Voice Disorders in Teachers: Clinical, Videolaryngoscopical, and Vocal Aspects  ia Neves Pereira, †,‡Elaine Lara Mendes Tavares, and †,‡Regina Helena Garcia Martins, *,†Eny Regina Bo *yzBotucatu, S~ao Paulo, Brazil

Summary: Goal. Dysphonia is more prevalent in teachers than among the general population. The objective of this study was to analyze clinical, vocal, and videolaryngoscopical aspects in dysphonic teachers. Methods. Ninety dysphonic teachers were inquired about their voice, comorbidities, and work conditions. They underwent vocal auditory-perceptual evaluation (maximum phonation time and GRBASI scale), acoustic voice analysis, and videolaryngoscopy. The results were compared with a control group consisting of 90 dysphonic nonteachers, of similar gender and ages, and with professional activities excluding teaching and singing. Results. In both groups, there were 85 women and five men (age range 31–50 years). In the controls, the majority of subjects worked in domestic activities, whereas the majority of teachers worked in primary (42.8%) and secondary school (37.7%). Teachers and controls reported, respectively: vocal abuse (76.7%; 37.8%), weekly hours of work between 21 and 40 years (72.2%; 80%), under 10 years of practice (36%; 23%), absenteeism (23%; 0%), sinonasal (66%; 20%) and gastroesophageal symptoms (44%; 22%), hoarseness (82%; 78%), throat clearing (70%; 62%), and phonatory effort (72%; 52%). In both groups, there were decreased values of maximum phonation time, impairment of the G parameter in the GRBASI scale (82%), decrease of F0 and increase of the rest of acoustic parameters. Nodules and laryngopharyngeal reflux were predominant in teachers; laryngopharyngeal reflux, polyps, and sulcus vocalis predominated in the controls. Conclusions. Vocal symptoms, comorbidities, and absenteeism were predominant among teachers. The vocal analyses were similar in both groups. Nodules and laryngopharyngeal reflux were predominant among teachers, whereas polyps, laryngopharyngeal reflux, and sulcus were predominant among controls. Key Words: Teachers–Voice–Dysphonia–Vocal analyses–Videolaryngoscopy. INTRODUCTION Voice disorders are more prevalent in teachers (between 15% and 80%) than among the general population (6–15%),1–3 which justifies the high number of publications on the theme. In most studies, women are predominant and most reported symptoms are hoarseness, vocal fatigue, aphonia, and singing difficulties.1,4–6 The causes of dysphonia in teachers are numerous and noisy classes, too long workdays, and high intensity vocal emissions are highlighted.3,7–9 Many teachers are smokers and/or affected by systemic disorders that impair even more vocal qualities, such as neurologic, rheumatologic, autoimmune, respiratory, or gastroesophageal conditions, among others.10–12 The majority of studies dealing with teachers’ vocal problems analyze data from surveys or questionnaires.1–6 Few of them performed auditory-perceptual or acoustic evaluations of voice or videolaryngoscopic assessments to confirm the diagnosis. The acoustic measurements of teachers’ voices show decreased F0 and increased jitter, shimmer, and noiseto-harmonic ratio (NHR).10,13–15

The videolaryngoscopy of teachers identify the vocal nodule as the main laryngeal lesion, directly related to phonotrauma caused by vocal abuse and/or inadequate vocal habits.10,16 Thus, prevention measures and vocal reeducation are important methods in teachers’ vocal heath preservation. Teacher dysphonia causes social, professional, financial, and emotional damages.5–9 The absenteeism index reported by them reaches 17–23%, with more than 20% of them having thought of changing profession because of vocal problems.1,3,4,6 Furthermore, most teachers do not know prevention measures to look after their voice and lack access to medical care.4,10 Some authors, however, report the satisfactory results of vocal education programs aimed at teachers, applying quality of life protocols to the voice, before and after vocal training.17–19 Few studies are thorough enough to include auditory-perceptual and acoustic evaluations of voice and videolaryngoscopy to confirm the diagnosis. So, the purpose of this study was to know in which aspects (clinical, videolaryngoscopic, or vocal) to the teaching profession differs from other professions.

