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Voice Disorders in Teachers. A Review

Article  in  Journal of voice: official journal of the Voice Foundation · June 2014

DOI: 10.1016/j.jvoice.2014.02.008 · Source: PubMed

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Voice Disorders in Teachers. A Review
*Regina Helena Garcia Martins, †Eny Regina Bo
ia Neves Pereira, ‡Caio Bosque Hidalgo,
and §Elaine Lara Mendes Tavares, *yzxBotucatu, S~ao Paulo, Brazil

Summary: Introduction. Voice disorders are very prevalent among teachers and consequences are serious.
Although the literature is extensive, there are differences in the concepts and methodology related to voice problems;
most studies are restricted to analyzing the responses of teachers to questionnaires and only a few studies include vocal
assessments and videolaryngoscopic examinations to obtain a definitive diagnosis.
Objective. To review demographic studies related to vocal disorders in teachers to analyze the diverse methodologies,
the prevalence rates pointed out by the authors, the main risk factors, the most prevalent laryngeal lesions, and the re-
percussions of dysphonias on professional activities.
Materials and Methods. The available literature (from 1997 to 2013) was narratively reviewed based on Medline,
PubMed, Lilacs, SciELO, and Cochrane library databases. Excluded were articles that specifically analyzed treatment
modalities and those that did not make their abstracts available in those databases. The keywords included were teacher,
dysphonia, voice disorders, professional voice.
Key Words: Voice disorders–Teacher–Dysphonia–Professional voice.

CLINICAL AND EPIDEMIOLOGICAL ASPECTS OF
DYSPHONIAS IN TEACHERS
Estimates of the prevalence of voice disorders among the gen-
eral population are 6–15%. However, when teachers are consid-
ered, these values increase to 20–50%, reaching up to 80%1–4
(Table 1). Such high prevalence of dysphonia for this profes-
sional population is reflected in the large literature base and
number of sessions at voice conferences.
oes5 conducted the study ‘‘Refer^encias
In Brazil, in 2004, Sim~
bibliogr
aficas nacionais sobre voz dos profissionais da voz’’
(National bibliographic references on the voice of voice profes-
sionals), which identified 283 studies on this subject dated from
1987 to 2004; most of these studies were published in meeting
annals, whereas only 11% were published in journals. That
same author then included 2004 and 2005 and found more
than 80 publications. By including 2005, 2006, and 2007 to up-
date those data, Dragone et al6 found an increase of over 207
publications, which corresponded to around 60–80 publications
per year. Considering that voice disorders among teachers have
been common and discussed worldwide, the extensive number
of publications on this subject is understandable.
Mattiske et al2 conducted a review of the major publications
on voice problems affecting teachers and found that most au-
thors apply questionnaires as methodology, whereas only a
few include endoscopic tests to elucidate the laryngeal diag-
nosis. In addition, several publications have evidenced around
50% prevalence of dysphonia among teachers,7–9 and vocal
From the *Department of Ophthalmology, Otolaryngology and Head and Neck Surgery,
Botucatu Medical School, UNESP-Univ Estadual Paulista, Botucatu, S~ao Paulo, Brazil;
yBotucatu Medical School, UNESP-Univ Estadual Paulista, Botucatu, S~ao Paulo, Brazil;
zAcademic of Botucatu Medical School, Unesp-Univ Estadual Paulista, Botucatu, S~ao
Paulo, Brazil; and the xDiscipline Otolaryngology, Botucatu Medical School, UNESP-
Univ Estadual Paulista, Botucatu, S~ao Paulo, Brazil.
Address correspondence and reprint requests to Regina Helena Garcia Martins, Depar-
tamento de Oftalmologia, Otorrinolaringologia e Cirurgia de Cabeça e Pescoço, Faculdade
de Medicina da Universidade Estadual Paulista (UNESP), Distrito de Rubi~ao Junior, CEP
18618-970 Botucatu, S~ao Paulo, Brazil. E-mail: rmartins@fmb.unesp.br
Journal of Voice, Vol. 28, No. 6, pp. 716-724
0892-1997/$36.00
Ó 2014 The Voice Foundation
http://dx.doi.org/10.1016/j.jvoice.2014.02.008
fatigue, throat discomfort, roughness, and dysphonia have
been the major symptoms.
Voice problems affecting teachers were not always transitory
and several cases demanded vocal rehabilitation and even drug
and/or surgical treatment. Munier and Kinsella8 analyzed 304
questionnaires filled in by teachers and found similar symptoms
like vocal fatigue (18%), parched throat (19%), and singing dif-
ficulties (20%). In this study, teachers were asked to quantify
the consequences of voice problems for their professional
development; results indicated that compromising of activities
due to voice problems was severe for 12%, moderate for 34%,
and slight for 48%.
Roy et al4 presented a questionnaire to 2401 participants
from Iowa and Utah (1243 teachers and 1279 workers of
different areas) to compare the incidence of voice disorder be-
tween teachers and the general population. Voice symptoms
were found more frequently in teachers than the general popu-
lation (93.7% vs 88.7%), especially hoarseness, discomfort and
effort to speak, and singing difficulty. The possible correlation
between teacher’s voice symptoms and the professional activ-
ities they participated in was reported by 60.2% of teachers
and only 20.5% of the general population. Investigation into
the consequences of voice disorders on the professional dy-
namics indicated that 43% of teachers needed to reduce their di-
dactic activities at least once in the previous year, whereas 18%
were absent from work at least 1 day due to a voice problem
(compared with 7.2% of the general population).
In a similar study, De Jong et al9 analyzed questionnaires
distributed to a population composed of 1877 teachers and
239 controls. Results indicated that 67.4% teachers and
43.6% controls complained of voice problems in the previous
year, whereas 27.3% teachers and only 1.9% of controls were
absent from their professional activities due to voice problems.
Van Houtte et al10 obtained lower proportions after analyzing
questionnaires responded to by 994 teachers and 290 workers
of different areas without vocal abuse. Voice disorders were re-
ported by 51.2% teachers and 27.4% controls. Absence from
work at least once a week, due to a voice problem, was reported
by 20.6% teachers.

