The economic impact of vocal attrition in public school teachers in Miami-Dade County

A Comparison of Voice and Psychotherapeutic Treatments for Adults With Functional Voice Disorders: A Systematic Review

OBJECTIVE

To examine the effect of traditional voice therapy and cognitive therapy on the voice and client-wellbeing outcomes in adults with functional voice disorders (FVD).

METHODS

A systematic review of English articles was conducted using Medline (Ovid), Embase (Elsevier), CINAHL (Ebsco), The Cochrane Central Register of Controlled Trials (CENTRAL), PsychInfo (Ebsco) and Speechbite from inception to current date. Additional studies were identified through bibliographies and authors were contacted when further information was required from an article. All study designs were included with pretest/posttest outcome measures related to voice. Independent extraction of studies was completed by three authors using predefined data fields and quality assessment tools.

RESULTS

Outcomes of 23 studies (2 RCTs and 21 cohort or case studies) are summarised using a narrative style due to heterogeneity of interventions and outcome scales used. Overall research quality of included studies was low, with many cohort and case studies lacking controls, blinding and robust outcome measures.

CONCLUSIONS

There are some benefits to pairing cognitive behavioural therapy (CBT) with traditional voice therapy for FVD including improved voice quality, psychosocial wellbeing and prevention of relapse. It is feasible to train speech-language pathologists (SLPs) in CBT-enhanced voice therapy. Further high-quality research is needed, however, to guide the clinical implementation of CBT for the management of FVD.

Dysphonia Interference in Schoolteachers' Speech Intelligibility in the Classroom

"Among the most common occupations, schooteachers are the ones who experience the most changes throughout their career. Considering this, the present study aims to verify whether dysphonia in three different degrees may compromise the speech intelligibility of schoolteachers in the classroom.

METHOD

Overall, 39 students, average age 10 years, randomly selected from a public school in the Federal District, Brazil (Distrito Federal, Brasil) performed a transcription task of 20 sentences spoken by four distinct female voices in a classroom, one with a control voice (normal), another with mild dysphonia, 1 with moderate dysphonia and another with severe dysphonia. None of the voices in the study presented changes, neither in fluency nor articulation nor neurological changes. The sentences were previously recorded in an acoustically treated booth, with a microphone on a pedestal 5 cm away from the speaker's mouth. For each sentence to be recorded, the speech model was provided by the speech therapist and then repeated by the speaker according to the model. Each voice recorded 5 different sentences, phonetically balanced and with equivalent number of words. The students included in the study underwent auditory, auditory processing, sequential memory for verbal sounds and sound source location tests, fulfilling the normality criteria. They also did not have neurological or motor disorders or learning, speech or language disorders. Academic success was also taken into account. For the experiment, a speaker was placed in front of the classroom, 1 m from the wall and 1 m from the floor, and students were randomly assigned to the classroom seats. After listening to each sentence, some time was assigned for its transcription by each student.

RESULTS

The occurrence of errors was higher in voices with moderate and severe dysphonia, in which a significant difference was found (P ≤0.003) showing that voices with moderate and severe dysphonia were less intelligible than the normal voice (control voice). No difference was found between the normal voice and the mild dysphonic voice. Binary logistic regression analysis also showed that students had a 2.55 times higher chance of making mistakes with moderate dysphonic voice (P ≤0.011), and that this chance was 3.06 times greater for severe dysphonic voice (P ≤0.002) when compared to the normal voice (control voice).

CONCLUSION

Moderate and severe dysphonia in the voices of schoolteachers interferes with the intelligibility of students, and the greater the degree of dysphonia of the teacher, the greater the chance that the student will make intelligibility errors."

Factors Associated With the Limitation at Work Because of the Voice: Study With Teachers of Basic Education In Brazil

INTRODUCTION

The voice disorder can cause limitations at work, as it affects the communication and the performance of the teaching function.

OBJECTIVE

To analyze the limitation at work because of the voice and to examine possible associations with sociodemographic characteristics, life and health habits and work conditions among Basic Education teachers in Brazil.

METHODS

Cross-sectional epidemiological study, with a representative sample, carried out between October 2015 and March 2016, with 6,324 teachers working in Basic Education in Brazil. Data collection was carried out through the application of a questionnaire via telephone with questions regarding health and working conditions. The "limitation at work because of the voice" was considered a dependent variable, whose response options were a scale with four Likert items that varied from frequently to never. The independent variables were grouped in blocks for ordinal logistic regression analysis with hierarchical entry. The magnitude of the association was assessed by the Odds Ratio (OR) with the respective confidence intervals (95% CI).