Accepted for publication September 15, 2014. The authors thank the financial support provided by Fundunesp (no. - 0452/011/14) to revision of the idiom. From the *Botucatu Medical School (UNESP), Botucatu, S~ao Paulo, Brazil; yDepartment of Otolaryngology, S~ao Paulo State University (UNESP), Botucatu, S~ao Paulo, Brazil; and the zDepartment of Ophtalmology, Otorhinolaryngology and Head and Neck Surgery, Botucatu Medical School, Univ. 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, Botucatu, S~ao Paulo, Brazil CEP 18618-970. E-mail: [email protected] Journal of Voice, Vol. -, No. -, pp. 1-8 0892-1997/$36.00 Ó 2014 The Voice Foundation http://dx.doi.org/10.1016/j.jvoice.2014.09.019

METHODS The study was approved by the Ethics Committee for Research on Human Beings of Botucatu Medical School (reference number 3683–2010). Participants We invited to participate in the study dysphonic patients evaluated between 2010 and 2013 at the Outpatients Center for Voice Disorders, at Botucatu Medical School (Unesp). The patients were distributed into two groups: teachers (n ¼ 90) and


Journal of Voice, Vol. -, No. -, 2014

nonteachers (n ¼ 90). Teacher participants were professionals from the public and private schools, from Botucatu city. Nonteachers participants were dysphonic patients who work in other professions except teaching and singing. Exclusion criteria for both groups. The exclusion criteria are severe deafness, singers, smokers, endotracheal intubation, cervical trauma, systemic disorders (metabolic, autoimmune, or neurologic) that might affect vocal qualities and patients aged older than 60 years. Teachers with inconstant professional activities or with other high voice demand activities, such as singers, orators and salesmen, were also excluded. All participants answered a questionnaire with demographic (age and gender) and professional data (work conditions, weekly hours of work, and absenteeism; time in job), vocal symptoms (hoarseness, throat clearing, dysphagia, singing difficulty, vocal fatigue, cough, neck pain, vocal projection difficulty, and vocal range decrease) and comorbidities (nasal, gastroesophageal, and auditory symptoms). Voice assessment Auditory-perceptual vocal assessments. The auditoryperceptual evaluations were performed using the GRBASI scale, calculation of the maximum phonation time (MPT) and s-to-z ratio. All evaluations were conducted by speech therapists, who were experts in voice, in a silent room during sustained vowel emission (/a/), keeping a pitch constant. The results of such assessments were interpreted by three speech pathologists, and there should be concordance between their judgments in inter- and intra-analysis. Computerized acoustic vocal assessments. The software Multi-Dimensional Voice Program (MDVP, model 5105; KayPENTAX, EUA, Germany) was used, and the definitive measurements were preceded by the training. The participants were required to speech at comfortable loudness level and F0 during the sustained emission of vowel /a/. Vocal samples were recorded in a silent room. A microphone-type headset (Shure, S~ao Paulo [SP], Brasil) was attached to the computer to collect the voice samples. The analyzed vocal parameters were fundamental frequency (F0), Jitter percentage (%), pitch perturbation quotient (PPQ), shimmer percentage (%), amplitude perturbation quotient (APQ), NHR, and soft phonation index (SPI).  GRBASI scale parameters were quantified through a 0–3 intensity score (0, absent; 1, mild; 2, moderate; and 3, severe) by three professionals with experience in voice assessments, with at least two of them having to be in agreement.  Acoustic voice analysis: to the acoustic voice analysis, the MDVP program was used (MDVP, Multi-Speech, KayPENTAX). Vocal parameters were recorded during sustained phonation of vowel /a/ with comfortable intensity and frequency. The acoustic parameters analyzed were fundamental frequency (F0), jitter percentage, APQ, shimmer percentage, PPQ, NHR, and SPI.

