REVIEW

CURRENT
OPINION Managing dysphonia in occupational voice users
Mara Behlau a,b, Fabiana Zambon a,b,c, and Glaucya Madazio a

Purpose of review
Recent advances with regard to occupational voice disorders are highlighted with emphasis on issues
warranting consideration when assessing, training, and treating professional voice users.
Recent findings
Findings include the many particularities between the various categories of professional voice users, the
concept that the environment plays a major role in occupational voice disorders, and that biopsychosocial
influences should be analyzed on an individual basis. Assessment via self-evaluation protocols to quantify
the impact of these disorders is mandatory as a component of an evaluation and to document treatment
outcomes. Discomfort or odynophonia has evolved as a critical symptom in this population. Clinical trials
are limited and the complexity of the environment may be a limitation in experiment design.
Summary
This review reinforced the need for large population studies of professional voice users; new data
highlighted important factors specific to each group of voice users. Interventions directed at student
teachers are necessities to not only improving the quality of future professionals, but also to avoid the
frustration and limitations associated with chronic voice problems. The causative relationship between the
work environment and voice disorders has not yet been established. Randomized controlled trials are
lacking and must be a focus to enhance treatment paradigms for this population.
Keywords
call center agents, dysphonia, occupational voice disorders, professional voice, quality of life, soldiers,
teachers, voice, voice symptoms

INTRODUCTION to the nature of their vocal demands (i.e., the prime

Vocal performance is an ancient art and professional
voice users were likely the first patients to seek care
for voice problems related to chronic misuse of the
vocal mechanism. However, only recently, the semi-
nal work of Vilkman (2000) [1] considered vocal
quality and vocal load in this population, providing
a conceptual framework for the field and a change in
how these challenging patients are considered.
Vocal quality depends on both the artistic and
nonartistic nature of voice usage. Even when focus-
ing only on the artistic component, requirements
may vary enormously, for example, from the pure
sound required for classical singing to a distorted
quality for heavy metal performers. To the contrary,
vocal load is derived from a combination of the
duration of voice usage and environmental factors
(room acoustics, air quality, and type of communi-
cation). Physical load on the vocal apparatus may
require physiological changes increasing the occu-
pational risk. Moreover, environmental factors may
affect vocal load in a complex manner [2].
A new taxonomy system was recently proposed
[3] to categorize professional voice users according
motivation for voice use): supporters, callers, trans-
mitters, informers, leader and sellers, and perform-
ers. This system may be helpful, with implications
for managing voice problems in specific situations.
However, it has not gained popularity to date. In
spite of these advances, a multicentric approach is
necessary to address some of the basic issues includ-
ing obtaining epidemiological data as well as the
characterization of certain occupations, and even-
tually, the development of clinical trials to test
various interventions.
a
Centro de Estudos da Voz – CEV, bUniversidade Federal de São
Paulo – UNIFESP and cSindicato dos Professores de São Paulo –
SINPRO, São Paulo, Brazil
Correspondence to Mara Behlau, PhD, Centro de Estudos da Voz, Rua
Machado Bittencourt 361, São Paulo, SP 04044-001, Brazil. E-mail:
mbehlau@cevfono.com
Curr Opin Otolaryngol Head Neck Surg 2014, 22:188–194
DOI:10.1097/MOO.0000000000000047

www.co-otolaryngology.com Volume 22
Number 3
June 2014

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

KEY POINTS

Occupational and professional voice users are
considered traditional patients with regard to voice
disorders, but there is no consensus regarding the
definition of an occupational voice disorder.

Many specific professional demands may contribute to
both transient and chronic vocal problems and the
environment must be taken into consideration in the
assessment and management of this population.

Epidemiological studies are limited and variable in
quality; caution should be taken when attributing a
voice disorder to an occupation.

Professional voice users do not always recognize
perceptual auditory symptoms and signs of discomfort
as important factors warranting consultation, which can
delay treatment.
OCCUPATIONAL VOICE DISORDERS
VERSUS PROFESSIONAL VOICE
DISORDERS
It is estimated that one-third of the world‘s current
workforce consists of individuals who rely on voice
as a primary tool of work [4]. Occupational disorders
are seen as diseases caused by exposure at work [2,5],
primarily related to the occupation itself. Neverthe-
less, no consensus exists regarding the definition
of occupational voice disorders [6]. The terms
professional and occupational voice have been used
interchangeably, but recent publications tend to
employ the term occupational voice when dealing
&&
with safety and health in the workplace [7 ,8 ]
and professional voice when referring to specific
personal conditions [9,10].
