Original Paper

Folia Phoniatr Logop 2006;58:85101

DOI: 10.1159/000089610

The Prevalence and Risk Factors

for Occupational Voice Disorders
in Teachers
M. Sliwinska-Kowalskaa E. Niebudek-Bogusza M. Fiszera
T. Los-Spychalskab P. Kotyloa B. Sznurowska-Przygockac
M. Modrzewskad
a
Centre of Audiology and Phoniatrics, Nofer Institute of Occupational Medicine,
Lodz, b Regional Centre of Occupational Medicine, Bydgoszcz, c Regional Centre of
Occupational Medicine, Gdansk, and d Centre of Phoniatrics, Staszow, Poland

Key Words
Teachers
Voice training
Hygiene
Psychological factors

Abstract
Objective: Occupational voice disorders in Poland account for over 25% of
all occupational diseases. The aim of the study was to assess the prevalence of
voice problems in the general population of Polish teachers, and identify risk
factors for developing voice pathology. Patients and Methods: The study group
comprised 425 female full-time teachers (most of them primary and secondary
school, age ranging from 23 to 61 years) and 83 non-teacher women (control)
whose jobs did not involve vocal effort, matched for age to the study group. All
participants were subjected to a survey using an extensive questionnaire, and
to laryngological, phoniatric and videostroboscopic examinations. Results: The
overall lifetime vocal symptoms were more frequent in the teachers than in the
non-teachers (69 vs. 36%), and in particular it related to permanent and recurrent
hoarseness, and dryness in the throat. Mean number of the voice symptoms was
3.21 in teachers and 1.98 in controls (p ! 0.001). Abnormal (non-euphonic) voice,
neck muscle hypertension during phonation and incorrect resonator function
were also significantly more frequent in the teachers. Mean maximum phona-
tion time was shorter in teachers than in the controls (14.3 vs. 15.9 s, p ! 0.01).
Occupational voice disorders and hyperfunctional dysphonia (that is thought to
predispose to such pathology) were found in 32.7% of teachers and 9.6% of con-
trol subjects. The probability of developing incomplete glottal closure (odds ra-
tio 13.2x; 95% CI: 1.896.8) and hyperfunctional dysphonia (odds ratio 2.7; 95%
CI: 1.146.44) were significantly higher in the teacher group versus non-teachers.
A significant positive relationship was found in teachers between the prevalence
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2006 S. Karger AG, Basel Prof. Mariola Sliwinska-Kowalska, Centre of Audiology

10217762/06/05820085$23.50/0 and Phoniatrics, Nofer Institute of Occupational Medicine
Fax +41 61 306 12 34 8 Sw. Teresy Street, PO Box 199, PL90-950 Lodz (Poland)
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E-Mail karger@karger.ch Accessible online at: Tel. +48 42 6314 520, Fax +48 42 6314 519
www.karger.com www.karger.com/fpl E-Mail marsliw@imp.lodz.pl
of hyperfunctional dysphonia and strained phonation, neck muscle hyperten-
sion, instability of voice, self-assessed hyperarousal, and lifetime vocal effort
index (years of employment as a teacher ! hours of professional activity/week).
The prevalence of vocal nodules and incomplete glottal closure were correlated
with incorrect phonation technique parameters, but not with psychological fac-
tors. No correlation was found with environmental variables, such as classroom
temperature, humidity, airborne dust. Conclusion: The prevalence of self-report-
ed symptoms and clinical signs of voice disorders is around 23 times more fre-
quent in Polish female teachers than in non-teachers. Lifetime vocal effort, incor-
rect technique of phonation and psychological predisposition seem to constitute
major risk factors for developing occupational voice disorders.
Copyright 2006 S. Karger AG, Basel

Introduction

With the advent of the information age, voice has assumed an important role
in occupational activities. Therefore, voice disorders can affect the quality of life and
the career of numerous professional voice users as well as reduce benets. No single
denition of voice problems has been agreed on. Rather, it is presumed that such
problems may represent an array of self-reported symptoms and clinical signs [1].
Several literature data show that teachers are at high risk of developing voice
disorders [25]. In the study by Smith et al. [2] employing a self-reported question-
naire, over 38% of teachers reported work-related voice disorders and 39% of this
group had to reduce their teaching activities in consequence. In 2004, Roy et al. [3]
revealed in large-scale studies that the prevalence of current voice disorders was sig-
nicantly higher in teachers (11%) compared to non-teachers (6.2%), as was their
prevalence during the subjects lifetime (57.7% in teachers vs. 28.8% in non-teach-
ers). Fritzell [4] and Titze et al. [5] have shown an increased risk ratio for developing
voice disorders among teachers.
During the recent years, voice disorders in teachers accounted for over 25% of
all occupational diseases diagnosed in Poland, increasing from 1.9% in 1977 to 28%
in 2001. The Central Register of Occupational Diseases reported 1,100 new cases of
occupational voice diseases in 2003 (25% of all occupational diseases at that time)
[6]. According to current Polish legal regulations, the list of occupational diseases
includes the following organic pathologies of the vocal apparatus: (1) vocal nodules,
(2) hypertrophy of vocal folds (secondary to vocal effort), and (3) weakness of in-
ternal larynx muscles adducting and tensing vocal folds with incomplete glottal clo-
sure during phonation and permanent dysphonia.
The diseases listed above could be considered to represent occupation-related
pathology when they result from occupational exposure to vocal effort continued for
at least 15 years of the full-time employment (the Ordinance by the Council of Min-
isters of 30 July, 2002, on occupational diseases [7]). According to the Polish regula-
tion, full-time employment of teachers of primary, secondary and college schools
ranges from 18 to 25 h a week, depending on the type of school (Labour Code). In
case of universities this limit is lower and may differ between schools.
Although the number of teachers in Poland approaches 740,000 and voice dis-
orders are the largest group of all the recorded cases of occupational diseases, the
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 50 47.3% Primary school
Secondary school
45
College
40 Kindergarden
University
35 Others
Teachers (%)