TABLE 1.
Major Publications on the Prevalence/Epidemiology of Voice Problems in Teachers
Author and Journal Objective
Smith et al To compare the frequency
J Voice, 1997 and the effects of voice
symptoms between teachers
and a group with different
occupations.
Mattiske et al To review the prevalence, the
JVoice, 1998 causes, the prevention, and
the treatment of voice
problems among teachers.
Simberg et al To study the prevalence of
J Voice, 2000 voice disorders among
teacher students.
Roy et al To study the prevalence of
J Voice, 2004 voice disorders in teachers
and the general population.
De Jong et al To study the epidemiology of
Folia Phoniatr Logop, voice problems in Dutch
2006 teachers.
Munier and Kinsella To study the prevalence and
Occup Med (Lond), 2008 the impact of voice problems
in primary school teachers.
Methodology Results
Questionnaires Teachers were more likely to
report having a voice
problem (15% vs 6%), having
specific voice symptoms,
and having symptoms of
physical discomfort.
Review 42 Manuscripts were reviewed.
The criteria for determining
the presence of voice
problem creates further
difficulties in reaching
conclusions about the
prevalence of voice disorders
among teachers.
Interview/questionnaires 226 Students were surveyed.
Perceptual vocal analysis 20% Reported two or more
Laryngoscopic examination voice symptoms during the
previous year and 19% had
an organic voice disorder.
Questionnaires 1243 Teachers and 1288
nonteachers were surveyed.
The prevalence of current
voice problems was greater
in teachers compared with
nonteachers (11.0% vs 6.2%).
The prevalence of voice
disorders during their
lifetime was 57.7% for
teachers and 28.8% for
nonteachers.
Questionnaires 1878 Teachers and 239 controls
were surveyed. More than
half of the teachers reported
voice problems.
Questionnaires 550 Teachers were surveyed.
27% Of teachers suffered
from a voice problem, 53%
had an intermittent’ voice
problem, whereas only 20%
had no voice problem.
Regina Helena Garcia Martins, et al
Conclusions
Teaching is a high-risk
occupation for voice
disorders and this health
problem may have
significant work-related and
economic effects.
The actual prevalence of voice
problems in teachers is
unclear. Preventive
programs are needed.
Voice Disorders in Teachers
Clinical evaluation of students
with voice symptoms and
more vocal training in the
teacher education programs
are needed.
Teaching is a high-risk
occupation for voice
disorders
Teaching is a high-risk
profession for the
development of voice
problems.
Voice disorders were very
common in our study of
primary school teachers.
(Continued )
717