As with any voice problem, dysphonia in pro-
fessional users is multifactorial with the added com-
plexity of an environment that is likely difficult
to manipulate. Although there is no international
position statement, in some countries such as
Poland, a combination of medical and legal aspects
defines voice disorders as an occupational disease
[11].
Voice disorders occur when an individual‘s
voice fails to meet the criteria and demands necessi-
tated by the profession [1]. Professional voice users
work in a wide range of disciplines and genres. The
classical singer demands a specific vocal quality for
subsistence, the actor relies on vocal flexibility to
embody a character, the clergy on endurance and
expressivity, the radio performer‘s voice must
correspond to a specific market, and the teacher
needs not only a resilient voice, but also a unique
communicative competence to attract students and
1068-9508 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Managing dysphonia in occupational voice users Behlau et al.
maintain their attention to impart knowledge. Each
discipline demands peak performance to ensure
longevity. Clinicians often have a narrow percep-
tion of each of these specific aspects. Only recently,
the scientific literature has begun to address prefer-
ences for certain voices with each industry, such as
&
the radio performers [12 ] or call center operators
[13,14].
&
A recent qualitative Australian study [12 ]
included nine semi-structured interviews with radio
employers and concluded that these professionals
sound differently than in the past. The tendency is
to use a natural sound, easy-on-the-ear, with the
ability to read and produce vocal quality that suits
the station. In spite of the perception of the vocal
demands, the interviewees did not express any con-
cern regarding vocal health. To this end, employers
and clinicians must exchange information. A lack of
training cannot be repeatedly discussed as the main
cause for voice complaints; environmental factors
related to voice disorders must be addressed.
EPIDEMIOLOGY
Incidence data regarding voice disorders in pro-
fessional voice users depend highly on methodology,
variables, and types of samples investigated. Quanti-
fication of voice disorders in the workplace may be
difficult, as a causal relationship is often difficult
to prove.
Some interesting data reinforce the notion that
teachers present with significant limitations regard-
less of the cultural scene [15]. Recently, a compre-
hensive investigation in Brazil studied 3265 people
&
&
[16 ]. The results were strikingly similar to data
obtained in the United States by Roy et al. [17,18],
a randomized study. Voice symptoms were highly
related to occupational use; the lifetime prevalence
was 63% for teachers (35% for nonteachers). This
figure increased at 30–39 years and persisted with
advancing age. Teachers presented with an average
of 3.6 symptoms (2.3 in the general population),
including vocal fatigue, increased effort to talk, and
discomfort. Teachers missed more workdays during
the year (12 vs. 2.4% at the general population)
because of diminished capacity to perform certain
tasks (29 vs. 5.4% general population). Some
actually considered a change in career due to voice
problems (16.7 vs. 0.9% general population).
A cross-sectional epidemiological study [19] of
Brazilian teachers (N ¼ 4496) revealed a mix of indi-
vidual and environmental factors contributing to
voice disorders: vocal effort was associated with
dysphonia in addition to female sex, lack of ampli-
fication, increased background noise, administra-
tive pressures, heartburn, and rhinitis. Similar
www.co-otolaryngology.com 189
 Speech therapy and rehabilitation
figures were also found in North Carolina, United
States, in 237 kindergarten teachers: 58% presented
with lifetime hoarseness and 22% were currently
hoarse. Moreover, although 32% sought pro-
fessional help, 30% believed that hoarseness was
normal [20]. Several work-related and individual
variables were associated with voice disorders world-
wide such as noise in classrooms, being a physical
education instructor, and habitual loud speaking
voice [15].
An interesting Brazilian study of 575 teachers
from urban and rural public schools [21] concluded
that there is a close association between voice prob-
lems and common mental disorders (mood, anxiety,
or somatoform disorders). Elevated scores on the
emotional domain of the Voice Handicap Index
(VHI) were related to large class size, lack of voice
rest, and loss of workdays due to voice problems.
Similarly, elevated scores on the functional subscale
were related to female sex, lack of voice rest, loss of
working days due to voice problems, and increased
vocal load.
Student teachers were assessed in Sweden and
a high prevalence of voice disorders (17%) was
observed, suggesting the need for early intervention
[22]. From a large group of 1250 students, 208
presented with at least two symptoms weekly. Risk
factors included female sex, vocal fold problems
in childhood and/or adulthood, throat infections,
airborne allergies, smoking, hearing problems,
previous work as teacher or leader, vocally taxing
hobbies, and previous voice therapy or voice train-
ing. A strong association was observed between the
number of potential risk factors and voice symp-
toms. Risk factors were not related to the work
environment because these students had not yet
been exposed to teaching.
