Voice Disorders in Teachers. A Review ia Neves Pereira, ‡Caio Bosque Hidalgo, *Regina Helena Garcia Martins, †Eny Regina Bo and §Elaine Lara Mendes Tavares, *yzxBotucatu, S~ao Paulo, Brazil Summary: Introduction. Voice disorders are very prevalent among teachers and consequences are serious. Although the literature is extensive, there are differences in the concepts and methodology related to voice problems; most studies are restricted to analyzing the responses of teachers to questionnaires and only a few studies include vocal assessments and videolaryngoscopic examinations to obtain a definitive diagnosis. Objective. To review demographic studies related to vocal disorders in teachers to analyze the diverse methodologies, the prevalence rates pointed out by the authors, the main risk factors, the most prevalent laryngeal lesions, and the repercussions of dysphonias on professional activities. Materials and Methods. The available literature (from 1997 to 2013) was narratively reviewed based on Medline, PubMed, Lilacs, SciELO, and Cochrane library databases. Excluded were articles that specifically analyzed treatment modalities and those that did not make their abstracts available in those databases. The keywords included were teacher, dysphonia, voice disorders, professional voice. Key Words: Voice disorders–Teacher–Dysphonia–Professional voice.
CLINICAL AND EPIDEMIOLOGICAL ASPECTS OF DYSPHONIAS IN TEACHERS Estimates of the prevalence of voice disorders among the general population are 6–15%. However, when teachers are considered, these values increase to 20–50%, reaching up to 80%1–4 (Table 1). Such high prevalence of dysphonia for this professional population is reflected in the large literature base and number of sessions at voice conferences. In Brazil, in 2004, Sim~ oes5 conducted the study ‘‘Refer^encias bibliogr aficas nacionais sobre voz dos profissionais da voz’’ (National bibliographic references on the voice of voice professionals), which identified 283 studies on this subject dated from 1987 to 2004; most of these studies were published in meeting annals, whereas only 11% were published in journals. That same author then included 2004 and 2005 and found more than 80 publications. By including 2005, 2006, and 2007 to update those data, Dragone et al6 found an increase of over 207 publications, which corresponded to around 60–80 publications per year. Considering that voice disorders among teachers have been common and discussed worldwide, the extensive number of publications on this subject is understandable. Mattiske et al2 conducted a review of the major publications on voice problems affecting teachers and found that most authors apply questionnaires as methodology, whereas only a few include endoscopic tests to elucidate the laryngeal diagnosis. In addition, several publications have evidenced around 50% prevalence of dysphonia among teachers,7–9 and vocal
From the *Department of Ophthalmology, Otolaryngology and Head and Neck Surgery, Botucatu Medical School, UNESP-Univ Estadual Paulista, Botucatu, S~ao Paulo, Brazil; yBotucatu Medical School, UNESP-Univ Estadual Paulista, Botucatu, S~ao Paulo, Brazil; zAcademic of Botucatu Medical School, Unesp-Univ Estadual Paulista, Botucatu, S~ao Paulo, Brazil; and the xDiscipline Otolaryngology, Botucatu Medical School, UNESPUniv Estadual Paulista, Botucatu, S~ao Paulo, Brazil. Address correspondence and reprint requests to Regina Helena Garcia Martins, Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabec¸a e Pescoc¸o, Faculdade de Medicina da Universidade Estadual Paulista (UNESP), Distrito de Rubi~ao Junior, CEP 18618-970 Botucatu, S~ao Paulo, Brazil. E-mail: [email protected] Journal of Voice, Vol. 28, No. 6, pp. 716-724 0892-1997/$36.00 Ó 2014 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.02.008
fatigue, throat discomfort, roughness, and dysphonia have been the major symptoms. Voice problems affecting teachers were not always transitory and several cases demanded vocal rehabilitation and even drug and/or surgical treatment. Munier and Kinsella8 analyzed 304 questionnaires filled in by teachers and found similar symptoms like vocal fatigue (18%), parched throat (19%), and singing difficulties (20%). In this study, teachers were asked to quantify the consequences of voice problems for their professional development; results indicated that compromising of activities due to voice problems was severe for 12%, moderate for 34%, and slight for 48%. Roy et al4 presented a questionnaire to 2401 participants from Iowa and Utah (1243 teachers and 1279 workers of different areas) to compare the incidence of voice disorder between teachers and the general population. Voice symptoms were found more frequently in teachers than the general population (93.7% vs 88.7%), especially hoarseness, discomfort and effort to speak, and singing difficulty. The possible correlation between teacher’s voice symptoms and the professional activities they participated in was reported by 60.2% of teachers and only 20.5% of the general population. Investigation into the consequences of voice disorders on the professional dynamics indicated that 43% of teachers needed to reduce their didactic activities at least once in the previous year, whereas 18% were absent from work at least 1 day due to a voice problem (compared with 7.2% of the general population). In a similar study, De Jong et al9 analyzed questionnaires distributed to a population composed of 1877 teachers and 239 controls. Results indicated that 67.4% teachers and 43.6% controls complained of voice problems in the previous year, whereas 27.3% teachers and only 1.9% of controls were absent from their professional activities due to voice problems. Van Houtte et al10 obtained lower proportions after analyzing questionnaires responded to by 994 teachers and 290 workers of different areas without vocal abuse. Voice disorders were reported by 51.2% teachers and 27.4% controls. Absence from work at least once a week, due to a voice problem, was reported by 20.6% teachers.
Author and Journal
Objective
Methodology
To compare the frequency and the effects of voice symptoms between teachers and a group with different occupations.
Questionnaires
Mattiske et al JVoice, 1998
To review the prevalence, the causes, the prevention, and the treatment of voice problems among teachers.
Review
Simberg et al J Voice, 2000
To study the prevalence of voice disorders among teacher students.
Interview/questionnaires Perceptual vocal analysis Laryngoscopic examination
Roy et al J Voice, 2004
To study the prevalence of voice disorders in teachers and the general population.
Questionnaires
De Jong et al Folia Phoniatr Logop, 2006
To study the epidemiology of voice problems in Dutch teachers.
Questionnaires
Munier and Kinsella Occup Med (Lond), 2008
To study the prevalence and the impact of voice problems in primary school teachers.
Questionnaires
Teachers were more likely to report having a voice problem (15% vs 6%), having specific voice symptoms, and having symptoms of physical discomfort. 42 Manuscripts were reviewed. The criteria for determining the presence of voice problem creates further difficulties in reaching conclusions about the prevalence of voice disorders among teachers. 226 Students were surveyed. 20% Reported two or more voice symptoms during the previous year and 19% had an organic voice disorder. 1243 Teachers and 1288 nonteachers were surveyed. The prevalence of current voice problems was greater in teachers compared with nonteachers (11.0% vs 6.2%). The prevalence of voice disorders during their lifetime was 57.7% for teachers and 28.8% for nonteachers. 1878 Teachers and 239 controls were surveyed. More than half of the teachers reported voice problems. 550 Teachers were surveyed. 27% Of teachers suffered from a voice problem, 53% had an intermittent’ voice problem, whereas only 20% had no voice problem.
Conclusions Teaching is a high-risk occupation for voice disorders and this health problem may have significant work-related and economic effects. The actual prevalence of voice problems in teachers is unclear. Preventive programs are needed.