TABLE 1
(Continued )
Author and Journal Objective
Angelillo et al To study the prevalence of
J Prev Med Hyg, 2009 occupational voice disorders
in teachers
Van Houtte et al To study the impact of voice
J Voice, 2011 disorders among teachers.
Da Costa et al To study the barriers to care
J Voice, 2012 that teachers may face.
Behlau et al To compare the frequency and
J Voice, 2012 the adverse effects of voice
disorders between Brazilian
teachers and nonteachers.
Cantor Cutiva et al To study the prevalence of
J Commun Disord, 2013 voice disorders affecting
teachers.
Methodology Results
Questionnaires 504 Teachers and 402 controls
were surveyed. The
prevalence of current voice
problems was significantly
greater in teachers compared
with nonteachers (8.7% vs
2.9%), as well as the
prevalence of voice disorders
during their lifetime (51.4%
vs 25.9%)
Questionnaires 994 Teachers and 290 controls
were surveyed. Teachers
reported more voice
problems than the controls
(51.2% vs 27.4%). 25.4% Of
teachers sought medical care
and 20.6% had missed work.
Questionnaires 237 Teachers were surveyed.
22% Had current hoarse and
58% had had hoarse at one
point. 23% Had missed work
for hoarseness and only
one-third (32.6%) had sought
professional help.
Interview/questionnaire 1651 Teachers and 1614
nonteachers were surveyed.
Prevalence of reporting a
current voice disorder was
11.6% for teachers and 7.5%
for nonteachers. 63%
Teachers and 35.8%
nonteachers had a voice
problem at some point
during their lifetime.
Systematic review 23 Publication were reviewed.
Variable indexes of
dysphonia prevalence were
found.
718
Conclusions
Teachers have a higher rate of
self-reported voice problems
than subjects with other
occupations.
Voice disorders have an impact
on teachers’ personal and
professional life and imply a
major financial burden for
the society.
There are multiple barriers to
care for the dysphonic
teacher, such as lack of
awareness of the availability
of professional help.
Teaching at school is a
high-risk occupation for
developing voice disorders.
Journal of Voice, Vol. 28, No. 6, 2014
Teachers constitute a
professional group
vulnerable to voice disorders
but there are variable indexes
of dysphonia prevalence due
to the discrepancies among
studies.
Regina Helena Garcia Martins, et al Voice Disorders in Teachers
Angellilo et al11 investigated the voice symptoms and the
working conditions of 504 teachers randomly chosen from 28
schools in Naples (Italy) and 402 nonteachers as a control
group. Voice symptoms were more prevalent for the group of
teachers (51.4% vs 25.9%). Participation of women was
greater, and absence from work was reported by 116 teachers
(23.01%). Considering the high incidence of dysphonias among
teachers, those authors emphasized the importance of preven-
tive voice care work for teachers and student teachers, thus pre-
paring future teachers for their new profession.
Sampaio et al12 carried out an extensive transversal epidemi-
ologic cohort study including 4496 teachers of municipal
elementary schools in Salvador City (Bahia, Brazil). This study
aimed to analyze the relationship between voice handicap,
quantified by Voice Handicap Index 10, and vocal effort, quan-
tified by LVEI (Lifetime Vocal Effort Index). Females were
prevalent and had an average of 14 years in the profession
and 30 hours a week as mean workload. Vocal handicap among
the studied teachers was 21.7% and was associated with vocal
effort during their professional activities.
Among 237 teachers from North Carolina who responded to
a questionnaire distributed by Da Costa et al,7 recent hoarseness
was mentioned by 22% of teachers and some episode of hoarse-
ness during the teaching career was mentioned by 58% of those
teachers. Sick leave due to a voice problem was reported by
23% teachers and treatment to hoarseness by only 32%; less
than half of the teachers were aware of the benefits of vocal
therapy.
Analyzing 1651 questionnaires responded to by teachers and
1614 questionnaires responded to by nonteachers, Behlau
et al13 identified current voice disorders for 11.6% teachers
and 7.5% nonteachers and voice problem at some point during
their life for 63% teachers and 35.8% nonteachers. The reported
number of voice symptoms was greater for teachers (3.7 vs 1.7).
Cantor Cutiva et al14 recently carried out an extensive sys-