In addition to teachers, recent studies have
focused on soldiers, cantors, professional soccer
&
managers, and fitness instructors. Dion et al. [8 ]
analyzed 1.3 million health records of active duty US
army soldiers with no history of dysphonia. Soldiers
have occupational and environmental exposure,
reduced hydration, hot dry climates, altered sleep
patterns, and many other stressors. Voice is a key
element in combat situations and a voice disorder
may be dangerous. Soldiers were 1.13 times more
likely to have dysphonia if they were deployed.
A lack of association with diagnosis type, tobacco,
and alcohol use indicates specific occupational
exposures, warranting the implementation of pre-
ventive measures.
Cantors [23] maintain a vocally intense lifestyle
and have been largely underserved with regard to
voice problems. These professionals face the chal-
lenge of both singing and teaching and present with
190 www.co-otolaryngology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
risk factors for developing dysphonia, including
high vocal demands, reduced vocal downtime, aller-
gies, and reflux.
O’Neill and McMenamin [24] described voice
use among professional soccer managers in Ireland
and identified four variables related to increased risk
for dysphonia: voice use, factors affecting voice
change, impact of voice use, and the importance
of voice at work. These risk factors were related to
intense and prolonged voice use in poor acoustic
environments and lack of vocal technique. Finally,
Rumbach [25] reported on 38 Australian fitness
instructors that revealed a lack of job satisfaction
(65%) and emotional distress. The need to be more
proactive is clear; however, critical epidemiological
data are lacking.
COMMON PRESENTING SIGNS,
SYMPTOMS, AND LARYNGEAL FINDINGS
Vocal endurance seems to be more critical than
vocal quality for many professionals. Flexibility
can also be a particular requirement for some indi-
viduals such as the impersonators [9]; this variable
has not been studied adequately. Symptoms in pro-
fessional voice users do not always reflect awareness
of a vocal problem and do not usually relate to
&&
decreased professional performance [7 ,13,26,27].
&
Symptomatology can be abundant [16 ,18,22] with
no specific sign or symptom to clearly represent the
main complaint of a professional voice user. Never-
theless, these individuals clearly link voice and/or
&
discomfort with the workplace [16 ,18,28–30]. Dis-
comfort with phonation is a key issue in teachers
and may be the predominant symptom among these
professionals [28,29]. The Voice Discomfort Scale
[31] was employed to study teachers and revealed
that discomfort was associated with diminished
vocal self-assessment, but did not necessarily corre-
late with the degree of dysphonia [28]. Therapy can
reduce the frequency and severity of discomfort
symptoms quantified by this scale [29].
Pain during speaking in professional and non-
professional voice users was studied in a large
sample of 1152 Belgian individuals [32]. Signifi-
cantly more pain symptoms were observed in pro-
fessional voice users (84 vs. 55%). These symptoms
were isolated to the throat, neck, shoulder, head-
ache, ear, and back pain. Vocal training may play a
role in reducing pain [33].
Recognition of the increased number of symp-
toms in the professional voice population is critical;
however, as voice problems are typically chronic,
increased symptoms do not lead to treatment seek-
ing. The average number of symptoms necessary to
motivate teachers to seek diagnosis and treatment
Volume 22
Number 3
June 2014
 Managing dysphonia in occupational voice users Behlau et al.
was 8.6 [27]. Beyond the number and frequency of
symptoms, recovery time following heavy vocal
load appears to play a role in the perception of vocal
dysfunction [34]. Interestingly, when student teach-
ers were assessed [22], symptoms of discomfort
during phonation were most common.
Specific laryngeal information on student teach-
ers reinforced the need for early intervention. Data
from 30 first-year American acting students [26]
revealed incomplete glottal closure (62%), hyper-
function (59%), decreased mucosal wave (55%), and
findings of laryngopharyngeal reflux (48%). Sim-
ilarly alarming data were reported for 79 first-year
Israeli acting students [35], with 50% prevalence of
aberrant laryngeal findings, and associated with
auditory and acoustic deviations. Even if these find-
ings are not life-threatening, they may cause stress,
impair work conditions, and limit career longevity.
An Australian fitness instructors group [30] pre-
sented with laryngeal disorder, even if working with
amplification (80%), including vocal fold nodules
(80%; N ¼ 30), cysts (6.6%), hemorrhage (3.33%),
and recurrent chronic laryngitis (10%) in addition
to vocal strain and muscle tension dysphonia. These
professionals self-reported acute (78.95%) and
chronic (70.91%) voice symptoms [25] as well as a
negative impact of their voice on their lives, includ-
ing social withdrawal, decreased job satisfaction,
and emotional distress. Clearly, amplification does
not ameliorate these issues.