Clinical evaluation of students with voice symptoms and more vocal training in the teacher education programs are needed. Teaching is a high-risk occupation for voice disorders
Voice Disorders in Teachers
Smith et al J Voice, 1997
Results
Regina Helena Garcia Martins, et al
TABLE 1. Major Publications on the Prevalence/Epidemiology of Voice Problems in Teachers
Teaching is a high-risk profession for the development of voice problems. Voice disorders were very common in our study of primary school teachers.
(Continued )
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TABLE 1 (Continued ) Author and Journal
Objective
Methodology
To study the prevalence of occupational voice disorders in teachers
Questionnaires
Van Houtte et al J Voice, 2011
To study the impact of voice disorders among teachers.
Questionnaires
Da Costa et al J Voice, 2012
To study the barriers to care that teachers may face.
Questionnaires
Behlau et al J Voice, 2012
To compare the frequency and the adverse effects of voice disorders between Brazilian teachers and nonteachers.
Interview/questionnaire
Cantor Cutiva et al J Commun Disord, 2013
To study the prevalence of voice disorders affecting teachers.
Systematic review
Conclusions
504 Teachers and 402 controls were surveyed. The prevalence of current voice problems was significantly greater in teachers compared with nonteachers (8.7% vs 2.9%), as well as the prevalence of voice disorders during their lifetime (51.4% vs 25.9%) 994 Teachers and 290 controls were surveyed. Teachers reported more voice problems than the controls (51.2% vs 27.4%). 25.4% Of teachers sought medical care and 20.6% had missed work. 237 Teachers were surveyed. 22% Had current hoarse and 58% had had hoarse at one point. 23% Had missed work for hoarseness and only one-third (32.6%) had sought professional help. 1651 Teachers and 1614 nonteachers were surveyed. Prevalence of reporting a current voice disorder was 11.6% for teachers and 7.5% for nonteachers. 63% Teachers and 35.8% nonteachers had a voice problem at some point during their lifetime. 23 Publication were reviewed. Variable indexes of dysphonia prevalence were found.
Teachers have a higher rate of self-reported voice problems than subjects with other occupations.
Voice disorders have an impact on teachers’ personal and professional life and imply a major financial burden for the society.
There are multiple barriers to care for the dysphonic teacher, such as lack of awareness of the availability of professional help.
Teaching at school is a high-risk occupation for developing voice disorders.
Teachers constitute a professional group vulnerable to voice disorders but there are variable indexes of dysphonia prevalence due to the discrepancies among studies.
Journal of Voice, Vol. 28, No. 6, 2014
Angelillo et al J Prev Med Hyg, 2009
Results
Regina Helena Garcia Martins, et al
Voice Disorders in Teachers
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Angellilo et al11 investigated the voice symptoms and the working conditions of 504 teachers randomly chosen from 28 schools in Naples (Italy) and 402 nonteachers as a control group. Voice symptoms were more prevalent for the group of teachers (51.4% vs 25.9%). Participation of women was greater, and absence from work was reported by 116 teachers (23.01%). Considering the high incidence of dysphonias among teachers, those authors emphasized the importance of preventive voice care work for teachers and student teachers, thus preparing future teachers for their new profession. Sampaio et al12 carried out an extensive transversal epidemiologic cohort study including 4496 teachers of municipal elementary schools in Salvador City (Bahia, Brazil). This study aimed to analyze the relationship between voice handicap, quantified by Voice Handicap Index 10, and vocal effort, quantified by LVEI (Lifetime Vocal Effort Index). Females were prevalent and had an average of 14 years in the profession and 30 hours a week as mean workload. Vocal handicap among the studied teachers was 21.7% and was associated with vocal effort during their professional activities. Among 237 teachers from North Carolina who responded to a questionnaire distributed by Da Costa et al,7 recent hoarseness was mentioned by 22% of teachers and some episode of hoarseness during the teaching career was mentioned by 58% of those teachers. Sick leave due to a voice problem was reported by 23% teachers and treatment to hoarseness by only 32%; less than half of the teachers were aware of the benefits of vocal therapy. Analyzing 1651 questionnaires responded to by teachers and 1614 questionnaires responded to by nonteachers, Behlau et al13 identified current voice disorders for 11.6% teachers and 7.5% nonteachers and voice problem at some point during their life for 63% teachers and 35.8% nonteachers. The reported number of voice symptoms was greater for teachers (3.7 vs 1.7). Cantor Cutiva et al14 recently carried out an extensive systematic review on voice disorders affecting teachers. The dysphonia prevalence indexes in the 23 publications that met the study inclusion criteria were highly variable, again confirming the discrepancies among studies. The Mattiske’s review2 confirm the different methodologies used by the authors and the difficulties in reaching conclusions about prevalence of dysphonia in teachers. The authors, however, were unanimous in considering teachers a vulnerable professional group to voice disorders.
sent in teachers at the beginning of their carrier or even when they are still students; in addition, the age of patients and the emergence period are highly variable. Analyzing the responses of 1250 teacher students to questionnaires, Ohlsson et al16 found that 208 (17%) participants had at least two symptoms of voice problems in a week, and a large number of them could relate those symptoms to voice disorders manifested during their childhood or recurrent infections of the upper airways, respiratory allergies, smoking, auditory problems, and vocal abuse. Crowded classrooms and excessive noise are undoubtedly risk factors that contribute to the development of dysphonia in teachers.17 This work environment causes teachers to increase their voice intensity to keep the students’ attention.17–19 This is the essence of phonotrauma, which may result in the development of future laryngeal lesions. The measurements of the vocal intensity of a teacher in an excessively noisy classroom may vary from 58 to 90.5 dB. These values are close to those recorded during a yell and indicate intense vocal effort.17 Excessive environmental noise in the classrooms has led some teachers to use voice amplification to decrease phonatory overload.17–25 Larsen and Blair24 noted an improvement of 13 dB in the voice intensity of teachers who use amplifiers. They considered voice amplification a highly advantageous and important measure to prevent dysphonias. The teaching level may also influence the degree of vocal demand. Kindergarten and elementary education teachers have more voice symptoms than middle or high school teachers.2 Kindergarten teachers have greater vocal demands because their students are still in alphabetization. On account of their daily rush, a large number of teachers generally substitute conventional meals for snacks and fast foods, favoring gastrointestinal disorders, especially gastroesophageal reflux, which is an important cause of acid laryngitis.26,27 Neurological or endocrine diseases, smoking or alcohol habits, and recurrent upper respiratory disease can also compromise vocal qualities.21,26–29 Perez Fernandez and Preciado Lopez30 interviewed 240 teachers (120 diagnosed with vocal nodules and 120 without laryngeal lesions) and identified some potential predisposing factors for voice disorders such as classrooms with poor and noisy conditions, previous laryngeal or nasal surgeries, and gastroesophageal reflux symptoms. These were the most relevant factors among teachers with vocal nodules.
RISK FACTORS FOR THE DEVELOPMENT OF DYSPHONIAS IN TEACHERS Dysphonia risk factors for teachers include extensive working hours, frequently longer than 40 hours a week, excessive number of students per classroom, environmental noise, inappropriate classroom facilities, and chalk powder15–24 (Table 2). Thibeault et al15 conducted a survey with 1243 teachers, of whom 58% reported voice disorder at a certain point of their career; age and time worked in the profession are parameters that may contribute to dysphonias. Other authors,16 however, believe that voice symptoms and laryngeal lesions may be pre-
VIDEOLARYNGOSCOPIC FINDINGS Videolaryngoscopic examinations are important to elucidate the laryngeal diagnosis of dysphonia in teachers. The most commonly found lesions were those named ‘‘phonotraumatic,’’ which develop from inappropriate vocal patterns, secondary to phonatory overload. Tavares and Martins27 performed videolaryngoscopic examinations in 80 teachers and found normal results for 42.5%, vocal nodules for 30%, vocal polyps for 7.5%, and sulcus vocalis for 6.25%, as well as other less frequent lesions.
