Journal of Voice

Vol. 16, No. 2, pp. 244–250

© 2002 The Voice Foundation

A Pilot Survey of Vocal Health in Young Singers

*Emily S. Tepe, *Ellen S. Deutsch, *Quiana Sampson, †Stephen Lawless, *James S. Reilly,
and ‡Robert Thayer Sataloff
*Division of Pediatric Otolaryngology, Department of Pediatric Surgery, Alfred I. duPont Hospital for Children,
Wilmington, Delaware; and Department of Otolaryngology—Head and Neck Surgery, Jefferson Medical College of
Thomas Jefferson University, Philadelphia, Pennsylvania; †Department of Anesthesiology and Critical Care, Alfred I.
duPont Hospital for Children, Wilmington, Delaware; and Department of Pediatrics, Jefferson Medical College of
Thomas Jefferson University, Philadelphia, Pennsylvania; ‡Department of Otolaryngology—Head and Neck Surgery,
Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania

Summary: The objective of this study was to determine the incidence of vocal
problems in young choir singers and to correlate vocal problems with demo-
graphic and behavioral information. A questionnaire addressing vocal habits
and hygiene was offered to 571 young choir singers, up to 25 years of age, who
sing at least weekly; 129 (22.6%) responded. More than one-half of the respon-
dents had experienced vocal difficulty, particularly older adolescents. Detri-
mental behaviors and circumstances surveyed were not reflective of the inci-
dence of vocal difficulty, except for morning hoarseness, chronic fatigue,
insomnia, and female gender after puberty. Voice care professionals should be
aware that self-reported voice difficulties are common among young choral
singers, especially postpubescent girls, and children with symptoms consistent
with reflux (morning hoarseness) and emotional stress (insomnia). Laryngolo-
gists should communicate with choral conductors and singing teachers to en-
hance early identification and treatment of children with voice complaints, and
to develop choral educational strategies that help decrease their incidence. Key
Words: Adolescents—Children—Choir—Choral—Dysphonia—Hoarseness—
Singing—Vocal health—Voice lessons—Voice training—Young adults.

INTRODUCTION singing. Some people sing casually, and some sing

Throughout history, people of all ages, cultures,
and socioeconomic backgrounds have enjoyed
Accepted for publication July 9, 2001.
Address correspondence to Ellen S. Deutsch, MD, Alfred I.
duPont Hospital for Children, Department of Surgery, Division
of Otolaryngology, 1600 Rockland Road, Wilmington, DE
19803, USA.
e-mail: edeutsch@nemours.org
on a formal basis. For children, adolescents, and
young adults, singing may provide an opportunity for
self-expression or religious or spiritual expression,
and, for some, it may blossom into career opportuni-
ties. Little has been written in the medical literature
about the incidence of vocal complaints of young
singers, the vocal habits and hygiene of young choral
singers, or the relationship between pediatric voice
problems and subsequent voice dysfunction in adult-
hood. The goal of this study was to survey choral

