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

Prevalence of Perceived Voice Disorders and Associated Risk Factors in Teachers and General Population in Croatia

OBJECTIVES

There is no available data on the prevalence of voice disorders in Croatia. The objective of this research was to determine the prevalence of perceived voice disorders (PVD) in teachers and general population in Croatia using the Croatian Voice Handicap Index (VHI-HR) questionnaire.

METHODS

This research was divided into two phases. In phase I, the potential of the VHI-HR questionnaire to distinguish individuals with and without voice disorders was assessed. A total of 113 participants completed the VHI-HR. Receiver operating characteristic analysis was performed. In phase II, a cross-sectional study was conducted. A total of 1898 participants, including 1088 teachers from 434 Croatian schools, and 810 nonteachers were included in the study. The questionnaire on sociodemographic factors, potential risk factors associated with voice disorders, and the VHI-HR was administered. The differences in the PVD prevalence in teachers and nonteacher adults and adverse effects of PVD were investigated. The multiple logistic regression model was used to examine the factors associated with PVD occurrence.

RESULTS

In phase I, the cut-off point of 18.32 with 93.44% sensitivity and 98.08% specificity for VHI-HR was determined. In phase II, higher lifetime PVD prevalence was found among teachers. The point prevalence of PVD was 45.68% for teachers, and 21.11% for nonteachers. This study demonstrated that being a teacher, a woman, having a family history of voice disorders, reflux, working in environment with elevated noise levels, and having more than 30years of employment are associated with PVD occurrence.

CONCLUSIONS

VHI-HR score of 19 and higher proves effective in distinguishing individuals with voice disorders from those without. The odds of having PVD for teachers are 2.83 times higher than for nonteachers. Risk factors for voice disorders, among others, include occupational use of voice and working in environments with elevated noise levels.

Vocal Fatigue and Its Relationship with Vocal Hygiene and Work-Related Factors in Professional and Nonprofessional Voice Users: A Multiple Linear Regression Model Study

OBJECTIVES

To investigate vocal fatigue severity between professional voice users (PVUs) and nonprofessional voice users (NPVUs), and across different levels of voice users. Also to examine the relationship between vocal hygiene and work-related factors with vocal fatigue.

METHODS

This is a cross-sectional descriptive study. Four hundred one individuals from different professions were included in total. Participants were divided into four levels of voice users by classification of Koufman and Isaacson. The top three levels of voice users further identified as PVU, and level 4 voice users identified as NPVU. An online questionnaire which included vocal hygiene checklist, work-related factors, and Turkish version of vocal fatigue index (VFI) was submitted by the participants.

RESULTS

Vocal fatigue severity of PVUs were found higher than NPVUs in all VFI scores (P < 0.05). Level 2 voice users were found to have more vocal fatigue severity than all other levels of voice users. Call center workers (CCWs) had the highest means of vocal fatigue severity. Based on the multiple linear regression model vocal hygiene and the number of vocal rest breaks were found to have related with vocal fatigue the most (P < 0.05). There was also a relation with some VFI scores (P < 0.05) with voice usage duration at work and vocal rest duration. We found no relationship between working experience and vocal fatigue. The data suggests the relation between vocal fatigue and vocal hygiene, and work-related factors explain a small proportion of the association. However, in CCWs r2 was found 0.44.

CONCLUSIONS

The change in vocal fatigue severity did not match with Koufman and Isaacson's classification of voice users. We suggest that there may be other contributing factors to vocal fatigue than vocal hygiene, vocal rest, and voice usage duration even those factors may differ from profession to profession.

Prevalence of Occupational Voice Disorder Among Teachers of Kathmandu District, Nepal

The objective of this research was to identify the prevalence of voice disorders among teachers in the Kathmandu District of Nepal, with an emphasis on identifying possible risk factors that may be associated with these disorders. A cross-sectional study design was used, with both quantitative and qualitative data-gathering techniques using a mixed-methods approach. Data were collected from 95 non-teachers and 194 participating teachers from different schools in Kathmandu Valley. The analysis covered self-reported voice problem prevalence, job details, and demographic data. We examined the relationships between several variables and voice issues, including gender, class size, length of instruction, and tobacco usage. Findings: Compared with nonteachers (33.7%), teachers had a considerably greater prevalence of voice issues (69.1%). Greater class size and more than ten years of teaching experience were shown to be risk factors, while female instructors reported a greater prevalence of voice issues. Additionally, it was shown that instructors' voice issues are also linked to tobacco usage. The results of this study highlight how critical it is to provide voice therapy to educators employed in the Kathmandu District, particularly those in at-risk categories such as female instructors, more experienced educators, and educators with larger class sizes. The outcomes demonstrated important impacts on teacher well-being, job satisfaction, and academic achievement. More research and intervention strategies are needed to minimize the effects of voice problems and promote a positive teaching and learning environment.

Clinical Characteristics of Individuals Presenting to Physiotherapy for Voice and Throat Care: A Retrospective Case Notes Review

BACKGROUND

Currently, little is known about the characteristics of individuals presenting for physiotherapy care with voice and throat problems.

PURPOSE

The aim of this study is to describe the demographic and clinical characteristics of individuals presenting to physiotherapy for voice and throat-related problems, and to use this information to clarify the role of physiotherapy in the management of people with voice and throat problems.

METHODS

A retrospective clinical case notes review was conducted of all clients who accessed physiotherapy for voice and throat problems at a private practice based in Christchurch within a 12-month period from 1st October 2020 to 1st October 2021.

RESULTS

Data were analyzed from 53 patient charts. The typical profile of an individual accessing physiotherapy for voice and throat problems were female (n = 37), NZ European (n = 26), singer (n = 43), with chronic problems (n = 20), of a nontraumatic origin (n = 45). Voice problems were present in 39 cases and muscle-related problems were present in 42 cases. Treatment primarily included manual therapy and various modes of exercise therapy.

CONCLUSIONS

The clinical characteristics described offer insight into the demographic and clinical characteristics of individuals accessing physiotherapy services for voice and throat problems. A high prevalence of muscle-related problems and wider issues were identified, consistent with the physiotherapy skill set. Physiotherapy appears to complement existing ENT or SLT services by identifying and managing muscle-related voice problems and addressing wider factors contributing to voice and throat problems.

The Influence of Age, Gender, Health-Related Behaviors, and Other Factors on Occupationally Relevant Health Complaints of Singers

OBJECTIVES

Professional singers' careers are usually associated with health-relevant factors that they themselves may or may not be able to influence. We have therefore investigated the effect of modifiable health-related behaviors and non-modifiable factors on singers' occupational health.

METHODS

In an explorative, questionnaire-based study, self-reported, occupationally relevant health complaints and behaviors, along with singer-specific characteristics, were surveyed from 349 professional singers and voice teachers (116 men, 233 women; age 18-73 years) and the influence of age, gender, duration of daily and lifelong singing, voice category, and health-related behaviors (smoking, alcohol consumption, physical activity) on occupationally relevant health complaints were analyzed using bi- and multivariate statistical methods.

RESULTS

Singers reported less risky alcohol consumption (5.4% versus ≈15%) and smoking (15.5% versus 29.7%) than the general population, and too little physical activity was described in two thirds of both populations. After controlling for multiple testing, no effect was found for these behaviors, the time spent singing daily, gender, or voice categories on singers' complaints. Health complaints were significantly fewer for males (P < .001) and older women and were reported more frequently for higher-pitched male voices, a trend not found in females.

CONCLUSION

Singers seem to smoke and drink less than members of the general population. These factors did not affect their complaints. Female singers described more work-related health complaints than males, a finding that corresponds to women in the general population. Older singers reported fewer complaints than younger singers, possibly because of selection effects or older singers acquiring strategies to avoid health-damaging behavior.

Development and Application of Automated Vocal Fold Tracking Software in a Rat Surgical Model

OBJECTIVE

The rat is a widely used model for studying vocal fold (VF) function after recurrent laryngeal nerve injury, but common techniques for evaluating rat VF motion remain subjective and imprecise. To address this, we developed a software package, called RatVocalTracker1.0 (RVT1.0), to quantify VF motion and tested it on rats with iatrogenic unilateral vocal fold paralysis (VFP).

METHODS

A deep neural network was trained to identify the positions of the VFs and arytenoid cartilages (ACs) in transoral laryngoscope videos of the rat glottis. Software was developed to estimate glottic midline, VF displacement, VF velocity, and AC angle. The software was applied to laryngoscope videos of adult rats before and after right recurrent and superior laryngeal nerve transection (N = 15; 6M, 9F). All software calculated metrics were compared before and after injury and validated against manually calculated metrics.

