Teachers' Working Postures and Their Effects on the Voice.

OBJECTIVE: To evaluate associations between voice and working postures used during teaching. METHODS: A researcher assessed 30 teachers' typical working postures of the torso, head, shoulders, upper back, and arms by observing and/or asking questions about them. Teachers' options to rest and to adjust furniture according to their needs were also elicited. Voice symptoms were evaluated through 2 self-assessment forms. Fundamental frequency, sound pressure level (SPL), and alpha ratio were calculated from voice samples recorded before, during, and after teaching. RESULTS: The head was most typically in an unergonomic posture while speaking (in 60% of participants). Other frequently used unergonomic postures were hunched upper back (55%), raised shoulders (46%), and twisted torso (43%). Head and torso twisted and arms upheld were associated with specific voice symptoms and head postures and hunched upper back with voice use. The number of postures was also connected with voice use: if the teachers used over 3 unergonomic postures, their SPL was higher and the voice broke more often than in those with a lower number of postures. CONCLUSION: Unergonomic postures during speaking affect the voice. It is important to evaluate working postures as part of voice ergonomic assessment in voice patients.

Effects of pedagogical ideology on the perceived loudness and noise levels in preschools.

High activity noise levels that result in detrimental effects on speech communication have been measured in preschools. To find out if different pedagogical ideologies affect the perceived loudness and levels of noise, a questionnaire study inquiring about the experience of loudness and voice symptoms was carried out in Iceland in eight private preschools, called "Hjalli model", and in six public preschools. Noise levels were also measured in the preschools. Background variables (stress level, age, length of working career, education, smoking, and number of children per teacher) were also analyzed in order to determine how much they contributed toward voice symptoms and the experience of noisiness. Results indicate that pedagogical ideology is a significant factor for predicting noise and its consequences. Teachers in the preschool with tighter pedagogical control of discipline (the "Hjalli model") experienced lower activity noise loudness than teachers in the preschool with a more relaxed control of behavior (public preschool). Lower noise levels were also measured in the "Hjalli model" preschool and fewer "Hjalli model" teachers reported voice symptoms. Public preschool teachers experienced more stress than "Hjalli model" teachers and the stress level was, indeed, the background variable that best explained the voice symptoms and the teacher's perception of a noisy environment. Discipline, structure, and organization in the type of activity predicted the activity noise level better than the number of children in the group. Results indicate that pedagogical ideology is a significant factor for predicting self-reported noise and its consequences.

Classroom Noise and Teachers' Voice Production.

PURPOSE: The aim of this study was to research the associations between noise (ambient and activity noise) and objective metrics of teachers' voices in real working environments (i.e., classrooms). METHOD: Thirty-two female and 8 male teachers from 14 elementary schools were randomly selected for the study. Ambient noise was measured during breaks in unoccupied classrooms and, likewise, the noise caused by pupils' activity during lessons. Voice samples were recorded before and after a working day. Voice variables measured were sound pressure level (voice SPL), fundamental frequency, jitter, shimmer, and the tilt of the sound spectrum slope (alpha ratio). RESULTS: The ambient noise correlated most often with the fundamental frequency of men and voice SPL, whereas activity noise correlated with the alpha ratio and perturbation values. Teachers working in louder ambient noise spoke more loudly before work than those working in lower noise levels. Voice variables generally changed less during work among teachers working in loud activity noise than among those working in lower noise levels. CONCLUSIONS: Ambient and activity noises affect teachers' voice use. Under loud ambient noise teachers seem to speak habitually loudly, and under loud activity noise teachers' ability to react to loading deteriorates.

Associations between voice ergonomic risk factors and acoustic features of the voice.

The associations between voice ergonomic risk factors in 40 classrooms and the acoustic parameters of 40 schoolteachers' voices were investigated. The risk factors assessed were connected to participants' working practices, working postures, and the indoor air quality in their workplaces. The teachers recorded spontaneous speech and sustained /a/ before and after a working day. Fundamental frequency, sound pressure level, the slope of the spectrum, perturbation, and harmonic-to-noise ratio were analysed. The results showed that the more the voice ergonomic risk factors were involved, the louder the teachers' voices became. Working practices correlated most often with the acoustic parameters; associations were found especially before a working day. The results suggest that a risky voice ergonomic environment affects voice production.

Voice quality after treatment of early vocal cord cancer: a randomized trial comparing laser surgery with radiation therapy.