Videolaryngoscopic assessments The videolaryngosocpic examinations were performed by the same otorhinolaryngologist in all participants, using a conjugate image capture system (multifunctional videosystem type XE-50, Eco V 50W, Carl Zeiss, Germany), a rigid laryngeal telescope (8 mm diameter, 70 , Asap, Germany) and conjugated microcamera (Asap). A flexible nasofibrolaryngoscope (3.3 mm; Olympus, Japan) was used in patients with vomiting reflex exacerbated. Statistical methods For GRBASI scale, we used Goodman’s test complemented with multiple comparisons between and within multinomial populations, applying a 5% significance level.20 Analyses are shown in the Table 4 using uppercase and lowercase letters. Different uppercase letters in the same column mean significant differences between groups (P value < 0.05); different lowercase letters in the same line mean significant differences between variables within the same group (P value < 0.05). For parameters relating to vocal symptoms and videolaryngoscopic findings, we used the calculation of occurrence percentages and graphic representations, with 95% confidence intervals.21 For MPT parameters, we used the Mann-Whitney parametric test, with a 5% significance level. Acoustic parameters were analyzed with position and dispersion measurements. To compare groups, we used the t test when the variable followed a normal distribution of probability, and the Mann-Whitney test if it did not, applying a 5% significance level.22 RESULTS Sex and age In both groups, there were 90 patients, with same gender proportions (85 females and five males). The distribution of the teacher’s group and control’s group according to age was, respectively: up to 30 years (n ¼ 18 teachers; n ¼ 13 controls); 31–50 years (n ¼ 60 teachers; n ¼ 54 controls); 51–60 years (n ¼ 12 teachers; n ¼ 23 controls). Profession This study included 180 patients, 90 teachers (teachers group) and 90 nonteachers (controls group). In controls, the occupations were painter (n ¼ 1), baker (n ¼ 1), speech pathologist (n ¼ 1), mason (n ¼ 1), banking (n ¼ 1), engine driver (n ¼ 2), engineer (n ¼ 2), seamstress (n ¼ 3), nurse (n ¼ 3), store manager (n ¼ 5), salesman (n ¼ 5), barman (n ¼ 6), student (n ¼ 13), general services (n ¼ 15), housemaid (n ¼ 31) in the control group, these being by far housekeeping and general services. Among teachers, 13 worked in preschool (13.26%), 42 in primary school (42.85%), 37 in secondary school (37.75%), three in higher education (3.07%), and three in technical schools (3.07%). Reporting of vocal abuse and/or high phonatory effort at work Vocal abuse was reported by 69 teachers (76.67%) and only 34 control patients (37.77%).

 ia Neves Pereira, et al Eny Regina Bo


Dysphonia in Teachers

TABLE 1. Comorbidities in Both Groups Teachers


Groups Comorbidities





Sinonasal symptoms Gastroesophageal symptoms Auditory symptoms

60 40 26

66.70 44.40 28.90

18 20 7

20.00 22.20 7.78

Number of students per class In the teachers group, 17 of them (18.89%) handled classes of under 20 students, 69 (76.67%) had classes between 21 and 40 students, and 4 (4.44%) had classes of over 40 students. Weekly work hours Most participants, in both groups had 21- to 40-hour weeks (n ¼ 65 teachers [72.2%] and n ¼ 72 controls [80.0%]). Whereas 21 teachers (23.33%) and 14 controls (15.55%) had more than 40 weekly hours of work. Only four teachers (4.4%) and four controls (4.4%) had up to 20 weekly hours. Time in the profession In the teachers group, 36 (40.00%) of them had less than 10 years of practice, as did 21 controls (23.33%); 33 teachers (36.67%) and 38 controls (42.22%) had 11–20 years of practice; and 21 teachers (23.33%) and 31 controls (34.45%) had 21 or more years of practice. Absenteeism because of voice problems Absence from work because of voice problems was only reported by teachers. The number of teachers that reported 1 to 5 days of absenteeism was 18 (20%); more than 6 days was reported by three teachers (3.3%). Comorbidities Respiratory, gastroesophageal, and auditory symptoms were reported by a greater number of teachers (Table 1).