RESULTS

One third of Brazilian teachers (32.7%) reported some frequency of limitation at work (sometimes; rarely, frequently) because of the voice at some moment in the month before the survey and, of these, 5% declared high frequency. The factors that increased the chance of a greater frequency of limitation at work because of the voice were: being female (OR = 1.32; 95% CI = 1.15-1.51); teaching for elementary school (OR = 1.35; 95% CI = 1.02-1.78); use anxiolytic or antidepressant medications (OR = 1.46; 95% CI = 1.20-1.78); losing sleep due to concerns (OR = 1.69; CI = 95% = 1.46-1.95); high noise at school (OR = 2.09; 95% CI = 1.78-2.46); agitated environment by students' indiscipline (OR = 1.37; 95% CI =1.15-1.63); high demands at work (OR = 1.18; 95% CI = 1.02-1.36); not having social support (OR = 1.19; 95% CI = 1.04-1.38); having suffered verbal violence by the students (OR = 1.43; 95% CI = 1.23-1.67). On the other hand, the practice of regular physical activity (OR = 0.86; 95% CI = 0.75-1.00) and the fact of having enough time to complete work tasks (OR = 0.71; 95% CI = 0,62-0.82) decreased the chance of a higher frequency of limitation at work due to vocal problems. The perception that the work limits the teaching performance because of the voice was more frequent among teachers in the North (OR=1.41; 95% CI = 1.17-1.71) and Northeast (OR=1.46; 95% CI = 1.22-1.76) compared to the Southeast region.

CONCLUSION

Factors associated with an increase in the chance of higher frequency of reporting work limitations due to the voice: being female, lack of physical activity, losing sleep due to concern, using anxiolytic or antidepressant medication, school location in the North and Northeast, teaching for the elementary school stage, high noise at school and psychosocial aspects of work organization. The Brazilian educational sector needs public policies that take into account regional inequalities and the health and work conditions of teachers.

The prevalence and risk factors for perceived voice disorders in public school teachers

Objectives

The aim of this study was to explore the prevalence and risk factors in public kindergarten and elementary school teachers in the Jimei district in Xiamen. We took particular interest in the relationship between work‐related factors and voice disorders.

Study Design

A cross‐sectional investigation; a General Investigation.

Methods

This study was conducted from September 14 to 18, 2020 at public kindergarten and elementary schools in Xiamen, China. A total of 3140 teachers were separated into a perceived voice disorder group (PVD) and no perceived voice disorder group (NPVD) according to the Voice Handicap Index. The chi‐square test was applied to explore the differences between the PVD and NPVD groups. The univariate logistic regression models were used to identify the risk factors in terms of unadjusted odds ratio and 95% confidence interval. Stepwise logistic regression was then used to ascertain independent determinants.

Results

We found that the prevalence of PVD was 47.52%. The results showed that risk factors of PVD included being female (OR = 1.574), middle‐rank technical title and higher (OR = 2.199), continuous lecturing for more than 3 classes (OR = 3.034), lectured more than 10 classes a week (OR = 1.436) and taught art or physical education (OR = 1.742).

Conclusions

Teachers' work‐related characteristics were associated with PVD. This proves that a preventive voice care program for teachers, administered by the school or education bureau, is urgent. This could include components such as the reasonable arrangement of timetables and recruitment of a sufficient number of kindergarten and elementary school teachers.

Level of evidence: Case‐series

We researched 3140 public kindergarten and elementary schools teachers through general investigation, and performed stepwise logistic regression model to identify uniquely increase risk factors for developing perceived voice disorder. Our investigation is the first study that showed teachers who continuous lecturing 3 or 4 classes had a 3.034‐fold higher risk of PVD than those who have no continuous lecturing (OR = 3.034) in Mainland China. This proves that a preventive voice care program for teachers, administered by the school or education bureau, is urgent.

Voice Disorders in the Workplace: A Scoping Review

OBJECTIVE

Occupational voice users (OVU) are at risk for developing voice disorders (VD). Otolaryngologists need to advocate for workplace accommodations for these patients. The objective of this study was to assess the literature on VDs in the workplace and to describe how results may guide the Otolaryngologist.

DATA SOURCES

EBSCO, PubMed, Google Scholar, UBC libraries, and SpringerLink databases.