30
25 21.8%
20
15 11.1%
10 6.8% 7.1%
5.9%
5
0

Fig. 1. Percent of teachers by the type of school.

prevalence of voice problems among Polish teachers has not been thus far investi-
gated in a large survey. The only accessible reports are based on the assessment of
the condition of the upper respiratory tract in teachers seeking medical advice or
applying for the disability pension [8]. Our earlier study addressing the problem of
prevalence of voice disorders in a general population was performed on a group of
66 teacher college students, and demonstrated that as much as 32% of them had signs
of incomplete glottal closure, while 6.1% had (soft) vocal nodules [9].
The aim of this study was to assess the prevalence of voice disorders in the gen-
eral population of Polish teachers as compared to non-teachers. The probability of
developing vocal organ occupational pathologies and the respective risk factors were
also evaluated.

Subjects and Methods

Two groups of women were included into the study. The rst group comprised profession-
ally active teachers (working for more than 1 year) of different schools and universities who had
been examined by the otolaryngologist during regular preventive check-up examination (study
group). According to the legal Polish regulations, all teachers are supposed to be seen by the ear,
nose and throat (ENT) specialist every 5 years. To increase the homogeneity of the study group
in respect of voice effort, from the entire group of over 465 subjects only 425 teachers working
full-time (at least 18 h a week) have been selected for statistical analysis. Most of the study group
were primary and secondary school teachers (almost 70%), less numerous were college and uni-
versity teachers (g. 1). The control group included 83 female ofce workers with no vocal load-
ing (either work-related or connected with leisure-time activities). The subjects age was similar
in both groups, ranging from 23 to 61 years (mean 39.6) for the teachers and from 22 to 64 years
(mean 40.0) for non-teachers (table 1). The duration of employment also did not differ signi-
cantly between groups (table 1).
All the subjects responded to a specially designed self-reported questionnaire and had ENT,
phoniatric and videostroboscopic examinations performed. They were examined in four region-
al phoniatric outpatient clinics in Poland, located in the cities of Lodz, Bydgoszcz, Gdansk and
Staszow. Uniform standard study protocol was agreed between the centres prior to project start-
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Table 1. Questionnaire-based variables and lifetime vocal symptoms (mean 8 SD or percent-
age)

Variable Teachers, % Controls, % p

Number of subjects 425 83

Age, years 39.6 (89.4) 40 (88.3) 0.70
Range 2361 2264
Time of employment, years 14.9 (89.7) 16.8 (89.2) 0.09
Range 140 135
Lecture hours per weekb 21.8 (84.0)
Range 1840
Environmental factors and habits
Humidity (<45%) 86.6 87.5 0.86
Temperature (>21 C) 13.4 7.8 <0.01a
Dust 70.1 57.8 0.05
Table chalk dust 69.2 3.1 <0.01a
Chemical substances 8.0 23.4 <0.01a
Draught 56.2 64.1 0.23
Load voice 87.8 76.6 0.02a
Tobacco smoking 13.4 25.3 0.01a
Health factors
Allergies 17.6 28.9 0.02a
Past thyroid diseases 10.6 14.5 0.32
Sexual hormone therapy 18.6 24.1 0.25
Hyperarousal 40.9 38.6 0.68
Voice rehabilitation/training in the past 12.5 4.8 0.03a
Sick leave due to voice disorders 25.4 1.2 0.01a
Lifetime vocal symptoms (overall) 68.7 36.1 0.01a
Chronic hoarseness 16.0 6.0 0.01a
Recurrent hoarseness 52.9 33.7 0.01a
Voice tiredness 40.5 31.3 0.11
Voiceless 38.2 25.3 0.02a
Aphonia 30.0 18.1 0.02a
Dryness in the throat 63.3 38.6 0.01a
Lump in the throat 42.8 31.3 0.048a
Persistent dry cough 32.9 14.5 0.01a
Mean number of symptoms 3.21 (82.49) 1.98 (82.36) <0.01
a
The differences between frequencies in groups are statistically signicant.
b
Teachers only.

ing, and it was rigorously applied to all study subjects. Most of the subjects were examined during
their off time, the minority (around 10%) before or after work. The data was stored in the com-
puterized database.