Symptoms In both groups, the main symptoms were hoarseness, throat clearing, and phonatory effort. The symptoms are presented in Table 2. Maximum phonation time MPT values were found to be diminished in both groups (Table 3). Auditory-perceptual evaluation of voice – GRBASI GRBASI scale parameters were altered in similar numbers of patients in both groups. Higher scores, however, were observed in the control group (Table 4). Acoustic vocal analysis Both groups showed an F0 decrease and an increase of all other acoustic parameters when compared with standard values. Shimmer percentage and APQ values were higher in the control group (Table 5). Videolaryngoscopic findings Videolaryngoscopic diagnoses are presented in Table 6. Normal examinations were found in 30 teachers and in 24 controls. Vocal nodules and laryngopharyngeal reflux were predominant among teachers. Polyps, laryngopharyngeal reflux, and sulcus vocalis were predominant among control patients (Figures 1–4). DISCUSSION In this study, clinical data, vocal, and videolaryngoscopy findings of dysphonic teachers were compared with those of a control group composed of nonteachers dysphonic patients to identify some particularities in the parameters assessed among teachers relative to other professions. In both groups, there was a predominance of dysphonic women in accordance with other authors.1–5 This result can be explained by a greater concern in women regarding their vocal qualities, by the superior number of women in the

TABLE 2. Vocal Symptoms Reported by Patients in Both Groups and Their 95% Confidence Limits Teachers Vocal Symptoms Hoarseness Throat clearing Phonatory effort Dysphagia Speaking with a noisy Singing difficulty Vocal fatigue Chronic cough Neck pain Projection difficulties Vocal range decrease


N (%)

Lower Limit

Higher Limit

N (%)

Lower Limit

Higher Limit

74 (82.2) 63 (70.0) 65 (72.2) 25 (27.8) 62 (68.9) 47 (52.2) 62 (68.9) 33 (36.7) 29 (32.2) 38 (42.2) 48 (53.3)

74.3 60.5 63.0 18.5 59.3 41.9 59.3 26.7 22.6 32.0 43.0

90.1 79.5 81.5 37.0 78.5 62.5 78.5 46.6 41.9 52.4 63.6

71 (78.9) 56 (62.2) 47 (52.2) 13 (14.4) 17 (18.9) 15 (16.7) 39 (43.3) 8 (8.9) 2 (2.2) 12 (13.3) 11 (12.2)

70.5 52.2 41.9 7.2 10.8 9.0 33.1 3.0 0.0 6.3 5.5

87.3 72.2 62.5 21.7 27.0 24.4 53.6 14.8 5.3 20.4 19.0


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TABLE 3. Distribution of Groups According to Mean and Standard Deviation (SD) Values of Maximum Phonation Time (MPT) for Vowel /a/, Phonemes /s/, and /z/ and s/z Relation Groups MPT /a/ /s/ /z/ s/z

Teachers (Means ± SD)

Controls (Means ± SD)

P Value

10.14 ± 4.43 11.45 ± 4.46 10.95 ± 4.12 1.04 ± 0.28

9.45 ± 3.67 9.83 ± 3.91 9.21 ± 3.23 1.05 ± 0.28

0.34 0.01 0.05). Two frequencies followed by the same capital letter do not differ concerning to the genders (columns), fixing the age group (P > 0.05). OBS: Goodman Test.

 ia Neves Pereira, et al Eny Regina Bo


Dysphonia in Teachers

TABLE 5. Acoustic Vocal Parameters in Both Groups and Standard Values Acoustic Parameters F0 (Hz)

Jitter (%)


Shimmer (%)





Teachers (G1)

Nonteachers (GII)

Standard Values

P Value


198.23 ± 40.85

209.01 ± 39.06

243.973 ± 27.45


119.755 ± 12.65

115.785 ± 14.76

138.744 ± 12.90

















































>0.01 (GI 3 GII) 0.01 (GI 3 GII) 0.01 (GI 3 GII) 0.01 (GI 3 GII)

Voice Disorders in Teachers: Clinical, Videolaryngoscopical, and Vocal Aspects.

Dysphonia is more prevalent in teachers than among the general population. The objective of this study was to analyze clinical, vocal, and videolaryng...
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