REVIEW METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analysis extension for Scoping Reviews protocol was used to conduct a scoping review from inception to December 30, 2019. Oxford Levels of Evidence were used to assess the quality of included studies. Common themes and types of accommodations and barriers were explored. This study was registered with the Open Science Framework Open Source for Collaboration in Scientific Research (10.17605/OSF.IO/RYDVN).

RESULTS

One hundred and ninety-three abstracts were screened; 32 studies met inclusion criteria. Oxford Levels of Evidence ranged from 3 to 5. Eight overarching themes were identified: prevalence of VDs among OVUs; identifying risk factors for VDs; raising awareness of VDs medico-legally, politically; the education and treatment of VDs, the importance of diagnosing VDs; measuring the impact of VDs on work productivity; identifying perceived barriers to integration into the workplace; and calculating the economic costs of VDs. VDs affect workplace productivity and have associated absenteeism, medical, and economic costs. Increased awareness and education on the risk factors for VD development can assist with prevention, early diagnosis, and treatment. Accommodations and barriers are discussed.

CONCLUSION

There is emerging literature on VDs in the workplace. A multitude of VDs exist with varying pathologies, associated barriers, and implications for functioning within the workplace. Otolaryngologists play a unique role in diagnosing voice disorders and defining and facilitating workplace accommodations.

Improvement in Work Productivity After Group Voice Therapy in Professional Voice Users

OBJECTIVE

A disordered voice may significantly impair the ability of workers to perform optimally on the job, especially those classified as professional voice users (PVU). Voice therapy is a common treatment option for voice disorders, but there are few studies demonstrating its effect on work productivity. The objective of this study was to evaluate the change in work productivity in PVU after group voice therapy.

STUDY DESIGN

Prospective cohort study SETTING: Academic Voice Center METHODS: PVUs whose primary treatment for their voice disorder was voice therapy were recruited. Participants completed a 7-week group voice therapy course from January 2018 to December 2020. Participants completed the validated Work Productivity and Activity Impairment questionnaire (WPAI) which measured presenteeism (on the job work productivity impairment) and absenteeism (time missed from work), general self-efficacy scale (GSES), and Voice handicap index -10 (VHI-10) before and after group voice therapy. Changes in scores before and after therapy were compared using a Wilcoxon Signed-Rank test.

RESULTS

Twenty-seven PVU were recruited; 25 had complete data (100% female, mean age 45.4 years, 68% teachers). Presenteeism (SD) decreased from 72.0% (23.3) to 36.8% (24.8), which represented a significant improvement of 35.2% (27.8) [95% CI 21.7-38.7; P < 0.001]. Activity impairment decreased from 48.4% (32.0) to 25.6% (23.8), which represented a significant improvement of 22.8% (26.5) [95% CI 20.7-37.0; P < 0.00]. There was no change in absenteeism (P = 0.27). Patients had high mean GSES of 34.4 (3.7) and abnormal mean VHI-10 of 18.2 (7.2). Changes in VHI-10 and GSES were not significant.

CONCLUSION

PVU had an improvement in work productivity that was largely represented by decreased presenteeism after completing group voice therapy.

Comparison of teachers’ voice disorders before and during COVID -19 pandemic

Purpose: The aim of the study was to analyze the impact of the COVID-19 pandemic and the associated change in teaching mode from stationary to distance learning on the severity of voice-related complaints among teachers. Materials and methods: A questionnaire survey of teachers was conducted to assess voice disorders during stationary and remote work using the Vocal Tract Dyscomfort (VTDs) scale and Numeric Rating Scale (NRS), and respondents' subjective feelings were assessed. The demographic and environmental factors related to voice work were examined. Data on sickness absenteeism obtained from the Healthcare Needs Maps 2020 of the Ministry of Health were also analyzed. The statistical analysis of responses was conducted. A p-value below 0.05 was considered statistically significant. Results: 128 teachers participated in the survey. The overall assessment of voice disorders using VTDs and NRS scales did not show statistically significant differences for complaints between stationary and remote work. Detailed analysis revealed more severe voice disorders in teachers working more than 6 months remotely (p = 0.049) and having more than 20 lessons per week (p = 0.012). The subjective assessment confirmed a significantly lower percentage of teachers reporting voice disorders during remote work compared to stationary work (p = 0.043). This resulted in a reduction of sickness absences and a 40% decrease in sick leave related to voice disorders in 2020 compared to 2019. Conclusions: During the remote learning period in the COVID-19 pandemic, teachers reported lower severity of voice disorders and this contributed to a reduction in sickness absences. There were no statistically significant differences in voice-related complaints assessed by the VTDs and NRS scales for either mode of teaching. Several factors affecting the severity of vocal tract disorders were identified - the number of teaching hours per week (> 20) for stationary work and a long period of remote teaching (> 6 months).