244
 VOCAL HEALTH IN YOUNG SINGERS
singers to gain insight into the incidence of voice dis-
turbance and to identify risk factors.
MATERIALS AND METHODS
A closed set questionnaire addressing vocal health
and habits was developed, based on a previously
published, extensively utilized questionnaire.1,2 Ad-
ditional questions concerning the pubertal status of
respondents were included. Two of the authors, ama-
teur singers EST and QS, identified youth choirs
known to them in the Wilmington, Delaware, area as
well as youth choirs identified by contacting local
churches. A variety of social and economic back-
grounds were represented. The authors met with the
choir directors, explained the purpose of the study,
and requested that the choir directors distribute the
questionnaire to choir singers 25 years of age and
younger. Five-hundred seventy-one questionnaires
were distributed.
Data analysis
Demographic and behavioral factors that might im-
pact the incidence of vocal difficulty were analyzed
using Fisher’s exact or Pearson’s chi-squared test.
Continuous data were analyzed using an unpaired
Student’s t-test. Respondents were grouped into cat-
egories as a function of the presence or absence of
voice problems and whether they had ever had for-
mal singing lessons. No data were obtained on the
nature of vocal training because of the difficulties in
obtaining valid, reliable details about pedagogical
approach through a questionnaire study. Data are
presented as a mean ± standard deviation. A p < 0.05
concurrent with a phi value > 0.4 was considered of
both statistical and explanatory significance.
TABLE 1. Relationship Between Age in Years, History of
Vocal Difficulty, and Voice Lessons
Lessons?
No
Vocal difficulty?
No 11 ± 4.3 years
Yes 16 ± 3.2 years
p value 0.001
245
RESULTS
One-hundred twenty-nine (22.6%) of the 571
questionnaires were returned. Respondents ranged in
age from 3 to 25 years (mean 15 years, ± 4.4 years);
34 (26%) were male, 94 (73%) were female, and 1
was unspecified. The few very young children who
responded had assistance from their parents in com-
pleting the questionnaire.
Seventy-two (55.8%) of 129 respondents reported
that they had experienced vocal difficulty, and 16
(12%) reported experiencing vocal stress at the time
of the survey. Pareto distribution of the voice prob-
lems encountered demonstrates the following inci-
dence of the voice problems: hoarseness (55, 42.6%),
fatigue (31, 24%), change in voice range (25, 19.4%),
tickling or choking sensation (22, 17%), volume dis-
turbance (21, 16.3%), breathiness (20, 15.5%), pro-
longed warm-up (8, 6.2%), and other (16, 12.4%). Al-
most one-third (31%) reported a sensation of
“oversinging,” and over one-third (43%) felt that they
had to strain their voices while singing. Some report-
ed that their voice hurt, either after they had finished
singing (10%), while singing (8%), or when speaking
(5%).
Thirty-eight (29.4%) of the young singers sur-
veyed reported having had voice lessons; however,
the nature, frequency, and quality of the lessons were
not assessed. Among young singers who had voice
lessons, there was no difference in the ages of those
with and without a history of vocal difficulty (Table
1). Among young singers who had never had voice
lessons, those with a history of vocal difficulty were
older than those without. Among young singers with
no history of vocal difficulty, those taking lessons
were older. Although there was a statistically signifi-
Yes p value
16 ± 3.5 years 0.005
18 ± 2.6 years 0.006
0.096
Journal of Voice, Vol. 16, No. 2, 2002
246 EMILY S. TEPE ET AL

cant difference in the ages of young choral singers
with a history of vocal difficulty who had or had not
had singing lessons (18 ± 2.6 versus 16 ± 3.2 years,
p = 0.006), this is probably not clinically significant.
Among the 72 respondents with a past history of
vocal difficulties, there was no statistically signifi-
cant difference between the 8 of 41 who had not tak-
en lessons and who were experiencing vocal difficul-
ty at the time of the survey, when compared to the 6
of 31 respondents who had taken lessons and who
were experiencing vocal difficulty (p = 1.000). Simi-
larly, among those who reported that they had no past
history of vocal difficulty, there was no statistically
significant difference between the 1 of 50 who had
not had lessons and who was experiencing vocal dif-
ficulty at the time of the survey, when compared to
the 1 of 7 who had taken lessons and who was expe-
riencing vocal difficulty (p = 0.245).
Only two of the 23 questions comparing the be-
haviors and circumstances of respondents who had or
had not ever experienced vocal difficulty elicited re-
sponses that demonstrated statistically significant
differences and adequate phi scores (Table 2). Twen-
ty-nine of 30 respondents (97%) with chronic fatigue

TABLE 2. Comparison of Groups Depending on Experience of Vocal Difficulty

Ever experienced
vocal difficulty?

No Yes p value phi value

A. No statistically significant difference in answers to the following questions.

Ever used antacids? No 48 61
Yes 6 11 0.603 0.060
Eat late at night? No 31 42
Yes 22 29 0.96 0.019
Exercise frequently? No 35 51
Yes 19 21 0.563 -0.064
Bitter or acid taste or bad breath first thing in the morning? No 53 68
Yes 1 4 0.285 0.094
Frequent “heartburn” or hiatal hernia? No 54 71
Yes 0 1 1.000 0.077
Cheerleader? No 52 68
Yes 2 4 0.700 0.043
Live, work, or perform around smoke or fumes? No 48 56
Yes 6 16 0.154 0.145
Sing performances or rehearsals in the morning? No 39 41
Yes 15 31 0.094 0.157
Do you live or work in a smoky environment? No 49 60
Yes 5 12 0.296 0.107
Frequent sore throat? No 49 63
Yes 5 9 0.776 0.051
Under particular stress at present? No 49 58
Yes 5 14 0.136 0.141
Do you warm up your voice before singing? No 16 12
Yes 36 56 0.215 0.156
Do you warm down your voice when you finish singing? No 48 68
Yes 5 4 0.363 0.127
(continues)

Journal of Voice, Vol. 16, No. 2, 2002

 VOCAL HEALTH IN YOUNG SINGERS 247

TABLE 2. (continued)
Ever experienced
vocal difficulty?