RESULTS

RVT1.0 accurately tracked and quantified VF displacement, VF velocity, and AC angle. Significant differences were found before and after surgery for all RVT1.0 calculated metrics. There was strong agreement between programmatically and manually calculated measures. Automated analysis was also more efficient than nearly all manual methods.

CONCLUSION

This approach provides fast, accurate assessment of VF motion in rats with minimal labor and allows for quantitative comparison of lateral differences in movement. Through this novel analysis method, we can differentiate healthy movement from unilateral VFP. RVT1.0 is open-source and will be a valuable tool for researchers using the rat model for laryngology research.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:340-346, 2024.

Influence of a Surgical Mask on Voice Analysis in Dysphonic Patients During the COVID-19 Pandemic

Objective

COVID-19 has radically changed medical practice. The main objective of this study was to assess the impact of surgical mask (SM) on voice quality analyzes in a group of patient with different common benign vocal organic pathologies.

Study Design

A cross-over study.

Setting

A group of 20 patients with different organic benign vocal pathologies was recruited from the ENT consultation of the University Hospital of Charleroi in Belgium.

Methods

On the day of the assessment, each subject underwent an endonasal laryngeal videostroboscopy followed by a voice analysis (VA) with and without a new SM. The following parameters were analyzed: fundamental frequency, maximum frequency, range in amplitude and frequency of the voice, jitter and maximum phonatory time.

Results

In this research, we showed that VA can be performed with an SM while not changing the measured vocal parameters. These results also suggest that for the same individual a VA performed before the pandemic without SM could be compared to one with a SM to follow the patient's evolution of his or her voice quality.

Conclusion

The wearing of an SM during VA should always be recommended in case of immunodeficiency, a contagious disease of the patient or during a (new) pandemic.

A General Survey of Pharynlaryngeal Diseases and Voice Disorders Among Basic Education Teachers in Tianjin

OBJECTIVE

In this study, we created a city-wide database of pharynlaryngeal diseases and voice disorders among basic education teachers to analyze the incidence, distribution, and risk factors of pharynlaryngeal diseases and voice disorders.

METHODS

A total of 47,823 teachers in primary and secondary schools and kindergartens of Tianjin were enrolled in this study and underwent questionnaires and throat examinations. In addition, the data were subjected to descriptive statistics, chi-square analysis, and univariate and multivariate logistic regression analyses.

RESULTS

Pharynlaryngeal diseases and voice disorders had an overall prevalence of 69.42% among basic education teachers in Tianjin, wherein the prevalence of chronic pharyngitis, chronic hyperplastic laryngitis, and chronic simple laryngitis were the highest at 39.45%, 19.80%, and 15.59%, respectively. The results of multivariate logistic regression analysis suggest that pharynlaryngeal diseases and voice disorders were statistically correlated with gender (P < 0.001), years of teaching (P < 0.001), school district (P < 0.001), class size (P < 0.001), subjective assessment of teachers on vocal loudness (P < 0.001), neck and shoulder discomfort (P < 0.001), smoking (P < 0.001), psychological stress (P = 0.002), and frequent habitual throat clearing (P < 0.001). Furthermore, the risk factors for pharynlaryngeal diseases and voice disorders were age (P = 0.002), school district (P < 0.001), class size (P = 0.008), neck and shoulder discomfort (P = 0.038), smoking (P < 0.001), water intake habits during class (P = 0.023), and frequent habitual throat clearing (P = 0.001) for male teachers, and for female teachers, it was age (P < 0.001), school district (P < 0.001), daily teaching hours (P = 0.005), class size (P < 0.001), subjective assessment of teachers on vocal loudness (P < 0.001), neck and shoulder discomfort (P < 0.001), smoking (P = 0.033), psychological stress (P = 0.003), and frequent habitual throat clearing (P < 0.001).

CONCLUSION

Due to the high prevalence of pharynlaryngeal diseases and voice disorders among basic education teachers, throat and voice health education-related activities should be conducted for teachers to intervene in the occurrence of pharynlaryngeal diseases and voice disorders at an early stage.

The Vocal Hygiene Treatment Programs for Singers: A Systematic Review

OBJECTIVES

This systematic review aims to explore the effectiveness of voice health education interventions among singers, particularly focusing on vocal hygiene treatment programs tailored for professional voice users.

STUDY DESIGN

Systematic review.

METHODS

Preferred Reporting Items on Systematic Reviews and Meta-Analysis guidelines were followed to conduct this systematic review. Comprehensive searches were conducted in PubMed, Web of Science, Scopus, Science Direct, and Cochrane Library databases. Four articles were selected for detailed review. The studies were evaluated using the Effective Public Health Practice Project tool for quality assessment.

RESULTS

The four reviewed studies primarily utilized the pretest-posttest design to examine the effectiveness of vocal hygiene interventions on singers' vocal health. Two studies investigated the effect of hydration as a treatment method, while the remaining two focused on vocal hygiene instruction. Significant improvements were observed in various vocal health parameters, including maximum phonation time, intensity, Dysphonia Severity Index, and number of daily vocal breaks taken.

CONCLUSION

This systematic review provides valuable insights into the efficacy of vocal hygiene treatment programs for singers. The positive outcomes observed in the reviewed studies underscore the importance of voice health education tailored to singers' specific needs. However, the limited number of eligible studies and the common limitation of small sample sizes highlight the need for further research in this area. Vocal health practitioners, educators, and researchers can utilize the findings of this review to develop evidence-based vocal hygiene interventions that promote the well-being and longevity of singers' vocal performance careers.

How older adults relate to their own voices: a qualitative study of subjective experiences of the aging voice

AIM

The aim of this study was to investigate how otherwise healthy older adults with self-assessed voice problems relate to their voice and voice changes.

METHOD

Focus groups were conducted at an activity center to identify how older adults reflect on their own voice and the aging voice in general. The interviews were audio recorded and transcribed. The analysis was done using thematic content analysis.

RESULTS

The analysis resulted in three main themes: "communicational aspects of the aging voice," "consequences of deteriorating vocal and communicative capacity," and "attitudes, strategies, and ideas". The participants considered voice to be an important communication tool and presented what could be interpreted as awareness regarding their voice. Voice changes were considered a natural part of aging. This attitude was also an important reason why the participants had not sought medical care for their voice problems. The participants discussed ideas concerning extended voice use to maintain a functioning voice when aging. Simultaneously, voice changes due to aging were considered to have a negative effect on communication and social participation.

CONCLUSIONS

The voice is important for older adults, and an insufficient voice can affect communication and social participation. Information about aging voice and voice exercises, for example from speech language pathologists, could be of interest among older adults. Further studies on the voice of older adults are needed regarding how they experience their voice and the general aspects of a healthy aging voice.

Adaptation and validation of the Persian Version of the Singing Voice Handicap Index-10 (SVHI-10)

OBJECTIVES

Singers' self-reporting of their voice problems can be helpful in the treatment of voice disorders by speech-language pathologists (SLP), which requires a valid questionnaire. This study was conducted to translate and validate the Singing Voice Handicap Index-10 (SVHI-10) questionnaire in the Persian language.

METHODS

This cross-sectional study was conducted in two main steps (1) translation of the questionnaire and determination of face and content validity and (2) survey of singers. The questionnaire was first translated by a SLP who was an expert in voice disorder and also proficient in the English language. The face and content validity of the questionnaire was confirmed by experts through impact score, content validity ratio, and content validity index. Then it was translated into English and adapted to its original version. A valid questionnaire was given to 70 singers to determine their ability to distinguish singers with voice problems from healthy singers and their internal consistency.

RESULTS

The face and content validity of the questionnaire was confirmed without excluding any item. The results showed that the questionnaire has excellent internal consistency (α = 0.930). With the optimal cut-off point of 14.5, this questionnaire was able to identify singers with voice problems with 90% accuracy. Also, the sensitivity and specificity were 84.85% and 94.59%, respectively. Also, the area under the Receiver Operating Characteristic (ROC) curve was equal to 0.937.

CONCLUSION

The results revealed that the Persian version of SVHI-10 is a reliable and valid instrument to identify singers with voice problems, so it can be used by SLPs.

Immediate Effects of Semi-occluded Vocal Tract Exercises as a Vocal Warm-Up in Singers

OBJECTIVE

The present study aimed to investigate the Immediate Effects of Semi-occluded Vocal Tract Exercises (SOVTEs) as a vocal warm-up on the Electrical Activity of Extrinsic Laryngeal Muscles and acoustic parameters of voice in singers.

STUDY DESIGN

This study used a pre-/post-interventional (quasi-experimental) design and a simple non-random sampling method.

SETTING

Musculoskeletal Rehabilitation Research Center.

METHOD

Surface electromyography of the suprahyoid and infrahyoid muscle areas and acoustic measurements were assessed before and immediately after performing three SOVTEs: lip-trill, humming, and straw phonation for 20 minutes as a vocal warm-up in eleven healthy male singers with an average age of 26.5 ± 4.2.