Evaluating the Effect of Recurrent Respiratory Papillomatosis on Work Productivity

OBJECTIVE

Patients with recurrent respiratory papillomatosis (RRP) have significant vocal dysfunction which affects their performance at work. This study aimed to evaluate voice-related work productivity before and after ablative treatment for RRP.

METHODS

This is a prospective case series conducted at 2 academic laryngology outpatient clinics. Adult employed patients with RRP completed the Work Productivity & Activity Impairment instrument (WPAI), Voice Handicap Index (VHI-10), WorkHoarse, Hospital Anxiety and Depression Scale (HADS), and a demographics questionnaire immediately before and 1 month after ablative treatment of papilloma. The primary outcome measure was the change in work productivity impairment domain of the WPAI, and changes in ratings before and after ablation were compared using a Wilcoxon Signed-Rank test.

RESULTS

The 32 participants (mean age 45, 84% male) had a median (interquartile range) voice-related work productivity impairment score of 48.8% (30.0) at baseline which was improved to 5.0% (10.0) at 1 month after surgical ablation of papillomata (difference 30.0% (30.0) improvement). For the secondary outcome measures, there were significant improvements in VHI-10 (P < .001), self-reported voice quality (P = .002), and Workhoarse (P = .001), but no significant change in HADS.

CONCLUSION

Patients with RRP experience significant voice-related work productivity impairment, and ablation of papillomata significantly improves work productivity.

Vocal Fold Fibroblasts in Reinke's Edema Show Alterations Involved in Extracellular Matrix Production, Cytokine Response and Cell Cycle Control

The voice disorder Reinke’s edema (RE) is a smoking- and voice-abuse associated benign lesion of the vocal folds, defined by an edema of the Reinke’s space, accompanied by pathological microvasculature changes and immune cell infiltration. Vocal fold fibroblasts (VFF) are the main cell type of the lamina propria and play a key role in the disease progression. Current therapy is restricted to symptomatic treatment. Hence, there is an urgent need for a better understanding of the molecular causes of the disease. In the present study, we investigated differential expression profiles of RE and control VFF by means of RNA sequencing. In addition, fast gene set enrichment analysis (FGSEA) was performed in order to obtain involved biological processes, mRNA and protein levels of targets of interest were further evaluated. We identified 74 differentially regulated genes in total, 19 of which were upregulated and 55 downregulated. Differential expression analysis and FGSEA revealed upregulated genes and pathways involved in extracellular matrix (ECM) remodeling, inflammation and fibrosis. Downregulated genes and pathways were involved in ECM degradation, cell cycle control and proliferation. The current study addressed for the first time a direct comparison of VFF from RE to control and evaluated immediate functional consequences.

Predictors of health-related absenteeism, presenteeism and sick leave among brazilian elementary school teachers: A cross-sectional study

BACKGROUND

The health risks that usually affect teachers are already known; however, the predictors of health related absenteeism, presenteeism, and sick leave have not yet been fully described.

OBJECTIVE

To analyze the predictors of health-related absenteeism, presenteeism, and sick leave among elementary school teachers.

METHODS

This study involved a probabilistic sample of 519 Brazilian elementary school teachers. The outcomes were days of health-related absenteeism, presenteeism, and sick leave in the previous 12 months. Work-place and individual factors were the independent variables analyzed.

RESULTS

Inadequate infrastructure of schools, disability, and medical consultations were positively associated with all outcomes. Teachers who reported having a chronic disease, common mental disorders, and voice disorders presented higher absenteeism and presenteeism days. Musculoskeletal pain and low job support were associated with higher presenteeism and sick leave days. Teachers who performed strength and flexibility activities presented less presenteeism, those who reported physical violence at school were more frequently absent, and teachers with depersonalization presented a higher likelihood of sick leave.

CONCLUSIONS

The prevention of health-related absenteeism, presenteeism, and sick leave among elementary teachers should ensure adequate work conditions and prevention and monitoring of health risks.

Communication-related affective, behavioral, and cognitive reactions in speakers with spasmodic dysphonia

Objectives

To investigate the self‐perceived affective, behavioral, and cognitive reactions associated with communication of speakers with spasmodic dysphonia as a function of employment status.