OBJECTIVE: Early laryngeal cancer is usually treated with either transoral laser surgery or radiation therapy. The quality of voice achieved with these treatments has not been compared in a randomized trial. METHODS AND MATERIALS: Male patients with carcinoma limited to 1 mobile vocal cord (T1aN0M0) were randomly assigned to receive either laser surgery (n=32) or external beam radiation therapy (n=28). Surgery consisted of tumor excision with a CO2 laser with the patient under general anaesthesia. External beam radiation therapy to the larynx was delivered to a cumulative dose of 66 Gy in 2-Gy daily fractions over 6.5 weeks. Voice quality was assessed at baseline and 6 and 24 months after treatment. The main outcome measures were expert-rated voice quality on a grade, roughness, breathiness, asthenia, and strain (GRBAS) scale, videolaryngostroboscopic findings, and the patients' self-rated voice quality and its impact on activities of daily living. RESULTS: Overall voice quality between the groups was rated similar, but voice was more breathy and the glottal gap was wider in patients treated with laser surgery than in those who received radiation therapy. Patients treated with radiation therapy reported less hoarseness-related inconvenience in daily living 2 years after treatment. Three patients in each group had local cancer recurrence within 2 years from randomization. CONCLUSIONS: Radiation therapy may be the treatment of choice for patients whose requirements for voice quality are demanding. Overall voice quality was similar in both treatment groups, however, indicating a need for careful consideration of patient-related factors in the choice of a treatment option.

The association between possible stress markers and vocal symptoms.

OBJECTIVES/HYPOTHESIS: Stress reaction provokes changes in the body involving cardiovascular alterations, autonomic reactions, neuroendocrine and immunologic as well as psychoneuroimmunologic changes. Both the primary and secondary effect of stress reaction may be of consequence for vocal function. The purpose of this questionnaire study was to determine the effect of stress symptoms on the occurrence of vocal symptoms. The study also aimed at investigating whether a possible effect was different for men and women. METHODS: A total number of 1728 participants completed a questionnaire concerning speech, language, and voice. Six vocal symptoms and four possible stress symptoms were included in the questionnaire. RESULTS: There was a significant association between stress symptoms and the occurrence of vocal symptoms. The occurrence of muscle tension or a lump in the throat was significant regarding all the four possible stress symptoms. There were also significant results concerning gender difference. All vocal symptoms and two of four stress symptoms were more common among women. CONCLUSIONS: Physical changes caused by the stress reaction may result in vocal symptoms as those presented in the study. Both vocal symptoms and stress symptoms were more common among women. Stress should preferably be acknowledged as a risk factor containing and possibly entailing a number of physiological, psychological, and behavioral symptoms affecting the voice negatively.

[From a voice disturbance symptom to specific diagnosis]. / Aänihäiriöoireesta spesifiseen diagnoosiin.

Voice disturbances cause significant disability for speech professionals and persons using plenty of speech in their work. It is important for a basic healthcare physician to know when to refer the patient to specialized care, speech therapist or occupational health care. A general practitioner should be able to carry out endoscopy of the vocal cords and have an understanding of the major etiological factors causing voice disturbances. Primary care holds the key position in providing initial instructions and preventing the prolonging of voice disturbances. The article describes the functioning of the larynx along with the most common organic, neurologic and functional voice disturbances and their treatment.

Connections between voice ergonomic risk factors and voice symptoms, voice handicap, and respiratory tract diseases.

OBJECTIVES: The aim of the study was to investigate the connections between voice ergonomic risk factors found in classrooms and voice-related problems in teachers. METHODS: Voice ergonomic assessment was performed in 39 classrooms in 14 elementary schools by means of a Voice Ergonomic Assessment in Work Environment--Handbook and Checklist. The voice ergonomic risk factors assessed included working culture, noise, indoor air quality, working posture, stress, and access to a sound amplifier. Teachers from the above-mentioned classrooms reported their voice symptoms, respiratory tract diseases, and completed a Voice Handicap Index (VHI). RESULTS: The more voice ergonomic risk factors found in the classroom the higher were the teachers' total scores on voice symptoms and VHI. Stress was the factor that correlated most strongly with voice symptoms. Poor indoor air quality increased the occurrence of laryngitis. CONCLUSIONS: Voice ergonomics were poor in the classrooms studied and voice ergonomic risk factors affected the voice. It is important to convey information on voice ergonomics to education administrators and those responsible for school planning and taking care of school buildings.

Connections between voice ergonomic risk factors in classrooms and teachers' voice production.