RESULTS

After performing the vocal warm-up, root mean square in channels two and three (left and right infrahyoid muscle areas) in all vocal tasks, including /i/, /u/, and counting from 20 to 30 was significantly decreased (P < 0.05). The acoustic parameters, F1, and F1-F0 difference were significantly decreased (P < 0.05).

CONCLUSION

The results suggest that after performing SOVTEs as a vocal warm-up, the electrical activity of the extrinsic laryngeal muscles is reduced. The acoustic analysis also demonstrated a decrease in F0, F1, and F1-F0 variables. Therefore, it seems that the results of acoustic and electromyographic assessments are in line and it is likely that SOVTEs through the vocal economy lead to a reduction in the load applied to the phonatory system.

Investigating the Effects of Warm-up Exercises on Acoustic Characteristics of Voice in Female Gym Coaches

INTRODUCTION

A plethora of vocal enhancement and rehabilitation programs for voice professionals define vocal exercises irrespective of analyzing their effects on the specific population on which they are applied, in the established dose and often without considering the presence and absence of vocal alteration. So, in this study we investigated the impact of warm-up exercises (WUE) on the acoustic features of the gym coaches.

OBJECTIVE

To determine the effectiveness of WUE on the acoustic characteristics of the voice in gym coaches.

STUDY DESIGN

This was a Quasi-experimental control group design study.

METHOD

The study was carried out through participation of forty-five female gym coaches with a mean age of 31.4 years (range: 19-44 years) in Mashhad gym salon. Participants were recruited into two conditions. In the first condition, participants did not receive the exercises for a week and were acoustically evaluated at the beginning and end of the week. In the second condition, participants received the exercises once a day for a week and were acoustically evaluated at the beginning and end of the week. Voice samples were included: at least 3 vowels / a / for at least five seconds. The voice samples analyzed by the Praat software recorder (Version 6.0.23) were collected to detect the acoustic characteristics of voice including fundamental frequency (f0) (Hz), jitter (%), shimmer (dB) and noise to harmonic ratio (NHR) (dB). Finally, the data obtained from these two condition were compared.

RESULTS

After WUE, a significant increased f0, decreased jitter, decreased shimmer and decreased NHR were measured. (p-value < 0.005).

CONCLUSION

The WUE had an immediate positive effect on acoustic characteristics of voice)f0, jitter, shimmer and NHR(in the short term and this study suggests that the WUE is an effective technique for enhancing the overall voice quality of gym coaches.

Characterization of Vocal Fold Pathology in Military Drill Instructors

OBJECTIVE

Military drill instructors have extreme vocal demands that place them at risk for phonotrauma. Characterization of laryngeal pathology and vibratory characteristics among drill instructors presenting for specialized voice care is lacking.

METHODS

A retrospective review in a specialized voice clinic over a two-year period was conducted. Patients identified as current drill instructors between the ages of 28-43 with a diagnosis of dysphonia were included. Laryngeal pathology was diagnosed by a fellowship trained laryngologist and vibratory characteristics were evaluated utilizing the Voice-Vibratory Assessment with Laryngeal Imaging (VALI) rating form. All patients were also evaluated by a speech-language pathologist. Patient reported outcome measures were collected along with perceptual voice evaluations utilizing the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V).

RESULTS

Twelve current drill instructors were identified, and all had phonotraumatic lesions. Lesions were categorized as vocal fold hemorrhage (8%), ectasia (25%), unilateral epithelial thickening (33.3%), bilateral epithelial thickening (58.3%), ventricular cyst (8%), polyp (25%), and sulcus vocalis (25%). Vibratory abnormalities were assessed with the VALI rating scale and correlated to CAPE-V perceptual ratings with 83% having reduced mucosal wave, 75% reduced amplitude of lateral excursion, 50% aperiodic vibrations, 50% asymmetric or chasing wave, 58% glottal insufficiency, 100% supraglottic hyperfunction, and an average CAPE-V overall severity of 50% with severe perceptual dysphonia. The average Voice Handicap Index (VHI-10) and Reflux Symptom Index (RSI) score was 15.5 and 14.7, respectively.

CONCLUSION

Phonotraumatic lesions were universally present in drill instructors complaining of hoarseness, suggesting early referral, and intervention may be warranted in this population.

LEVEL OF EVIDENCE

4.

Prevalence of Laryngopharyngeal Reflux Symptoms, Dysphonia, and Vocal Tract Discomfort in Amateur Choir Singers

INTRODUCTION

Vocal tract discomfort (VTD), dysphonia, and laryngopharyngeal reflux (LPR) symptoms are complaints frequently reported by amateur singers. There are two aims of this study. The first is to evaluate the prevalence of these symptoms using validated questionnaires. The second is to correlate singing-related variables with the questionnaire responses.

METHODS

A total of 392 amateur choir singers (ACS) and 514 control subjects completed an online survey divided into four parts: (1) clinical and demographic characteristics, (2) training in singing and singing experience, (3) history of gastroesophageal reflux disease and LPR symptoms, (4) validated questionnaires. Specifically, the reflux symptom index (RSI), the vocal tract discomfort scale (VTDS), and the voice symptom scale (VoiSS) were included to analyze the actual burden related to LPR symptoms, VTD, and dysphonia.

RESULTS

ACS demonstrated a healthier lifestyle and a lower prevalence of gastroesophageal reflux disease symptoms in comparison with control subjects. ACS scored significantly higher in VTDS and VoiSS than control subjects, while no differences in the RSI results were found. Significant correlations among the questionnaires' results were demonstrated. Occasional professional singing was the variable influencing VTDS and VoiSS results the most.

CONCLUSION

ACS do not evidently manifest a higher impairment connected to LPR (RSI score), while they do report higher levels of voice (VoiSS score) and vocal tract (VTDS score) impairments, in comparison with control subjects. The relevant correlations among the PRO measures suggest that LPR symptoms, VTD, and dysphonia are related to each other. Given the relevant repercussion on the severity of VTD and dysphonia, providers should specifically ask about occasional professional singing when treating amateur singers.

Effect of a Workplace Vocal Health Promotion Program and Working Conditions on Voice Functioning of College Professors

OBJECTIVE

To determine the effect of a Workplace Vocal Health Promotion Program (WVHPP) and working conditions on voice functioning of college professors.

STUDY DESIGN

This is a pre-post intervention study.

METHODS

College professors were randomly assigned in a control group or an intervention group. Participants filled out a questionnaire and recorded a voice sample at baseline and at the end of the follow-up. This program contains four sessions (2 face-to-face and 2 virtual sessions; one per week) focused on voice hygiene, vocal training, and strategies to modify teaching-learning process.

RESULTS

The Intervention group (n = 15) showed increased scores in V-RQOL in comparison with the control group (n = 14), but the effect was not statistically significant. After the program, shimmer decreased (P = 0.05), whereas MPT and HNR increased (P = 0.02 and 0.04 respectively) among professors in the intervention group after the implementation of the WVHPP. Concerning working conditions, number of students per class was statistically associated with SPL. MPT was statistically associated with age and good acoustics inside the classroom.

CONCLUSIONS

Our results indicate that implementation of a WVHPP, as well as working conditions, influence voice functioning measured by means of instrumental voice measures and voice-related quality of life. Therefore, workplace promotion programs may be good approaches to decrease the high prevalence of voice disorders among professors.

Prevalence of Self-Reported Voice Concerns and Associated Risk Markers in a Nonclinical Sample of Military Service Members

INTRODUCTION

Difficult communication environments are common in military settings, and effective voice use can be critical to mission success. This study aimed to estimate the prevalence of self-reported voice disorders among U.S. military service members and to identify factors that contribute to their voice concerns.

METHOD

A nonclinical sample of 4,123 active-duty service members was recruited across Department of Defense hearing conservation clinics. During their required annual hearing evaluation, volunteers provided responses to voice-related questions including a slightly adapted version of the Voice Handicap Index-10 (VHI-10) as part of a larger survey about communication issues. Changepoint detection was applied to age and years of service to explore cohort effects in the reporting of voice concerns. Logistic regression analyses examined multiple available factors related to communication to identify factors associated with abnormal results on the VHI-10.

RESULTS

Among the respondents, 41% reported experiencing vocal hoarseness or fatigue at least several times per year, and 8.2% (n = 336) scored above the recommended abnormal cut-point value of 11 on the VHI-10. Factors independently associated with the greatest risk for self-reported voice concerns were sex (female), cadmium exposure, vocal demands (the need for a strong, clear voice), and auditory health measures (frequency of experiencing temporary threshold shifts; self-reported hearing difficulties).