The Screening Index for Voice Disorder (SIVD)
was proposed as an instrument of epidemiologic
screening tool for teachers with voice problems
[36]. It is not clear, however, how specific this instru-
ment is with regard to teachers when compared
with the general population or other professional
categories.
A critical lack of data regarding professional
populations without voice problems remains prob-
lematic. A study of 72 American trained singers
with no voice complaints [37] revealed a high occur-
rence of abnormalities on strobovideolaryngoscopy
(86.1% of participants: laryngopharyngeal reflux,
prominent varicosities or ectasias, incomplete
glottic closure, and/or structural abnormalities) and
acoustic analysis (deviated values from the norm
in shimmer, relative average perturbation, and
maximum fundamental frequency for female partici-
pants). These data must be considered when assessing
a singer.
Many predisposing factors in professional voice
users have been described, such as lack of training,
health-related problems, and psychological stressors
[2,38,39]; however, none of these explain why
certain people present with dysphonia, whereas
others, under the same conditions, are more resilient.
1068-9508 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Vocal behavior is usually considered an important
risk factor; however, a recent Italian study of 92 call-
center operators using the ambulatory phonation
monitor during a workday concluded that neither
the number of working hours nor the percentage
of phonation time was statistically related to the
&
perception of voice disturbances [40 ].
A recent review regarding functional voice prob-
lems [41] proposed a cognitive behavioral model to
deal with these patients. Individual factors (genetics,
early experience, and personality), precipitating fac-
tors (life events and coping, vocal vulnerability), and
perpetuating factors (anxiety, depression, and gen-
eral fatigue) were proposed to be causative in voice
problems. Even if this review did not focus specifi-
cally on professional voice users, it was clear that
vocal vulnerability was the consequence of vocal
load, which fits the current model of occupational
voice demands.
ASSESSMENT CRITERIA AND
ASSESSMENT MEASURES
Patients with voice problems are typically assessed
by a multidisciplinary team consisting of an otolar-
yngologist and a speech-language pathologist. A
singing specialist, voice coach, and/or psychologist
may also be required. The European Laryngological
Society proposed a standard assessment protocol
for evaluating voice problems: perception, video-
stroboscopy, acoustics, aerodynamics, and subjec-
tive rating by the patient [42]. According to the
American Academy of Otolaryngology–Head and
Neck Surgery, the minimum battery to evaluate a
patient with vocal complaint is clinical history,
physical examination, and visualization of the
larynx via laryngoscopy [43]. Specific procedures
for screening, assessment, or follow-up of pro-
fessional voice users have not been proposed.
For the speech-language pathologist evaluation,
auditory and acoustic analyses are fundamental to
understand the underlying physiology. Moreover,
the inclusion of self-assessment protocols to evalu-
ate the impact of a voice problem is mandatory
to help understand the relationship between the
patient and his or her problem, to estimate adher-
ence and coping, and to establish a prognosis
[27,44]. Auditory analysis may not be reliable; a
distorted voice may be characteristic of an actor,
for example. Perception of the voice may not reflect
discomfort during phonation; auditory assessment
may underestimate the problem. Even if there is
some evidence for selected acoustic, laryngeal
imaging, auditory perceptual, functional, and
aerodynamic measures to be used as effective
components in a clinical voice evaluation [44],
www.co-otolaryngology.com 191
 Speech therapy and rehabilitation
high-level research to provide evidence regarding
these recommendations is warranted.
Normative data for professional voice users and
for aging professionals are also required [37].
Recently, an Italian group [45] proposed the use
of the singing power ratio as an electroacoustic
measure, correlated to both the years of singing
activity and the vocal category of each singer. More-
over, it was highly correlated to clinician subjective
assessment.
Professional choir singers usually have a long
career; to understand the difference between normal
aging problems and the effect of the professional
voice remains challenging [10]. Professional voice
users may manipulate their voice to reduce the
negative impact of a voice problem, which may pose
difficulties in the evaluative process. The use of
specific protocols for self-assessment of the singing
voice was proposed [46–49] as a more sensitive tool,
but data are limited. No specific protocols for pro-
fessional speaking voice were proposed.
In London, students of the arts seem to be at
increased risk for voice problems as quantified by
the VHI-10 [50]. Additionally, high scores were
found in musical theater students (n ¼ 49) when
compared with medical students (n ¼ 43), particu-
larly in three specific domains: voice strain, lack of
clarity, and being upset from voice problem [50]. It is
difficult to interpret these findings as they may
reflect awareness of a potential voice problem or
initial symptoms due to a greater voice use over
time. Regardless, the need for early laryngeal exam-
ination and voice evaluation of future professional
voice users is enhanced by these findings.