tematic review on voice disorders affecting teachers. The
dysphonia prevalence indexes in the 23 publications that met
the study inclusion criteria were highly variable, again confirm-
ing the discrepancies among studies. The Mattiske’s review2
confirm the different methodologies used by the authors and
the difficulties in reaching conclusions about prevalence of
dysphonia in teachers. The authors, however, were unanimous
in considering teachers a vulnerable professional group to voice
disorders.
RISK FACTORS FOR THE DEVELOPMENT OF
DYSPHONIAS IN TEACHERS
Dysphonia risk factors for teachers include extensive working
hours, frequently longer than 40 hours a week, excessive num-
ber of students per classroom, environmental noise, inappro-
priate classroom facilities, and chalk powder15–24 (Table 2).
Thibeault et al15 conducted a survey with 1243 teachers, of
whom 58% reported voice disorder at a certain point of their
career; age and time worked in the profession are parameters
that may contribute to dysphonias. Other authors,16 however,
believe that voice symptoms and laryngeal lesions may be pre-
719
sent in teachers at the beginning of their carrier or even when
they are still students; in addition, the age of patients and the
emergence period are highly variable.
Analyzing the responses of 1250 teacher students to ques-
tionnaires, Ohlsson et al16 found that 208 (17%) participants
had at least two symptoms of voice problems in a week, and
a large number of them could relate those symptoms to voice
disorders manifested during their childhood or recurrent infec-
tions of the upper airways, respiratory allergies, smoking, audi-
tory problems, and vocal abuse.
Crowded classrooms and excessive noise are undoubtedly
risk factors that contribute to the development of dysphonia in
teachers.17 This work environment causes teachers to increase
their voice intensity to keep the students’ attention.17–19 This
is the essence of phonotrauma, which may result in the
development of future laryngeal lesions.
The measurements of the vocal intensity of a teacher in an
excessively noisy classroom may vary from 58 to 90.5 dB.
These values are close to those recorded during a yell and indi-
cate intense vocal effort.17 Excessive environmental noise in the
classrooms has led some teachers to use voice amplification to
decrease phonatory overload.17–25 Larsen and Blair24 noted an
improvement of 13 dB in the voice intensity of teachers who use
amplifiers. They considered voice amplification a highly advan-
tageous and important measure to prevent dysphonias.
The teaching level may also influence the degree of vocal de-
mand. Kindergarten and elementary education teachers have
more voice symptoms than middle or high school teachers.2
Kindergarten teachers have greater vocal demands because
their students are still in alphabetization.
On account of their daily rush, a large number of teachers
generally substitute conventional meals for snacks and fast
foods, favoring gastrointestinal disorders, especially gastro-
esophageal reflux, which is an important cause of acid laryn-
gitis.26,27 Neurological or endocrine diseases, smoking or
alcohol habits, and recurrent upper respiratory disease can also
compromise vocal qualities.21,26–29
Perez Fernandez and Preciado Lopez30 interviewed 240
teachers (120 diagnosed with vocal nodules and 120 without
laryngeal lesions) and identified some potential predisposing
factors for voice disorders such as classrooms with poor and
noisy conditions, previous laryngeal or nasal surgeries, and
gastroesophageal reflux symptoms. These were the most rele-
vant factors among teachers with vocal nodules.
VIDEOLARYNGOSCOPIC FINDINGS
Videolaryngoscopic examinations are important to elucidate
the laryngeal diagnosis of dysphonia in teachers. The most
commonly found lesions were those named ‘‘phonotraumatic,’’
which develop from inappropriate vocal patterns, secondary to
phonatory overload. Tavares and Martins27 performed videolar-
yngoscopic examinations in 80 teachers and found normal re-
sults for 42.5%, vocal nodules for 30%, vocal polyps for
7.5%, and sulcus vocalis for 6.25%, as well as other less
frequent lesions.
 720
TABLE 2.
Major Publications on the Risk Factors for Voice Problems in Teachers
Author and Journal Objective Methodology Results Conclusions

