeking Behavior, Knowledge of Vocal Care, and Voice-Related Absenteeism

Objectives

Teachers are at increased risk for developing voice disorders. Occupational risk factors have been extensively examined; however, little attention has been paid to the consequences of the vocal complaints. The objective of this study was to investigate the knowledge that teachers have about vocal care, treatment-seeking behavior, and voice-related absenteeism.

Methods

The study group comprised 994 teachers and 290 controls whose jobs did not involve vocal effort. All participants completed a questionnaire inquiring about vocal complaints, treatment-seeking behavior, voice-related absenteeism, and knowledge about vocal care. Comparisons were made between teachers with and without vocal complaints and with the control group.

Results

Teachers reported significantly more voice problems than the control population (51.2% vs 27.4%) (χ² = 50.45, df = 1, P < 0.001). Female teachers reported significantly higher levels of voice disorders than their male colleagues (38% vs 13.2%, χ² = 22.34, df = 1, P < 0.001). Teachers (25.4%) sought medical care and eventually 20.6% had missed at least 1 day of work because of voice problems. Female teachers were significantly more likely to seek medical help (χ² = 7.24, df = 1, P = 0.007) and to stay at home (χ² = 7.10, df = 1, P = 0.008) in comparison with their male colleagues. Only 13.5% of all teachers received information during their education.

Conclusions

Voice disorders have an impact on teachers' personal and professional life and imply a major financial burden for society. A substantial number of teachers needed medical help and was obligated to stay at home because of voice problems. This study strongly recommends the implementation of vocal education during the training of teacher students to prepare the vocal professional user.     

Physical Appearance and Voice in Male-To-Female Transsexuals

It has been suggested that sex judgments of male-to-female transsexuals based on the voice may be influenced by the physical appearance of the clients. To explore this hypothesis, a listener experiment was designed in which a panel of 22 laypersons and 22 students in speech-language pathology rated the “femaleness” of fourteen male-to-female transsexuals from video-recorded speech samples in three modes of presentation: auditory-only presentation, visual-only presentation, and audiovisual presentation. Results indicate that appearance and voice are indeed interacting factors. Ratings from the auditory-only presentation were significantly lower than ratings from the audiovisual presentation and ratings from the visual-only presentation were significantly higher than those from the audiovisual presentation. It follows that the success of voice training in male-to-female transsexuals is not solely dependent on vocal characteristics and that speech pathologists should consider incorporating physical appearance as a treatment and outcome variable in the voice training of male-to-female transsexuals.     

Changes in Objective Acoustic Measurements and Subjective Voice Complaints in Call Center Customer-Service Advisors During One Working Day

SUMMARY: The aim of this study was to investigate how different acoustic parameters, extracted both from speech pressure waveforms and glottal flows, can be used in measuring vocal loading in modern working environments and how these parameters reflect the possible changes in the vocal function during a working day. In addition, correlations between objective acoustic parameters and subjective voice symptoms were addressed. The subjects were 24 female and 8 male customer-service advisors, who mainly use telephone during their working hours. Speech samples were recorded from continuous speech four times during a working day and voice symptom questionnaires were completed simultaneously. Among the various objective parameters, only F0 resulted in a statistically significant increase for both genders. No correlations between the changes in objective and subjective parameters appeared. However, the results encourage researchers within the field of occupational voice use to apply versatile measurement techniques in studying occupational voice loading.     

Correlation of VHI-10 to Voice Laboratory Measurements Across Five Common Voice Disorders

ObjectiveTo correlate change in Voice Handicap Index (VHI)-10 scores with corresponding voice laboratory measures across five voice disorders.Study DesignRetrospective study.MethodsOne hundred fifty patients aged >18 years with primary diagnosis of vocal fold lesions, primary muscle tension dysphonia-1, atrophy, unilateral vocal fold paralysis (UVFP), and scar. For each group, participants with the largest change in VHI-10 between two periods (T_A and T_B) were selected. The dates of the VHI-10 values were linked to corresponding acoustic/aerodynamic and audio-perceptual measures. Change in voice laboratory values were analyzed for correlation with each other and with VHI-10.ResultsVHI-10 scores were greater for patients with UVFP than other disorders. The only disorder-specific correlation between voice laboratory measure and VHI-10 was average phonatory airflow in speech for patients with UVFP. Average airflow in repeated phonemes was strongly correlated with average airflow in speech (r = 0.75). Acoustic measures did not significantly change between time points.ConclusionsThe lack of correlations between the VHI-10 change scores and voice laboratory measures may be due to differing constructs of each measure; namely, handicap versus physiological function. Presuming corroboration between these measures may be faulty. Average airflow in speech may be the most ecologically valid measure for patients with UVFP. Although aerodynamic measures changed between the time points, acoustic measures did not. Correlations to VHI-10 and change between time points may be found with other acoustic measures.     