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TABLE 2. Major Publications on the Risk Factors for Voice Problems in Teachers Author and Journal
Objective
Results 120 Teachers with vocal nodules and 120 with normal vocal folds were selected. Risk factors: classroom’s dryness, loudness, echo, previous vocal pathology, laryngeal surgery, nasal surgery, and gastroesophageal reflux. Vocal intensity and vocal frequency ranks were shorter in the nodule group. Phonatory flow was less effective in the pathological group. The review identified case reports, studies of attendees at hospital voice clinics, and a few cross-sectional studies of occupational groups in the workplace. There were no longitudinal studies found or intervention studies looking at reduction of risk. 1243 Teachers were surveyed, 58% of teachers reported voice disorders at a certain point of their carrier. Chronic voice disorders were more prevalent among teachers of vocal music and less prevalent among teachers of vocational education. 425 Teachers and 85 nonteachers were surveyed. Voice symptoms were more frequent in teachers than in nonteachers (69 vs 36%)
rez Fernandez and Pe pez Preciado Lo Acta Otorrinolaringol Esp, 2003
To study the risk factors to vocal nodules in teachers.
Questionnaires Aerodynamic measures of the voice Acoustic and perceptual voice analysis Videolaryngostroboscopy
Williams NR Occup Med (Lond), 2003
To study the occupational groups at risk of voice disorders.
Review
Thibeault et al Ann Epidemiol, 2004
To study the occupational risk factors associated with voice disorders among teachers.
Questionnaires
Sliwinska-Kowalska et al Folia Phoniatr Logop, 2006
To study the prevalence and the risk factors for occupational voice disorders in teachers.
Questionnaires Laryngoscopy Phoniatric examination
Conclusions Authors showed the most important risk factors to vocal nodules in teachers.
Further research on occupational voice disorders needs to be based in the workplace and consider the risk factors for the development of voice problems and for control efficacy.
Teachers of specific courses are at greater risk of developing a voice disorder.
The prevalence of symptoms and clinical signs of voice disorders is around 2- to 3-fold more frequent in Polish female teachers than in nonteachers.
Journal of Voice, Vol. 28, No. 6, 2014
Methodology
Questionnaires
Tavares et al J Voice, 2007
To study the vocal evaluation in teachers with or without symptoms.
Questionnaires Perceptive auditory and acoustic vocal analysis Laryngoscopy
Araujo et al Cad Saude Publica, 2008
To study the factors associated with voice disorders among women teachers.
Questionnaires
Larsen and Blair. Lang Speech Hear Serv Sch, 2008
To study the effect of classroom amplification on the signal-to-noise ratio in classrooms while class is in session.
Measurements of noise and reverberation were collected for 5 different classrooms.
40 Teachers with vocal symptoms and 40 teachers without vocal symptoms were included. Risk factors: excessive noise in classes, working hours over 40 h, time to teaching more than 20 y. 747 Teachers were surveyed. Hoarseness in the previous 6 mo was reported by 59.2% of teachers and vocal fold nodules by 12.9%. Risk factors: more than 24 classroom hours per week, work in more than one school, effort to speak. Vocal fold nodules were associated with working for more than 5 y as a teacher, working in more than one school, working at another job besides teaching, and having to make an effort to speak. When classroom amplification was used, students heard the teacher’s voice at a level that was an average of 13 dB above the noise floor, compared with an average of +2 dB above the noise floor without amplification.
The results of this study stress the importance of a multifactorial approach in the diagnosis and treatment of voice disorders in teachers. Teachers’ voice is compromised and requires more attention including control of environmental factors and associated diseases.
Voice disorders are frequent among school teachers and are associated with multiple occupational risk factors, besides purely biological ones.
Voice Disorders in Teachers
To study the risk factors for voice problems in teachers.
Risk factors: lifetime vocal effort, incorrect phonation technique, and psychological predisposition.
Regina Helena Garcia Martins, et al
Kooijman et al Folia Phoniatr Logop, 2006
Risk factors: occupational voice disorders and hyperfunctional dysphonia were found in 32.7% of teachers and 9.6% of controls. 1878 Teachers were surveyed. The most important risk factors were physical and psycho-emotional factors
The author confirmed the benefits of the classroom amplification.
(Continued)
721
722
TABLE 2 (Continued ) Author and Journal
Objective
Methodology
To study the risk factors and the effects of voice problems for teachers.
Questionnaires
De Ceballos et al Rev Bras Epidemiol, 2011
To study the auditory vocal analysis and factors associated with voice disorders among teachers.
Questionnaires Auditory vocal analysis
Lindstrom et al J Voice, 2011
To study the relationship between noise exposure and preschool teacher voice usage in daycare center environments.
Measurement of noise and voice levels. Acoustic vocal analysis.
Ohlsson et al J Voice, 2012
To study the prevalence of voice symptom and risk factors in teacher students.
Questionnaires
Sampaio et al J Voice, 2012
To study the vocal effort and voice handicap among teachers.
Questionnaires
Conclusions
1017 Teachers were surveyed. Risk factors: loud voice in teaching and emotional state. 476 Teachers were surveyed. Risk factors: age above 40 y, family history of dysphonia, over 20 h of weekly working hours and presence of chalk dust in the classroom.
These results imply the need for a preventive voice care program for teachers.
13 Teachers were surveyed. Teachers react individually to the noise exposure; some teachers increase their voice-to-noise level ratio when the noise is reduced, whereas others do not. 1250 Students were surveyed. 208 Students (17%) had voice problems. Risk factors: vocal fold problems in childhood and adulthood, throat infections, allergy, smoking, hearing problems, work as teacher or leader, voice demanding hobbies, and previous speech therapy or voice training. 4496 Teachers were surveyed. Risk factors: vocal effort, excessive noise, heartburn, and rhinitis.
Teachers, 40 y old and over, with a family history of dysphonia, working over 20 h weekly, and teaching in classrooms with chalk dust are more likely to develop voice disorders than others. Teachers react individually to the noise exposure; some teachers increase their voice-to-noise level ratio when the noise is reduced, whereas others do not. There was a clear association between the number of potential vocal risk factors and the number of voice symptoms.
The authors pointed out the risk factors to vocal disorders among teachers.
Journal of Voice, Vol. 28, No. 6, 2014
Chen et al J Voice, 2010
Results
Regina Helena Garcia Martins, et al
Voice Disorders in Teachers
Urrutikoetxea et al31 studied 1046 teachers with and without vocal complaints and found 828 normal examinations and 218 organic lesions, of which 94 were nodules, 39 Reinke’s edema, 24 hypertrophy of vestibular folds, 19 polyps, and other less frequent lesions. Perez Fernandez and Preciado Lopez30 emphasized that phonotraumatic lesions, especially vocal nodules, can be diagnosed even for student teachers, reinforcing the importance of preventive vocal guidance. With the aim of early detection of voice disorders, Meulenbroek and de Jong32 conducted an auditory perceptual vocal analysis, according to GRBAS scale and videolaryngoscopy for a population of teacher students. Of the 214 included students, those reporting voice problems had a larger number of laryngeal lesions (96%) and higher scores on the GRBAS scale, compared with asymptomatic ones (81%). Again, preventive measures for voice care were highlighted by these authors.
