Voice Disorders in Lower Primary School Teachers: An Observational Study

Published:December 18, 2020DOI:



      Voice problems are very common among teachers, and etiology-based methods are used in the diagnosis and treatment process. Our study aims to reveal the changes in subjective voice analysis during the diagnosis and treatment process of dysphonia in lower primary school teachers.


      The nature of the study is a prospective observational one designed for lower primary school teachers in Kahramanmaraş conducted between the year 2015 and 2019 and evaluations for parameters including sociodemographic characteristics, laryngeal lesions and pre- and post-treatment scales such as Voice Handicap Index-10 (VHI-10), Reflux Symptom Index (RSI) and Hospital-Anxiety Depression Scale (HADS) for treatment subgroups were made. Statistical analysis was analyzed using SPSS.


      Three hundred and fifty-one lower primary school teachers were included in the study. A statistically significant difference was found for the development of dysphonia in terms of sociodemographic features such as smoking, professional experience and crowdedness of classroom. Changes in RSI, VHI-10 and HADS values after treatment were clinically significant in all treatment groups. While there was a significant post-treatment improvement in terms of RSI in patients with granuloma and laryngopharyngeal reflux disorders, the VHI-10, and HADS assessments revealed a significant difference in clinical recovery compared to laryngeal lesions.


      The RSI, VHI-10 and HADS values for various laryngeal pathologies were found to be high in dysphonic teachers. An improvement was observed in the scale scores upon the application of treatment modalities. This situation emphasizes the importance of questionnaire survey in the diagnosis, treatment, and follow-up process of dysphonia.