CONCLUSIONS

Based on self-reported voice concerns and false negative rates reported in the literature, the prevalence of dysphonia in a large sample of active-duty service members is estimated to be 11.7%, which is higher than that in the general population. Certain predictors for voice concerns were expected based on previous literature, like female sex and voice use, but frequency of temporary threshold shifts and exposure to cadmium were surprising. The strong link between voice and auditory problems has particular implications regarding the need for effective communication in high-noise military and other occupational environments.

Voice Acoustics and Vocal Effort in Mask-Wearing Healthcare Professionals: A Comparison Pre- and Post-Workday

OBJECTIVE

We evaluated voice acoustics and self-perceptual ratings in healthcare workers required to wear face masks throughout their workday.

METHODS

Eighteen subjects (11 cisgender female, 7 cisgender male; M = 33.72 years, SD = 8.30) completed self-perceptual ratings and acoustic recordings before and after a typical workday. Chosen measures were specific to vocal effort, dysphonia, and laryngeal tension. Mixed effects models were calculated to determine the impact of session, mask type, sex, and their interactions on the set of perceptual and acoustic measures.

RESULTS

The subjects self-reported a significant increase in vocal effort following the workday. These perceptual changes coincided with an increase in vocal intensity and harmonics-to-noise ratio, but decrease in relative fundamental frequency offset 10. As expected, men and women differed in measures related to fundamental frequency and vocal tract length.

CONCLUSION

Healthcare professionals wearing masks reported greater vocal symptoms post-workday compared to pre-workday. These symptoms coincided with acoustic changes previously related to vocal effort; however, the degree of change was considered mild. Further research is needed to determine whether vocal hygiene strategies may reduce vocal symptoms in mask-wearing workers.

Performers With History of Voice Injury: A Survey Study of Treatment Outcomes and Vocal Function

INTRODUCTION

Past studies show that performers are more susceptible to voice injury, have higher incidence of injury, and experience greater vocal impairment than non-performers. Despite literature demonstrating otherwise, there remains fear and stigma that voice injury is a career-ending circumstance. Much of this is due to a lack of information about post-treatment vocal function.

METHODS

An anonymous online survey was distributed via email, flyer, and social media to a target audience of performers with a history of voice injury. It inquired about occupation, vocal symptoms, professionals consulted, and treatment adherence. Outcome measures included ability to perform, resolution of symptoms, and attitudes about their voices after voice injury. Findings were analyzed descriptively with statistical analysis to determine factors that may be related to favorable outcomes.

RESULTS

The survey was completed by 151 performers representing a range of genres, including musical theatre, classical, and popular genres. The most reported vocal symptoms were decreased range, singing voice quality changes, increased singing effort, and vocal fatigue. Most initially sought care from an otolaryngologist, laryngologist, or voice teacher. Diagnoses and recommendations varied, but those who adhered to treatment were more likely to report resolution of voice symptoms (P = 0.025). Those with symptoms for 2-4 weeks reported greater vocal confidence than those with a longer symptom duration (P = 0.0251). Performers working with a voice teacher were more likely to find treatment helpful (P = 0.0174). Those with neurogenic voice conditions reported less vocal reliability than participants with other pathologies (P = 0.0155).

CONCLUSION

The majority of participants continued to perform, reported resolved or improved voice symptoms after treatment, and reported positive attitudes about their voices, regardless of their injury or current presence or absence of pathology on exam. Findings of this study highlight a need for continued outreach to voice teachers, education programs, and production teams about vocal function after voice injury.

LEVEL OF EVIDENCE: 4

Visual-perceptive assessment of glottic characteristics of vocal nodules by means of high-speed videoendoscopy

OBJECTIVE

Visual-perceptive assessment of glottic characteristics of vocal nodules by means of high-speed videoendoscopy.

METHODS

Descriptive observational research with convenience sampling of five laryngeal videos of women with an average age of 25 years. The diagnosis of vocal nodules was defined by two otolaryngologists, with 100% intra-rater agreement and 53.40% inter-rater agreement and five otolaryngologists as judge assessed the laryngeal videos based on an adapted protocol. The statistical analysis calculated measures of central tendency and dispersion, as well as percentage. The AC1 coefficient was used for agreement analysis.

RESULTS

In high-speed videoendoscopy imaging, vocal nodules are characterized by amplitude of the mucosal wave and muco-undulatory movement with magnitude between 50% and 60%. Non-vibrating segments of vocal folds are scarce, and the glottal cycle does not show a predominant phase, it is symmetric and periodic. Glottal closure is characterized by the presence of a mid-posterior triangular chink (double chink or isolated mid-posterior triangular chink), without movement of supraglottic laryngeal structures, with irregular contour of the free edge of vocal folds, which are vertically on-plane.

CONCLUSION

Vocal nodules present mid-posterior triangular chink and irregular free edge contour. Amplitude and mucosal wave were partially reduced.

LEVEL OF EVIDENCE

Level 4 (Case-series).

Comparing Vocal Health and Attitudes to Voice care in Primary Teachers and Voiceover Artists - A Survey Study Using the Health Belief Model

OBJECTIVES

A range of professions experience high demands on their voices and are potentially at risk of developing voice disorders. Teachers have been studied extensively in this respect, while voiceover artists are a growing professional group with unknown levels of voice training, voice problems and voice care attitudes. To better understand profession-specific voice care requirements, we compared voice training, voice care habits and self-reported voice problems of these two professional groups and measured attitudes to voice care, informed by the Health Belief Model (HBM).

STUDY DESIGN

The study was a cross-sectional survey study with two cohorts.

METHODS

We surveyed 264 Scottish primary school teachers and 96 UK voiceover artists . Responses were obtained with multiple-choice and free-text questions. Attitudes to voice care were assessed with Likert-type questions that addressed five dimensions of the HBM.

RESULTS

Most voiceover artists had some level of voice training, compared to a minority of teachers. Low numbers of teachers reported regular voice care, compared to over half of voiceover artists. Higher numbers of teachers reported work-related voice problems. Voiceover artists reported greater awareness for vocal health and perceived potential effects of voice problems on their work as more severe. Voiceover artists also saw voice care as more beneficial. Teachers perceived barriers to voice care as substantially higher and felt less confident about voice care. Teachers with existing voice problems showed increased perceptions of voice problem susceptibility and severity and saw more benefit in voice care. Cronbach's alpha was below 0.7 for about half of the HBM-informed survey subsets, suggesting that reliability could be improved.

CONCLUSIONS

Both groups reported substantial levels of voice problems, and different attitudes to voice care suggest that the two groups require different approaches to preventative intervention. Future studies will benefit from the inclusion of further attitude dimensions beyond the HBM.

Speaking with mask in the COVID-19 era: Multiclass machine learning classification of acoustic and perceptual parameters

The intensive use of personal protective equipment often requires increasing voice intensity, with possible development of voice disorders. This paper exploits machine learning approaches to investigate the impact of different types of masks on sustained vowels /a/, /i/, and /u/ and the sequence /a'jw/ inside a standardized sentence. Both objective acoustical parameters and subjective ratings were used for statistical analysis, multiple comparisons, and in multivariate machine learning classification experiments. Significant differences were found between mask+shield configuration and no-mask and between mask and mask+shield conditions. Power spectral density decreases with statistical significance above 1.5 kHz when wearing masks. Subjective ratings confirmed increasing discomfort from no-mask condition to protective masks and shield. Machine learning techniques proved that masks alter voice production: in a multiclass experiment, random forest (RF) models were able to distinguish amongst seven masks conditions with up to 94% validation accuracy, separating masked from unmasked conditions with up to 100% validation accuracy and detecting the shield presence with up to 86% validation accuracy. Moreover, an RF classifier allowed distinguishing male from female subject in masked conditions with 100% validation accuracy. Combining acoustic and perceptual analysis represents a robust approach to characterize masks configurations and quantify the corresponding level of discomfort.

Objective and Subjective Voice Examination in Turkish Imams

OBJECTIVE

Imams are professional voice users and they are at high risk of developing voice problems. The aim of the present study was to investigate vocal acoustic parameters and voice handicap index (VHI) scores in Turkish imams and comparing these paramaters with a control group of male nonprofessional voice users.

METHODS

A total of 62 active working Turkish imams that never applied to our clinic with voice problems volunteered as subjects for the study and the control group consisted of 47 male nonprofessional voice users. Every participant completed a VHI questionnaire. A voice analysis was performed using computer program Dr.Speech Version 4 in an acoustically treated setting. Mean fundamental frequency, jitter, shimmer, harmonics to noise ratio values were recorded during the phonation and were analyzed.