rez Fernandez and
Pe To study the risk factors to Questionnaires 120 Teachers with vocal Authors showed the most

pez
Preciado Lo vocal nodules in teachers. Aerodynamic measures of nodules and 120 with important risk factors to
Acta Otorrinolaringol Esp, the voice normal vocal folds were vocal nodules in teachers.
2003 Acoustic and perceptual voice selected.
analysis Risk factors: classroom’s
Videolaryngostroboscopy dryness, loudness,
echo, previous vocal
pathology, laryngeal
surgery, nasal surgery, and
gastroesophageal reflux.
Vocal intensity and vocal
frequency ranks were
shorter in the nodule group.
Phonatory flow was less
effective in the pathological
group.
Williams NR To study the occupational Review The review identified case Further research on
Occup Med (Lond), 2003 groups at risk of voice reports, studies of occupational voice
disorders. attendees at hospital disorders needs to be based
voice clinics, and a few in the workplace and
cross-sectional studies of consider the risk factors for
occupational groups in the the development of voice
workplace. There were no problems and for control
longitudinal studies found efficacy.
or intervention studies
looking at reduction of risk.
Thibeault et al To study the occupational risk Questionnaires 1243 Teachers were surveyed, Teachers of specific courses
Ann Epidemiol, 2004 factors associated with 58% of teachers reported are at greater risk of

Journal of Voice, Vol. 28, No. 6, 2014

voice disorders among
teachers.
Sliwinska-Kowalska et al To study the prevalence
Folia Phoniatr Logop, 2006 and the risk factors for
occupational voice
disorders in teachers.
voice disorders at a certain developing a voice
point of their carrier. disorder.
Chronic voice disorders were
more prevalent among
teachers of vocal music and
less prevalent among
teachers of vocational
education.
Questionnaires 425 Teachers and 85 The prevalence of symptoms
Laryngoscopy nonteachers were and clinical signs of voice
Phoniatric examination surveyed. disorders is around 2- to
Voice symptoms were more 3-fold more frequent in
frequent in teachers than in Polish female teachers than
nonteachers (69 vs 36%) in nonteachers.