OBJECTIVE: The aim of the study was to investigate if voice ergonomic risk factors in classrooms correlated with acoustic parameters of teachers' voice production. METHODS: The voice ergonomic risk factors in the fields of working culture, working postures and indoor air quality were assessed in 40 classrooms using the Voice Ergonomic Assessment in Work Environment - Handbook and Checklist. Teachers (32 females, 8 males) from the above-mentioned classrooms recorded text readings before and after a working day. Fundamental frequency, sound pressure level (SPL) and the slope of the spectrum (alpha ratio) were analyzed. RESULTS: The higher the number of the risk factors in the classrooms, the higher SPL the teachers used and the more strained the males' voices (increased alpha ratio) were. The SPL was already higher before the working day in the teachers with higher risk than in those with lower risk. CONCLUSION: In the working environment with many voice ergonomic risk factors, speakers increase voice loudness and use more strained voice quality (males). A practical implication of the results is that voice ergonomic assessments are needed in schools.

Genetic and environmental effects on vocal symptoms and their intercorrelations.

PURPOSE: Recently, Simberg et al. (2009) found genetic effects on a composite variable consisting of 6 vocal symptom items measuring dysphonia. The purpose of the present study was to determine genetic and environmental effects on the individual vocal symptoms in a population-based sample of Finnish twins. METHOD: The sample comprised 1,728 twins (125 monozygotic and 108 dizygotic twin pairs) born between 1961 and 1989, who completed a questionnaire concerning 6 vocal symptoms. Values for additive genetic, dominant genetic, shared environmental, and nonshared environmental components were computed separately for all symptoms. Multivariate analyses to determine genetic and environmental associations between the vocal symptoms were also performed. RESULTS: Variance was explained by significant additive genetic effects (27%) in only one of the vocal symptoms, namely, voice gets low or hoarse, whereas the variance of one of the vocal symptoms, voice gets strained or tires, could be explained by nonshared environmental influence alone. Multivariate analyses showed that the correlations for most of the symptom combinations were significant. CONCLUSIONS: Both genetic and environmental components influence vocal symptoms. Genetic and environmental influences seem to be differently balanced in different vocal symptoms. Genetic effects are moderate, whereas environmental effects seem to be the most important factor contributing to the presence of vocal symptoms.

Vocal symptoms and allergy--a pilot study.

Allergic rhinitis and asthma are common among university students. Inhalant allergies have been considered to be a risk factor contributing to voice disorders. The purpose of this pilot study was to determine if students with confirmed respiratory allergies have frequently occurring vocal symptoms. A questionnaire concerning the prevalence of vocal symptoms was distributed to 49 students attending a 3-year allergen immunotherapy program and to 54 students without known allergy. The results indicated that subjects with allergy report significantly more vocal symptoms than subjects without allergy. Allergy should be considered as an underlying factor for vocal symptoms, especially for persons who work in or study for vocally demanding occupations.

Long-term prognosis of immediate hypersensitivity type of occupational laryngitis.

The present study investigated, for the first time, the long-term prognosis of hypersensitivity type of occupational laryngitis (OL). Thirteen patients with OL diagnosed in 1990-1993 at the Finnish Institute of Occupational Health participated in a questionnaire follow-up study. The records of the primary diagnostic investigations were also reviewed. The mean follow-up time was 12.5 (range 11-15) years. The mean age of the study subjects was 51.5 (range 32-64) years; nine (69%) were women. In addition to OL during the primary examinations, two patients were diagnosed to have occupational asthma, and nine patients occupational rhinitis. During the follow-up, six additional patients had developed asthma. Asthma had thus been diagnosed in 8 of the 13 (61%) patients. At present, nine patients (69%) were non-employed. Of these, seven were on work disability pension, of whom six had occupational or non-occupational asthma in addition to OL. The remaining four patients (31%) were still working: three had training for some other type of work, and one had been transferred to another job. None of them had developed asthma during the follow-up. The current study, based on a small series, suggests that many of the patients with previously diagnosed OL developed asthma and were not employed.

Exploring genetic and environmental effects in dysphonia: a twin study.