RESULTS

All imams were active working men aged 27-57 and the control group was comprised of male nonprofessional voice users of a similar age group. The measure of mean fundamental frequency, harmonics to noise ratio, jitter and shimmer rates were similar between two groups. In comparison of VHI between the groups no significant differences were found.

CONCLUSION

Even though imams in the study group stated that they experienced voice problems in their professional lives, this did not cause any adverse changes in acoustic and subjective parameters (VHI) compared with control group.

A User-Centered Design Approach to Developing a Voice Monitoring System for Disorder Prevention

BACKGROUND

Many individuals will experience a voice disorder in their lifetime, especially occupational voice users. While a number of voice monitoring systems have been developed, most were designed with the clinician/researcher as the end user. For a patient to use these systems, they need field experts to help them interpret data from the system to understand its meaning. Most of these systems would have challenges in being used in a preventative context with the occupational voice user as the sole system user.

OBJECTIVE

The current study introduces a novel design approach: user-centered design (UCD) with paper prototypes in the creation of a voice monitoring system for voice disorder prevention (VDP). The goal of this design approach is to design systems that are engaging and intuitive for users so they will be interested in interacting with the system and be able to benefit from the system without the need of external support.

METHODS

The current study was conducted in two phases: an iterative design phase and a test phase. In the iterative design phase, 15 participants gave their opinions on the measures and feedback designs they felt would be the most beneficial to users. In the test phase, the researchers collected real voice data over multiple sessions for 18 additional participants and provided this data using the final feedback displays from the design phase.

RESULTS

By engaging in UCD, the researchers identified key design challenges for VDP: (1) educating the user, (2) balancing contextualization and granularity, and (3) addressing disconnection between user and system goals.

CONCLUSION

UCD holds promise for designing VDP systems that are both engaging and intuitive for occupational voice users.

Vocal Tract Discomfort Symptoms in Elementary and High School Teachers

OBJECTIVES

The vocal tract discomfort scale is a self-rating seven-point Likert scale that quantifies frequency and severity of eight qualitative descriptors including burning, tight, dry, aching, tickling, sore, irritable, and lump in the throat, and ranges from 0 (never/none) to 6 (always/extreme; Mathieson et al. 2009). The objectives of the current study were to compare the vocal tract discomfort scale results between elementary school teachers and high school teachers and between male and female teachers using the Persian vocal tract discomfort scale. Also, teachers in different age ranges and with different experiences were compared regarding vocal tract discomfort symptoms.

METHODS

The researchers chose 20 elementary and high schools by simple random sampling in Khorramabad, Iran. The survey was given to available teachers of the selected schools. Considering the inclusion criteria, required sample size, and after excluding questionnaires that were not correctly answered, 120 were selected such that 30 were chosen for each subgroup. Subjects consisted of 60 elementary school teachers (30 females and 30 males) with the mean age of 40.92 years (standard deviation = 6.07) and 60 high school teachers (30 females and 30 males) with the mean age of 40.67 years (standard deviation = 6.00). SPSS 25 was used for analyzing the data.

RESULTS

Results indicated that the frequency and severity of the vocal tract discomfort in elementary school teachers were significantly higher than for the high school teachers with a medium to large effect size. Although the frequency and severity of the symptoms were higher in female compared with male teachers, those differences were not significantly different. Younger teachers had lower frequency and severity ratings of vocal tract discomfort symptoms than older teachers. Teaching experience was not an important factor in predicting vocal tract discomfort symptoms in teachers.

CONCLUSIONS

The results of this study suggest that there is higher frequency, greater severity, and higher percentages of vocal tract discomfort symptoms in elementary compared with high school teachers. In addition, although the mean frequency and severity of vocal tract discomfort symptoms were not significantly different between females and males, females reported higher percentages of the symptoms. Because each of the eight vocal tract symptoms was experienced at the time of testing by between 42% (tightness) and 68% (dryness) of the participants, it is suggested that an educational program regarding vocal tract discomfort may be helpful for this profession.

The Effects of Collegiate Sports Coaching on the Male Voice: Pilot Data

PURPOSE

This research gathered pilot data on the effects of a typical collegiate athletic season on the male coach's voice.

MATERIALS AND METHODS

Ten male coaches and ten age- and sex-matched controls participated. Qualitative and quantitative analyses were performed to assess group differences in: 1) written self-reports obtained during one session, 2) acoustic and aerodynamic variables obtained during regular season and during off-season for the coaches and only once for the controls, and 3) auditory-perceptual data provided by three speech-language pathologists using the Consensus Auditory-Perceptual Evaluation of Voice during one listening session. Data pertaining to the coaches' regular season, to the coaches' off-season, and to the control participants were designated as in-season, off-season, and control, respectively.

RESULTS

Significant self-reported findings included more phonotraumatic behaviors in the coaches than in the controls and higher in-season than off-season and control vocal demand. The coaches' history of voice problems was unrelated and the controls' was related to respiratory illness and addressing a large audience. A significant acoustic finding was lower off-season than control low fundamental frequency. Finally, trained listeners perceived control loudness as more aberrant than off-season loudness and they noted vocal fry twice as many times in in-season and off-season than in control voices.

CONCLUSIONS

This study exposed traces of adverse voice reactions to coaching and confirmed that coaches harbor a job-based proclivity to voice overuse. Self-reported measures appeared to be the least and aerodynamic the most immune to phonatory exertion that pervades daily coaching tasks. Future studies are warranted to further delineate how athletic coaching interferes with voice production.

Predictive Factors of Listeners' Attitudes Related to Dysphonic Voices in Native Brazilian Portuguese

OBJECTIVES

To verify whether there are differences in the judgments of listeners' attitudes as a function of the presence, severity, and type of vocal deviation, and to identify the predictive factors of listeners' attitudes toward dysphonic voices in Brazilian Portuguese speakers.

METHODS

A sample of CAPE-V sentences was used from 44 subjects of both genders. The samples presented different severities of vocal deviation (general grade - GG) (healthy, mild, moderate, and severe) and different degrees of roughness (GR), breathiness (GB), and strain (GS), characterized by a perceptual-auditory judgment performed by speech therapists. The samples were presented to 152 listeners of both genders who performed the judgment of 12 attitudes inserted in a semantic differential scale previously validated for this study. Here, we used a Logistic Regression Model.

RESULTS

There was no association between listener's gender and the judgment of attitudes. Subjects with vocal quality deviation were judged more negatively in relation to vocally healthy individuals. We observed that higher the GG, higher the negative judgment of listeners in relation to the speakers. Listeners judged breathy and strained voices as more negative. In the general model for female and male voices, the increase in GB and GG reduced the chance of a voice being evaluated positively by 16 and 20%, respectively. For female voices, GB and GS reduced the chance of a female voice being evaluated positively by 36 and 19%, respectively. GG reduces the chance of a male voice being evaluated positively by 46%, while GR increases the chance of a male voice being judged positively by 62 %.

CONCLUSIONS

There is an association between the presence, severity, and type of vocal deviation and listeners' attitudes. We identified a predictive model of listeners' attitudes related to dysphonic voices among Brazilian Portuguese speakers. In general, GG and GB were predictors of negative attitudes toward listeners. GB and GS were predictors of negative attitudes toward female voices. The GG is a predictor of negative attitudes toward male voices, while the GR increases the chance of positive judgments.

The Additive Effectiveness of Inspiratory Muscle Training on Glottic Closure and Subjective Voice Outcomes of Patients With Benign Lesion After Hyaluronic Acid Laryngoplasty

OBJECTIVES

For patients with glottic insufficiency disease, injection laryngoplasty is a rapid and efficient management option that complements voice therapy. Some studies have indicated that respiratory muscle training may also show promise in patients with voice disorders. However, the effect of respiratory muscle training in patients with glottic insufficiency was reported to be limited, and whether it provides additional benefit after standard management requires further evaluation. We aimed to investigate the effectiveness of inspiratory muscle training on glottis closure and patient-reported voice quality in glottic insufficiency patients who had been treated with hyaluronic acid injection.

STUDY DESIGN

Retrospective observational study.

METHODS

We included 46 patients with glottic insufficiency who had undergone hyaluronic acid injection. Twenty of them had undergone inspiratory muscle training during three months. We measured patients' changes in glottic status according to the normalized glottal gap area and bowing index, as well as voice quality of life according to the voice handicap index 10 and the voice outcome survey, before and after training.

RESULTS

Patients who underwent inspiratory muscle training had higher odds of experiencing better improvement in all scores. The range of odds ratios ranged from 2.5 to 6.3 for changes in scores, and from 3.8 to 22.2 for changes in score percentages. Of note, the effect of training on percentage changes in the normalized glottal gap area score was significant (P= 0.0127) after adjustment for the duration of vocal disease, body mass index and BMI, and history of gastroesophageal reflux disease.