Instrumental and Perceptual Evaluations of Two Related Singers

The primary goal of this study was to characterize a performer's singing and speaking voice. One woman was not admitted to a premier choral group, but her sister, who was comparable in physical characteristics and background, was admitted and provided a valuable control subject. The perceptual judgment of a vocal coach who conducted the group's auditions was decisive in discriminating these 2 singers. The singer not admitted to the group described a history of voice pathology, lacked a functional head register, and spoke with a voice characterized by hoarseness. Multiple listener judgments and acoustic and aerodynamic evaluations of both singers provided a more systematic basis for determining: 1) the phonatory basis for this judgment; 2) whether similar judgments would be made by groups of vocal coaches and speech-language pathologists; and 3) whether the type of tasks (e.g., sung vs. spoken) would influence these judgments. Statistically significant differences were observed between the ratings of vocal health provided by two different groups of listeners. Significant interactions were also observed as a function of the types of voice samples heard by these listeners. Instrumental analyses provided evidence that, in comparison to her sister, the rejected singer had a compromised vocal range, glottal insufficiencies as assessed aerodynamically and electroglottographically, and impaired acoustic quality, especially in her speaking voice.     

G. Paul Moore Lecture—1993: New voices for old

Otolaryngology and voice science have entered the era of “phonosurgery.” Several techniques allow voice professionals to intervene to restore or modify the voice in patients with immobile vocal folds and other problems related to voice production. It is necessary and appropriate that physicians and speech and language pathologists critically examine what has been accomplished and what may yet be possible for further voice improvement.     

Loud Speech in Realistic Environmental Noise: Phonetogram Data, Perceptual Voice Quality, Subjective Ratings, and Gender Differences in Healthy Speakers

A new method for cancelling background noise from running speech was used to study voice production during realistic environmental noise exposure. Normal subjects, 12 women and 11 men, read a text in five conditions: quiet, soft continuous noise (75 dBA to 70 dBA), day-care babble (74 dBA), disco (87 dBA), and loud continuous noise (78 dBA to 85 dBA). The noise was presented over loudspeakers and then removed from the recordings in an off-line processing operation. The voice signals were analyzed acoustically with an automatic phonetograph and perceptually by four expert listeners. Subjective data were collected after each vocal loading task. The perceptual parameters press, instability, and roughness increased significantly as an effect of speaking loudly over noise, whereas vocal fry decreased. Having to make oneself heard over noise resulted in higher SPL and F0, as expected, and in higher phonation time. The total reading time was slightly longer in continuous noise than in intermittent noise. The women had 4 dB lower voice SPL overall and increased their phonation time more in noise than did the men. Subjectively, women reported less success making themselves heard and higher effort. The results support the contention that female voices are more vulnerable to vocal loading in background noise.     

Populations in the U.S. workforce who rely on voice as a primary tool of trade: a preliminary report

The United States Bureau of Labor Statistics and other sources wereconsulted about the percentages of the working population that we identified as professional voice users. The largest percentage may be in sales and sales related occupations (13%), but the exact breakdown of those who approach their clients vocally rather than by mail is still uncertain. The second largest population is teachers, who comprise 4.2% percent of the U.S. workforce (1994 statistic). Teachers have been identified as having the greatest incidence of voice disorders. Population data are also given for professional voice users who could present a significant hazard to public safety if their vocal communication skills were severely impaired.     

The effects of preventive vocal hygiene education on the vocal hygiene habits and perceptual vocal characteristics of training singers

The purpose of the present study was to determine the effects of vocal hygiene education on the vocal hygiene behaviors and perceptual vocal characteristics of untrained singers. Eleven adult untrained singers served as subjects. They attended four 1-hour class sessions on vocal hygiene, including anatomy and physiology of the phonatory mechanism, vocally abusive behaviors, voice disorders commonly seen in singers, and measures to prevent voice disorders. Pre- and postinstruction surveys were used to record subjects' vocal abuses and their perceptions of their speaking and singing voice. They also rated their perceived value of vocal hygiene education. Results revealed minimal changes in vocal hygiene behaviors and perceptual voice characteristics. The subjects did report a high degree of benefit and learning, however.     