PURPOSE: To explore the existence of genetic effects as well as the interaction between potential genetic effects and a voice-demanding occupation on dysphonia. METHOD: One thousand seven hundred and twenty-eight Finnish twins (555 male; 1,173 female) born between 1961 and 1989 completed a questionnaire concerning vocal symptoms and occupation. The zygosity determination resulted in 125 monozygotic and 108 dizygotic full twin pairs. A composite variable called dysphonia was formed by summing 6 vocal symptoms based on the results of a factor analysis. Twin model fitting was used to explore the contribution of genetic and environmental effects on the dysphonia variable. RESULTS: Individual differences in dysphonia were explained by genetic effects (35%) and nonshared environmental effects (65%). Shared environmental effects were estimated at 0%. Also, the authors found that for the participants who worked in voice-demanding occupations, the causes of dysphonia were more environmental, whereas the etiology of the symptoms was more strongly affected by genes in the participants with less voice-demanding occupations. However, this gene-environment interaction was not statistically significant. CONCLUSION: Both genetic and environmental factors have an impact on the etiology of voice problems. Environmental factors, either independently or interacting with genetic factors, seem to play the key role, especially if the person has a voice-demanding occupation.

Laryngopharyngeal reflux disease treated with laparoscopic fundoplication.

The objective of this clinical prospective study was to find out if laparoscopic Nissen fundoplication is an effective treatment in laryngopharyngeal reflux disease. Twenty-two consecutive patients, 16 female and 6 male, who were referred to laparoscopic fundoplication and operated by a senior gastroenterology surgeon were included in this study. Their mean age was 41 years (SD 13), and ranged from 18 to 64. The patients selected for surgical treatment had LPRD with several vocal and laryngeal symptoms. The status findings were typical for laryngopharyngeal reflux and the symptoms and signs had responded to antireflux medication. Vocal symptoms were interviewed and patients underwent laryngoscopy, esophagogastroscopy, and 24-h esophageal pH monitoring. The follow-up of symptoms and signs were 3 months after beginning of medication, before surgery, 3 months, and 1 year after surgery. The number of patients experiencing vocal symptoms decreased during the medical treatment, from the situation before medical treatment to the situation before surgery (P < 0.001), from the situation before surgery to the situation 3 months (P < 0.001) and 1 year post operation (P < 0.001), but no significant changes were found from the situation 3 months to 1 year post operation. Voice quality improved significantly only from the time point before surgery to 3 months post operation. Three months after medical treatment, laryngeal and pharyngeal findings did not decrease significantly, but several findings decreased significantly (P < 0.001) from the time point before surgery compared to 3 months and to 1 year post operation. Based on this study, the laparoscopic fundoplication is an effective and safe treatment of LPRD.

Reflux laryngitis: a feasible indication for laparoscopic antireflux surgery?

Laparoscopic fundoplication is a routine surgical approach in the treatment of moderate or severe gastro-esophageal reflux disease. However, there are still contradictions regarding supraesophageal symptoms as an indication for surgery. The aim of this study was to determine the subjective symptomatic outcome and objective laryngeal findings after antireflux surgery in patients with pH monitoring proven reflux laryngitis. Between 1998 and 2002, 40 patients with reflux laryngitis underwent laparoscopic Nissen fundoplication. Patients were referred to surgery and followed-up by a specialist in otorhinolaryngology. Subjective symptoms were collected by a structured questionnaire at a median follow-up of 42 months. The objective laryngeal findings improved from the preoperative situation; at 12 months after surgery, the otorhinolaryngeal status was improved in 92.3% (n=24) of the patients. However, only 38.5% (n=10) of these patients evaluated an improvement in their voice quality. Of all, 62.5% (n=25) of the patients reported no or only mild cough or voice hoarseness symptoms postoperatively, 22.5% (n=9) had moderate symptoms, and 15.0% (n=6) suffered from difficult supraesophageal symptoms. Ninety-five percent of the patients regarded the result of their surgery excellent, good, or satisfactory. Of all, 82.5% (n=33) of the patients would still choose surgery, 7.5% (n=3) would abstain from surgery, and 10% (n=4) of the patients were hesitant about their choice. For patients suffering from supraesophageal symptoms of gastro-esophageal reflux disease with objective evidence of pharyngeal acid exposure, laparoscopic Nissen fundoplication provides a good and alternative adding to current treatment.

Ingested acidic food and liquids may lead to misinterpretation of 24-hour ambulatory pH tests: focus on measurement of extra-esophageal reflux.

Normal values of extra-esophageal reflux are difficult to determine owing to variation in the location of the proximal electrode, limited information on the ingestion of acidic food, different exclusion periods for meals, and poor reproducibility of measurement of extra-esophageal reflux. We studied whether ambulatory esophageal pH testing is disturbed by acidic food ingestion. Eighteen healthy subjects were enrolled in standard dual-channel esophageal pH tests (recorder 1). Ten subjects were equipped with another pH device (recorder 2), positioned to measure extra-esophageal reflux. The subjects were exposed to controlled ingestion of different acidic food or liquid for five 1-min periods. The present study showed that acidic food ingestion for 5 min has a significant effect on the outcome of standard dual-channel ambulatory pH testing. Reflux occurs equally on proximal channels during ingestion of acidic food, whether the proximal channel position is normal or 2 cm above the upper esophageal sphincter. We recommend avoiding acidic food intake during esophageal pH testing.