Questionnaire
The questionnaire (Appendix 1) comprised enquiries on subjects age, current job and dura-
tion of employment (for teachers: the type of school class, number of students in class, number
of class hours a week), environmental work conditions, such as ambient temperature (below 18 C,
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1821 C or above 21 C), humidity (low vs. high), dust pollution including table chalk dust and
chemical substances (yes/no), draughts (yes/no) and air conditioning (yes/no). Further, questions
were asked about the habit of speaking with loud voice and smoking. The teachers were asked
about previous or concomitant ENT and general diseases (including thyroid diseases, sexual hor-
monal therapy, laryngological diseases such as nose and sinus diseases, pharyngitis or allergies
(in the latter case the diagnosis was based on positive skin prick test in anamnesis). Since vocal
symptoms and disorders might be psychologically determined, all subjects self-assessed symptoms
of hyperarousal in everyday life (yes/no).
The detailed questions included subjective vocal symptoms appearing over the entire work-
ing life time. The latter ones included: hoarseness, either chronic (present all the time or recurring
frequently in the past and lasting longer than 4 weeks) or recurrent (periodical, related to voice
loading or infection, lasting no longer than 4 weeks; vocal tiredness (changes in the quality of
voice while speaking); getting voiceless (sudden inability to speak for a few seconds, while speak-
ing); or aphonia (inability to use voice for more than 1 day); chronic dryness in the throat; sensa-
tion of lump in the throat and persistent dry cough. Based on this information the mean number
of symptoms was calculated in both study groups (percent of vocal symptoms out of the total of
8 symptoms listed above).
Questions referring to current and past phoniatric care, including pharmacotherapy, voice
training/rehabilitation and sick leaves due to voice disorders were addressed particularly to the
teachers.

Clinical Examination
In the ENT pre-assessment particular attention was paid to the detection of pathologies
which might disturb a correct voice emission, such as nasal congestion, deviation of nasal septum,
allergic rhinitis, symptoms of tonsillitis or paranasal sinusitis, etc. (Appendix 2).
The phoniatric examination included an assessment of voice quality (normal-euphonic or
abnormal: e.g. hoarse voice, rough, blank, i.e. with no resonance); type of phonation (normal vs.
incorrect, i.e. breathy or strained); voice instability (uncontrolled changes in voice pitch and loud-
ness while speaking); breathing technique (correct, i.e. mixed path of breathing involving both
upper and lower parts of the chest versus incorrect, i.e. path of breathing involving predomi-
nantly upper or lower parts of the chest); correctness of articulation (correct vs. incorrect); activa-
tion of supraglottic resonators (correct vs. incorrect), presence of nasalization (absent vs. present)
and neck muscle tension during voicing (normal vs. increased). The assessment involved also
determination of maximum phonation time (each subject was asked to phonate a sustained /a/
vowel at a comfortable pitch and loudness as long as possible during a single exhalation).
Next, the videostroboscopic examination was performed using a rigid scope (Wolf 5052)
after prior pharyngeal and laryngeal anaesthesia with 10% solution of lignocaine if necessary and
the results were recorded on a videotape. Vocal fold function was assessed in normal and strobo-
scopic light in resting position and during the pronunciation of the sustained /i/ vowel at a com-
fortable level of pitch and loudness. Particular attention was given to vocal fold movement, i.e.
regularity of vocal fold vibration (regular vs. non-regular, i.e. irregular or asymmetrical) and am-
plitude of vocal fold movement (normal vs. incorrect, i.e. reduced or increased), the quality of
mucosal wave (normal vs. limited), and conguration of glottal closure (complete closure vs. in-
complete closure, i.e. irregular chink, anterior gap, spindle incomplete closure, anterior-posterior
chink, total incomplete closure [10]). According to Sodersten and Lindestad [11] and Sodersten
et al. [12], incomplete glottal closure of the posterior parts of the glottis (posterior chink) was re-
garded as normal, while other types of glottal incompleteness were considered pathological. In
addition to qualitative parameters, two quantitative values were determined, that is subjects
fundamental frequency of voice and intensity of normal speaking voice while counting from
20 to 1.
Further, the presence of functional and organic changes of the vocal folds was evaluated.
Among functional disorders, special attention was given to hyperfunctional dysphonia that is
viewed as a causative factor of organic pathologies, e.g. vocal nodules. It was dened as non-or-
ganic dysphonia related to phonation with excessive and/or imbalanced muscular forces. The
most common laryngeal manifestation of vocal hyperfunction includes excessive force in vocal
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Fig. 2. Percent of teachers by school subjects.

fold approximation and/or tension with occasional use of ventricular fold phonation. Organic
disorders included vocal nodules, polypoid hypertrophy, Reinke oedema, and other diseases rep-
resenting clinically dened entities.