CONCLUSIONS

Inspiratory muscle training can improve the glottal gap after injection laryngoplasty, and may be applied in clinical practice.

Menopausal Voice-Related Work Limitation Scale (MenoVWL): Development and Validation

OBJECTIVES

Menopause has been reported to affect the voice of female professional voice users (FPVUs). The present study aims at the development and validation of a scale to measure self-perceived menopausal voice-related limitation to work in FPVUs, henceforth the Menopausal Voice-Related Work Limitation Scale (MenoVWL).

METHODS

Items were drawn from previous studies on impacts of sex steroid hormones on voice, available validated scales, and in-depth interviews with post-menopausal FPVUs. A preliminary version with 16 items was evaluated by a panel of 15 voice experts. The resulting revised version was filled in online, together with questions on current endocrinological reproductive status and related symptoms, history of amenorrhea, professional occupation, and demographic information. Responses concerning only professional voice users were selected and inclusive and exclusive criteria were applied for correct allocation of participants into pre- and post-menopausal stages within a restrict age range;192 responses were subject to factorial analysis for MenoVWL validation. Cronbach's alpha measured internal reliability. The scale was tested by comparing MenoVWL scores between pre- and post-menopausal FPVUs (98 and 94, respectively).

RESULTS

Thirteen items were retained from the expert panel evaluation. Items presented a high Content Validity Index (.94 out of 1) and high Item Acceptance Ratio (86.25 %). Both exploratory and confirmatory factorial analysis rendered one dimension scale with an excellent internal consistency (Cronbach's alpha = .9). The results of a Mann-Whitney test showed a higher MenoVWL score for post- as compared to pre-menopausal FPVUs (Z = - 2.818; P = .005).

CONCLUSIONS

MenoVWL is a comprehensive and validated scale with a known factor structure. It constitutes a health care and safety outcome self-perceived measure of value to the early detection of voice-related limitations to work in FPVUs during menopause.

Vocal ergonomics with sports coaches: Co-devised approaches to occupational voice

BACKGROUND: Work-system participation and factors are associated with occupational vocal health for vocally reliant workers, such as sports coaches. However, there is limited use of systems approaches and worker collaboration to address occupational voice. OBJECTIVE: The current research aimed to cooperatively consider coaches’ vocally reliant systems participation, including addressing vocal ergonomic factors that can create barriers for occupational vocal health and voice use. METHODS: Collaborative action inquiries explored vocal ergonomics with coaches (n = 24) from nine professional basketball teams. Across three basketball seasons, coaches and a subject matter expert identified what influenced coaches’ voices and trialed approaches to optimize vocally reliant coaching participation. Nine action inquiry methods were used, including search conferences, ergonomic approaches to enhance systems participation, and focus groups. Multi-level analyses were also undertaken. RESULTS: Participants cooperatively generated, implemented, and evaluated different strategies. A cumulative total of 57 strategies were explored within teams (team mean = 6.33, SD = 3, range = 4–14). Cross-case analysis identified 25 different strategy types. Overall, participants appraised 31.58% (18/57) strategies as supportive (i.e., enhanced facilitators for voice), 61.40% (35/57) strategies as somewhat supportive (i.e., some enhanced facilitators and some ongoing barriers), and 7.02% (4/57) strategies as unsupportive (i.e., pervasive ongoing barriers not mitigated by strategies). Further, factors across coaches’ work-systems continued to influence coaches’ voices in dynamic and complex ways. CONCLUSIONS: Collaboration with coaches enriched vocal ergonomic approaches by providing novel, context-anchored insights. Collaboration should form ‘part’ of broader mechanisms to support coaches’ voice use and vocal health at work.

Self-reported voice difficulties in educational professionals during COVID-19 in Quebec: a cross-sectional mixed-methods study

Background: The health measures imposed by COVID-19 on workplaces created adverse communication settings. Our cross-sectional study aimed to document the nature and severity of the vocal difficulties experienced by educational professionals a few weeks after the implementation of health measures in schools and early childhood settings in Quebec, Canada while teaching in class.Methods: To this end, we conducted a self-report survey containing nine close-ended questions and one open-ended question regarding self-reported vocal difficulties and the implementation of health measures. The survey was answered by 194 educational professionals in October 2020.Results: Since the introduction of the health measures, respondents reported often or always: having difficulty making themselves heard (66.5%), needing to strain their voice (68.1%), having throat pain after work (38.1%), and being concerned about their vocal health (25.2%). 35.6% perceived that their voice changed moderately or a lot and 75.3% did not feel equipped to take care of their vocal health. Fisher's exact tests revealed the difficulties overall were more present in women (p < 0.05).Discussion: The qualitative analysis of open-ended question answers shows a circular process at play, where the vocal responses to the COVID-19-induced communication barriers contribute to creating more problematic communication settings, thus increasing the challenges for vocal health. Better equipping the professionals to take care of their vocal health by developing resources in their professional settings to help them face vocal challenges in both every day as well as extreme situations, should be a priority.

Systematic Review of Literature on Prevalence of Vocal Fatigue Among Teachers

BACKGROUND

Previous results suggest that teaching is a high-risk profession for developing voice disorders.

OBJECTIVE

This study aims to determine the prevalence of vocal fatigue among teachers and its relationship with voice acoustic parameters reported in previous studies.

METHOD

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement Guidelines, we performed a systematic literature review including five databases: Scopus, Scielo, ScienceDirect, PubMed, and Web of Science. Information on study population, definition and evaluation of vocal fatigue, and teaching characteristics were extracted from each paper. The quality of the included publications was assessed using the "Quality assessment tool for quantitative studies".

RESULTS

In total, 14 publications met the inclusion criteria. The two most common work-related factors of vocal fatigue were high levels of noise inside classrooms and loud speaking voice use. Some investigations reported voice acoustic parameters such as fundamental frequency and vocal Sound Pressure Levels as associated with vocal fatigue.

CONCLUSION

Vocal fatigue is a prevalent symptom among teachers associated with teaching vocal demands. However, studies on objective parameters that complement self-reports, to quantify vocal fatigue are needed to determine permissible values for healthy occupational voice use.

The Reliability and Validity of the Mandarin Chinese Version of the Vocal Fatigue Index: Preliminary Validation

PURPOSE

This study attempted to develop and to preliminarily validate the Mandarin Chinese version of the Vocal Fatigue Index (VFI) as a standardized self-assessment questionnaire tool for potential clinical applications.

METHOD

The experimental procedure involved (a) cross-cultural adaptation of the VFI into the Mandarin Chinese version (CVFI), (b) evaluation by an expert panel, (c) back translation, (d) pilot testing, and (e) validation of the questionnaire by three participant groups: 50 with voice disorders, 50 occupational voice users (at-risk group), and 50 with normal voice (control group). Internal consistency, test-retest reliability, content validity, and convergent validity of the CVFI were examined, and discriminatory ability (diagnostic accuracy) for distinguishing between the groups was evaluated.

RESULTS

Results showed high internal consistency (Cronbach's alpha ≥ .8817 for the total CVFI scores for all groups), high test-retest reliability (intraclass correlation coefficients ≥ .9072, p < .001 for the total CVFI scores for all groups), high content validity (total content validity index = 0.9368), and high convergent validity (Pearson r ≥ .8155, p < .001 between the total CVFI scores and Factors 1 and 2 scores). Significant differences between the three groups were found in all scores. Receiver operating characteristic analysis revealed a high diagnostic accuracy for distinguishing between the disorders group and the normal group (area under the curve ≥ 0.927, p < .001 for the total CVFI scores and Factors 1 and 2 scores), with cutoff scores of ≥ 36 (total CVFI score), ≥ 23.5 (Factor 1 score), ≥ 7.5 (Factor 2 score), and ≤ 6.5 (Factor 3 score).

CONCLUSIONS

These findings suggested that the CVFI could be a reliable and valid self-assessment tool for the clinical evaluation of vocal fatigue in Mandarin Chinese-speaking populations. A full-scale validation study of the CVFI is recommended to verify these results.

Perception of Primary School Teachers Towards Voice Problems and Vocal Health-Seeking Behaviors: A qualitative study

OBJECTIVE

Teachers are the most common occupational group reporting to the voice clinics with dysphonia across the globe. However, less is known about teachers' perceptions about their voice and voice problems. Hence the present study aimed to explore teachers' perception about their teaching voice, voice problems and vocal health-seeking behaviors.

METHOD

A qualitative phenomenological research design using semi-structured interviews were conducted with fifteen female primary school teachers. Participants were asked to express their perception of teaching voice, vocal health care knowledge, and vocal hygiene practices. Using inductive analysis, the researchers converted the raw data into concepts or themes and discussed.