No Yes p value phi value

Frequent whispering? No 53 66
Yes 1 6 0.237 0.140
Frequent yelling or loud talking? No 41 42
Yes 13 30 0.057 0.039
B. Statistically significant difference but low phi score suggests
lack of explanatory power.
Work in extremely dry conditions? No 52 61
Yes 2 11 0.041 0.188
Hoarse first thing in the morning? No 52 53
Yes 2 19 0.001 0.301
Speak extensively? No 44 43
Yes 10 29 0.011 0.233
Thirsty or dehydrated frequently? No 49 54
Yes 5 18 0.035 0.202
Voice feels worse later in the day after it has been used? No 53 59
Yes 1 13 0.004 0.255
C. Statistically significant difference.
Chronic fatigue (insomnia)? No 53 43
Yes 1 29 0.000 0.446
Voice feels worse in the morning? No 47 31
Yes 7 41 0.000 0.448

or insomnia had experienced vocal difficulty, com-
pared to 43 of 96 respondents (45%) without chron-
ic fatigue (p < 0.000, phi = 0.446). Forty-one of 48
respondents (85%) whose voice felt worse in the
morning had experienced vocal difficulty, compared
to 31 of 78 respondents (40%) whose voice did not
feel worse in the morning (p < 0.000, phi = 0.448).
Comparing singers who had taken voice lessons ver-
sus those who had not, none of the 23 questions con-
cerning behaviors or circumstances related to habits
that could impact voice demonstrated both statistical
differences and adequate explanatory power (Table 3).
Eighty-nine percent of young singers surveyed
consume less than the adult recommendation of eight
8-ounce cups of water per day.3 Although singers
who have taken voice lessons drink an average of 2.1
cups of water per day compared to 1.5 cups for those
who have never taken lessons, the difference is not
statistically significant (p = 0.091). There was also no
statistically significant difference in the daily quanti-
ty of water consumed by those who have or have not
had voice problems (1.9 versus 1.4 cups, p = 0.131).
Among female singers taking voice lessons, there
was an increased incidence of voice difficulties in
girls who have reached puberty (47 of 63 versus 5 of
29 who have not reached puberty, p < 0.001). This
circumstance did not apply to male singers taking
voice lessons; there was no difference in the inci-
dence of voice difficulties in male respondents who
have reached puberty compared with those who have
not (4 of 10 versus 15 of 22, p = 0.244).
DISCUSSION
More than half of the survey respondents had ex-
perienced vocal difficulty, with hoarseness being the

Journal of Voice, Vol. 16, No. 2, 2002

248 EMILY S. TEPE ET AL

TABLE 3. Comparison of Groups Depending on Whether Respondents Have Had Voice Lessons
Ever taken
voice lessons?

No Yes p value phi value

A. No statistically significant differences in answers to the following questions.

Work in extremely dry conditions? No 84 31
Yes 7 7 0.117 0.157
Exercise frequently? No 60 28
Yes 31 10 0.416 -0.076
Chronic fatigue (insomnia)? No 72 26
Yes 19 12 0.258 0.114
Frequent bad breath? No 86 38
Yes 5 0 0.321 -0.130
Frequent “heartburn” or hiatal hernia? No 91 37
Yes 0 1 0.295 0.137
Hoarse first thing in the morning? No 78 29
Yes 13 9 0.208 0.114
Cheerleader? No 86 37
Yes 5 1 0.670 -0.062
Frequently clear your throat? No 69 31
Yes 22 7 0.644 -0.063
Live, work, or perform around smoke or fumes? No 77 29
Yes 14 9 0.314 0.099
Are you currently experiencing vocal difficulty? No 80 31
Yes 10 6 0.556 0.070
Sing performances or rehearsals in the morning? No 59 23
Yes 32 15 0.690 0.041
Frequent sore throat? No 81 33
Yes 10 5 0.766 0.031
Under particular stress at present? No 79 31
Yes 12 7 0.429 0.067
Thirsty or dehydrated frequently? No 77 29
Yes 14 9 0.314 0.099
Frequent whispering? No 88 34
Yes 3 4 0.194 0.145
Voice feels worse later in the day, after it has been used? No 82 33
Yes 9 5 0.552 0.048
Frequent yelling or loud talking? No 59 25
Yes 32 13 1.000 -0.009
Do you warm down your voice when you finish singing? No 83 36
Yes 7 2 0.712 0.073
(continues)

Journal of Voice, Vol. 16, No. 2, 2002

 VOCAL HEALTH IN YOUNG SINGERS 249

TABLE 3. (continued)
Ever taken
voice lessons?