The effectiveness of group therapy for students with mild voice disorders: a controlled clinical trial.

Previous studies of students studying to be teachers have indicated that these students commonly have voice disorders. Ideally, voice disorders should be treated before students start their work as teachers, but the resources for this treatment are often limited. This study examines whether group voice therapy is effective for teacher students. Accordingly, 20 teacher students with mild voice disorders received group voice therapy (in three small groups), whereas 20 students with similar voice disorders served as a control group and consequently did not receive voice therapy. Two out of three outcome measures (perceptual evaluation of voice quality and a questionnaire on the occurrence of vocal symptoms) indicated significant changes in the treatment group compared with the control group. No differences between groups were noted in the laryngeal status. The results suggest that group voice therapy seems to be an effective method to treat students with mild voice disorders.

Changes in the prevalence of vocal symptoms among teachers during a twelve-year period.

Vocal symptoms and voice disorders among teachers were studied in 1988 using a questionnaire designed to obtain information on six vocal symptoms that had appeared during the past 2 years. Twelve percent of the 478 respondents reported vocal symptoms occurring weekly or more often. The study was repeated using the same questionnaire in 2001. The results of this second study (n=241) indicate that vocal symptoms had increased considerably. Twenty-nine percent of the teachers reported symptoms occurring weekly or more often, and 20% reported two symptoms or more occurring at least once a week, which is significantly more than in 1988. Accordingly, voice disorders are probably a growing problem among teachers. Several factors may explain these increases. In 2001, the teachers complained more often about increases in the size of their classes. Factors that disturbed normal work routines, such as noisy or misbehaving pupils, had also increased significantly. A growing number of misbehaving pupils probably cause increased background noise and stress and, thus, increase the vocal symptoms in teachers.

A comparison of the prevalence of vocal symptoms among teacher students and other university students.

Studies focusing on different groups of students show that the prevalence of vocal symptoms and voice disorder vary depending on the study populations. A previous study of vocal symptoms and voice disorders among teacher students has shown that 20% of the students studying to become teachers in comprehensive schools and upper secondary schools reported frequently occurring vocal symptoms, ie, two symptoms or more occurring weekly or more often during the past year, and that most of these students had an organic voice disorder. This raised the question of whether other university students would also report similar, frequently occurring vocal symptoms. A questionnaire was distributed to 220 students of several faculties at the University of Turku, Finland. The results were compared with the results of a study of vocal symptoms reported by 175 students studying to become teachers. This comparison showed that students in general reported frequently occurring vocal symptoms, whereas the students studying to become teachers reported a greater number of frequently occurring symptoms than did other students at the university.

Loading-related subjective symptoms during a vocal loading test with special reference to gender and some ergonomic factors.

Vocal loading-related subjective symptoms were studied in a day-long vocal loading test. The voices of 40 female and 40 male voluntary young students were loaded by having them read aloud a novel for five times 45 min. The subjective symptoms that occurred during the vocal loading session were reported by filling in a questionnaire after each session. The responses loaded on five factors in a factor analysis: (1) 'central fatigue'; (2) 'symptoms of the neck, shoulders and back'; (3) 'drying in the mouth and throat'; (4) 'symptoms of the throat'; (5) 'symptoms of the voice'. The exposure groups (5 females and 5 males per cell) consisted of eight combinations of the following factors: (1) low (25 +/- 5%) or high (65 +/- 5%) relative humidity of ambient air; (2) low [<65 dB(SPL)] or high [>65 dB(SPL)] speech output level of vocal loading; (3) sitting or standing posture during vocal loading. The lowest mean score for symptoms pooled over the test were found in 'symptoms of the neck, shoulders and back' and the highest mean symptom score in 'drying in the mouth and throat' and 'symptoms of the throat'. Most symptoms were at their minimum during the first loading session and increased statistically significantly to a peak mean value after three or five vocal loading sessions. Statistically significant differences in the mean level between the gender or exposure groups emerged for 'central fatigue' (humidity had clear effects) and 'symptoms of the neck, shoulders and back' (gender, humidity and posture had clear effects). In these cases, females had more symptoms than males; the low-humidity group had more symptoms than the high-humidity group, and the standing subjects had more symptoms than the sitting subjects.