RESULT

The present study results showed that teachers perceive voice as the primary tool for their profession. However, teachers consider voice problems as part of their professional commitments. Despite knowing the harmful effects of voice problems, teachers' pay less attention to their voice problems and perceive them as usual, unavoidable and part of their profession. Due to their demanding work schedule and not getting enough support from the management, they hesitate to consult medical professionals unless it severely affects them.

CONCLUSIONS

The data obtained from this study can be used to improve the teachers' knowledge regarding vocal health and convince the school management to extend their support for the successful implementation of the vocal health training programs for teachers.

Systems Approaches to Occupational Vocal Health: Considerations for Community Faith Leaders

Systems thinking approaches can benefit the occupational vocal health of vocally reliant workers. This paper explores community faith leaders as an example of a highly vocally reliant occupation, who may benefit from systems thinking being used to support their vocal occupational health and safety. A scoping review of the current literature regarding faith leaders' occupational voice use and vocal health is detailed, including recognised occupational hazards. This article then discusses the unique and potential use of systems thinking for facilitating faith leaders' vocal occupational health and safety. Rather than using a solely clinical perspective, the sociotechnical systems approach and the biopsychosocial-spiritual approach are noted as particularly pertinent for this occupational group.

REDCap Delivery of a Web-Based Intervention for Patients With Voice Disorders: Usability Study

Background

Web-based health interventions are increasingly common and are promising for patients with voice disorders because web-based participation does not require voice use. To address needs such as Health Insurance Portability and Accountability Act compliance, unique user access, the ability to send automated reminders, and a limited development budget, we used the Research Electronic Data Capture (REDCap) data management platform to deliver a patient-facing psychological intervention designed for patients with voice disorders. This was a novel use of REDCap.

Objective

We aimed to evaluate the usability of the intervention, with this intervention serving as a use case for REDCap-based patient-facing interventions.

Methods

We used REDCap survey instruments to develop the web-based voice intervention modules, then conducted usability evaluations using (1) heuristic evaluations by 2 evaluators, and (2) formal usability testing with 7 participants, consisting of predetermined tasks, a think-aloud protocol, ease-of-use measurements, a product reaction card, and a debriefing interview.

Results

Heuristic evaluations found strengths in visibility of system status and real-world match, and weaknesses in user control and help documentation. Based on this feedback, changes to the intervention were made before usability testing. Overall, usability testing participants found the intervention useful and easy to use, although testing revealed some concerns with design, content, and terminology. Some concerns were readily addressed, and others required adaptations within REDCap.

Conclusions

The REDCap version of a complex web-based patient-facing intervention performed well in heuristic evaluation and formal usability testing. REDCap can effectively be used for patient-facing intervention delivery, particularly if the limitations of the platform are anticipated and mitigated.

Voice rest after vocal fold polyp surgery: A Swedish register study of 588 patients

Objective

To evaluate the impact of voice rest on patient‐reported voice outcome 4 months after vocal fold polyp surgery.

Methods

Preoperative information was collected about age, sex, and smoking habits and the voice handicap index‐10 (VHI‐10). Four months postoperatively, voice rest (total voice rest, spoke single words, and spoke normally), and pre and postoperative voice therapy were reported. This was correlated to voice satisfaction from a two‐category subjective evaluation “satisfied/ not satisfied” and to VHI‐10. Logistic regression models with relative risk for NOT being satisfied with voice after surgery were performed.

Results

Data from 588 patients were available. The group “spoke normally” showed the highest degree of patient satisfaction (92%). Younger patients (<59 years) were more satisfied than older (90% vs. 81.5%). High age and low VHI‐10 scores before surgery were statistically significant for negative voice outcome. Gender or voice rest type did not significantly affect outcome. The largest improvement in VHI‐scores was in the group who spoke normally and least in the group who spoke single words.

Conclusion

We found no significant difference in the two‐category subjective voice outcome depending on voice rest. VHI‐10 showed a statistically significant positive effect on self‐evaluated voice outcome, with the largest improvement in the group with no voice rest. However, the clinical relevance of the VHI changes is unclear. The present study does not show any advantage of total voice rest as compared to relative voice rest or speaking freely. High age and low preoperative VHI scores were significant risk factors for worse voice outcome.

Level of evidence: 4

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.

Amount and Characteristics of Speaking and Singing Voice Use in Vocally Healthy Female College Student Singers During a Typical Week

OBJECTIVES

Singers, college students, and females are groups known to be at an elevated risk of developing functional/hyperfunctional voice disorders; therefore, female college students majoring in vocal performance may be at an even higher risk. To mitigate this risk, it would be helpful to know the "safe limits" for voice use that would help maintain vocal health in this vulnerable group, but there is a paucity of high-quality objective information upon which to base such limits. This study employed weeklong ambulatory voice monitoring in a large group of vocally healthy female college student singers to begin providing the types of objective data that could be used to help develop improved vocal health guidelines.

METHODS

Participants included 64 vocally healthy females currently enrolled in a vocal performance or similar program at a college or university. An ambulatory voice monitor recorded neck-surface acceleration throughout a typical week. A singing classifier was applied to the data to separate singing from speech. Weeklong vocal dose measures and distributional characteristics for standard voice measures were computed separately for singing and speech, and for both types of phonation combined.

RESULTS

Participants spent 6.2% of the total monitoring time speaking and 2.1% singing (with total phonation time being 8.4%). Singing had a higher f_o mode, more pitch variability, higher average sound pressure level (SPL), negatively skewed SPL distributions, lower average CPP, and higher H₁-H₂ values than speaking.

CONCLUSIONS

These results provide a basis for beginning to establish vocal health guidelines for female students enrolled in college-level vocal performance programs and for future studies of the types of voice disorders that are common in this group. Results also demonstrate the potential value that ambulatory voice monitoring may have in helping to objectively identify vocal behaviors that could contribute to voice problems in this population.

Impact of Face Masks on Speech Acoustics and Vocal Effort in Healthcare Professionals

OBJECTIVES/HYPOTHESIS

We investigated speech acoustics and self-reported vocal symptoms in mask-wearing healthcare professionals. We hypothesized that there would be an attenuation of spectral energies and increase in vocal effort during masked speech compared to unmasked speech.

STUDY DESIGN

Within and between subject quasi-experimental design.

METHODS

We prospectively enrolled 21 healthcare providers (13 cisgender female, 8 cisgender male; M = 32.9 years; SD = 7.9 years) and assessed acoustics and perceptual measures with and without a face mask in place. Measurements included: 1) acoustic Vowel Articulation Index (VAI); 2) cepstral and spectral acoustic measures; 3) traditional vocal measures (e.g., fundamental frequency, intensity); 4) relative fundamental frequency (RFF); and 5) self-reported ratings of vocal effort and dyspnea.

RESULTS

During masked speech, there was a significant reduction in VAI, high-frequency information (>4 kHz), and RFF offset 10, as well as a significant increase in cepstral peak prominence and perceived vocal effort. Further analysis showed that high-frequency attenuation was more pronounced when wearing an N95 mask compared to a simple mask.

CONCLUSIONS

Face masks pose an additional barrier to effective communication that primarily impacts spectral characteristics, vowel space measures, and vocal effort. Future work should evaluate how long-term mask use impacts vocal health and may contribute to vocal problems.

LEVEL OF EVIDENCE

3 Laryngoscope, 132:391-397, 2022.

Developing Educational Health Modules to Improve Vocal Wellness in Mask-Wearing Occupational Voice Users

OBJECTIVE

To develop educational modules to improve vocal wellness and optimize communication in mask-wearing occupational voice users.

METHODS

Module development focused on identifying accurate, understandable, and actionable steps to improve vocal wellness in the workplace. We i) interviewed eight voice-specialized speech-language pathologists and researchers on current speech and voice recommendations for mask-wearers, ii) developed educational content using the standardized Patient Education Materials Assessment Tool (PEMAT), iii) assessed the ability of nine mask-wearing community members to learn educational content, and iv) compared behavioral, acoustical, and perceptual changes in four mask-wearing healthcare professionals following educational training.

RESULTS

We created three educational modules that described key vocal health and communication strategies, including microphone amplification, postural alignment, clear speech, hydration, vocal naps, and vocal warm-ups. PEMAT scores were 96% and 93% on understandability and actionability, respectively. Mask-wearing healthcare professionals increased use of 4 out of the 6 strategies following educational training and were able to retain information at rates >90% at 1-week follow-up.

CONCLUSIONS

We developed a set of free-to-use educational modules to promote vocal wellness among mask-wearing occupational voice users (see VSMechLab.com). Future work should examine the impact of these strategies on voice measures in a larger group of mask-wearing community members.

Relationships Among Personality, Daily Speaking Voice Use, and Phonotrauma in Adult Female Singers

PURPOSE

This study sought to determine whether personality traits related to extraversion and impulsivity are more strongly associated with singers with nodules compared to vocally healthy singers and to understand the relationship between personality and the types of daily speaking voice use.