No Yes p value phi value

B. Statistically significant difference but low phi score suggests

lack of explanatory power.
Ever used antacids? No 84 28
Yes 7 10 0.008 0.251
Speak extensively? No 70 19
Yes 21 19 0.004 0.222
Voice feels worse in the morning? No 62 18
Yes 29 20 0.031 0.195
Eat late at night? No 60 16
Yes 30 21 0.042 0.222
Do you warm up your voice before singing? No 27 2
Yes 62 32 0.002 0.306

most common subjective complaint. About one-third
reported straining or “oversinging.” Late adolescent
singers are most at risk for vocal difficulties (deter-
mined by self-reporting, not laryngoscopy), and age
seems to be a more important predictor of vocal dif-
ficulty than detrimental behaviors or self-reported
voice lessons. Possible explanations include the cu-
mulative effect of unhealthy habits or techniques, an
increase in vocal demands associated with a more
mature repertoire, increased vocal abuse related to
social and recreational activities other than singing,
the effects of the concurrent physiologic changes of
puberty, or other factors. The two risk factors identi-
fied in this study as having an increased incidence in
singers with vocal difficulty were (1) a perception
that the singer’s voice feels worse in the morning and
(2) chronic fatigue or insomnia. These symptoms
may be manifestations of gastroesophageal reflux,
emotional stress, or other factors.
The incidences of most of the surveyed habits, ac-
tivities, and circumstances that were thought to affect
vocal health were similar in singers who had and
who had not had vocal problems, as well as those
who had or had not had voice lessons. It is possible
that risk factors for vocal problems in adults may not
be applicable to children, adolescents, and young
adults because of their different capabilities, motiva-
tions, and physiology.
In addition, and contrary to our expectations, be-
haviors and circumstances thought to be detrimental
to vocal health were not less common among singers
who reported having taken voice lessons. Children
and adolescents may have more difficulty than adults
in complying with optimal behaviors, as well as less
ability to control environmental factors. Several ad-
ditional explanations are possible. This particular
survey may not have sufficiently addressed issues
relevant to vocal problems among young singers, or
voice lessons may appear to be ineffective because
they were given “too little, too late” to those singers
having the greatest difficulties. This survey did not
address several factors that may contribute to the suc-
cess of voice lessons, such as the quality or duration
of the voice lessons, the training and skill of the
teacher, or whether the lessons were intended to be
preventive or restorative. We are aware anecdotally
that some of the self-reported singing lessons were
provided by choral conductors, many of whom are
not trained singing teachers or singers.4
This study should not be interpreted to mean that
expert vocal training does not have a positive impact
on vocal health. In light of the prevalence of vocal
health problems in this population, it does highlight
the need for additional research to determine the na-
ture and quality of voice lessons generally provided
to children in choirs, as well as the nature of ideal
voice lessons.

Journal of Voice, Vol. 16, No. 2, 2002

250 EMILY S. TEPE ET AL
CONCLUSIONS
Vocal difficulty is common among young choral
singers, with older adolescents particularly at in-
creased risk of vocal difficulty. The presumed detri-
mental behaviors and circumstances surveyed did not
correlate with the incidence of vocal difficulty, and
their incidence was similar in respondents who had
or had not “taken voice lessons.” This study demon-
strates that a history of “voice lessons” does not en-
sure good vocal practice and does not appear to be
associated with a decreased risk of vocal difficulties
in this population of young, amateur choral singers.
However, great care must be exercised when inter-
preting these results. Extensive anecdotal experience
among singing teachers and laryngologists suggests
that good voice training is helpful in not only im-
proving vocal performance capabilities but also in
avoiding vocal injuries. Our study should not be in-
terpreted as refuting these impressions. Rather, it
suggests that physicians should not interpret a histo-
ry of “voice lessons” in children as guaranteeing
good vocal hygiene or technique, or a decreased risk
of developing vocal problems. Laryngologists should
be aware of the high incidence (over half) of self-re-
Journal of Voice, Vol. 16, No. 2, 2002
ported vocal difficulties among children in choirs,
and of risk factors including dysphonia in the morn-
ing, chronic fatigue, insomnia, and female gender
following puberty. Laryngologists should collaborate
with choral conductors to identify vocal problems
early for prompt intervention, and to enhance educa-
tion within the choral environment to help prevent
voice dysfunction in young singers.
Acknowledgment: Ms. Tepe received an educa-
tional grant from the Princeton University Class of
1969 Community Service Fund.
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2. Sataloff RT. Professional Voice: The Science and Art of Clini-
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1997:837–844.
3. Harvey PL, Miller SH. Nutrition and the Professional Voice
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4. Smith B, Sataloff RT. Choral Pedagogy. San Diego, Calif:
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