Kooijman et al To study the risk factors for
Folia Phoniatr Logop, 2006 voice problems in teachers.
Tavares et al To study the vocal evaluation
J Voice, 2007 in teachers with or without
symptoms.
Araujo et al To study the factors
Cad Saude Publica, 2008 associated with voice
disorders among women
teachers.
Larsen and Blair. To study the effect of
Lang Speech Hear Serv classroom amplification
Sch, 2008 on the signal-to-noise ratio
in classrooms while class
is in session.
Risk factors: occupational
voice disorders and
hyperfunctional dysphonia
were found in 32.7% of
teachers and 9.6% of
controls.
Questionnaires 1878 Teachers were surveyed.
The most important risk
factors were physical and
psycho-emotional factors
Questionnaires 40 Teachers with vocal
Perceptive auditory and symptoms and 40 teachers
acoustic vocal analysis without vocal symptoms
Laryngoscopy were included.
Risk factors: excessive noise
in classes, working hours
over 40 h, time to teaching
more than 20 y.
Questionnaires 747 Teachers were surveyed.
Hoarseness in the previous
6 mo was reported by 59.2%
of teachers and vocal fold
nodules by 12.9%.
Risk factors: more than 24
classroom hours per week,
work in more than one
school, effort to speak.
Vocal fold nodules were
associated with working for
more than 5 y as a teacher,
working in more than one
school, working at another
job besides teaching, and
having to make an effort to
speak.
Measurements of noise and When classroom amplification
reverberation were was used, students heard
collected for 5 different the teacher’s voice at a level
classrooms. that was an average of 13 dB
above the noise floor,
compared with an average
of +2 dB above the noise
floor without amplification.
Regina Helena Garcia Martins, et al
Risk factors: lifetime vocal
effort, incorrect phonation
technique, and
psychological
predisposition.
The results of this study
stress the importance of a
multifactorial approach in
the diagnosis and treatment
of voice disorders in
teachers.
Teachers’ voice is
compromised and requires
more attention including
control of environmental
factors and associated
Voice Disorders in Teachers
diseases.
Voice disorders are frequent
among school teachers and
are associated with multiple
occupational risk factors,
besides purely biological
ones.
The author confirmed the
benefits of the classroom
amplification.
(Continued)
721