REPERCUSSION OF DYSPHONIAS IN TEACHERS AND PREVENTIVE MEASURES The voice is the main tool for teachers. The consequences of persistent dysphonia can be devastating for their professional performance, sometimes resulting in sick leave and/or reassignment to administrative tasks, for which they are not always prepared or interested. Financial, emotional, and social sectors are also compromised.33 Statistical data show that, in the United States, 2.5 billion dollars are spent annually on sick leave and treatment of voice disorders of teachers.33 Prevention of voice disorders in teachers should be the primary goal. Prevention is considered ideal and requires the implementation of preventive measures before the problem arises. Unfortunately, this does not occur in a large number of schools. Munier and Kinsella8 found that 93% of the 305 teachers who responded to a questionnaire about vocal quality had never received any guidance or professional training to prevent voice disorders. Aimed at demonstrating the effectiveness of vocal education programs for teachers, Bovo et al34 studied a group of 21 teachers who received effective treatment and vocal guidance for 3 months and a control group of teachers, without intervention. The inclusion criteria were female gender, full time employment as school teachers, and motivation to collaborate. The exclusion criteria were previously treated dysphonia, smoking, alcohol habits, neurological or endocrine disease, psychiatric disturbances, acid reflux, multiple medical complaints, vocal fold lesion or severe dysphonia, allergies, and recurrent upper respiratory disease. Participants underwent videolaryngoscopic examination, acoustic and auditory perceptual vocal analysis and responded to a questionnaire of vocal self-perception. The treated group had an evident improvement in voice symptoms, a decrease in jitter and shimmer values, and an improvement in values of maximum phonation time and Voice Handicap Index. Sometimes, the vocal disorders of teachers require medical or speech therapy treatment and follow-ups.34,35 So, teacher can absent from work and school directors have to convene substitute teachers, which is not always easy; in addition,
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students do not accept it very well, impairing the continuity of the pedagogical program. Thus, teachers are exposed to physical and emotional stress and generally prefer to delay the treatment, which never starts. Schools have been trying to prevent or minimize the voice symptoms of teachers by substituting blackboards and chalk for whiteboards and pens, providing amplifiers and microphones, decreasing the number of students per classroom, adapting the classroom infrastructure and acoustic conditions, and implementing vocal education programs by means of lectures and distribution of booklets and illustrative materials confectioned by vocal health professionals.36,37 Another important action directed to this professional class would certainly be easier access to diagnosis and multidisciplinary treatment with physicians, speech therapists, and psychologists. CONCLUSION The studies included in this review confirm the high prevalence of voice disorders in teachers, for whom it is two-to-three-fold more frequent than for the general population. The classroom conditions, the excessive noise, and the individual health conditions, habits, and addictions are considered risk factors for the development of dysphonias. To decrease the incidence of voice disorders among teachers, it is necessary to identify and eliminate the risk factors and adopt preventive measures for the vocal health. These measures involve multi-sectorial mobilization not only of teachers but also of health and education professionals. Future researches with these actions are necessary to confirm the benefits of these preventive programs. Acknowledgments This project was financially supported by CAPES and Prope/ Fundunesp (UNESP). REFERENCES 1. Smith E, Gray M, Dove S. Frequency and effects of teachers voice problems. J Voice. 1997;11:81–87. 2. Mattiske JA, Oates MJ, Greenwood KM. Vocal problems among teachers: a review of prevalence, causes, prevention, and treatment. J Voice. 1998;12: 489–499. 3. Simberg S, Laine A, Sala E, R€onnemaa AM. Prevalence of voice disorders among future teachers. J Voice. 2000;14:231–235. 4. Roy N, Merill RM, Thibeault S, Parsa RA, Gray SD, Smith EM. Prevalence of voice disorders in teachers and general population. J Voice. 2004;47: 281–293. 5. Sim~oes M. A voz do professor: historico da produc¸~ao cientıfica de fonoaudiologos brasileiros sobre o uso da voz nessa categoria profissional. In: Ferreira LP, Oliveira SMRP, eds. Voz profissional: produc¸~ao cientıfica da fonoaudiologia brasileira. S~ao Paulo, Brazil: Roca; 2004:1–9. 6. Dragone MLS, Ferreira LP, Sim~oes-Zenari M, Giannini SP. In: Oliveira IB, Almeida AAF, Raize T. A voz do professor. Voz profissional: produc¸~ao cientıfica da fonoaudiologia brasileira. Revis~ao Ampliada (2005-2007). Rev Soc Bras Fonoaudiol [Internet]. Suplemento 2008. Available at: http:// www.sbfa.org.br/portal/pg.php?id¼depto_motricidade&ttpg_comissao¼ VOZ&tpc¼cinza&ttpg/. Accessed January 4, 2010. 7. Da Costa V, Prada E, Roberts A, Cohen S. Voice disorders in primary school teachers and barriers to care. J Voice. 2012;26:69–76. 8. Munier C, Kinsella R. The prevalence and impact of voice problems in primary school teachers. Occup Med (Lond). 2008;58:74–76.
724 9. de Jong FI, Kooijman PG, Thomas G, Huinck WJ, Graamans K, Schutte HK. Epidemiology of voice problems in Dutch teachers. Folia Phoniatr Logop. 2006;58:186–198. 10. Van Houte E, Claeys S, Wuyts F, Van Lierde K. The impact of voice disorders among teachers: vocal complaints, treatment-seeking behavior, knowledge of vocal care, and voice-related absenteeism. J Voice. 2011; 25:570–575. 11. Angelillo M, DiMaaio G, Costa G, Angellilo N, Barillari V. Prevalence of occupational voice disorders in teachers. J Prev Med Hyg. 2009;50: 26–32. 12. Sampaio MC, dos Reis EJ, Carvalho FM, Porto LA, Araujo TM. Vocal effort and voice handicap among teachers. J Voice. 2012;26:820. e15–820.e18. 13. Behlau M, Zambon F, Guerrieri AC, Roy N. Epidemiology of voice disorders in teachers and nonteachers in Brazil: prevalence and adverse effects. J Voice. 2012;26:665. 14. Cantor Cutiva LC, Vogel I, Burdorf A. Voice disorders in teachers and their associations with work-related factors: a systematic review. J Commun Disord. 2013;46:143–155. 15. Thibeault SL, Merrill RM, Roy N, Gray SD, Smith EM. Occupational risk factors associated with voice disorders among teachers. Ann Epidemiol. 2004;14:786–792. 16. Ohlsson AC, Andersson EM, S€odersten M, Simberg S, Barregard L. Prevalence of voice symptom and risk factors in teacher students. J Voice. 2012; 26:629–634. 17. Servilha EAM, Leal ROF, Hidaka MTU. Occupational risks in the Brazilian labor legislation: highlight on those related to teacher’s health and voice. Rev Soc Bras Fonoaudiol. 2010;15:505–513. 18. Sliwinska-Kowalska M, Niebudek-Bogusz E, Fiszer M, Los-Spychalska T, Kotylo P, Sznurowska-Przygocka B, Modrzewska M. The prevalence and risk factors for occupational voice disorders in teachers. Folia Phoniatr Logop. 2006;58:85–101. 19. Chen SH, Chiang S, Chung Y, Hsiao L, Hsiao T. Risk factors and effects of voice problems for teachers. J Voice. 2010;24:183–190. 20. De Ceballos AG, Carvalho FM, de Araujo TM, Dos Reis EJ. Auditory vocal analysis and factors associated with voice disorders among teachers. Rev Bras Epidemiol. 2011;14:285–295. 21. Ara ujo TM, Reis EJ, Carvalho FM, Porto LA, Reis IC, Andrade JM. Factors associated with voice disorders among women teachers. Cad Saude P ublica. 2008;24:1229–1238. 22. Verdolini K, Ramig LO. Review: occupational risks for voice problems. Logoped Phoniatr Vocol. 2001;26:37–46.