Even when employing a specific protocol, the
S-VHI [51], musical theater singers perceived subtle
fluctuations or changes in physical functioning of
the voice that were not detected by the instrument.
These symptoms became clear through a series of
focus group interviews (n ¼ 43) and a written survey
(n ¼ 36) to detail the perception of the impact of
performing after a show, across a working week, and
across a production season. A list of 97 descriptors
was generated using the singers’ own terminology
and experiences: symptoms of vocal impairment,
vocal fatigue, and descriptors of positive vocal
changes as a consequence of heavy vocal load. From
this list, the 20-item Evaluation of the Ability of
Singing Ease was created to assess the perceptions of
healthy singers with regard to the singing voice as a
&
function of vocal load [52 ]. This scale has potential
to be included in clinical and performance settings.
Behavioral evaluation of the professional voice
usage in situ may offer important data nonreadily
&
ascertained during the clinical consultation [40 ];
however, this protocol is likely often impractical.
192 www.co-otolaryngology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Effectiveness of voice training and treatment
programs
Voice training focuses on vocal health, can poten-
tially prevent voice problems, and is usually
employed for improving normal voices for a specific
demand, whereas treatment aims at correcting func-
tional deficits. Training and therapy may use direct
approaches (vocal exercises) and/or indirect strat-
egies (relaxation, breathing techniques, and vocal
hygiene information). Vocal hygiene is a com-
ponent of almost all programs and some suggestions
are common sense and have been used for more
than one century [53]. Voice rest is an empiric treat-
ment, but it is a challenge to select cases that can
really benefit from complete silence. The concept of
compounded and noncompounded phonotrauma
may be used as a guide to predict success or failure of
voice rest regimens; in complex phonotraumatic
dysphonia, voice rest may be analogous to crash
diets in the morbidly obese. However, in noncom-
pounded cases, vocal rest may be a viable option
[54]. Intervention studies are rare likely related to
methodological complexity, which is even higher
for professional voice users.
Teachers and telemarketers have been the focus
of the sparse literature to date. Osteopathic therapy,
myofascial techniques together with voice exercises,
relaxation, and aerobic activities apart from balneo-
logical treatment were used to treat 40 teachers with
chronic vocal problems, in a health spa in Poland
[55]. A reduction of tenderness and normalization of
perilaryngeal tonus was observed. In spite of these
favorable outcomes, the concept of a voice spa is
difficult to implement elsewhere. The program pro-
posed is too broad and the lack of a control group is
problematic. Another study of 40 American female
kindergarten and primary school teachers showed
that the use of an individual, portable vocal ampli-
fication system reduced vocal fatigue and the degree
of vocal deviation. Vocal dosage and intensity was
also reduced with the use of a portable voice ampli-
fier [56]. Participants maintained the reduced vocal
intensity level after returning the amplification
device.
The telemarketing industry has become increas-
ingly critical since the 1970s and it is one of the
&&
fastest growing businesses worldwide [7 ]. A repre-
sentative effort in the UK proposed qualitative and
quantitative research protocols applied to telemark-
eters and managers of 13 call centers [57]; poor vocal
health habits and the lack of vocal training were
common findings in this population and symptoms
of reported muscle tension and voice problems had a
marked impact on work. Specific training for all
workers was recommended, particularly for those
early in their career. A recent survey in India [14]
Volume 22
Number 3
June 2014

analyzed 1093 call center workers from 11 centers.
Data suggest the current prevalence of dysphonia
was 59 and 27%, respectively, with female workers
missing more days of work.
The effectiveness of a voice training program
was analyzed by comparing 14 Brazilian call center
agents who underwent an 8-week training and 34
controls [58]. Unfortunately, the high rate of partici-
pant dropout in both groups was problematic.
Perceptual analysis did not show improvement;
however, jitter was consistently reduced after train-
ing, which can be considered an indirect measure
of voice stability. More sensitive measures must
be selected to better reflect improvement in
professional voice users. In addition to training,
real-time biofeedback seems highly promising. A
&&
prevention study was performed in Austria [7 ] with
76 call center operators. The study group used real-
time biofeedback software (VidiVoice) for 4 weeks to
improve vocal self-assessment and performance by
monitoring fundamental frequency, intensity, and
syllables per minute. Participants with vocal fatigue
showed a larger voice range profile; moreover,
all participants with hypofunction improved. This
work tested the software in real-life situations,
providing participants with the opportunity to
optimize vocal performance at work.
