Average Ambulatory Measures of Sound Pressure Level, Fundamental Frequency, and Vocal Dose Do Not Differ Between Adult Females With Phonotraumatic Lesions and Matched Control Subjects.

OBJECTIVES: Clinical management of phonotraumatic vocal fold lesions (nodules, polyps) is based largely on assumptions that abnormalities in habitual levels of sound pressure level (SPL), fundamental frequency (f0), and/or amount of voice use play a major role in lesion development and chronic persistence. This study used ambulatory voice monitoring to evaluate if significant differences in voice use exist between patients with phonotraumatic lesions and normal matched controls. METHODS: Subjects were 70 adult females: 35 with vocal fold nodules or polyps and 35 age-, sex-, and occupation-matched normal individuals. Weeklong summary statistics of voice use were computed from anterior neck surface acceleration recorded using a smartphone-based ambulatory voice monitor. RESULTS: Paired t tests and Kolmogorov-Smirnov tests resulted in no statistically significant differences between patients and matched controls regarding average measures of SPL, f0, vocal dose measures, and voicing/voice rest periods. Paired t tests comparing f0 variability between the groups resulted in statistically significant differences with moderate effect sizes. CONCLUSIONS: Individuals with phonotraumatic lesions did not exhibit differences in average ambulatory measures of vocal behavior when compared with matched controls. More refined characterizations of underlying phonatory mechanisms and other potentially contributing causes are warranted to better understand risk factors associated with phonotraumatic lesions.

Vocal health of sporting, fitness, and wellness leaders in Northern New York and Vermont.

INTRODUCTION: Fitness trainers and sporting coaches use their voices in acoustically poor conditions, for extended periods of time. Knowledge of the risk of voice problems in this cohort is emerging and has been documented in studies performed in Europe and Australia. This pilot study sought to identify the prevalence of voice problems of fitness trainers and sporting leaders in United States college towns. MATERIALS AND METHODS: An online questionnaire was distributed. The survey was based on the instrument developed by Rumbach (2013), "Vocal health of GFIs" (group fitness instructors (GFIs)) and adapted to account for the wider target population of this study. The survey included questions about participants' demographic information, as well as working conditions, including acoustic environment, leading requirements, equipment provision and maintenance and vocal diagnoses and symptoms. Questions on symptomatology included voice quality and physical symptoms (e.g. throat soreness). Recruitment took place between May and September 2018. RESULTS: Sixty-two participants completed the survey. Three participants (5.08%) reported having received a formal diagnosis of dysphonia, yet many more reported vocal symptoms, including physical symptoms (n = 15, 24.19%) and voice disturbance (n = 8, 12.90%). Few participants had received vocal education (n = 5, 8.06%) and many thought this should be included in their formal training (n = 24, 38.71%). CONCLUSIONS: In contrast to previous investigations, diagnosed voice disorders are less prevalent in this sample, based in US college towns. However, physical and vocal symptoms associated with voice overuse were common, suggesting that participants were unaware of their voice and the significance of the changes they reported.

Twenty Eight Days in the Life of a Vocal Pathology: A Case Study of Videolaryngostroboscopy, Acoustic, and Perceptual Variability.

The purpose of this investigation was to observe laryngeal tissue and vocal function changes over the course of 28 days in a single participant diagnosed by a laryngologist with bilateral nodules. Laryngeal imaging, acoustic variables and perceptual assessments of voice quality, and perceived vocal effort were obtained every morning for 28 consecutive days. A daily journal of occupational and recreational voice use as well as menstruation and alcohol consumption was maintained each day. It was hypothesized that the laryngeal pathology would appear more extensive and the vocal function measures obtained would be worse following extensive voice use. Laryngeal imaging, acoustic variables, and perceptual measures quantified provided evidence to support the study hypotheses. The size, extent, and asymmetry of the bilateral vocal pathologies observed were more extensive on days following occupational and recreational vocal loading. Acoustic and perceptual measures obtained correlated with the laryngeal tissue changes observed. Study findings support a more holistic approach to laryngeal pathology diagnosis that is based on a more thorough understanding of vocal loading considerations up to 48 hours prior to laryngeal endoscopy to better understand the pathophysiology of the observed lesion(s) for most accurate clinical diagnosis.