Statistical Analysis
The Fisher exact test [13], univariate and multiple logistic regression models [14] and t test
[13] were used in the statistical analysis of the data.
The Fisher exact test was used to compare the frequencies of pathological vocal signs and
symptoms and the frequency of ENT disorders diagnosed in the teachers versus control group.
Mean number of the voice complaints in teachers and in controls was compared by t test (limit
theorems made it possible). The logistic regression model was used to estimate the relationship
between the probability of the selected disorders and some of the independent variables (covari-
ates). In all statistical tests, the signicance level was assumed to be
= 0.05.

Results

Questionnaire Data
The work conditions were similar among the teachers. The number of students
in class varied from 25 to 35. 2.58% of music teachers and 5.41% of sports teachers
could possibly be exposed to higher voice overloading. The remaining participants
were teachers of different subjects, including mainly primary education teachers,
language and science lectors (g. 2). The teachers worked on average 21.82 (range
1840) h a week (3.68 h a day), and the mean period of teaching was 14.9 years
(table 1). The administrative ofce employees worked 8 h a day (40 h a week) and
the mean period of employment was 16.8 years. Air conditioning was not provided
in the classrooms or ofces.
The study and control groups differed in the percentage of subjects working un-
der conditions of high temperature, table chalk dust pollution, chemical substance
pollution; they differed also in the habit of loud voice speaking (higher value in the
teacher group). The proportion of smokers was signicantly lower in the teachers
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Table 2. The results of phoniatric and videostroboscopic examination (%)

Teachers Controls p
(n = 425) (n = 83)

Voice quality (abnormal, i.e. blank or hoarse) 37.4 19.3 <0.01a

Incorrect (strained) type of phonation 2.6 4.8 <0.08
Voice instability 15.3 7.2 <0.08
Incorrect breathing technique 76.5 73.5 <0.56
Incorrect articulation 4.9 9.6 <0.12
Incorrect activation of supraglottic resonators 48.3 25.3 <0.01a
Presence of nasalization 7.1 10.8 <0.26
Neck muscle hypertension 52.0 19.3 <0.01a
Non-regular vocal fold vibration 33.3 28.9 <0.07
Incorrect amplitude of vocal fold vibration 55.5 24.1 <0.01a
Limited presence of mucosal wave 34.2 19.3 <0.01a
Incomplete glottal closure 35.0 9.4 <0.01a
a
Differences between frequencies in groups are statistically signicant.

(13.4%) than in the controls (25.3%). Allergies were also less frequent in the teachers
compared to controls (17.6 vs. 28.9%, respectively; table 1). The number of subjects
reporting symptoms of hyperarousal was similar in both groups. The teachers more
frequently reported voice rehabilitation/training in the past and sick leaves due to
voice disorders (24.8% in teachers vs. 1.2% in the controls). The groups did not dif-
fer in other environmental and habitual factors, or in general health problems, in-
cluding sexual hormone therapy.
There were statistically signicant differences in the prevalence of vocal symp-
toms between the study group of the female teachers and the controls (table 1). In
overall, lifetime voice problems were reported by 68.7% of teachers and 36.1% of
control group subjects (p ! 0.01). The teachers signicantly more frequently report-
ed chronic and recurrent hoarseness, voicelessness, aphonia, dryness of the throat or
lump in the throat, and permanent dry cough. The mean number of voice symptoms
was 3.21 (82.49) in teachers and 1.98 (82.36) in controls (p ! 0.001).

Clinical Examination
In the teacher group, the phoniatric examination revealed more frequent cases
of abnormal (non-euphonic) voice, excessive neck muscle tension during phonation
and incorrect resonator function (table 2). Besides, signicantly more frequent in
this group were incorrect (reduced) amplitude of vibration of vocal folds, limited
mucosal wave and incomplete closure of glottis during phonation phase. The teach-
er group was characterized by signicantly shorter value of maximum phonation
time, on the average 14.3 (table 3). The study and control groups did not signicant-
ly differ in respect of other parameters assessed in the phoniatric and videostrobo-
scopic examinations, including mode of phonation, breathing technique, articula-
tion, nasalization, overall pathology of the larynx (table 2), mean position of funda-
mental frequency, and mean intensity of voice (table 3).
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Table 3. Mean phonation time, mean fundamental frequency and mean intensity of voice in
teacher and control groups

Teachers Controls p
(n = 425) (n = 83)

Mean phonation time, s 14.3 15.9 0.01a

Mean position of fundamental frequency, Hz 221.6 231.5 0.3
Mean intensity of voice, dB 65.6 64.6 0.09
a
The difference between frequencies (mean values) in groups is statistically signicant.