Study Design

Prospective cross‐sectional investigation

Methods

148 Participants with spasmodic dysphonia (SD) completed an adapted version of the Behavior Assessment Battery (BAB‐Voice), a multidimensional assessment of self‐perceived reactions to communication. The BAB‐Voice consisted of four subtests: the Speech Situation Checklist for A) Emotional Reaction (SSC‐ER) and B) Speech Disruption (SSC‐SD), C) the Behavior Checklist (BCL), and D) the Communication Attitude Test for Adults (BigCAT). Participants were assigned to groups based on employment status (working versus retired).

Results

Descriptive comparison of the BAB‐Voice in speakers with SD to previously published non‐dysphonic speaker data revealed substantially higher scores associated with SD across all four subtests. Multivariate Analysis of Variance (MANOVA) revealed no significantly different BAB‐Voice subtest scores as a function of SD group status (working vs. retired).

Conclusions

BAB‐Voice scores revealed that speakers with SD experienced substantial impact of their voice disorder on communication attitude, coping behaviors, and affective reactions in speaking situations as reflected in their high BAB scores. These impacts do not appear to be influenced by work status, as speakers with SD who were employed or retired experienced similar levels of affective and behavioral reactions in various speaking situations and cognitive responses. These findings are consistent with previously published pilot data. The specificity of items assessed by means of the BAB‐Voice may inform the clinician of valid patient‐centered treatment goals which target the impairment extended beyond the physiological dimension.

Level of Evidence

2b

Voice disorders and associated risk markers among young adults in the United States

OBJECTIVES/HYPOTHESIS

To examine the prevalence of voice disorders in young adults and identify sociodemographic factors, health conditions, and behaviors associated with voice disorder prevalence.

STUDY DESIGN

Cross-sectional analysis of data from the National Longitudinal Study of Adolescent to Adult Health.

METHODS

During home interviews, 14,794 young adults, aged 24 to 34 years, reported their health conditions and behaviors. Presence and duration of voice disorders were reported over the past 12 months. We computed overall and stratified prevalence estimates by age, gender, race/ethnicity, medical conditions, smoking, and alcohol use. Multiple logistic regression was used to identify independent risk factors for a voice disorder while accounting for the complex sample design.

RESULTS

Six percent of participants reported a voice disorder lasting at least 3 days. Females had 56% greater odds of voice disorders than males. Number of days drinking alcohol was associated with voice disorders, but number of smoking days was not. Conditions that increased the likelihood of voice disorders included hypertension (OR = 1.42 [95% confidence interval {CI}: 1.07-1.89]), tinnitus (OR = 1.53 [95% CI: 1.06-2.20]), and anxiety/panic disorder (OR = 1.26 [95% CI: 1.00-1.60]). Results were independent of gender, alcohol consumption, upper respiratory symptoms, and lower respiratory conditions including asthma, bronchitis/emphysema, and gastrointestinal symptoms (diarrhea/nausea/vomiting).

CONCLUSIONS

Voice disorders in young adulthood were associated with hypertension, tinnitus, and anxiety. Greater awareness of these relationships may facilitate voice evaluation among people who seek healthcare for these chronic conditions.

LEVEL OF EVIDENCE

2b Laryngoscope, 127:2093-2099, 2017.

Tissue engineering-based therapeutic strategies for vocal fold repair and regeneration

Vocal folds are soft laryngeal connective tissues with distinct layered structures and complex multicomponent matrix compositions that endow phonatory and respiratory functions. This delicate tissue is easily damaged by various environmental factors and pathological conditions, altering vocal biomechanics and causing debilitating vocal disorders that detrimentally affect the daily lives of suffering individuals. Modern techniques and advanced knowledge of regenerative medicine have led to a deeper understanding of the microstructure, microphysiology, and micropathophysiology of vocal fold tissues. State-of-the-art materials ranging from extracecullar-matrix (ECM)-derived biomaterials to synthetic polymer scaffolds have been proposed for the prevention and treatment of voice disorders including vocal fold scarring and fibrosis. This review intends to provide a thorough overview of current achievements in the field of vocal fold tissue engineering, including the fabrication of injectable biomaterials to mimic in vitro cell microenvironments, novel designs of bioreactors that capture in vivo tissue biomechanics, and establishment of various animal models to characterize the in vivo biocompatibility of these materials. The combination of polymeric scaffolds, cell transplantation, biomechanical stimulation, and delivery of antifibrotic growth factors will lead to successful restoration of functional vocal folds and improved vocal recovery in animal models, facilitating the application of these materials and related methodologies in clinical practice.