Journal of Voice, Vol. 28, No. 6, 2014 23. Lindstrom F, Waye KP, Dersten M, Mcallister A, Ternstro M. Observations of the relationship between noise exposure and preschool teacher voice usage in daycare center environments. J Voice. 2011;25:166–172. 24. Larsen JB, Blair JC. The effect of classroom amplification on the signal-tonoise ratio in classrooms while class is in session. Lang Speech Hear Serv Sch. 2008;39:451–460. 25. Gaskill CS, O’Brien SG, Tinter SR. The effect of voice amplification on occupational vocal dose in elementary school teachers. J Voice. 2012;26: 667.e19–667.e27. 26. Hawkshaw MJ, Pebdani P, Sataloff RT. Reflux laryngitis: an update, 20092012. J Voice. 2013;27:486–494. 27. Pendleton H, Ahlner-Elmqvist M, Olsson R, Thorsson O, Hammar O, Jannert M, Ohlsson B. Posterior laryngitis: a disease with different aetiologies affecting health-related quality of life: a prospective case-control study. BMC Ear Nose Throat Disord. 2013;13:11. 28. Tavares EL, Martins RH. Vocal evaluation in teachers with or without symptoms. J Voice. 2007;21:407–414. 29. Kooijman PG, de Jong FI, Thomas G, Huinck W, Donders R, Graamans K, Schutte HK. Risk factors for voice problems in teachers. Folia Phoniatr Logop. 2006;58:159–174. 30. Perez Fernandez CA, Preciado Lopez J. Vocal fold nodules. Risk factors in teachers. A case control study design. Acta Otorrinolaringol Esp. 2003;54: 253–260. 31. Urrutikoetxea A, Ispizua A, Matellanes F. Vocal pathology in techers: a videolaryngostroboscopic study in 1046 teachers. Rev Laryngol Otol Rhinol. 1995;116:255–262. 32. Meulenbroek LF, de Jong FI. Voice quality in relation to voice complaints and vocal fold condition during the screening of female student teachers. J Voice. 2011;25:462–466. 33. Williams NR. Occupational groups at risk of voice disorders: a review of the literature. Occup Med (Lond). 2003;53:456–460 [Review]. 34. Bovo R, Galceran M, Petruccelli J, Hatzopoulos S. Vocal problems among teachers: evaluation of a preventive voice program. J Voice. 2007;21:705–722. 35. Gebska M, Wojciechowska A, Zyzniewska-Banaszak E. Principles and methods of rehabilitation of patients with occupational voice disorders. Ann Acad Med Stetin. 2011;57:78–84 [Review]. 36. Hunter EJ. Teacher response to ambulatory monitoring of voice. Logoped Phoniatr Vocol. 2012;37:133–135. 37. Timmermans B, Coveliers Y, Wuyts FL, Van Looy L. Voice training in teacher education: the effect of adding an individualized microteaching session of 30 minutes to the regular 6-hour voice training program. J Voice. 2012;26:669.e1–669.e9.
CLINICAL AND EPIDEMIOLOGICAL ASPECTS OF DYSPHONIAS IN TEACHERS Estimates of the prevalence of voice disorders among the general population are 6–15%. However, when teachers are considered, these values increase to 20–50%, reaching up to 80%1–4 (Table 1). Such high prevalence of dysphonia for this professional population is reflected in the large literature base and number of sessions at voice conferences. In Brazil, in 2004, Sim~ oes5 conducted the study ‘‘Refer^encias bibliogr aficas nacionais sobre voz dos profissionais da voz’’ (National bibliographic references on the voice of voice professionals), which identified 283 studies on this subject dated from 1987 to 2004; most of these studies were published in meeting annals, whereas only 11% were published in journals. That same author then included 2004 and 2005 and found more than 80 publications. By including 2005, 2006, and 2007 to update those data, Dragone et al6 found an increase of over 207 publications, which corresponded to around 60–80 publications per year. Considering that voice disorders among teachers have been common and discussed worldwide, the extensive number of publications on this subject is understandable. Mattiske et al2 conducted a review of the major publications on voice problems affecting teachers and found that most authors apply questionnaires as methodology, whereas only a few include endoscopic tests to elucidate the laryngeal diagnosis. In addition, several publications have evidenced around 50% prevalence of dysphonia among teachers,7–9 and vocal
From the *Department of Ophthalmology, Otolaryngology and Head and Neck Surgery, Botucatu Medical School, UNESP-Univ Estadual Paulista, Botucatu, S~ao Paulo, Brazil; yBotucatu Medical School, UNESP-Univ Estadual Paulista, Botucatu, S~ao Paulo, Brazil; zAcademic of Botucatu Medical School, Unesp-Univ Estadual Paulista, Botucatu, S~ao Paulo, Brazil; and the xDiscipline Otolaryngology, Botucatu Medical School, UNESPUniv Estadual Paulista, Botucatu, S~ao Paulo, Brazil. Address correspondence and reprint requests to Regina Helena Garcia Martins, Departamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabec¸a e Pescoc¸o, Faculdade de Medicina da Universidade Estadual Paulista (UNESP), Distrito de Rubi~ao Junior, CEP 18618-970 Botucatu, S~ao Paulo, Brazil. E-mail: [email protected] Journal of Voice, Vol. 28, No. 6, pp. 716-724 0892-1997/$36.00 Ó 2014 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.02.008
fatigue, throat discomfort, roughness, and dysphonia have been the major symptoms. Voice problems affecting teachers were not always transitory and several cases demanded vocal rehabilitation and even drug and/or surgical treatment. Munier and Kinsella8 analyzed 304 questionnaires filled in by teachers and found similar symptoms like vocal fatigue (18%), parched throat (19%), and singing difficulties (20%). In this study, teachers were asked to quantify the consequences of voice problems for their professional development; results indicated that compromising of activities due to voice problems was severe for 12%, moderate for 34%, and slight for 48%. Roy et al4 presented a questionnaire to 2401 participants from Iowa and Utah (1243 teachers and 1279 workers of different areas) to compare the incidence of voice disorder between teachers and the general population. Voice symptoms were found more frequently in teachers than the general population (93.7% vs 88.7%), especially hoarseness, discomfort and effort to speak, and singing difficulty. The possible correlation between teacher’s voice symptoms and the professional activities they participated in was reported by 60.2% of teachers and only 20.5% of the general population. Investigation into the consequences of voice disorders on the professional dynamics indicated that 43% of teachers needed to reduce their didactic activities at least once in the previous year, whereas 18% were absent from work at least 1 day due to a voice problem (compared with 7.2% of the general population). In a similar study, De Jong et al9 analyzed questionnaires distributed to a population composed of 1877 teachers and 239 controls. Results indicated that 67.4% teachers and 43.6% controls complained of voice problems in the previous year, whereas 27.3% teachers and only 1.9% of controls were absent from their professional activities due to voice problems. Van Houtte et al10 obtained lower proportions after analyzing questionnaires responded to by 994 teachers and 290 workers of different areas without vocal abuse. Voice disorders were reported by 51.2% teachers and 27.4% controls. Absence from work at least once a week, due to a voice problem, was reported by 20.6% teachers.