Efficacy of a Behaviorally Based Voice Therapy Protocol for Vocal Nodules

The aim of this study was to assess the effects on vocal function of voice therapy for vocal nodules. Perceptual and physiological progressive changes were examined during a strictly structured, behaviorally based voice therapy protocol in which 11 women with vocal nodules participated. Randomized audio recordings from pretherapy and from each of the therapy approaches (vocal hygiene, respiration, direct facilitation, carryover) were used for perceptual evaluations. Six speech-language pathologists rated ten voice quality parameters. Two evaluation procedures were performed and compared. Interlistener reliability was sufficiently high in both tests. Significant effects of therapy were found for decreased overall dysphonia, press, instability, gratings, roughness, vocal fry, and "scrape." Nonsignificant group effects were found for breathiness, aphonic instances, and lack of sonority. No significant parameter changes occurred between baseline assessment and the completion of the initial (vocal hygiene) phase of therapy. Significant changes were found following the direct facilitation and respiration phases of therapy. Videostroboscopic evaluations made by two laryngologists showed that in no case were the nodules completely resolved. However, the nodules had decreased in size and edema was reduced after therapy for all clients, but one. Combined results suggest: (1) Alterations in vocal function were reflected in perceptual parameters, and (2) the voice therapy had a positive effect on voice quality, vocal status, and vocal function for the majority of the vocal nodule clients.     

Reliability in Perceptual Analysis of Voice Quality

This study focuses on speaking voice quality in male teachers (n = 35) and male actors (n = 36), who represent untrained and trained voice users, because we wanted to investigate normal and supranormal voices. In this study, both substantial and methodologic aspects were considered. It includes a method for perceptual voice evaluation, and a basic issue was rater reliability. A listening group of 10 listeners, 7 experienced speech-language therapists, and 3 speech-language therapist students evaluated the voices by 15 vocal characteristics using VA scales. Two sets of voice signals were investigated: text reading (2 loudness levels) and sustained vowel (3 levels). The results indicated a high interrater reliability for most perceptual characteristics. Connected speech was evaluated more reliably, especially at the normal level, but both types of voice signals were evaluated reliably, although the reliability for connected speech was somewhat higher than for vowels. Experienced listeners tended to be more consistent in their ratings than did the student raters. Some vocal characteristics achieved acceptable reliability even with a smaller panel of listeners. The perceptual characteristics grouped in 4 factors reflected perceptual dimensions.     

Voice Problems of Future Speech-Language Pathologists

Students training to be educators frequently exhibit voice disorders prior to employment. To date, there exist no similar studies of future speech-language pathologists (SLPs). The study is designed as a prospective, nonrandomized survey. The objective of this study is to determine the voice problems of first year graduate students training to be SLPs. Participants were 104 first year graduate students majoring in speech-language pathology at two universities. The Quick Screen for Voice was administered. Participants who failed completed a questionnaire regarding voice problems, medical history, daily habits, and voice use. When responses further indicated voice-related problems, endoscopic examination was completed. Fourteen percent (N=15) of the participants failed the screening by demonstrating two or more abnormal voice characteristics. These included persistent glottal fry (present in all who failed), low habitual pitch, juvenile resonance, hoarse, breathy, or strained phonation, abnormally low pitch on sustained vowels, and voice breaks during the frequency range. Twelve percent (N=12) failed both the screening and follow-up questionnaire. Responses included self-reported dysphonia, medical history with voice-related side effects, difficulty with excessive voice use, and voice problems occurring daily or weekly. Endoscopic evaluation showed one participant with bilateral vocal nodules. The results suggest that voice problems among future SLPs (12%) are more common than the 3-9% reported in the general population and similar to the 11% previously reported for teachers. However, future SLP voice problems are less frequent than those reported among education majors (21%) and all college students (17%). Faculty should identify students with voice problems and emphasize optimal voice use in classroom and clinical settings.     

Laryngeal Hyperfunction During Whispering: Reality or Myth?