Table 4. Prevalence of clinically diagnosed vocal disorders in

the group of teachers and controls (%)

Clinical diagnosis Teachers Controls p

(n = 425) (n = 83)

Voice disorders (overall)a 32.9 9.6 <0.01b

Hyperfunctional dysphonia 17.4 7.2 <0.02b
Incomplete glottal closure 13.9 1.2 <0.01b
Vocal nodules 9.9 3.6 <0.04b
a
Voice disorders that are believed to predispose to occupa-
tional diseases (hyperfunctional dysphonia) and that are as-
sumed to be due to occupation-related pathology (incomplete
glottal closure, vocal nodules).
b
The differences between frequencies in groups are statisti-
cally signicant.

One or more clinically dened pathologies of the larynx were diagnosed in 68.2%
teachers versus 32.5% in controls (p ! 0.01), and the most frequent disease was
chronic laryngitis (p ! 0.0005). The others were incomplete closure of the glottis,
dysphonia hyperfunctionalis and hypofunctionalis, polyps, Reinke oedema, paraly-
sis or paresis of vocal cord, etc. Overall, voice disorders that could predispose to oc-
cupational diseases (hyperfunctional dysphonia) and that are assumed to be occupa-
tion-related pathology (like vocal nodules and incomplete glottal closure due to the
weakness of larynx internal muscles) were over 3 times more frequent in teachers
than in the controls (32.9 vs. 9.6%, table 4).

Odds Ratio of Occupational Voice Diseases and Risk Factors

Odds ratio (OR) of voice disorder in teachers was signicantly increased as com-
pared to the control group for incomplete glottal closure (over 13-fold) and hyper-
functional dysphonia (2.7-fold) (g. 3). Although the prevalence of vocal nodules was
almost 3 times more frequent in teachers than in the control group, the OR value
did not reach the level of statistical signicance.
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Fig. 3. Odds ratio of developing occupational voice disorders. *p ! 0.05.

A stepwise procedure was used to identify risk factors for occupation-related

voice disorders. The list of controlled variables included: a lifetime vocal effort index
(dened as a product of the time of employment as a teacher and mean hours of pro-
fessional activity a week); tobacco smoking and allergies, the prevalence of which
differed between groups, and all other variables of univariate logistic analysis that
were signicant for developing voice disorders (table 5). The risk factors for hyper-
functional dysphonia were hyperarousal, instability of voice, neck muscle hyperten-
sion, and lifetime vocal effort (assessed by vocal effort index). Incomplete glottal
closure correlated with voice instability, hoarseness in the anamnesis and lifetime
vocal effort. The prevalence of vocal nodules correlated with strained phonation,
instability of voice and pharmacotherapy of voice disorders in the past (table 6).

Discussion

This investigation represents the rst survey of the general working population
of Polish teachers. Its advantage in relation to the latest and largest epidemiological
study [3] on 2,401 US subjects is that subjective vocal symptoms were veried by
clinical (phoniatric and videostroboscopic) examination, while in the investigation
by Roy et al. [3] only questionnaire interviews were collected.
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Table 5. The results of univariate logistic analysis for voice organ disorders1 (only signicant
variables listed)

95% condence

odds ratio interval p

Hyperfunctional dysphonia
Hyperarousal 8.8 4.916.0 <0.01
Strained phonation 4.3 1.413.1 <0.01
Voice instability 6.6 3.811.7 <0.01
Neck muscle hypertension 31.5 11.387.8 <0.01
Incomplete glottal closure
Table chalk dust 1.9 1.03.4 <0.04
Pharyngitis in the past 2.4 1.44.1 <0.02
Laryngitis in the past 2.2 1.23.8 <0.01
Hyperarousal 1.8 1.13.17 <0.01
Pharmacotherapy of voice disorders in the past 1.9 1.23.4 <0.01
Hoarseness (chronic and recurrent) 3.7 1.77.7 <0.01
Voice tiredness 1.8 1.13.1 <0.03
Voiceless 1.9 1.13.3 <0.02
Dryness in the throat 2.5 1.34.6 <0.04
Voice instability 6.8 3.712.4 <0.01
Upper chest breathing 2.2 1.04.8 <0.05
Vocal nodules
Pharyngitis in the past 2.3 1.14.2 <0.02
Laryngitis in the past 3.2 1.75.9 <0.01
Pharmacotherapy of voice disorders in the past 3.7 1.97.2 <0.01
Hoarseness (chronic and recurrent) 5.1 2.013.3 <0.01
Voice tiredness 3.5 1.86.7 <0.01
Voiceless 3.3 1.76.1 <0.01
Aphonia 2.2 1.24.1 <0.01
Dryness in the throat 2.6 1.35.4 <0.01
Lump in the throat 2.1 1.13.9 <0.02
Strained phonation 9.5 3.030.1 <0.01
Voice instability 7.0 3.513.8 <0.01