Author and Journal
Objective
Methodology
To compare the frequency and the effects of voice symptoms between teachers and a group with different occupations.
Questionnaires
Mattiske et al JVoice, 1998
To review the prevalence, the causes, the prevention, and the treatment of voice problems among teachers.
Review
Simberg et al J Voice, 2000
To study the prevalence of voice disorders among teacher students.
Interview/questionnaires Perceptual vocal analysis Laryngoscopic examination
Roy et al J Voice, 2004
To study the prevalence of voice disorders in teachers and the general population.
Questionnaires
De Jong et al Folia Phoniatr Logop, 2006
To study the epidemiology of voice problems in Dutch teachers.
Questionnaires
Munier and Kinsella Occup Med (Lond), 2008
To study the prevalence and the impact of voice problems in primary school teachers.
Questionnaires
Teachers were more likely to report having a voice problem (15% vs 6%), having specific voice symptoms, and having symptoms of physical discomfort. 42 Manuscripts were reviewed. The criteria for determining the presence of voice problem creates further difficulties in reaching conclusions about the prevalence of voice disorders among teachers. 226 Students were surveyed. 20% Reported two or more voice symptoms during the previous year and 19% had an organic voice disorder. 1243 Teachers and 1288 nonteachers were surveyed. The prevalence of current voice problems was greater in teachers compared with nonteachers (11.0% vs 6.2%). The prevalence of voice disorders during their lifetime was 57.7% for teachers and 28.8% for nonteachers. 1878 Teachers and 239 controls were surveyed. More than half of the teachers reported voice problems. 550 Teachers were surveyed. 27% Of teachers suffered from a voice problem, 53% had an intermittent’ voice problem, whereas only 20% had no voice problem.
Conclusions Teaching is a high-risk occupation for voice disorders and this health problem may have significant work-related and economic effects. The actual prevalence of voice problems in teachers is unclear. Preventive programs are needed.
Clinical evaluation of students with voice symptoms and more vocal training in the teacher education programs are needed. Teaching is a high-risk occupation for voice disorders
Voice Disorders in Teachers
Smith et al J Voice, 1997
Results
Regina Helena Garcia Martins, et al
TABLE 1. Major Publications on the Prevalence/Epidemiology of Voice Problems in Teachers
Teaching is a high-risk profession for the development of voice problems. Voice disorders were very common in our study of primary school teachers.
(Continued )
717
718
TABLE 1 (Continued ) Author and Journal
Objective
Methodology
To study the prevalence of occupational voice disorders in teachers
Questionnaires
Van Houtte et al J Voice, 2011
To study the impact of voice disorders among teachers.
Questionnaires
Da Costa et al J Voice, 2012
To study the barriers to care that teachers may face.
Questionnaires
Behlau et al J Voice, 2012
To compare the frequency and the adverse effects of voice disorders between Brazilian teachers and nonteachers.
Interview/questionnaire
Cantor Cutiva et al J Commun Disord, 2013
To study the prevalence of voice disorders affecting teachers.
Systematic review
Conclusions
504 Teachers and 402 controls were surveyed. The prevalence of current voice problems was significantly greater in teachers compared with nonteachers (8.7% vs 2.9%), as well as the prevalence of voice disorders during their lifetime (51.4% vs 25.9%) 994 Teachers and 290 controls were surveyed. Teachers reported more voice problems than the controls (51.2% vs 27.4%). 25.4% Of teachers sought medical care and 20.6% had missed work. 237 Teachers were surveyed. 22% Had current hoarse and 58% had had hoarse at one point. 23% Had missed work for hoarseness and only one-third (32.6%) had sought professional help. 1651 Teachers and 1614 nonteachers were surveyed. Prevalence of reporting a current voice disorder was 11.6% for teachers and 7.5% for nonteachers. 63% Teachers and 35.8% nonteachers had a voice problem at some point during their lifetime. 23 Publication were reviewed. Variable indexes of dysphonia prevalence were found.
Teachers have a higher rate of self-reported voice problems than subjects with other occupations.
Voice disorders have an impact on teachers’ personal and professional life and imply a major financial burden for the society.
There are multiple barriers to care for the dysphonic teacher, such as lack of awareness of the availability of professional help.
Teaching at school is a high-risk occupation for developing voice disorders.
Teachers constitute a professional group vulnerable to voice disorders but there are variable indexes of dysphonia prevalence due to the discrepancies among studies.
Journal of Voice, Vol. 28, No. 6, 2014
Angelillo et al J Prev Med Hyg, 2009
Results
Regina Helena Garcia Martins, et al
Voice Disorders in Teachers
719
Angellilo et al11 investigated the voice symptoms and the working conditions of 504 teachers randomly chosen from 28 schools in Naples (Italy) and 402 nonteachers as a control group. Voice symptoms were more prevalent for the group of teachers (51.4% vs 25.9%). Participation of women was greater, and absence from work was reported by 116 teachers (23.01%). Considering the high incidence of dysphonias among teachers, those authors emphasized the importance of preventive voice care work for teachers and student teachers, thus preparing future teachers for their new profession. Sampaio et al12 carried out an extensive transversal epidemiologic cohort study including 4496 teachers of municipal elementary schools in Salvador City (Bahia, Brazil). This study aimed to analyze the relationship between voice handicap, quantified by Voice Handicap Index 10, and vocal effort, quantified by LVEI (Lifetime Vocal Effort Index). Females were prevalent and had an average of 14 years in the profession and 30 hours a week as mean workload. Vocal handicap among the studied teachers was 21.7% and was associated with vocal effort during their professional activities. Among 237 teachers from North Carolina who responded to a questionnaire distributed by Da Costa et al,7 recent hoarseness was mentioned by 22% of teachers and some episode of hoarseness during the teaching career was mentioned by 58% of those teachers. Sick leave due to a voice problem was reported by 23% teachers and treatment to hoarseness by only 32%; less than half of the teachers were aware of the benefits of vocal therapy. Analyzing 1651 questionnaires responded to by teachers and 1614 questionnaires responded to by nonteachers, Behlau et al13 identified current voice disorders for 11.6% teachers and 7.5% nonteachers and voice problem at some point during their life for 63% teachers and 35.8% nonteachers. The reported number of voice symptoms was greater for teachers (3.7 vs 1.7). Cantor Cutiva et al14 recently carried out an extensive systematic review on voice disorders affecting teachers. The dysphonia prevalence indexes in the 23 publications that met the study inclusion criteria were highly variable, again confirming the discrepancies among studies. The Mattiske’s review2 confirm the different methodologies used by the authors and the difficulties in reaching conclusions about prevalence of dysphonia in teachers. The authors, however, were unanimous in considering teachers a vulnerable professional group to voice disorders.