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        • Akinbode R
        • Lam KB
        • Ayres JG
        • et al.
        Voice disorders in Nigerian primary school teachers.
        Occup Med (Lond). 2014; 64: 382-386
        • Hillman RE
        • Stepp CE
        • Van Stan JH
        • et al.
        An updated theoretical framework for vocal hyperfunction.
        Am J Speech Lang Pathol. 2020; : 1-7
        • Angelillo M
        • Di Maio G
        • Costa G
        • et al.
        Prevalence of occupational voice disorders in teachers.
        J. Prev. Med. Hyg. 2009; 50: 26-32
        • Behlau M
        • Zambon F
        • Guerrieri AC.
        Epidemiology of voice disorders in teachers and nonteachers in Brazil: prevalence and adverse effects.
        J Voice. 2012; 26: 665-669
        • Medeiros M
        • Barreto SM
        • Assunção AA
        Voice disorders (dysphonia) in public school female teachers working in Belo Horizonte: prevalence and associated factors.
        J Voice. 2008; 22: 676-687
        • Sliwinska-Kowalska M
        • Niebudek-Bogusz E
        • Fiszer M
        • et al.
        The prevalence and risk factors for occupational voice disorders in teachers.
        Folia Phoniatr. Logop. 2006; 58: 85-101
        • Martins RH
        • Pereira ER
        • Hidalgo CB
        • et al.
        Voice disorders in teachers. a review.
        J Voice. 2014; 28: 716-724
        • Roy N
        • Merrill RM
        • Thibeault SL
        Prevalence of voice problems in teachers and the general population.
        J Speech Lang Hear Res. 2004; 47: 281-293
        • Welham NV
        • Maclagan MA
        Vocal fatigue: current knowledge and future directions.
        J. Voice. 2003; 17: 21-30
        • Ohlsson AC
        • Andersson EM
        • Södersten M
        Prevalence of voice symptoms and risk factors in teacher students.
        J Voice. 2012; 26: 629-634
        • Verdolini K.
        • Ramig L.O.
        Review: occupational risks for voice problems.
        Logoped Phoniatr Vocol. 2001; 26: 37-46
        • Cantor Cutiva LC
        • Vogel I
        • Burdorf A
        Voice disorders in teachers and their associations with work-related factors: a systematic review.
        J Commun Disord. 2013; 46: 143-155
        • Alanazi R
        • Alrahim A
        • Baoyunos S
        • et al.
        Association between voice handicap index and reflux symptom index. A cross-sectional study of undiagnosed general and teacher cohorts in Saudi Arabia.
        Sultan Qaboos Univ Med J. 2018; 18: 350-354
        • Gadepalli C
        • Fullwood C
        • Ascott F
        • et al.
        Voice burden in teachers and non-teachers in a UK population: a questionnaire-based survey.
        Clin Otolaryngol. 2019; 44: 1045-1058
        • Arffa RE
        • Krishna P
        • Gartner-Schmidt J.
        Normative values for the voice handicap index-10.
        J Voice. 2012; 26: 462-465
        • Moy FM
        • Hoe VC
        • Hairi NN.
        Determinants and effects of voice disorders among secondary school teachers in peninsular Malaysia using a validated Malay version of VHI-10.
        PLoS ONE. 2015; 10e0141963
        • Rosen CA
        • Lee AS
        • Osborne J
        • et al.
        Development and validation of the voice handicap index-10.
        The Laryngoscope. 2004; 114: 1549-1556
        • Belafsky PC
        • Postma GN
        • Koufman JA.
        Validity and reliability of the reflux symptoms index (RSI).
        J Voice. 2002; 16: 274-277
        • Tyrer P
        • Methuen C.
        Rating Scales in Psychiatry.
        RCPSYCH Publications, London2007
        • Leong K
        • Hawkshaw MJ
        • Dentchev D
        • et al.
        Reliability of objective voice measures of normal speaking voices.
        J Voice. 2013; 27: 170-176
        • Arffa RE
        • Krishna P
        • Gartner-Schmidt J
        • et al.
        Normative values for the voice handicap index-10.
        J Voice. 2012; 26: 462-465
        • Bovo R
        • Galceran M
        • Petruccelli J
        • et al.
        Vocal problems among teachers: evaluation of a preventive voice program.
        J Voice. 2007; 21: 705-722
        • Gebska M
        • Wojciechowska A
        • Zyzniewska-Banaszak E.
        Principles and methods of rehabilitation of patients with occupational voice disorders.
        Ann Acad Med Stetin. 2011; 57: 78-84
        • Hunter EJ.
        Teacher response to ambulatory monitoring of voice.
        Logoped Phoniatr Vocol. 2012; 37: 133-135
        • Lechien JR
        • Saussez S
        • Schindler A
        • et al.
        Clinical outcomes of laryngopharyngeal reflux treatment: a systematic review and meta-analysis.
        Laryngoscope. 2018;
        • Chung JH
        • Tae K
        • Lee YS
        • et al.
        The significance of laryngopharyngeal reflux in benign vocal mucosal lesions.
        Otolaryngol Head Neck Surg. 2009; 141: 369-373
        • Koufman JA
        • Aviv JE
        • Casiano RR
        • et al.
        Laryngopharyngeal reflux: position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery.
        Otolaryngol Head Neck Surg. 2002; 127: 32-35
        • Koufman JA
        • Amin MR
        • Panetti M.
        Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders.
        Otolaryngol Head Neck Surg. 2000; 123: 343-385
        • Lechien JR
        • Huet K
        • Khalife M
        • et al.
        Impact of laryngopharyngeal reflux on subjective and objective voice assessments: a prospective study.
        J Otolaryngol Head Neck Surg. 2016; 859
        • Elam Jackson C
        • Ishman Stacey L
        • Dunbar Kerry B
        • et al.
        The relationship between depressive symptoms and voice handicap index scores in laryngopharyngeal reflux.
        Laryngoscope. 2010; 120: 1900-1903
        • Cheung TK
        • Lam PK
        • Wei WM
        • et al.
        Quality of life in patients with laryngopharyngeal reflux.
        Digestion. 2009; 79: 52-57
        • Thomas JP
        • Zubiaur FM.
        Over-diagnosis of laryngopharyngealreflux as the cause of hoarseness.
        Eur Arch Otorhinolaryngol. 2013; 270: 995-999
        • Santana Mda C
        • Goulart BN
        • Chiari BM.
        Voice disorders in teachers: critical review on the worker's health surveillance practice.
        J Soc Bras Fonoaudiol. 2012; 24: 288-295
        • Alvear RM
        • Martínez-Arquero G
        • Barón FJ
        • et al.
        An interdisciplinary approach to teachers' voice disorders and psychosocial working conditions.
        Folia Phoniatr Logop. 2010; 62: 24-34
        • Rantala LM
        • Hakala SJ
        • Holmqvist S
        • et al.
        Connections between voice ergonomic risk factors and voice symptoms, voice handicap, and respiratory tract diseases.
        J Voice. 2012; 26: 13-20
        • Siupsinskiene N
        • Razbadauskas A
        • Dubosas L.
        Psychological distress in patients with benign voice disorders.
        Folia Phoniatr Logop. 2011; 63: 281-288
        • Da Costa V
        • Prada E
        • Roberts A
        • et al.
        Voice disorders in primary school teachers and barriers to care.
        J Voice. 2012; 26: 69-76
        • Thibeault SL
        • Merrill RM
        • Roy N
        • et al.
        Occupational risk factors associated with voice disorders among teachers.
        Ann Epidemiol. 2004; 14: 786-792
        • Butler JE
        • Hammond TH
        • Gray SD.
        Gender-related differences of hyaluronic acid distribution in the human vocal fold.
        Laryngoscope. 2001; 111: 907-911
        • Kavookjian H
        • Thomas Irwin T
        • James D.
        • et al.
        The reflux symptom index and symptom overlap in dysphonic patients.
        Laryngoscope. 2020;
        • Barletta JF
        • El-Ibiary SY
        • Davis LE
        • et al.
        Proton pump inhibitors and the risk for hospital-acquired Clostridium difficile infection.
        Mayo Clin Proc. 2013; 88: 1085-1090
        • Maggio M
        • Lauretani F
        • Ceda GP
        • et al.
        Use of proton pump inhibitors is associated with lower trabecular bone density in older individuals.
        Bone. 2013; 57: 437-442
        • Brewster UC
        • Perazella MA.
        Proton pump inhibitors and the kidney: critical review.
        Clin Nephrol. 2007; 68: 65-72
        • Xie Y
        • Bowe B
        • Li T
        • et al.
        Proton pump inhibitors and risk of incident CKD and progression to ESRD.
        J Am Soc Nephrol. 2016; 27: 3153-3163
        • Cohen SM
        • Pitman MJ
        • Noordzij JP
        • et al.
        Management of dysphonic patients by otolaryngologists.
        Otolaryngol Head Neck Surg. 2012; 147: 289-294
        • Gillivan-Murphy P
        • Drinnan MJ
        • O'Dwyer TP
        • et al.
        The effectiveness of a voice treatment approach for teachers with self-reported voice problems.
        J Voice. 2006; 20: 423-431