1
Both (teacher and control) groups included.

Although the population of teachers in our study comprised a relatively large

spectrum of types of schools and subjects, working conditions of teachers were very
similar in respect of environmental factors in the classroom, number of students in
the classroom, as well as number of working hours a week (more than 18). Thus, the
group could be considered homogeneous and representative. The literature data sug-
gest that in sports and music teachers, voice problems could be signicantly more
frequent than in other professional voice users. In sports teachers, partial or total
voice collapses were recorded in as much as 44% of subjects [15]. Teachers of sing-
ing were even considerably more likely to report a voice problem. In the group of
125 teachers of singing, 64% complained of vocal problems, while there were 33%
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Table 6. The results of multiple regression analysis for occupational voice disorders (teacher
group only)

Odds ratio 95% condence p

interval

Hyperfunctional dysphonia
Hyperarousal 4.3 2.18.9 <0.01
Voice instability 2.5 1.34.7 <0.01
Neck muscle hypertension 10.7 3.433.3 <0.01
Lifetime vocal effort index1 1.1 1.01.1 <0.01
Incomplete glottal closure
Hoarseness (chronic and recurrent) 2.5 1.15.4 <0.02
Voice instability 5.0 2.69.5 <0.01
Lifetime vocal effort index1 0.9 0.9961.0 <0.01
Vocal nodules
Strained phonation 9.6 2.537.1 <0.01
Voice instability 4.9 2.410.4 <0.01
Pharmacotherapy of voice disorders in the past 2.6 1.35.4 <0.01