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

OBJECTIVE: Teachers are the most common occupational group reporting to the voice clinics with dysphonia across the globe. However, less is known about teachers' perceptions about their voice and voice problems. Hence the present study aimed to explore teachers' perception about their teaching voice, voice problems and vocal health-seeking behaviors. METHOD: A qualitative phenomenological research design using semi-structured interviews were conducted with fifteen female primary school teachers. Participants were asked to express their perception of teaching voice, vocal health care knowledge, and vocal hygiene practices. Using inductive analysis, the researchers converted the raw data into concepts or themes and discussed. RESULT: The present study results showed that teachers perceive voice as the primary tool for their profession. However, teachers consider voice problems as part of their professional commitments. Despite knowing the harmful effects of voice problems, teachers' pay less attention to their voice problems and perceive them as usual, unavoidable and part of their profession. Due to their demanding work schedule and not getting enough support from the management, they hesitate to consult medical professionals unless it severely affects them. CONCLUSIONS: The data obtained from this study can be used to improve the teachers' knowledge regarding vocal health and convince the school management to extend their support for the successful implementation of the vocal health training programs for teachers.

Phonotraumatic Injury in Fitness Instructors: Risk Factors, Diagnoses, and Treatment Methods.

Fitness instructors are at risk for phonotraumatic injury caused by a combination of occupation-driven environmental and physiologic factors. OBJECTIVES: This study analyzes phonotraumatic injury in a cohort of fitness instructors to define the spectrum of disease, inform treatment, and make educational recommendations. STUDY DESIGN: Retrospective chart review. METHODS: Fitness instructors seen over a 2-year period comprised the study population. Stroboscopic findings, recommended treatment modalities, and treatment outcomes, including postoperative recurrence (when applicable) were analyzed. Demographic information (gender, age), past medical history, VHI-10 scores, and concurrent relevant vocal demands (performer vs. non-performer) were reviewed. Descriptive statistics and bivariate analyses with Fisher's exact test and Wilcoxon rank sum test were used to determine statistical significance of various factors in relation to phonotraumatic injury and response to treatment. Cochran-Armitage trend tests were performed to analyze trends in injuries across fitness types in relation to increased vocal demand. Occupational concerns reported by subjects were analyzed descriptively. RESULTS: The subject cohort consisted of 24 fitness instructors (20F; 4M) who taught a variety of fitness methods. Thirteen subjects (54.2%) were diagnosed with pseudocysts (five unilateral, eight bilateral), five (20.8%) with bilateral midfold masses, five (20.8%) with polyps (four unilateral, one bilateral), and one (4.2%) with cyst. Fourteen subjects (58.3%) were prescribed medication (oral steroids, reflux medication, and/or allergy medication). All were referred for behavioral management. Ten (41.7%) chose surgical intervention after failure to return to satisfactory function with behavioral management; Four (40%) experienced postoperative lesion recurrence. There were no statistically significant findings in relation to demographic information, past medical history, concurrent relevant vocal demands, or occupational vocal demands with choice for surgery. Trend test analysis found that lesions that are typically more likely to require surgical intervention (eg, polyps) tended to be found more frequently as vocal demand increased. The primary occupational concerns reported by subjects were related to amplification (lack of amplification, inadequate amplification/amplification problems) and scheduling (too many consecutive classes without adequate breaks). CONCLUSION: Fitness instructors are subject to a variety of phonotraumatic vocal fold injuries, nearly half which require surgical treatment. One in four recurs after such intervention. Instructors could benefit greatly from education on vocal health, strategies to improve and/or reduce voice use while in the fitness environment, and to help aid in recognizing early "red flags" for phonotraumatic injury. Occupational factors that place fitness instructors at risk for phonotraumatic injury (scheduling, environment, amplification) may be improved with education directed to studio owners and managers.