sent in teachers at the beginning of their carrier or even when they are still students; in addition, the age of patients and the emergence period are highly variable. Analyzing the responses of 1250 teacher students to questionnaires, Ohlsson et al16 found that 208 (17%) participants had at least two symptoms of voice problems in a week, and a large number of them could relate those symptoms to voice disorders manifested during their childhood or recurrent infections of the upper airways, respiratory allergies, smoking, auditory problems, and vocal abuse. Crowded classrooms and excessive noise are undoubtedly risk factors that contribute to the development of dysphonia in teachers.17 This work environment causes teachers to increase their voice intensity to keep the students’ attention.17–19 This is the essence of phonotrauma, which may result in the development of future laryngeal lesions. The measurements of the vocal intensity of a teacher in an excessively noisy classroom may vary from 58 to 90.5 dB. These values are close to those recorded during a yell and indicate intense vocal effort.17 Excessive environmental noise in the classrooms has led some teachers to use voice amplification to decrease phonatory overload.17–25 Larsen and Blair24 noted an improvement of 13 dB in the voice intensity of teachers who use amplifiers. They considered voice amplification a highly advantageous and important measure to prevent dysphonias. The teaching level may also influence the degree of vocal demand. Kindergarten and elementary education teachers have more voice symptoms than middle or high school teachers.2 Kindergarten teachers have greater vocal demands because their students are still in alphabetization. On account of their daily rush, a large number of teachers generally substitute conventional meals for snacks and fast foods, favoring gastrointestinal disorders, especially gastroesophageal reflux, which is an important cause of acid laryngitis.26,27 Neurological or endocrine diseases, smoking or alcohol habits, and recurrent upper respiratory disease can also compromise vocal qualities.21,26–29 Perez Fernandez and Preciado Lopez30 interviewed 240 teachers (120 diagnosed with vocal nodules and 120 without laryngeal lesions) and identified some potential predisposing factors for voice disorders such as classrooms with poor and noisy conditions, previous laryngeal or nasal surgeries, and gastroesophageal reflux symptoms. These were the most relevant factors among teachers with vocal nodules.
RISK FACTORS FOR THE DEVELOPMENT OF DYSPHONIAS IN TEACHERS Dysphonia risk factors for teachers include extensive working hours, frequently longer than 40 hours a week, excessive number of students per classroom, environmental noise, inappropriate classroom facilities, and chalk powder15–24 (Table 2). Thibeault et al15 conducted a survey with 1243 teachers, of whom 58% reported voice disorder at a certain point of their career; age and time worked in the profession are parameters that may contribute to dysphonias. Other authors,16 however, believe that voice symptoms and laryngeal lesions may be pre-
VIDEOLARYNGOSCOPIC FINDINGS Videolaryngoscopic examinations are important to elucidate the laryngeal diagnosis of dysphonia in teachers. The most commonly found lesions were those named ‘‘phonotraumatic,’’ which develop from inappropriate vocal patterns, secondary to phonatory overload. Tavares and Martins27 performed videolaryngoscopic examinations in 80 teachers and found normal results for 42.5%, vocal nodules for 30%, vocal polyps for 7.5%, and sulcus vocalis for 6.25%, as well as other less frequent lesions.
720
TABLE 2. Major Publications on the Risk Factors for Voice Problems in Teachers Author and Journal
Objective
Results 120 Teachers with vocal nodules and 120 with normal vocal folds were selected. Risk factors: classroom’s dryness, loudness, echo, previous vocal pathology, laryngeal surgery, nasal surgery, and gastroesophageal reflux. Vocal intensity and vocal frequency ranks were shorter in the nodule group. Phonatory flow was less effective in the pathological group. The review identified case reports, studies of attendees at hospital voice clinics, and a few cross-sectional studies of occupational groups in the workplace. There were no longitudinal studies found or intervention studies looking at reduction of risk. 1243 Teachers were surveyed, 58% of teachers reported voice disorders at a certain point of their carrier. Chronic voice disorders were more prevalent among teachers of vocal music and less prevalent among teachers of vocational education. 425 Teachers and 85 nonteachers were surveyed. Voice symptoms were more frequent in teachers than in nonteachers (69 vs 36%)
rez Fernandez and Pe pez Preciado Lo Acta Otorrinolaringol Esp, 2003
To study the risk factors to vocal nodules in teachers.
Questionnaires Aerodynamic measures of the voice Acoustic and perceptual voice analysis Videolaryngostroboscopy
Williams NR Occup Med (Lond), 2003
To study the occupational groups at risk of voice disorders.
Review
Thibeault et al Ann Epidemiol, 2004
To study the occupational risk factors associated with voice disorders among teachers.
Questionnaires
Sliwinska-Kowalska et al Folia Phoniatr Logop, 2006
To study the prevalence and the risk factors for occupational voice disorders in teachers.
Questionnaires Laryngoscopy Phoniatric examination
Conclusions Authors showed the most important risk factors to vocal nodules in teachers.
Further research on occupational voice disorders needs to be based in the workplace and consider the risk factors for the development of voice problems and for control efficacy.
Teachers of specific courses are at greater risk of developing a voice disorder.
The prevalence of symptoms and clinical signs of voice disorders is around 2- to 3-fold more frequent in Polish female teachers than in nonteachers.
Journal of Voice, Vol. 28, No. 6, 2014
Methodology
Questionnaires
Tavares et al J Voice, 2007
To study the vocal evaluation in teachers with or without symptoms.
Questionnaires Perceptive auditory and acoustic vocal analysis Laryngoscopy
Araujo et al Cad Saude Publica, 2008
To study the factors associated with voice disorders among women teachers.
Questionnaires
Larsen and Blair. Lang Speech Hear Serv Sch, 2008
To study the effect of classroom amplification on the signal-to-noise ratio in classrooms while class is in session.
Measurements of noise and reverberation were collected for 5 different classrooms.
40 Teachers with vocal symptoms and 40 teachers without vocal symptoms were included. Risk factors: excessive noise in classes, working hours over 40 h, time to teaching more than 20 y. 747 Teachers were surveyed. Hoarseness in the previous 6 mo was reported by 59.2% of teachers and vocal fold nodules by 12.9%. Risk factors: more than 24 classroom hours per week, work in more than one school, effort to speak. Vocal fold nodules were associated with working for more than 5 y as a teacher, working in more than one school, working at another job besides teaching, and having to make an effort to speak. When classroom amplification was used, students heard the teacher’s voice at a level that was an average of 13 dB above the noise floor, compared with an average of +2 dB above the noise floor without amplification.
The results of this study stress the importance of a multifactorial approach in the diagnosis and treatment of voice disorders in teachers. Teachers’ voice is compromised and requires more attention including control of environmental factors and associated diseases.
Voice disorders are frequent among school teachers and are associated with multiple occupational risk factors, besides purely biological ones.
Voice Disorders in Teachers
To study the risk factors for voice problems in teachers.
Risk factors: lifetime vocal effort, incorrect phonation technique, and psychological predisposition.
Regina Helena Garcia Martins, et al
Kooijman et al Folia Phoniatr Logop, 2006
Risk factors: occupational voice disorders and hyperfunctional dysphonia were found in 32.7% of teachers and 9.6% of controls. 1878 Teachers were surveyed. The most important risk factors were physical and psycho-emotional factors
The author confirmed the benefits of the classroom amplification.
(Continued)
721
722
TABLE 2 (Continued ) Author and Journal
Objective
Methodology
To study the risk factors and the effects of voice problems for teachers.
Questionnaires
De Ceballos et al Rev Bras Epidemiol, 2011
To study the auditory vocal analysis and factors associated with voice disorders among teachers.
Questionnaires Auditory vocal analysis
Lindstrom et al J Voice, 2011
To study the relationship between noise exposure and preschool teacher voice usage in daycare center environments.
Measurement of noise and voice levels. Acoustic vocal analysis.
Ohlsson et al J Voice, 2012
To study the prevalence of voice symptom and risk factors in teacher students.