The effect of a 6-h voice training program (direct
and indirect approaches) and a 30-min individual
counseling session was investigated in 51 Belgian
student teachers and 30 controls [59]. Several objec-
tive parameters improved in the training group,
most significantly in female participants. The results
support the effectiveness of this program and favor
its introduction in the education of student teachers
due to the already high prevalence of problems in
this yet nonworking population [22,26,35]. Teach-
ers usually consider their dysphonia as a part of their
& situation and proved that it is possible to monitor vocal parameters and to improve
occupation [16 ] and a good strategy to improve
adherence for these chronically dysphonic patients
seems to be to offer the experience of an immediate
change in vocal quality and/or discomfort with a
simple exercise protocol [60].
It is complex to define an ideal voice for a
professional user, particularly when considering
the singing voice. A distorted ‘harsh’ voice can be
quite valuable for a pop artist or heavy metal
vocalist. However, this style can lead to a devastat-
ing voice disorder. Vocal rehabilitation for artists
with intentional distortions should aim at a resilient
and effective voice regardless of the sound [61]. It is
possible to produce a healthy distorted sound for a
specific market purpose, but no studies have focused
on this issue. The cost-benefit ratio of providing
therapy remains unclear and warrants further inves-
tigation.
1068-9508 ß 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Managing dysphonia in occupational voice users Behlau et al.
CONCLUSION
The area of professional voice has grown with
regard to our understanding of the specifics of the
professional voice user. However, the main focus
remains on teachers. Large population studies are
needed and interventions targeting student teachers
must be implemented to avoid frustration and
chronic voice problems. However, a causative
relationship between the workplace and voice dis-
orders has yet to be established. Furthermore, longi-
tudinal studies and randomized controlled trials
are needed.
Acknowledgements
None.
Conflicts of interest
The authors declare no conflicts of interest.
REFERENCES AND RECOMMENDED
READING
Papers of particular interest, published within the annual period of review, have
been highlighted as:
& of special interest
&& of outstanding interest
1. Vilkman E. Voice problem at work: a challenge for occupational safety and
health arrangement. Folia Phoniatr Logop 2000; 52:120–125.
2. Vilkman E. Occupational safety and health aspects of voice and speech
professions. Folia Phoniatr Logop 2004; 56:220–253.
3. Schewell C. The daily working voice. Voice work: art and science in changing
voices. Chichester: Wiley-Blackwell, 2010.
4. Titze IR, Lemke J, Montequim D. Populations in the US workforce who rely on
voice as a primary tool of trade: a preliminary report. J Voice 1997; 11:254–
259.
5. Hunter EJ, Titze IR. Variations in intensity, fundamental frequency, and voicing
for teachers in occupational versus non occupational settings. J Speech Lang
Hear Res 2010; 53:862–875.
6. Epstein R, Remacle A, Morsomme D. From reactive intervention to proactive
prevention: the evolution of occupational dysphonia. Perspect Voice Voice
Dis 2011; 21:48–55.
7. Schneider-Stickler B, Knell C, Aichstill B, Jocher W. Biofeedback on voice
use in call center agents in order to prevent occupational voice disorders.
&&
J Voice 2012; 26:51–62.
This study introduced biofeedback software into a real-life call center workplace
vocal awareness and performance while working.
8. Dion GR, Miller CL, Ramos RG, et al. Characterization of voice disorders in
deployed and nondeployed US army soldiers. J Voice 2013; 27:57–60.
&
This is the largest cross-sectional study in the voice area; more than 1.3 million
health records were analyzed; occupational exposure of deployed soldiers
accounts for the increase in the diagnoses of dysphonia.
9. Revis J, De Looze C, Giovanni A. Vocal flexibility and prosodic strategies in a
professional impersonator. J Voice 2013; 27:524; e23-31.
10. Berghs G, Creylman N, Avaux M, et al. A lifetime of professional singing: voice
parameters and age in the Netherlands Radio Choir. Logoped Phoniatr Vocol
2013; 38:59–63.
11. Szeszenia-Dabrowska N, Wilczynska U. Occupational disease in Poland: an
overview of current trends. IJOMEH 2013; 26:457–470.
12. Warhurst S, McCabe P, Madill C. What makes a good voice for radio:
perceptions of radio employers and educators. J Voice 2013; 27:217–224.
&
This is a well presented qualitative study that focuses on the educators’ and
employers’ opinions on the needed characteristics of voices for radio; this approx-
imation between science and market is much needed in the professional voice area.
13. Piwowarczyk TC, Oliveira G, Lourenço L, Behlau M. Vocal symptoms, voice
activity and participation profile and professional performance of call center
operators. J Voice 2012; 26:194–200.
14. Devadas U, Rajashekhar B. The prevalence and impact of voice problems in
call center operators. J Laryngol Voice 2013; 3:3–9.