Keeping the Voice Fit in the Group Fitness Industry: A Qualitative Study to Determine What Instructors Want in a Voice Education Program.

OBJECTIVES: This study aimed to provide a descriptive summary of (1) group fitness instructors' (GFIs') experiences of occupational voice use and education, and (2) the content and mode of delivery desired by GFIs in an education and training program. STUDY DESIGN: This is a qualitative inductive approach using a semi-structured interview. METHOD: Semi-structured interviews were conducted with eight GFIs recruited via self-selection sampling. Participants were asked to comment on their experiences of voice use, voice education, and their preferences for future education and training. RESULT: Participants reported experiencing occupational voice difficulties, and cited inadequate voice education, faulty equipment, and apathetic fitness industry attitudes as core barriers to vocal health. Content focusing on vocal hygiene, safe occupational voice use, use of amplification equipment, and addressing industry attitudes to voice was desired by participants. A combination of face-to-face, web-based, and app-based delivery options was suggested. CONCLUSION: The data from this study should be considered when designing a vocal education and training package tailored to the needs of GFIs and the fitness industry.

Acoustic Perturbation Measures Improve with Increasing Vocal Intensity in Individuals With and Without Voice Disorders.

OBJECTIVE: In vocally healthy children and adults, speaking voice loudness differences can significantly confound acoustic perturbation measurements. This study examines the effects of voice sound pressure level (SPL) on jitter, shimmer, and harmonics-to-noise ratio (HNR) in adults with voice disorders and a control group with normal vocal status. STUDY DESIGN: This is a matched case-control study. METHODS: We assessed 58 adult female voice patients matched according to approximate age and occupation with 58 vocally healthy women. Diagnoses included vocal fold nodules (n = 39, 67.2%), polyps (n = 5, 8.6%), and muscle tension dysphonia (n = 14, 24.1%). All participants sustained the vowel /a/ at soft, comfortable, and loud phonation levels. Acoustic voice SPL, jitter, shimmer, and HNR were computed using Praat. The effects of loudness condition, voice SPL, pathology, differential diagnosis, age, and professional voice use level on acoustic perturbation measures were assessed using linear mixed models and Wilcoxon signed rank tests. RESULTS: In both patient and normative control groups, increasing voice SPL correlated significantly (P < 0.001) with decreased jitter and shimmer, and increased HNR. Voice pathology and differential diagnosis were not linked to systematically higher jitter and shimmer. HNR levels, however, were statistically higher in the patient group than in the control group at comfortable phonation levels. Professional voice use level had a significant effect (P < 0.05) on jitter, shimmer, and HNR. CONCLUSIONS: The clinical value of acoustic jitter, shimmer, and HNR may be limited if speaking voice SPL and professional voice use level effects are not controlled for. Future studies are warranted to investigate whether perturbation measures are useful clinical outcome metrics when controlling for these effects.

Gender Differences in the Reporting of Vocal Fatigue in Teachers as Quantified by the Vocal Fatigue Index.

OBJECTIVES: Occupational voice users report higher instances of vocal health problems. Women, who are more likely than men to report voice problems, are the largest members of some occupational voice users, such as teachers. While a common complaint among this population is vocal fatigue, it has been difficult to quantify. Therefore, the goal of this study is to quantify vocal fatigue generally in school teachers and investigate any related gender differences. METHODS: Six hundred forty (518 female, 122 male) teachers were surveyed using an online questionnaire consisting in part of the Vocal Fatigue Index (VFI), an index specifically designed to quantify vocal fatigue. RESULTS: Compared to vocally healthy adults, the teachers surveyed were 3 times as likely to report vocal tiredness or vocal avoidance and over 3 times as likely to report physical voice discomfort. Additionally, female teachers were more likely to have scores approaching those with dysphonia. CONCLUSIONS: The VFI quantified elevated levels of vocal fatigue in teachers, with a significant prevalence of symptoms reported among females compared to males. Further, because the VFI indicated elevated complaints (between normal and dysphonic) in a population likely to be elevated, the VFI might be used to identify early indications of voice problems and/or track recovery.