Questionnaires
Sampaio et al J Voice, 2012
To study the vocal effort and voice handicap among teachers.
Questionnaires
Conclusions
1017 Teachers were surveyed. Risk factors: loud voice in teaching and emotional state. 476 Teachers were surveyed. Risk factors: age above 40 y, family history of dysphonia, over 20 h of weekly working hours and presence of chalk dust in the classroom.
These results imply the need for a preventive voice care program for teachers.
13 Teachers were surveyed. Teachers react individually to the noise exposure; some teachers increase their voice-to-noise level ratio when the noise is reduced, whereas others do not. 1250 Students were surveyed. 208 Students (17%) had voice problems. Risk factors: vocal fold problems in childhood and adulthood, throat infections, allergy, smoking, hearing problems, work as teacher or leader, voice demanding hobbies, and previous speech therapy or voice training. 4496 Teachers were surveyed. Risk factors: vocal effort, excessive noise, heartburn, and rhinitis.
Teachers, 40 y old and over, with a family history of dysphonia, working over 20 h weekly, and teaching in classrooms with chalk dust are more likely to develop voice disorders than others. Teachers react individually to the noise exposure; some teachers increase their voice-to-noise level ratio when the noise is reduced, whereas others do not. There was a clear association between the number of potential vocal risk factors and the number of voice symptoms.
The authors pointed out the risk factors to vocal disorders among teachers.
Journal of Voice, Vol. 28, No. 6, 2014
Chen et al J Voice, 2010
Results
Regina Helena Garcia Martins, et al
Voice Disorders in Teachers
Urrutikoetxea et al31 studied 1046 teachers with and without vocal complaints and found 828 normal examinations and 218 organic lesions, of which 94 were nodules, 39 Reinke’s edema, 24 hypertrophy of vestibular folds, 19 polyps, and other less frequent lesions. Perez Fernandez and Preciado Lopez30 emphasized that phonotraumatic lesions, especially vocal nodules, can be diagnosed even for student teachers, reinforcing the importance of preventive vocal guidance. With the aim of early detection of voice disorders, Meulenbroek and de Jong32 conducted an auditory perceptual vocal analysis, according to GRBAS scale and videolaryngoscopy for a population of teacher students. Of the 214 included students, those reporting voice problems had a larger number of laryngeal lesions (96%) and higher scores on the GRBAS scale, compared with asymptomatic ones (81%). Again, preventive measures for voice care were highlighted by these authors.
REPERCUSSION OF DYSPHONIAS IN TEACHERS AND PREVENTIVE MEASURES The voice is the main tool for teachers. The consequences of persistent dysphonia can be devastating for their professional performance, sometimes resulting in sick leave and/or reassignment to administrative tasks, for which they are not always prepared or interested. Financial, emotional, and social sectors are also compromised.33 Statistical data show that, in the United States, 2.5 billion dollars are spent annually on sick leave and treatment of voice disorders of teachers.33 Prevention of voice disorders in teachers should be the primary goal. Prevention is considered ideal and requires the implementation of preventive measures before the problem arises. Unfortunately, this does not occur in a large number of schools. Munier and Kinsella8 found that 93% of the 305 teachers who responded to a questionnaire about vocal quality had never received any guidance or professional training to prevent voice disorders. Aimed at demonstrating the effectiveness of vocal education programs for teachers, Bovo et al34 studied a group of 21 teachers who received effective treatment and vocal guidance for 3 months and a control group of teachers, without intervention. The inclusion criteria were female gender, full time employment as school teachers, and motivation to collaborate. The exclusion criteria were previously treated dysphonia, smoking, alcohol habits, neurological or endocrine disease, psychiatric disturbances, acid reflux, multiple medical complaints, vocal fold lesion or severe dysphonia, allergies, and recurrent upper respiratory disease. Participants underwent videolaryngoscopic examination, acoustic and auditory perceptual vocal analysis and responded to a questionnaire of vocal self-perception. The treated group had an evident improvement in voice symptoms, a decrease in jitter and shimmer values, and an improvement in values of maximum phonation time and Voice Handicap Index. Sometimes, the vocal disorders of teachers require medical or speech therapy treatment and follow-ups.34,35 So, teacher can absent from work and school directors have to convene substitute teachers, which is not always easy; in addition,
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students do not accept it very well, impairing the continuity of the pedagogical program. Thus, teachers are exposed to physical and emotional stress and generally prefer to delay the treatment, which never starts. Schools have been trying to prevent or minimize the voice symptoms of teachers by substituting blackboards and chalk for whiteboards and pens, providing amplifiers and microphones, decreasing the number of students per classroom, adapting the classroom infrastructure and acoustic conditions, and implementing vocal education programs by means of lectures and distribution of booklets and illustrative materials confectioned by vocal health professionals.36,37 Another important action directed to this professional class would certainly be easier access to diagnosis and multidisciplinary treatment with physicians, speech therapists, and psychologists. CONCLUSION The studies included in this review confirm the high prevalence of voice disorders in teachers, for whom it is two-to-three-fold more frequent than for the general population. The classroom conditions, the excessive noise, and the individual health conditions, habits, and addictions are considered risk factors for the development of dysphonias. To decrease the incidence of voice disorders among teachers, it is necessary to identify and eliminate the risk factors and adopt preventive measures for the vocal health. These measures involve multi-sectorial mobilization not only of teachers but also of health and education professionals. Future researches with these actions are necessary to confirm the benefits of these preventive programs. Acknowledgments This project was financially supported by CAPES and Prope/ Fundunesp (UNESP). REFERENCES 1. Smith E, Gray M, Dove S. Frequency and effects of teachers voice problems. J Voice. 1997;11:81–87. 2. Mattiske JA, Oates MJ, Greenwood KM. Vocal problems among teachers: a review of prevalence, causes, prevention, and treatment. J Voice. 1998;12: 489–499. 3. Simberg S, Laine A, Sala E, R€onnemaa AM. Prevalence of voice disorders among future teachers. J Voice. 2000;14:231–235. 4. Roy N, Merill RM, Thibeault S, Parsa RA, Gray SD, Smith EM. Prevalence of voice disorders in teachers and general population. J Voice. 2004;47: 281–293. 5. Sim~oes M. A voz do professor: historico da produc¸~ao cientıfica de fonoaudiologos brasileiros sobre o uso da voz nessa categoria profissional. In: Ferreira LP, Oliveira SMRP, eds. Voz profissional: produc¸~ao cientıfica da fonoaudiologia brasileira. S~ao Paulo, Brazil: Roca; 2004:1–9. 6. Dragone MLS, Ferreira LP, Sim~oes-Zenari M, Giannini SP. In: Oliveira IB, Almeida AAF, Raize T. A voz do professor. Voz profissional: produc¸~ao cientıfica da fonoaudiologia brasileira. Revis~ao Ampliada (2005-2007). Rev Soc Bras Fonoaudiol [Internet]. Suplemento 2008. Available at: http:// www.sbfa.org.br/portal/pg.php?id¼depto_motricidade&ttpg_comissao¼ VOZ&tpc¼cinza&ttpg/. Accessed January 4, 2010. 7. Da Costa V, Prada E, Roberts A, Cohen S. Voice disorders in primary school teachers and barriers to care. J Voice. 2012;26:69–76. 8. Munier C, Kinsella R. The prevalence and impact of voice problems in primary school teachers. Occup Med (Lond). 2008;58:74–76.
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