1
Years of employment as a teacher ! hours of professional activity/week.

subjects with such complaints in the control group [16]. In our study, sports and mu-
sic teachers constituted a negligible portion of all study subjects and, therefore, their
results were not analysed separately.
The results of this study show that vocal symptoms are signicantly more fre-
quent in female teachers than among controls, who were not professional users of
voice, with 68.7% of the teachers reporting lifetime vocal symptoms versus 36.1%
of control subjects. In the study by Roy et al. [3] and Smith et al. [17] these values
were lower than in our study (about 58 and 39%, respectively). The discrepancies
could arise from the different female-to-male subjects proportion in the study pop-
ulation. In contrast to some previous studies [3, 17], in our investigation only female
teachers were evaluated. As reported earlier, voice disorders are more prevalent in
women than in men [3, 18, 19], and female gender is recognized as a risk factor for
voice disorders [18, 19]. It has been shown that being a female middle-aged teacher
and having 16 or more years of teaching (in our group mean time of employment
was 14.6 years) were each positively associated with having experienced a lifetime
voice disorder [3].
One teacher was affected on the average by more than 3 vocal symptoms, which
is in line with reports by other authors [2, 20]. Roy et al. [21] postulated that voice
deterioration in American teachers was signicantly more evident than in the gen-
eral population. The mean number of subjective symptoms reported in that study
was over 4, while over 40% teachers reported 5 or more symptoms [21]. However, it
should be borne in mind that the values quoted above are not comparable because
of the different number of total symptoms considered by different authors, i.e. the
number of total symptoms considered in our study was 8, while the corresponding
number in Roy et al. [21] was 14. In the results obtained by Smith et al. [2], the mean
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number of symptoms per capita reported by the subjects was twice that noted by the
controls; in our study this value was 1.6.
The most frequent vocal symptoms reported by the teachers in our study were
hoarseness and dryness in the throat. Chronic hoarse voice was reported by 15.1%
teachers vs. 6% in controls, while as much as 53.3% of teachers vs. 33.7% of controls
were affected by recurrent hoarse voice. The respective values for dryness in the
throat were 62.2% in teachers and 38.6% in controls. These values are slightly high-
er than reported by other authors. In the investigation by Smith et al. [17] there were
47.5% of teachers with hoarse voice, in the study by Roy et al. [21]about 44% of
teachers were with hoarseness, and in the study by Sapir et al [20] hoarse voice was
found in 45% and dry throat in 55% of female teachers. Both hoarse voice and dry
throat following vocal effort were reported about 2 times more frequently in teachers
than in controls, as it was in our study (1.7).
Dryness in the throat is likely to be worsened by indoor air quality. Previous
studies showed that female subjects have higher vocal symptom score in dry condi-
tions [18, 22]. In our study all the subjects have been working in classrooms lacking
air conditioning with low humidity, and the majority of them (70%) were exposed
to table chalk dust. In general the teachers did not have the habit of drinking water
during their lectures. That could explain the higher percentage of complaints on dry-
ness in the throat than previously reported.
Phoniatric and videostroboscopic examinations in our study revealed that in
overall hyperfunctional dysphonia, incomplete glottal closure and vocal nodules were
over 3-fold more frequent in teachers vs. controls (32.7 vs. 9.6%). Of these disorders,
permanent vocal nodules and incomplete glottal closure with permanent dysphonia
due to the weakness of internal larynx muscles are recognized in Poland as occupa-
tion-related diseases (see above). This frequency was higher than in the study by
Preciado et al. [19]; in their population the prevalence of occupational voice disor-
ders among teachers was 25% with predominance of nodular lesions (8.1%). In our
group, vocal nodules were diagnosed in 9.9% of teachers.
In large-scale US studies that assessed health risks from work-related voice
problems, the teacher profession was about 4 times as frequently represented clini-
cally as the general population [3]. Verdolini and Ramig [1] estimated the risk of
developing voice disorders in teachers to be equal to 3, Fritzell [4] estimated this
value among Swedish teachers at 2.76, while in the study by Titze et al. [5] the cor-
responding value was at the level of 4.67. In our own study, the likelihood of devel-
oping vocal nodules and hyperfunctional dysphonia was similar (about 3). For vocal
nodules, however, OR value was not statistically signicant. It could be explained
by a tendency among young female teachers with a short period of employment to
develop vocal nodules, sometimes even during their rst year of teaching [23]. Our
subjects do not include teachers employed for periods shorter than 1 year; middle-
aged female teachers with mean tenure of 14.6 years dominate among our subjects.
Additionally, in Poland, teachers with vocal nodules are entitled to a disability pen-
sion and usually retire early or change their profession. This could inuence the
statistics.
One of the important factors in the pathogenesis of occupational dysphonia to
be considered is incorrect phonation technique, contributing to pathological com-
pensatory behaviours in heavy vocal loading. This negative vocal adaptation could
predispose to phonotrauma and development of a functional or an organic laryn-
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geal pathology in occupational voice users. The results of our study show signicant-
ly poorer parameters of voicing technique in teachers than in control subjects, in-
cluding strained phonation, excessive neck muscle tension, decreased resonance, and
incorrect breathing conrmed by e.g. shorter mean phonation time. Besides, in the
videostroboscopic examination, teachers showed signicantly more frequently re-
duced vibration amplitude, limited mucosal wave of vocal folds, and incomplete
glottal closure. All these symptoms probably result from the persistently negative
vocal adaptation that occurs as a consequence of vocal loading during long years of
occupational careers. Multiple logistic regression analysis in this project conrmed
a signicance of neck muscle hypertension, strained phonation, voice instability and
lifetime vocal effort as risk factors for occupational voice disorders, supporting this
hypothesis. It is worth underlining that, although lifetime vocal effort was positively
correlated with hyperfunctional dysphonia, it was negatively correlated with incom-
plete glottal closure. The latter result is explainable by premature elimination of
teachers with incomplete glottal closure from the teaching profession. On the one
hand, incomplete glottal closure prevents people from effectively performing as lec-
tors, while on the other it gives Polish teachers the right to obtain disability pension,
and thus they retire early. After long years of employment, only those individuals
continue as teachers who have best adapted to the necessary vocal effort.
The problem of incorrect voicing has been raised by many authors [24, 25].
Koufman et al. [25] described a triad of symptoms including increased glottal mus-
cle tension, weak breathing support and lowered voice frequency, which is now re-
ferred to as laryngeal tension-fatigue syndrome. According to the authors, in heavy
vocal users, laryngeal tension-fatigue syndrome leads to rapid voice deterioration,
development of functional and, later on, organic disorders adversely affecting their
ability to perform as teachers.
The other risk factor for occupational voice diseases was pharmacotherapy of
voice disorders in the past. This observation supports the results of an earlier study
by Verdolini and Ramig [1], who noted that voice problems experienced in the past
increase the risk of developing voice disorders at present.
Vocal hyperfunction increasing the potential for vocal fold trauma and collision
forces is viewed as one of the causative factors in occupational voice disorders (such
as vocal nodules) [26, 27]. Hyperfunctional use of the voice during a long occupa-
tional career reduces also the capacity to maintain tension in the vocal folds [24]. In
our study hyperfunctional dysphonia was found in 17.4% of teachers, and the main
risk factors for developing this disorder were neck muscle hypertension and hyper-
arousal, besides lifetime vocal effort.
Bowing vocal folds contribute to incomplete glottal closure, mainly spindle-
shaped conguration. In our study the videostroboscopic examinations demonstrat-
ed incomplete glottal closure in 13.9% of teachers. Schneider et al. [28] reported the
relationship between insufcient glottal closure and reduced vocal capabilities. Ob-
rebowski et al. [29] postulated that irreversible, persistent incomplete glottal closure
may reect occupation-related changes in the vocal apparatus. They presumed that
this condition indicated a weakening of the muscles adducting vocal folds, particu-
larly of the musculus vocalis, that develops as a result of long-term hyperfunctional
disorders in professional users [29].
Some authors stress that psychological factors may be co-responsible for the de-
velopment of vocal disorders, or may constitute the direct cause of these disorders
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[3032]. It has been shown that psychological factors are essential in the develop-
ment of functional dysphonia, type pathology resulting from abnormal laryngeal in-
ner and outer muscle tension. Nichol et al. [32] suggested that muscular hypertension
results from the hyperactivity of the autonomous and peripheral nervous systems
that is frequently observed in individuals experiencing high levels of pavor or in hy-
peractive people. In patients with hyperfunctional dysphonia or vocal nodules, they
found signicantly higher scores for fear level, introversion, or the level of somatic
complaints than in subjects not affected by vocal diseases.
The results of our previous study showed that roughly one half of teachers with
voice problems referred to the phoniatrician exhibited severe psychological distur-
bances requiring psychological intervention (non-published data). This percentage
of symptoms was higher than in the general Polish population suffering from gen-
eral organic diseases, and was regarded to be high. In the present study, psychologi-
cal problems were assayed by self-assessment only, and the proportion of subjects
with the symptoms of hyperarousal did not differ in teachers versus non-teachers.
However, hyperarousal has been identied as a risk factor for developing hyperfunc-
tional dysphonia. It supports earlier suggestion to group both psychological distur-
bances and functional dysphonia under the designation psychogenic voice disor-
ders, reecting the aetiological supposition [30].
In conclusion, the frequency of vocal symptoms and voice disorders among
teachers in Poland is 23 times higher than in non-teachers, and seems to be slight-
ly higher than in other European countries and the US. Because voice disorders af-
fect a very large professional group, their prevention is of clinical importance. Polish
teachers do not receive any preventive voice training or psychological support; that,
in combination with poor hygienic work conditions, could increase health problems.
Thus, voice training of teachers and teacher college students with psychological coun-
selling in some cases should be considered as a useful tool in the prevention of voice
disorders.