15. Cutiva LCC, Vogel I, Burdorf A. Vocie disorders in teachers and their associa-
tions with work-related factors: a systematic review. J Commun Disord 2013;
46:143–155.
www.co-otolaryngology.com 193
 Speech therapy and rehabilitation
16. 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; e9-8.
This study analyzed more than 3000 questionnaires from all states in the same
country and reveals striking similarities among different locations and also with its
counterpart American study; data are strong enough to affirm that voice problems
in teachers are universal and deserve a global action.
17. Roy N, Merrill RM, Thibeault S, et al. Prevalence of voice disorders in teachers
and the general population. J Speech Lang Hear Res 2004; 47:281–293.
18. Roy N, Merrill RM, Thibeault S, et al. Voice disorders in teachers and the
general population: effects on work performance, attendance and future
career choices. J Speech Lang Hear Res 2004; 47:542–552.
19. Sampaio MC, Reis EJFB, Carvalho FM, et al. Vocal effort and voice handicap
among teachers. J Voice 2012; 26:820; e115-18.
20. Costa V, Prada E, Roberts A, Cohen S. Voice disorders in primary school
teachers and barriers to care. J Voice 2012; 26:69–76.
21. Rocha LM, Souza LDM. Voice handicap index associated with common
mental disorders in elementary school teachers. J Voice 2013; 27:595–602.
22. Ohlsson AC, Andersson EM, Sodersten M, et al. Prevalence of voice
symptoms and risk factors in teacher students. J Voice 2012; 26:629–634.
23. Hapner E, Gilman M. The vocal load on reform Jewish cantors in the USA.
J Voice 2012; 26:2001–2005.
24. O’Neill J, McMenamin R. Voice use in professional soccer management.
Logoped Phoniatr Vocol 2013. [Epub ahead of print]
25. Rumbach AF. Voice problems of group fitness instructors: diagnosis, treat-
ment, perceived and experienced attitudes and expectations of the industry.
J Voice 2013; 27:786; e1-9.
26. Lerner MZ, Paskhover B, Acton L, Young N. Voice disorders in actors. J Voice
2013; 27:705–708.
27. Zambon F, Moreti F, Behlau M. Coping strategies in teachers with vocal
complaint. J Voice 2014. [Epub ahead of print]
28. Rodrigues G, Zambon F, Mathieson L, Behlau M. Vocal tract discomfort in
teachers: its relationship to self-reported voice disorders. J Voice 2013;
27:473–480.
29. Woznicka E, Niedudek-Bogusz E, Kwiecien J, et al. Applicability of the vocal
tract discomfort (VTD) scale in evaluating the effects of voice therapy of
occupational voice disorders. Med Pr 2012; 63:141–152.
30. Rumbach AF. Voice problems of group fitness instructors: prevalence of self-
reported sensory and auditory-perceptual voice symptoms and the need for
preventive education and training. J Voice 2013; 27:524; e11-21.
31. Mathieson L, Hirani SP, Epstein R, et al. Laryngeal manual therapy: a
preliminary study to examine its treatment effects in the management of
muscle tension dysphonia. J Voice 2009; 23:353–366.
32. Van Lierde KM, Dijckmans J, Scheffel L, Behlau M. Type and severity of pain
during phonation in professional voice users and nonvocal professionals.
J Voice 2012; 26:671; e19-23.
33. Rocha C, Moraes M, Behlau M. Pain in popular singers. J Soc Bras Fonoaudiol
2012; 24:374–380.
34. Ahlander VL, Rydell R, Lofqvist A. How do teachers with self-reported voice
problems differ from their peers with self-reported voice health? J Voice 2012;
26:4; e149-161.
35. Amir O, Primov-Fever A, Kushnir T, et al. Evaluating voice characteristics of
first-year acting students in Israel: factor analysis. J Voice 2013; 27:68–77.
36. Ghirardi AC, Ferreira LP, Giannini SP, et al. Screening Index For Voice
Disorder (SIVD): development and validation. J Voice 2013; 27:195–200.
37. Sataloff RT, Hawkshaw MJ, Johnson JL, et al. Prevalence of abnormal
laryngeal findings in healthy singing teachers. J Voice 2012; 26:577–583.
38. Meulenbroek LFP, De Jong FI. Trainee experience in relation to voice handi-
cap, general coping and psychosomatic well being in female student
teachers: a descriptive study. Folia Phoniatr Logop 2010; 62:47–54.
39. Meulenbroek LFP, Thomas G, Kooijman PG, De Jong FI. Biopsychosocial
impact of the voice in relation to the psychological features in female student
teachers. J Psychosom Res 2010; 68:379–384.