TABLE 2
(Continued )
Author and Journal Objective
Chen et al To study the risk factors and
J Voice, 2010 the effects of voice
problems for teachers.
De Ceballos et al To study the auditory vocal
Rev Bras Epidemiol, 2011 analysis and factors
associated with voice
disorders among teachers.
Lindstrom et al To study the relationship
J Voice, 2011 between noise exposure
and preschool teacher voice
usage in daycare center
environments.
Ohlsson et al To study the prevalence of
J Voice, 2012 voice symptom and risk
factors in teacher students.
Sampaio et al To study the vocal effort and
J Voice, 2012 voice handicap among
teachers.
Methodology Results
Questionnaires 1017 Teachers were surveyed.
Risk factors: loud voice in
teaching and emotional
state.
Questionnaires 476 Teachers were surveyed.
Auditory vocal analysis Risk factors: age above 40 y,
family history of dysphonia,
over 20 h of weekly working
hours and presence of chalk
dust in the classroom.
Measurement of noise and 13 Teachers were surveyed.
voice levels. Teachers react individually to
Acoustic vocal analysis. the noise exposure; some
teachers increase their
voice-to-noise level ratio
when the noise is reduced,
whereas others do not.
Questionnaires 1250 Students were surveyed.
208 Students (17%) had
voice problems.
Risk factors: vocal fold
problems in childhood and
adulthood, throat infections,
allergy, smoking, hearing
problems, work as teacher
or leader, voice demanding
hobbies, and previous
speech therapy or voice
training.
Questionnaires 4496 Teachers were surveyed.
Risk factors: vocal effort,
excessive noise, heartburn,
and rhinitis.
722
Conclusions
These results imply the need
for a preventive voice care
program for teachers.
Teachers, 40 y old and over,
with a family history of
dysphonia, working over
20 h weekly, and teaching in
classrooms with chalk dust
are more likely to develop
voice disorders than others.
Teachers react individually to
the noise exposure; some
teachers increase their
voice-to-noise level ratio
when the noise is reduced,
whereas others do not.
There was a clear association
between the number of
potential vocal risk factors
and the number of voice
symptoms.
Journal of Voice, Vol. 28, No. 6, 2014
The authors pointed out
the risk factors to vocal
disorders among teachers.
Regina Helena Garcia Martins, et al Voice Disorders in Teachers
Urrutikoetxea et al31 studied 1046 teachers with and without
vocal complaints and found 828 normal examinations and
218 organic lesions, of which 94 were nodules, 39 Reinke’s
edema, 24 hypertrophy of vestibular folds, 19 polyps, and other
less frequent lesions. Perez Fernandez and Preciado Lopez30
emphasized that phonotraumatic lesions, especially vocal nod-
ules, can be diagnosed even for student teachers, reinforcing the
importance of preventive vocal guidance.
With the aim of early detection of voice disorders, Meulen-
broek and de Jong32 conducted an auditory perceptual vocal
analysis, according to GRBAS scale and videolaryngoscopy
for a population of teacher students. Of the 214 included stu-
dents, those reporting voice problems had a larger number of
laryngeal lesions (96%) and higher scores on the GRBAS scale,
compared with asymptomatic ones (81%). Again, preventive
measures for voice care were highlighted by these authors.
REPERCUSSION OF DYSPHONIAS IN TEACHERS
AND PREVENTIVE MEASURES
The voice is the main tool for teachers. The consequences of
persistent dysphonia can be devastating for their professional
performance, sometimes resulting in sick leave and/or reassign-
ment to administrative tasks, for which they are not always pre-
pared or interested. Financial, emotional, and social sectors are
also compromised.33 Statistical data show that, in the United
States, 2.5 billion dollars are spent annually on sick leave and
treatment of voice disorders of teachers.33
Prevention of voice disorders in teachers should be the pri-
mary goal. Prevention is considered ideal and requires the
implementation of preventive measures before the problem
arises. Unfortunately, this does not occur in a large number of
schools. Munier and Kinsella8 found that 93% of the 305 teach-
ers who responded to a questionnaire about vocal quality had
never received any guidance or professional training to prevent
voice disorders.
Aimed at demonstrating the effectiveness of vocal education
programs for teachers, Bovo et al34 studied a group of 21 teach-
ers who received effective treatment and vocal guidance for 3
months and a control group of teachers, without intervention.
The inclusion criteria were female gender, full time employ-
ment as school teachers, and motivation to collaborate. The
exclusion criteria were previously treated dysphonia, smoking,
alcohol habits, neurological or endocrine disease, psychiatric
disturbances, acid reflux, multiple medical complaints, vocal
fold lesion or severe dysphonia, allergies, and recurrent upper
respiratory disease. Participants underwent videolaryngoscopic
examination, acoustic and auditory perceptual vocal analysis
and responded to a questionnaire of vocal self-perception.
The treated group had an evident improvement in voice symp-
toms, a decrease in jitter and shimmer values, and an improve-
ment in values of maximum phonation time and Voice
Handicap Index.
Sometimes, the vocal disorders of teachers require medical
or speech therapy treatment and follow-ups.34,35 So, teacher
can absent from work and school directors have to convene
substitute teachers, which is not always easy; in addition,
723
students do not accept it very well, impairing the continuity
of the pedagogical program. Thus, teachers are exposed to
physical and emotional stress and generally prefer to delay
the treatment, which never starts.
Schools have been trying to prevent or minimize the voice
symptoms of teachers by substituting blackboards and chalk
for whiteboards and pens, providing amplifiers and micro-
phones, decreasing the number of students per classroom,
adapting the classroom infrastructure and acoustic conditions,
and implementing vocal education programs by means of lec-
tures and distribution of booklets and illustrative materials con-
fectioned by vocal health professionals.36,37 Another important
action directed to this professional class would certainly be
easier access to diagnosis and multidisciplinary treatment
with physicians, speech therapists, and psychologists.
CONCLUSION
The studies included in this review confirm the high prevalence
of voice disorders in teachers, for whom it is two-to-three-fold
more frequent than for the general population. The classroom
conditions, the excessive noise, and the individual health condi-
tions, habits, and addictions are considered risk factors for the
development of dysphonias. To decrease the incidence of voice
disorders among teachers, it is necessary to identify and elimi-
nate the risk factors and adopt preventive measures for the vocal
health. These measures involve multi-sectorial mobilization not
only of teachers but also of health and education professionals.
Future researches with these actions are necessary to confirm
the benefits of these preventive programs.
Acknowledgments
This project was financially supported by CAPES and Prope/
Fundunesp (UNESP).
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