Acknowledgement

The study was supported by a research project of the Polish Ministry of Health (Project No.
15/MP/2002).

Appendix 1: Questionnaire

(First and last) Name _______________________________________________ Date

Age ______________________________________
Workplace
School type ______________________________________________________
School subject ___________________________________________________
Pupils, number in attendance ______________________________________
Years of employment ______________________
Vocal effort, h/week _______________________
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Work and life hygiene
1 Room type Classroom g
Corridor g
Lecture room g
2 Ambient temperature Below 18 C g
Between 18 and 21 C g
Above 21 C g
3 Air humidity To 45% Above 45%
4 Dustiness
Dust accumulation on curtains Yes No
Blackboard wiping/chalk dust Yes No
5 Exposure to chemical substances Yes No
6 Air agitation
Draughts Yes No
Air conditioning Yes No
7 Phonation habits
Speaking in a low voice Yes No
Speaking in a raised voice Yes No
Speaking at the top of ones voice Yes No
8 Physical exercises/sport Yes No
Regular
Irregular
9 Tobacco use Yes No
Years: __________ ; cigarettes per day: __________
Concomitant laryngological diseases
1 Sinusitis Yes No
2 Pharyngitis Yes No
3 Laryngitis Yes No
4 Ear diseases Yes No
Other diseases
5 Allergy (prick test in anamnesis) Yes No
6 Thyroid disease Yes No
7 Sexual hormone therapy Yes No
8 Menstruation Regular Irregular
9 Hyperarousal Yes No

Lifetime vocal symptoms

1 Hoarseness
Chronic (permanent, without infection) Yes No
Recurrent (periodical, <4 weeks) Yes No
2 Voice tiredness Yes No
3 Voiceless Yes No
4 Aphonia Yes No
5 Dry throat Yes No
6 Lump in the throat Yes No
7 Persistent dry cough Yes No

Total number of symptoms

Phoniatric care
1 Pharmacotherapy of voice disorders in the past Yes No
2 Voice rehabilitation in the past Yes No
3 Sick leaves due to voice disorders in the past Yes No
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Appendix 2: Clinical Examination

ENT examination
1 Nose (unobstructed, mucosa, nasal septum, nasal conchae, secretion)
Normal Abnormal
2 Oral cavity and throat (mucosa, tongue, occlusion, soft palate, tonsils)
Normal Abnormal
3 Indirect laryngoscopy
(mucosa, epiglottis, vestibular and vocal cords, glottal closure, arythenoid region)
Normal Abnormal
4 Ears (otoscopy) Normal Abnormal

Phoniatric examination
1 Voice quality Normal (euphonic) Abnormal
Blank (without resonance)
Rough
Hoarse
Creaky
2 Type of phonation Normal Incorrect (breathy, strained)
3 Instability of voice (uncontrolled changes in voice pitch and loudness while speaking)
Yes No
4 Breathing technique
Mixed (thoraco-abdominal) Lower (abdominal) Upper (clavico-thoracal)
5 Articulation Correct Incorrect
6 Function of resonators Correct Incorrect
7 Nasalization Absent Present
8 Excessive neck muscle tension (neck tightness)
Yes No
9 Phonation time, s

Videostroboscopic examination
1 Regularity of vocal fold vibration Regular Non-regular (irregular or
asymmetrical)
2 Amplitude of vocal fold vibration Normal Incorrect (reduced or increased)
3 Quality of mucosal wave Normal Limited
4 Glottal closure Complete Incomplete
5 Pathological organic lesions of vocal folds (e.g. vocal nodules)
Sound level
Fundamental frequency, ____________ Hz
Intensity of speaking voice, __________ dB
Diagnosis

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