40. Cantarella G, Iofrida E, Boria P, et al. Ambulatory phonation monitoring in a
& sample of 92 call center operators. J Voice 2013. [Epub ahead of print]
This study offered data from a large group of call center operators and surprisingly
concluded that the number of work hours and the percentage of phonation time are
not related to the perception of voice disturbances, which can demystify several
assumptions.
194 www.co-otolaryngology.com
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
41. Deary V, Miller T. Reconsidering the role of psychosocial factors in functional
dysphonia. Curr Opin Otolaryngol Head Neck Surg 2011; 19:150–
154.
42. Dejonckere PH, Bradley P, Clemente P, et al. A basic protocol for functional
assessment of voice pathology, especially for investigating the efficacy of
(phonosurgical) treatments and evaluating new assessment techniques.
Guideline elaborated by the Committee on Phoniatrics of the European
Laryngological Society (ELS). Eur Arch Otorhinolaryngol 2001; 258:77–
82.
43. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline:
hoarseness (dysphonia). Otolaryngol Head Neck Surg 2009; 141:S1–
S31.
44. Roy N, Barkmeier-Kraemer J, Eadie T, et al. Evidence-based clinical voice
assessment: a systematic review. Am J Speech Lang Pathol 2013; 22:212–
226.
45. Cesari U, Iengo M, Apisa P. Qualitative and quantitative measurement of the
singing voice. Folia Phoniatr Logop 2012; 64:304–309.
46. Cohen SM, Jacobson BH, Garrett CG, et al. Creation and validation of the
Singing Voice Handicap Index. Ann Otol Rhinol Laryngol 2007; 116:402–
406.
47. Morsomme D, Gaspar M, Jamart J, et al. Adaptation du Voice Handicap Index
à la voixchantée [Adaptation of Voice Handicap Index to singing voice]. Rev
Laryngol Otol Rhinol 2007; 128:305–314.
48. Fussi F, Fuschini T. Foniatria artistica: la presa in carico foniatricologopedi-
cadel cantante classico e moderno [Artistic phoniatric: the role of the
physician and speech language pathology in classic and modern singing].
Audiol Foniatr 2008; 13:4–28.
49. Murry T, Zschommler A, Prokop J. Voice handicap in singers. J Voice 2009;
23:376–379.
50. Watson NA, Oakeshott P, Kwame I, Rubin JS. A comparison of the Voice
Handicap Index-10 scores between medical and musical theater students.
J Voice 2013; 27:129; e21-129. e23.
51. Phyland DJ, Thibeault SL, Benninger MS, et al. Perspectives on the impact on
vocal function of heavy vocal load among working professional music theater
performers. J Voice 2013; 27:390; e31-9.
52. Phyland DJ, Pallant JF, Benninger MS, et al. Development and preliminary
& validation of the EASE: a tool to measure perceived singing voice function. J
Voice 2013; 27:454–462.
This is an interesting protocol, with 20 items and two subscales (physical
symptoms of vocal fatigue and mucosal changes) carefully developed to assess
the singer‘s perception of the current status of their singing voices.
53. Ruben RJ. Morell Mackenzie’s The hygiene of the vocal organs: a study in
longevity or durability. Laryngoscope 2014; 124:522–530.
54. Haben CM. Voice rest and phonotrauma in singers. Med Probl Perform Art
2012; 27:165–168.
55. Marszałek S, Niebudek-Bogusz E, Woźnicka E, et al. Assessment of the
influence of osteopathic myofascial techniques on normalization of the vocal
tract functions in patients with occupational dysphonia. Intern J Occup Med
Environ Health 2012; 25:225–235.
56. Gaskill SC, O’Brien SG, Tinter SR. The effect of voice amplification on
occupational vocal dose in elementary school teachers. J Voice 2012;
26:667; e19-27.
57. Hazlett DE, Duffy OM, Moorhead SA. Review of the impact of voice training on
the vocal quality of professional voice users: implications for vocal health and
recommendation for further research. J Voice 2011; 25:181–191.
58. Oliveira AG, Gouveia N, Behlau M. The effectiveness of a voice training
program for telemarketers. J Voice 2012; 26:815; e1-8.
59. Timmermans B, Coveliers Y, Wuyts FL, Looy LV. 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; e1-9.
60. Paes SM, Zambon F, Yamasaki R, et al. Immediate effects of the Finnish
resonance tube method on behavioral dysphonia. J Voice 2013; 22:717–
722.
61. Wendler J, Dejonckere PH, Wienhausen S, et al. Therapeutic consequences
from changing voice ideals (clear to harsh, pleasant to jarring): summarizing
report on a round-table discussion at the 5th world voice congress, Luxor,
Egypt, 27-31 October 2012. Logoped Phoniatr Vocol 2013. [Epub ahead of
print]
Volume 22
Number 3
June 2014