METHOD

Weeklong ambulatory voice recordings and personality inventories were obtained for 47 female singers with nodules and 47 vocally healthy female singers. Paired t tests investigated trait differences between groups. Relationships between traits and weeklong speaking voice measures (vocal dose, sound pressure level [SPL], neck surface acceleration magnitude [NSAM], fundamental frequency, cepstral peak prominence [CPP], and the ratio of the first two harmonic magnitudes [H 1 -H 2]) were examined using pairwise Pearson r coefficients. Multiple regressions were performed to estimate voice parameters that correlated with two or more traits.

RESULTS

Singers with nodules scored higher on the Social Potency scale (reflecting a tendency toward social dominance) and lower on the Control scale (reflecting impulsivity) compared to the vocally healthy singers. In vocally healthy singers, vocal dose measures were positively correlated with a combination of Wellbeing (i.e., happiness) and Social Potency, mean SPL was positively correlated with Wellbeing, SPL variability was positively correlated with Social Potency and negatively with Harm Avoidance, and CPP mean was positively correlated with Wellbeing. Singers with nodules had a negative correlation between NSAM skewness and Social Potency. Both groups had negative correlations between H 1 -H 2 mean and Social Potency and Social Closeness.

CONCLUSIONS

Singers with nodules are more socially dominant and impulsive than vocally healthy singers. Personality traits are related to daily speaking voice use, particularly in vocally healthy singers. Individuals with higher levels of traits related to happiness and social dominance and lower Harm Avoidance tended to speak more, with higher laryngeal forces, with more SPL variability, and with more pressed glottal closure, which could increase risk of phonotrauma.

Action inquiry and vocal ergonomics: A pilot study with sports coaches

BACKGROUND

Coaches critically rely on voice for occupational functioning, which has associated risks to vocal health. However, vocal occupational health and safety (OHS) and vocal ergonomics are not typically considered for, by, or with coaches.

OBJECTIVE

This study piloted a participatory approach to vocal ergonomics, aiming to collaboratively (i) understand coaches' vocally reliant occupational participation, and (ii) consider vocal ergonomic factors.

METHODS

This research was undertaken at an international tournament for floorball (also known as 'Innebandy', 'Salibandy', or 'Unihockey'). Three national coaches (n = 3) and the lead researcher undertook cooperative action inquiry. This piloted a participatory vocal ergonomics programme. Action inquiry methods included fieldnotes, interviews, observations, a workshop, ergonomics approaches, and a focus group. Multi-level analyses supported the findings, including categorical aggregation, direct interpretation, and reflexive thematic analysis.

RESULTS

Participants identified vocal ergonomic factors present at the tournament; including personal, activity, physical environmental, and organisational factors. Participants developed four vocal ergonomic approaches responsive to factors. These were: (1) player consultation, (2) ongoing feedback discussions, (3) movement and postural change, and (4) specific task adaptation. Approaches 1-2 directly supported coaches' voices. Coaches posited limitations to other strategies, but made recommendations for future use. Coaches also reflected that this collaboration provided actionable voice insights and opportunities to address vocal ergonomics. They advocated for extended engagement with coaches, increased focus on vocal health, and inclusion of early career coaches in future programmes.

CONCLUSIONS

These findings support engagement of coaches, and other vocally reliant workers, in addressing voice use and vocal health at work.

Multiparametric analysis of voice following prolonged voice use and voice rest in teachers: evidence from discriminant analysis

PURPOSE

Even though recent investigations have used multiparametric protocol, the set of robust parameters in determining the effects of vocal fatigue and voice rest in teachers is not clear. The first objective of the study was to document the impact of prolonged voice use and voice rest on the subjective and objective voice parameters among Indian secondary school teachers. The second objective was to determine the set voice parameters sensitive to vocal changes resulting from continuous voice use and voice rest.

METHOD

The study included 15 male and 15 female secondary school teachers with a clinically normal voice and no history of voice disorders. Phonation samples were recorded in three different conditions, i.e., condition 1 (before voice use), condition 2 (following voice use), and condition 3 (following voice rest). The vocal Fatigue Index (version 2) was administered before the voice recordings in all three conditions. The objective parameters, namely fundamental frequency, range of fundamental frequency, jitter (%), shimmer (%), harmonic to noise ratio, and smoothened cepstral peak prominence, were extracted.

RESULTS

Results revealed that fundamental frequency, jitter, shimmer, Harmonic to noise ratio, and smoothened cepstral peak prominence were significantly different across the three conditions. The discriminant analysis revealed that only three parameters classified 98.3% of samples accurately between the three conditions.

CONCLUSION

Further research on the correlation between the other subjective and the objective parameters of voice after vocal fatigue would provide more penetrating and ample in-depth insights into the assessment and quantification of vocal fatigue.

Examining vocal attractiveness through articulatory working space

Robust gender differences exist in the acoustic correlates of clearly articulated speech, with females, on average, producing speech that is acoustically and phonetically more distinct than that of males. This study investigates the relationship between several acoustic correlates of clear speech and subjective ratings of vocal attractiveness. Talkers were recorded producing vowels in /bVd/ context and sentences containing the four corner vowels. Multiple measures of working vowel space were computed from continuously sampled formant trajectories and were combined with measures of speech timing known to co-vary with clear articulation. Partial least squares regression (PLS-R) modeling was used to predict ratings of vocal attractiveness for male and female talkers based on the acoustic measures. PLS components that loaded on size and shape measures of working vowel space-including the quadrilateral vowel space area, convex hull area, and bivariate spread of formants-along with measures of speech timing were highly successful at predicting attractiveness in female talkers producing /bVd/ words. These findings are consistent with a number of hypotheses regarding human attractiveness judgments, including the role of sexual dimorphism in mate selection, the significance of traits signalling underlying health, and perceptual fluency accounts of preferences.

Clinical characteristics of singers attending a phoniatric outpatient clinic

Purpose: Studies suggest that singers are over-represented in voice clinics and present a high risk of developing voice disorders. This retrospective study aims to describe the characteristics of 78 singers consulting a phoniatrician.Methods: In their medical files, data related to age, gender, occupational status, singing training, musical style, voice complaint, diagnosis, voice-quality grading (GRBAS) and treatment were gathered.Results: The patients were mostly female singers (87%). Non-professional singers (semi-professional included) represented 64%, professional singers 25% and students of singing 11%. The majority of singers were choristers (27%) and 22% were classical-style/oratorio-style singers. Two-thirds of the population had intensive vocal activity in speech or singing. Vocal endurance, somatosensory signs and difficulties with high pitches were the most frequent symptoms. Among the patients, 79% presented with singing-voice disorders with 85% of these having vocal fold lesions. Generally, their speaking voices were preserved. Vocal-folds nodules were the most prevalent pathology (37%) followed by sulcus (26%) and voice therapy was the main treatment.Conclusions: This study emphasizes the fact that singers have specific voice complaints related to their voice usage. The high occurrence of sulcus and other congenital-lesion suspicions, unusual in the general population consulting an ENT phoniatrician, seems to be rather specific for singers in agreement with the literature.

Self-rated vocal complaints relationship to Vocal Tract Discomfort and Singers Voice Handicap Index in Iranian religious singers

PURPOSE

The religious singing is a popular group of professional voice users in Iran which is performed in a sadness form to persuade the audiences to cry and think to holy persons. This style has its own unique vocal demands and abuses. Therefore, the present study, for the first time, aimed to investigate the prevalence of self-reported vocal complaints, vocal discomfort symptoms, and its effects on the vocal-related life of the Iranian religious singers.

METHODS

In a cross-sectional study, 62 religious singers (28 women, 34 men) completed Singers Voice Handicap Index (SVHI), Vocal Tract Discomfort (VTD), and also a non-standard self-rated vocal complaint question. Spearman correlation test was applied to analyze correlations. Furthermore, 39 non-singers (18 women, 21 men) as a control group participated in this study.

RESULTS

The religious singer's mean score of the SVHI test was 34.84 (SD = 24.89). According to the self-rated vocal complaint question, almost 80% of the participants reported mild to the severe vocal complaints that was significantly higher than control group which was about 10%. The self-rated complaints indicated a significant positive correlation with the SVHI and the VTD reported by singers (p ≤ 0.001). The mean scores of the VTD symptoms in singers were significantly greater than control group. There was also a significant positive correlation between the two VTD and SVHI tests (p ≤ 0.001).

CONCLUSION

Religious singers are at a great risk of developing voice problems. Therefore, their vocal demands and requirements need to be followed precisely. The SVHI and VTD tests should also be considered as two efficient tools for religious singers.