For years, otolaryngologists and voice therapists have warned voice patients that whispering causes more trauma to the larynx than normal speech. However, no large series of patients has ever been examined fiberoptically during whispering to test this hypothesis. As part of our routine examination, patients are asked to count from 1 to 10 in a normal voice and in a whispered voice. We reviewed recorded fiberoptic examinations of 100 patients who had voice complaints. We compared supraglottic hyperfunction and vocal fold closure during the normal and whispered phonation of each patient. Sixty-nine percent of the patients demonstrated increased supraglottic hyperfunction with whispered voice. Eighteen percent had no change, and 13% had less severe hyperfunction. The most common glottal configuration during whisper was an inverted Y, which resulted from compression of the anterior and middle thirds of the true vocal folds. However, 12 patients had no true vocal fold contact during whispered voice, despite having adequate glottic closure with normal voice. Although whispering involves more severe hyperfunction in most patients, it does not seem to do so in all patients. In some patients, it may be less traumatic than normal voice.     

The odyssey of Orpheus: The evolution of solo singing

Notated sacred solo song dates from 1,000 B.C. Early secular song exhibits modest vocal demands of chant-like character. Popular song and liturgical solo song share common origins. Western European secular song notation began in the early Medieval Age. Compositional writing for solo voice took a dramatic turn toward virtuosity about 1600. By the mid-17th century, the modern solo voice emerged. “Classical” solo vocal literature is not static but is constantly evolving, requiring skills far in excess of those of speech or of early solo song literature; this is equally the case with ethnomusicological and popular singing styles. Efficient use of the singing instrument is essential to the healthy accomplishment of all of these literatures.     

Acoustic Analysis of Voice Quality with or without False Vocal Fold Displacement After Cordectomy

Conventional cordectomy by means of a laryngofissure is one of the therapeutic options for treatment of early glottic cancer. To improve the poor voice quality related to this kind of operation, many authors have developed different techniques to repair the mucosal defect. We analyzed voice quality acoustically and compared it after cordectomy alone and after cordectomy with the reconstruction of the vocal cord in a group of 14 patients affected by T1 glottic carcinoma. All the patients underwent postoperative speech therapy. Three patients who underwent cordectomy with reconstruction showed the presence of diplophonia, while two patients without reconstruction showed the presence of bitonality. The differences of the acoustic parameters (jitter, shimmer, harmonic-to-noise ratio) between the two groups of patients were not statistically significant. Reconstruction of the vocal cord does not seem to improve voice quality after cordectomy even in combination with postoperative speech therapy.     

Fragments of a Greek Trilogy: impact on phonation

This study documents the vocal characteristics of an actor before and after a series of eight performances involving extended voice use. The hypothesis was that this type of extended voice use would result in symptoms of vocal abuse and that damage to the actor's voice would be evident in measures made after the performance series. Three pre-performance and three post-performance speech samples were gathered and analyzed using the CSL and Visipitch II. Measurements taken included maximum phonational range; maximum sustained phonation; fundamental frequency during reading; maximum intensity levels; sound pressure levels for soft, moderate, and loud productions of sustained /a/; and perturbation including jitter, shimmer, harmonics-to-noise ratio, and an s/z ratio. Pre- and post-performance samples of the “Rainbow passage” and sustained vowel phonation were rated by a group of blinded listeners that included professional voice trainers and speech pathologists. In addition, sample lines from the performance were played for the listeners to judge whether this technique would result in symptoms of vocal abuse. Eleven out of 12 professional voice trainers rated that this technique would result in symptoms of vocal abuse. The data revealed post-performance improvement in phonational range, maximum intensity levels, perturbation measures, and s/z ratio. Measures of maximum sustained phonation, fundamental frequency, and sound pressure levels remained stable. Videoendoscopy revealed normal function of the larynx and vocal folds.     

Performance effects on the voices of 10 choral tenors: Acoustic and perceptual findings

Trained choral tenors performed a series of vocal tasks before and after a “live” performance. Acoustic (perturbation, harmonic-to-noise ratio, pitch and amplitude ranges) and perceptual analyses (auditory and proprioceptive/kinesthetic) were undertaken to detect changes from pre- to postperformance. Individuality of response to the performance was revealed, with the majority of subjects showing vocal deterioration after performance. The most sensitive vocal tasks were the comfortably pitched notes, high soft notes, and the bottom notes in scale singing. The most sensitive acoustic measure in detecting change from pre- to postperformance was harmonic-to-noise ratio. In contrast to the demonstrated acoustic changes, no significant differences in perceptual ratings were evident after the performance. Perceptual ratings did not reflect the acoustic analysis results. The present study highlights the need to establish further normative data for the singing voice and to consider individual differences in vocal characteristics in future studies of the singing voice.